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Surgical approach to isolated mediastinal lymphoma.
J THORAC CARDlOYASC SURG 1990;99:691-5
Surgical approach to isolated mediastinal lymphoma. With the aim of assessing the role of surgery in the management of isolated mediastinal lymphoma, we have reviewed the data of 123 operations performed on 102 patients (64 with Hodgkin's disease and 38 with non-Hodgkin's lymphoma). One death and four major complications occurred in these patients. Macroscopically radical resection was performed in 14 patients who are free of disease after 1 to 14 years. Debulking resection was performed in five patients: Three are alive after 5 to 11 years and two died after 36 and 40 months. Ten patients (seven with non-Hodgkin's lymphoma and three with Hodgkin's disease) had residual mediastinal masses of more than 2 cm after chemotherapy; to assess the nature of the lesion (fibrosis or residual disease), we subjected these patients to surgical restaging of the mediastinum: Results were negative in seven and positive in three. We conclude that open biopsy is indispensable to obtain good tissue specimens suitable for histologic and immunohistochemical assessment. Biopsy must be performed as a major surgical procedure to avoid reoperation: Mediastinoscopy and sternal sp6tting incisions proved the most reliable approaches. Locally radical or debulking resection migbt be considered in selected cases to enhance long-term results.
Costante Ricci, MD,a Erino A. Rendina, MD,a Federico Venuta, MD,a Edoardo O. Pescarmona, MD,b Rocco Di Tolla," Luigi P. Ruco, MD,b Cesare Guglielmi, MD,c Anna Paola Anselmo, MD,c and Franco Mandelli, MD,c Rome, Italy
In 1973 we' published our experience with five patients with isolated Hodgkin's lymphoma of the mediastinum who had been treated by radical resection of disease and radiotherapy. All patients survived and were free of disease up to 9 years after the operation, results that compared most favorably with the poor outcome of patients treated by chemotherapy and radiotherapy. At present Hodgkin's disease (HD) is treated medically with a cure rate of over 70%,2,3 and chemotherapy has been effective in the treatment of non-Hodgkin's lymphomas (NHL) provided that a correct diagnosis is readily made and the appropriate therapy is instituted quickly.!" However, little information is present in the literature concerning the surgical approach to the mediastinum, a problem that must befaced especially in patients in whom no other site of disease can be detected. 5 The role of surgical treatment in the management of isolated mediastinal lymphoma From the Department of Thoracic Surgery," Department of Haematology," and II Chair of Pathological Anatomy," University "La Sapienza" Rome, Italy. Received for publication July 28, 1988. Accepted for publication May 22, 1989. Address for reprints: Dr. E. A. Rendina, Cattedra di Chirurgia Toracica, II Clinica Chirurgica, Policlinico Umberto I, 00161 Roma, Italy.
12/1/14376
thus acquires new perspectives, considering the need for a suitable quantity of histologic material for diagnosis, the importance of a dependable restaging procedure monitoring the response to therapy, and the role of radical or debulking resection as the first step of a multidisciplinary approach. Patients Between January 1973 and December 1987, 102 patients with isolated mediastinal lymphoma were operated on at our institution. Forty-six patients were male and 56 female, their ages ranging between 7 and 71 years (mean 3 I years). Thoracic symptoms such as dyspnea (n = 53), chest pain (n = 47), cough (n = 39), and superior vena cava syndrome (n = 35) were present in 78 patients; the other 24 patients were free of symptoms. Preoperative work-up was especially intended (I) to elucidate the nature of the lesion and its local extension and invasiveness" and (2) to investigate other possible sites of the disease. All patients underwent standard x-ray and tomographic examination of the chest until 1980, when computed tomography (CT) was included in the conventional preoperative roentgenologic work-up (40 patients); four patients also underwent pneumomediastinum and four magnetic resonance (MR) imaging. Types of operation are reported in Table I. Ninety-two patients were operated on at the first indication of disease; in six of them, two procedures were necessary to achieve the histologic diagnosis. The first operation was a chest wall biopsy for direct tumor infiltration under local anesthesia in four patients and a mediastinoscopy in two. Sixty-five patients had HD and 38 NHL.
691
The Journal of Thoracic and Cardiovascular Surgery
6 9 2 Ricci et al.
c Fig. 1. HD the thymus treated by locally radical resection. A, Standard posteroanterior chest x-ray film. B, CT demonstrates necrosis within the tumor and indicates the presence of cleavage planes with the surrounding ri,.ediastinal structures. C, resected specimen; the tumor is confined to the thymic gland, whose appearance and typical bilobated shape are maintained.
Table I. Operations performed in 102 patients (five needle aspirations not included) No.
Mediastinosccpy Thoracotomy Mediastinotomy Sternal splitting incision" Median sternotomy Minor biopsies High pretracheal node biopsyt Pretracheal tissue biopsyt Parasternal chest wall biopsy Subcutaneous biopsy of anterior chest wall Sternal biopsy Total
26 24 22 15 II
25 10 5 5 4 I 123
"Upper partial median sternotomy. t Thcsc patients were scheduled for mediastinoscopy. but the procedure was dis-
continued after sufficient histologic material was taken in the upper part of the mediastinum.
Overall, 104 biopsies, 14 (11 HD, 3 N HL) locally radical resections, and 5 (4 HD, 1 NHL) debulking resections (more than three fourths of the mass) were performed. Frozen sections were obtained in most cases, and the definitive histologic diagnosis was based on conventional histologic characteristics, histoenzymatic and immunohistochemical procedures on tissue specimens, and cell suspensions and electron microscopic studies in selected cases. Five specimens obtained by needle aspiration did not yield a precise diagnostic definition. When the tumor appeared resectable, cleavage planes were present on preoperative imaging, as demonstrated by the case reported in Fig. I, and no systemic foci of neoplastic proliferation were detectable, a major operation with radical intent was planned. All 14 patients treated by this approach are alive and free of disease I to 14 years after the operation. Postoperatively, seven patients underwent local radiotherapy alone, three radiotherapy alone plus splenectomy, three chemotherapy alone, and one radiotherapy plus chemotherapy; no toxicosity-related complications occurred and no recurrence of disease was observed. Three patients with HD undergoing debulking resection are alive and well after 5 to 11 years, and two with NHL
Volume 99 Number 4
Isolated mediastinal lymphoma
April 1990
Fig. 2. Restaging of isolated HD of the mediastinum after chemotherapy. A, CT reveals a mass in the anterior mediastinum infiltrating the surrounding structures. B, MR imaging: The presence of residual neoplastic tissue is suggested. No malignant disease was found at operation and no further therapy was administered. (CT: false positive; MR: false positive.) died 36 and 40 months postoperatively. The latter two patients had been operated on after unsuccessful chemotherapy that had been started in a periphery hospital because of a nonspecific diagnosis of lymphoma. Ten patients in whom the diagnosis had been obtained by mediastinal biopsy underwent surgical restaging of residual tissue occupying the mediastinium after therapy, with the aim of establishing whether it was residual disease or fibrosis. All patients in this group had undergone CT and four MR, but the accuracy of the two procedures was unsatisfactory (Figs. 2 and 3). Three patients had HD and seven had been treated for NHL by three courses of the F-MACHOP regimen." It has been demonstrated that patients with NHL who have residual disease after three courses of F-MACHOP will not respond to further
693
Fig. 3. Restaging of NHL of the mediastinum. A, CT imaging at presentation of disease. B, CT imaging after three courses of F-MACHOP. The residual mass was proved at operation to consist of fibrotic tissue. The last three courses of F-MACHOP were administered and the patient is free of disease after 26 months.
Table II No. of patients
Response
Result
Restaging of NHL after 3 courses of F-MACHOP* 6 Negative Completion F-MACHOP 1 4 Positive Change therapy Restaging of HD 1 Negative 2 Positive
N 0 further therapy 1 Died, 1 AWD
AWD, Alive with disease. 'No evidence of disease after 10 to 28 months.
treatment with the same regimen and thus require non-crossresistant alternative therapy." Therefore we have surgically restaged residual mediastinal masses of more than 2 ern on CT examination. As much abnormal tissue as possible was resected to rule out the presence of any residual neoplastic focus, but the
6 9 4 Ricci et al.
procedure was not intended for cure and was considered as a simplebiopsy. Thoracotomy was performed in one patient and a sternal splittingincision in six, the incision beingextended to total mediansternotomy in onepatientto controlbleeding from the internal mammary artery. Of the three patients with HD, one had a sternal splittingincision, one a median sternotomy, and onea mediastinotomy. The outcome of restaged NHL and HD is reported in Table II. One patient with relapsing HD died 3 days after anterior mediastinotomy because of massive hemoptysis that was not apparently related to the surgicalprocedure, and four had major complications (bleeding, heart rhythmdisturbances, phrenic nerveinjury, and wound infection).
Discussion The outcome of patients with lymphoproliferative disease has improved dramatically in recent years and the curability rate has reached 80% in HD3. 7 and 50% to 70% in NHL. 8,9 However, such good results may be obtained only if the histologic diagnosis, often difficult, is precise and the appropriate therapy is immediately started. The mediastinum is a frequent site of lymphoma." being involved in 50% to 60% of patients with HDlO, I J and in about 19% with NHL.12 If the disease does not appear in other organs, mediastinal biopsy is mandatory for definitive diagnosis. Direct fine needle aspiration biopsy has been proposed for this purpose, 13 but we use it only occasionally because of the insufficient histologic material supplied and the low but not insignificant risk entailed. Histologic diagnosis of lymphoproliferative diseases is based at our institution on histologic and immunohistochemical procedures that necessitate an amount of tissue that can be obtained only by open biopsy of the mediastinum through a route providing good control of the tumor and of the organs potentially involved. Despite this strategy, we were obliged in the early years of our experience to repeat the biopsy in six patients because of inadequacy of histologic material, thus exposing the patient to further discomfort and delaying medical therapy. It is important in our opinion that the surgical approach to isolated mediastinal lymphoma be intended primarily as the means to achieve a positive histologic diagnosis; multiple biopsy specimens should therefore be obtained from the tumor and the operation should be scheduled as a major surgical procedure providing good exposure of the lesion and sufficient control of mediastinal organs. In our experience, anterior parasternal mediastinotomy and mediastinoscopy were adequate to reach enlargled mediastinal lymph nodes or substernal lesions lower than the second or third intercostal space, and sternal splitting (partial median sternotomy) was suitable to control masses located behind the upper third of the sternum. The hitter is particularly indicated when larger tissue specimens are needed, especially after previous attempts have
The Journal of Thoracic and Cardiovascular Surgery
failed to provide a positive histologic diagnosis. We did not observe complications related to the impact of chemotherapy and radiotherapy on the healing sternum. Despite the availability of CT and MR, it is difficult to establish the differential diagnosis between lymphoma and other mediastinal tumors preoperatively'; although lymphoma, a typically systemic disease, may not be considered surgically curable, resection is the treatment of choice for other relatively frequent mediastinal lesions, especially thymoma. It is therefore necessary to select a surgical approach that is not preclusive in view of curative resection, after the extent of the tumor is directly evaluated and the histologic features are identified by frozen sections. For these reasons, we believe that mediastinoscopy and especially sternal splitting incisions