What Is a Mediastinoscopy?

A mediastinoscopy is a procedure performed in the operating room under general anesthesia in which a narrow scope (called a mediastinoscope) is inserted through the chest wall to examine the area between the lungs known as the mediastinum. It is commonly used to help determine the stage of lung cancer, but it may also be used to help diagnose or treat other types of cancers or diseases involving the mediastinum or organs within it.

Purpose of Test

Mediastinoscopy has been used for lung diseases since the 1950s. Today, it is done less often today than modern imaging options, like positron emission tomography (PET) scans and endobronchial ultrasounds, as they are not only less invasive but very accurate.

Even so, mediastinoscopy still has its place in the diagnosis and staging of lung cancer. These are, in fact, the most common reasons the procedure is performed.

More specifically, mediastinoscopy is used for three purposes in lung cancer:

• To determine whether lymph nodes are affected by the primary (original) tumor
• To biopsy suspected tumors by extracting a sample of tissue (confirming the presence of cancer cells and identifying the type of cancer involved)
• To remove a mediastinal mass and enlarged lymph nodes

But lung cancer is not the only disease that can affect the mediastinum—the space between the breastbone and lungs that houses the heart, esophagus, trachea, thymus gland, thyroid gland, blood vessels, and mediastinal lymph nodes.

Mediastinoscopy can also be used to diagnose or treat other conditions involving this part of the body, including:

• Aneurysms of mediastinal blood vessels
• Benign cysts
• Esophageal cancer
• Hodgkin and non-Hodgkin lymphoma
• Mesothelioma
• Neurogenic tumors (a type of tumor that develops in nerve cells)
• Sarcoidosis
• Thyroid tumors
• Tuberculosis

Mediastinoscopy is highly accurate, with a specificity of 100% and sensitivity of over 90%. By contrast, a PET scan has a specificity and sensitivity of 90% and 86% respectively, making it a highly competitive option.

The combination of endobronchial ultrasound and bronchoscopy (used to biopsy tissue within the airways) can also replace the need for a mediastinoscopy.

Risks and Contraindications

As with any surgical procedure, there are risks associated with mediastinoscopy.

Though uncommon, mediastinoscopy can cause:

• Adverse reaction to anesthesia
• Blood vessel or lung perforation
• Laryngeal nerve injury
• Pneumonia
• Pneumothorax (collapsed lung)
• Postoperative bleeding
• Post-surgical infections
• Pulmonary embolism
• Stroke (if there is compression of the innominate artery that supplies blood to the right arm and the head and neck)

There are circumstances in which mediastinoscopy is contraindicated due to the increased risk of these and other complications. Such contraindications include:

• Inoperable tumors
• Ascending aortic aneurysm
• Extreme frailty or debilitation
• Previous recurrent laryngeal nerve injury
• Previous mediastinoscopy (due to possible complications from scarring)

Although not absolutely contraindicated, mediastinoscopy should ideally be avoided in people with superior vena cava (SVC) syndrome or those who have undergone extensive chest radiation.

PET scans can generally be used as an alternative if mediastinoscopy is not possible.

Before the Test

Before ordering the procedure, your healthcare provider will talk with you about the risks associated with mediastinoscopy and what they expect to learn by doing the test. The healthcare provider will also review your medical history and do a physical exam to ensure there are no contraindications to the procedure.

If you have an automatic implantable heart defibrillator, hospitals will usually require you to get a clearance letter from your cardiologist before a mediastinoscopy is performed.

Do not hesitate to ask as many questions as you need to make an informed choice. If mediastinoscopy is recommended, ask if other less invasive procedures may be possible and, if not, