Mediastinal biopsy for indeterminate chest lesions.

The current literature contains numerous reports on the importance of the mediastinal lymph nodes in the diagnosis and prognosis of pulmonary neoplasms. We recently described a technique by which the mediastinal contents could be explored directly with little risk (Stemmer, Calvin, Chandor, and Connolly, 1965). Figure 1 illustrates the operative technique. An oblique incision is made just lateral to the sternum and over the second and third costal cartilages. These cartilages are resected subperiosteally. The anterior mediastinum can then be entered without opening the pleura. When the procedure is carried out on the right side, the innominate vein, superior vena cava, ascending aorta, and the upper portion of the pericardium are exposed by additional sharp and blunt dissection through the anterior mediastinal fat (Fig. ic). A plane is developed between the ascending aorta and the superior vena cava (Fig. 2), which is then retracted laterally to expose the trachea and right pulmonary vessels and provide access to the subcarinal areas (Figs ld and 3). If the surgeon wishes, the hilar structures can be dissected for a surprising distance peripherally without producing a pneumothorax. Any lymph nodes or tumour masses in this area are biopsied and the specimens are sent for frozen section. From this point the dissection can be carried into the posterior mediastinum, where a short segment of the oesophagus can be explored visually and needle biopsies of the vertebral bodies obtained as indicated. This procedure is, of course, terminated when the information being sought is obtained. When the procedure is performed on the left side, the dissection is carried out in a similar way, except that it may be difficult or impractical to expose the subcarinal region because of the intervening aortic arch. Mediastinal and hilar masses presenting on the left side radiographically are easily accessible. Table I summarizes our results with this technique of mediastinal biopsy. Although originally TABLE I