are the most suitable operations when the diagnosis of an anterior mediastinal tumor is uncertain and the possibility of lymphoma exists. These operations allow direct evaluation of the position ofthe tumor and extension of the incision caudally to the xiphoid to achieve complete control of the mediastinum through median sternotomy. Posterolateral thoracotomy, often used in the past for biopsy and resection, is no longer in use in our department for mediastinallesions because of greater trauma and inadequacy to control possible great vessel involvement or extension of tumor on the contralateral aspect of the mediastinum. Anterior parasternal mediastinotomy is an excellent route for biopsy but lacks flexibility, because it does not allow the incision to be extended if wider exposure is necessary. Even though surgical resection does not represent by itself a curative solution to isolated mediastinallymphoma, an aggressive surgical approach may be indicated if preoperative imaging demonstrates resectable disease (Fig. 1) and no apparent systemic involvement is found. No deaths or complications occurred after radical or debulking resection. In addition, some of these patients with HD may be effectively treated by local postoperative radiotherapy alone with positive long-term results. Surgical restaging of mediastinal lymphoma after therapy presents particular technical problems. The marked reduction of the neoplastic bulk and the reactive fibrosis induced by chemotherapy and radiotherapy cause displacement and tight adhesions on mediastinal organs; in addition, the wall of the vessels is often fragile and stiff with no cleavage planes with the surrounding tissues. On the other hand, it is important to resect and examine as much tissue as possible to rule out any focus of neoplastic cells. In our experience, a sternal splitting incision was adequate to control the mediastinal vessels and the diseased tissue, and in only one patient with residual disease in the cardiophrenic angle did we perform an ante-
Volume 99 Number 4
Isolated mediastinal lymphoma 69 5
April 1990
rolateral thoracotomy in the sixth intercostal space. In addition, the partial sternotomy incision may be easily extended if wider exposure is required. If the treatment planning in patients with mediastinal lymphoma is to be reevaluated because the mediastinum is occupied by residual tissue for which the doubt of relapsing disease arises, noninvasive diagnostic techniques are inadequate to provide a positive answer and surgical restaging must be undertaken. A sternal splitting incision has been in our experience the most adequate route for exploration. REFERENCES 1. Ricci C, De Leo G, Bombi G, Mineo C. Chirurgia delle 10calizzazioni mediastiniche isolate del Morbo di Hodgkin. Minerva Chir 1973;28:469-78. 2. Mandelli F, Anselmo AP, Cartoni C, Cimino G, Maurizi ER, Biagini C. Evaluation of therapeutic modalities in the control of Hodgkin's disease. Int J Radiat Oncol BioIPhys 1986;12:1617-20. 3. Hellman S, Mauch P. Role of radiation therapy in the treatment of Hodgkin's disease. Cancer Treat Rep 1982; 66:915-23. 4. Guglielmi C, Amadori S, Ruco LP, et al. Combination chemotherapy for the treatment of diffuse aggressive Iym-
5.
6.
7. 8.
9.
10. 11. 12.
13.
phomas: F-MACHOP update. Semin Onco11987; 14(suppl 1):104-9. Yellin A, Pak HY, Burke JS, Benfield JR. Surgical management of lymphomas involving the chest. Ann Thorac Surg 1987;44:363-9. Rendina EA, Venuta F, Ceroni L, et al. Computed tomographic evaluation of anterior mediastinal neoplasms. Thorax 1988;43:441-5. HoppeRT. Radiation therapy in the treatment of Hodgkin's disease. Semin Oncol 1980;7:144-54. DeVita VT, Canellos GP, Chabner B, et al. Advanced diffuse histiocytic lymphoma, a potentially curable disease: results with combination chemotherapy. Lancet 1975; 1:248-50. Ricci C. Chirurgia radicale dei tumori del mediastino. Proceedings of the Twentieth Congress of the Italian Society for Thoracic Surgery. Rome: Seros, 1986:124-40. MacDonald JB. Lung involvement in Hodgkin's disease. Thorax 1977;32:664-7. Moran EM, Ultmann JE. Clinical features and course of Hodgkin's disease. Clin Haematol 1974;3:91-129. Manoharan A, Pitney WR, Schonell ME, Bader LV. Intrathoracic manifestations in non-Hodgkin's lymphoma. Thorax -1979;34:29-32. Sinner WN. Direct fine needle biopsy of anterior and middle mediastinal masses. Oncology 1985;42:92-6.
Surgical approach to isolated mediastinal lymphoma. With the aim of assessing the role of surgery in the management of isolated mediastinal lymphoma, we have reviewed the data of 123 operations performed on 102 patients (64 with Hodgkin's disease and 38 with non-Hodgkin's lymphoma). One death and four major complications occurred in these patients. Macroscopically radical resection was performed in 14 patients who are free of disease after 1 to 14 years. Debulking resection was performed in five patients: Three are alive after 5 to 11 years and two died after 36 and 40 months. Ten patients (seven with non-Hodgkin's lymphoma and three with Hodgkin's disease) had residual mediastinal masses of more than 2 cm after chemotherapy; to assess the nature of the lesion (fibrosis or residual disease), we subjected these patients to surgical restaging of the mediastinum: Results were negative in seven and positive in three. We conclude that open biopsy is indispensable to obtain good tissue specimens suitable for histologic and immunohistochemical assessment. Biopsy must be performed as a major surgical procedure to avoid reoperation: Mediastinoscopy and sternal sp6tting incisions proved the most reliable approaches. Locally radical or debulking resection migbt be considered in selected cases to enhance long-term results.
Costante Ricci, MD,a Erino A. Rendina, MD,a Federico Venuta, MD,a Edoardo O. Pescarmona, MD,b Rocco Di Tolla," Luigi P. Ruco, MD,b Cesare Guglielmi, MD,c Anna Paola Anselmo, MD,c and Franco Mandelli, MD,c Rome, Italy
In 1973 we' published our experience with five patients with isolated Hodgkin's lymphoma of the mediastinum who had been treated by radical resection of disease and radiotherapy. All patients survived and were free of disease up to 9 years after the operation, results that compared most favorably with the poor outcome of patients treated by chemotherapy and radiotherapy. At present Hodgkin's disease (HD) is treated medically with a cure rate of over 70%,2,3 and chemotherapy has been effective in the treatment of non-Hodgkin's lymphomas (NHL) provided that a correct diagnosis is readily made and the appropriate therapy is instituted quickly.!" However, little information is present in the literature concerning the surgical approach to the mediastinum, a problem that must befaced especially in patients in whom no other site of disease can be detected. 5 The role of surgical treatment in the management of isolated mediastinal lymphoma From the Department of Thoracic Surgery," Department of Haematology," and II Chair of Pathological Anatomy," University "La Sapienza" Rome, Italy. Received for publication July 28, 1988. Accepted for publication May 22, 1989. Address for reprints: Dr. E. A. Rendina, Cattedra di Chirurgia Toracica, II Clinica Chirurgica, Policlinico Umberto I, 00161 Roma, Italy.
12/1/14376
thus acquires new perspectives, considering the need for a suitable quantity of histologic material for diagnosis, the importance of a dependable restaging procedure monitoring the response to therapy, and the role of radical or debulking resection as the first step of a multidisciplinary approach. Patients Between January 1973 and December 1987, 102 patients with isolated mediastinal lymphoma were operated on at our institution. Forty-six patients were male and 56 female, their ages ranging between 7 and 71 years (mean 3 I years). Thoracic symptoms such as dyspnea (n = 53), chest pain (n = 47), cough (n = 39), and superior vena cava syndrome (n = 35) were present in 78 patients; the other 24 patients were free of symptoms. Preoperative work-up was especially intended (I) to elucidate the nature of the lesion and its local extension and invasiveness" and (2) to investigate other possible sites of the disease. All patients underwent standard x-ray and tomographic examination of the chest until 1980, when computed tomography (CT) was included in the conventional preoperative roentgenologic work-up (40 patients); four patients also underwent pneumomediastinum and four magnetic resonance (MR) imaging. Types of operation are reported in Table I. Ninety-two patients were operated on at the first indication of disease; in six of them, two procedures were necessary to achieve the histologic diagnosis. The first operation was a chest wall biopsy for direct tumor infiltration under local anesthesia in four patients and a mediastinoscopy in two. Sixty-five patients had HD and 38 NHL.
691
The Journal of Thoracic and Cardiovascular Surgery
6 9 2 Ricci et al.
c Fig. 1. HD the thymus treated by locally radical resection. A, Standard posteroanterior chest x-ray film. B, CT demonstrates necrosis within the tumor and indicates the presence of cleavage planes with the surrounding ri,.ediastinal structures. C, resected specimen; the tumor is confined to the thymic gland, whose appearance and typical bilobated shape are maintained.
Table I. Operations performed in 102 patients (five needle aspirations not included) No.
Mediastinosccpy Thoracotomy Mediastinotomy Sternal splitting incision" Median sternotomy Minor biopsies High pretracheal node biopsyt Pretracheal tissue biopsyt Parasternal chest wall biopsy Subcutaneous biopsy of anterior chest wall Sternal biopsy Total
26 24 22 15 II
25 10 5 5 4 I 123
"Upper partial median sternotomy. t Thcsc patients were scheduled for mediastinoscopy. but the procedure was dis-
continued after sufficient histologic material was taken in the upper part of the mediastinum.
Overall, 104 biopsies, 14 (11 HD, 3 N HL) locally radical resections, and 5 (4 HD, 1 NHL) debulking resections (more than three fourths of the mass) were performed. Frozen sections were obtained in most cases, and the definitive histologic diagnosis was based on conventional histologic characteristics, histoenzymatic and immunohistochemical procedures on tissue specimens, and cell suspensions and electron microscopic studies in selected cases. Five specimens obtained by needle aspiration did not yield a precise diagnostic definition. When the tumor appeared resectable, cleavage planes were present on preoperative imaging, as demonstrated by the case reported in Fig. I, and no systemic foci of neoplastic proliferation were detectable, a major operation with radical intent was planned. All 14 patients treated by this approach are alive and free of disease I to 14 years after the operation. Postoperatively, seven patients underwent local radiotherapy alone, three radiotherapy alone plus splenectomy, three chemotherapy alone, and one radiotherapy plus chemotherapy; no toxicosity-related complications occurred and no recurrence of disease was observed. Three patients with HD undergoing debulking resection are alive and well after 5 to 11 years, and two with NHL
Volume 99 Number 4
Isolated mediastinal lymphoma
April 1990
Fig. 2. Restaging of isolated HD of the mediastinum after chemotherapy. A, CT reveals a mass in the anterior mediastinum infiltrating the surrounding structures. B, MR imaging: The presence of residual neoplastic tissue is suggested. No malignant disease was found at operation and no further therapy was administered. (CT: false positive; MR: false positive.) died 36 and 40 months postoperatively. The latter two patients had been operated on after unsuccessful chemotherapy that had been started in a periphery hospital because of a nonspecific diagnosis of lymphoma. Ten patients in whom the diagnosis had been obtained by mediastinal biopsy underwent surgical restaging of residual tissue occupying the mediastinium after therapy, with the aim of establishing whether it was residual disease or fibrosis. All patients in this group had undergone CT and four MR, but the accuracy of the two procedures was unsatisfactory (Figs. 2 and 3). Three patients had HD and seven had been treated for NHL by three courses of the F-MACHOP regimen." It has been demonstrated that patients with NHL who have residual disease after three courses of F-MACHOP will not respond to further
693
Fig. 3. Restaging of NHL of the mediastinum. A, CT imaging at presentation of disease. B, CT imaging after three courses of F-MACHOP. The residual mass was proved at operation to consist of fibrotic tissue. The last three courses of F-MACHOP were administered and the patient is free of disease after 26 months.
Table II No. of patients
Response
Result
Restaging of NHL after 3 courses of F-MACHOP* 6 Negative Completion F-MACHOP 1 4 Positive Change therapy Restaging of HD 1 Negative 2 Positive
N 0 further therapy 1 Died, 1 AWD
AWD, Alive with disease. 'No evidence of disease after 10 to 28 months.
treatment with the same regimen and thus require non-crossresistant alternative therapy." Therefore we have surgically restaged residual mediastinal masses of more than 2 ern on CT examination. As much abnormal tissue as possible was resected to rule out the presence of any residual neoplastic focus, but the
6 9 4 Ricci et al.
procedure was not intended for cure and was considered as a simplebiopsy. Thoracotomy was performed in one patient and a sternal splittingincision in six, the incision beingextended to total mediansternotomy in onepatientto controlbleeding from the internal mammary artery. Of the three patients with HD, one had a sternal splittingincision, one a median sternotomy, and onea mediastinotomy. The outcome of restaged NHL and HD is reported in Table II. One patient with relapsing HD died 3 days after anterior mediastinotomy because of massive hemoptysis that was not apparently related to the surgicalprocedure, and four had major complications (bleeding, heart rhythmdisturbances, phrenic nerveinjury, and wound infection).
Discussion The outcome of patients with lymphoproliferative disease has improved dramatically in recent years and the curability rate has reached 80% in HD3. 7 and 50% to 70% in NHL. 8,9 However, such good results may be obtained only if the histologic diagnosis, often difficult, is precise and the appropriate therapy is immediately started. The mediastinum is a frequent site of lymphoma." being involved in 50% to 60% of patients with HDlO, I J and in about 19% with NHL.12 If the disease does not appear in other organs, mediastinal biopsy is mandatory for definitive diagnosis. Direct fine needle aspiration biopsy has been proposed for this purpose, 13 but we use it only occasionally because of the insufficient histologic material supplied and the low but not insignificant risk entailed. Histologic diagnosis of lymphoproliferative diseases is based at our institution on histologic and immunohistochemical procedures that necessitate an amount of tissue that can be obtained only by open biopsy of the mediastinum through a route providing good control of the tumor and of the organs potentially involved. Despite this strategy, we were obliged in the early years of our experience to repeat the biopsy in six patients because of inadequacy of histologic material, thus exposing the patient to further discomfort and delaying medical therapy. It is important in our opinion that the surgical approach to isolated mediastinal lymphoma be intended primarily as the means to achieve a positive histologic diagnosis; multiple biopsy specimens should therefore be obtained from the tumor and the operation should be scheduled as a major surgical procedure providing good exposure of the lesion and sufficient control of mediastinal organs. In our experience, anterior parasternal mediastinotomy and mediastinoscopy were adequate to reach enlargled mediastinal lymph nodes or substernal lesions lower than the second or third intercostal space, and sternal splitting (partial median sternotomy) was suitable to control masses located behind the upper third of the sternum. The hitter is particularly indicated when larger tissue specimens are needed, especially after previous attempts have
The Journal of Thoracic and Cardiovascular Surgery
failed to provide a positive histologic diagnosis. We did not observe complications related to the impact of chemotherapy and radiotherapy on the healing sternum. Despite the availability of CT and MR, it is difficult to establish the differential diagnosis between lymphoma and other mediastinal tumors preoperatively'; although lymphoma, a typically systemic disease, may not be considered surgically curable, resection is the treatment of choice for other relatively frequent mediastinal lesions, especially thymoma. It is therefore necessary to select a surgical approach that is not preclusive in view of curative resection, after the extent of the tumor is directly evaluated and the histologic features are identified by frozen sections. For these reasons, we believe that mediastinoscopy and especially sternal splitting incisions are the most suitable operations when the diagnosis of an anterior mediastinal tumor is uncertain and the possibility of lymphoma exists. These operations allow direct evaluation of the position ofthe tumor and extension of the incision caudally to the xiphoid to achieve complete control of the mediastinum through median sternotomy. Posterolateral thoracotomy, often used in the past for biopsy and resection, is no longer in use in our department for mediastinallesions because of greater trauma and inadequacy to control possible great vessel involvement or extension of tumor on the contralateral aspect of the mediastinum. Anterior parasternal mediastinotomy is an excellent route for biopsy but lacks flexibility, because it does not allow the incision to be extended if wider exposure is necessary. Even though surgical resection does not represent by itself a curative solution to isolated mediastinallymphoma, an aggressive surgical approach may be indicated if preoperative imaging demonstrates resectable disease (Fig. 1) and no apparent systemic involvement is found. No deaths or complications occurred after radical or debulking resection. In addition, some of these patients with HD may be effectively treated by local postoperative radiotherapy alone with positive long-term results. Surgical restaging of mediastinal lymphoma after therapy presents particular technical problems. The marked reduction of the neoplastic bulk and the reactive fibrosis induced by chemotherapy and radiotherapy cause displacement and tight adhesions on mediastinal organs; in addition, the wall of the vessels is often fragile and stiff with no cleavage planes with the surrounding tissues. On the other hand, it is important to resect and examine as much tissue as possible to rule out any focus of neoplastic cells. In our experience, a sternal splitting incision was adequate to control the mediastinal vessels and the diseased tissue, and in only one patient with residual disease in the cardiophrenic angle did we perform an ante-
Volume 99 Number 4
Isolated mediastinal lymphoma 69 5
April 1990
rolateral thoracotomy in the sixth intercostal space. In addition, the partial sternotomy incision may be easily extended if wider exposure is required. If the treatment planning in patients with mediastinal lymphoma is to be reevaluated because the mediastinum is occupied by residual tissue for which the doubt of relapsing disease arises, noninvasive diagnostic techniques are inadequate to provide a positive answer and surgical restaging must be undertaken. A sternal splitting incision has been in our experience the most adequate route for exploration. REFERENCES 1. Ricci C, De Leo G, Bombi G, Mineo C. Chirurgia delle 10calizzazioni mediastiniche isolate del Morbo di Hodgkin. Minerva Chir 1973;28:469-78. 2. Mandelli F, Anselmo AP, Cartoni C, Cimino G, Maurizi ER, Biagini C. Evaluation of therapeutic modalities in the control of Hodgkin's disease. Int J Radiat Oncol BioIPhys 1986;12:1617-20. 3. Hellman S, Mauch P. Role of radiation therapy in the treatment of Hodgkin's disease. Cancer Treat Rep 1982; 66:915-23. 4. Guglielmi C, Amadori S, Ruco LP, et al. Combination chemotherapy for the treatment of diffuse aggressive Iym-
5.
6.
7. 8.
9.
10. 11. 12.
13.
phomas: F-MACHOP update. Semin Onco11987; 14(suppl 1):104-9. Yellin A, Pak HY, Burke JS, Benfield JR. Surgical management of lymphomas involving the chest. Ann Thorac Surg 1987;44:363-9. Rendina EA, Venuta F, Ceroni L, et al. Computed tomographic evaluation of anterior mediastinal neoplasms. Thorax 1988;43:441-5. HoppeRT. Radiation therapy in the treatment of Hodgkin's disease. Semin Oncol 1980;7:144-54. DeVita VT, Canellos GP, Chabner B, et al. Advanced diffuse histiocytic lymphoma, a potentially curable disease: results with combination chemotherapy. Lancet 1975; 1:248-50. Ricci C. Chirurgia radicale dei tumori del mediastino. Proceedings of the Twentieth Congress of the Italian Society for Thoracic Surgery. Rome: Seros, 1986:124-40. MacDonald JB. Lung involvement in Hodgkin's disease. Thorax 1977;32:664-7. Moran EM, Ultmann JE. Clinical features and course of Hodgkin's disease. Clin Haematol 1974;3:91-129. Manoharan A, Pitney WR, Schonell ME, Bader LV. Intrathoracic manifestations in non-Hodgkin's lymphoma. Thorax -1979;34:29-32. Sinner WN. Direct fine needle biopsy of anterior and middle mediastinal masses. Oncology 1985;42:92-6.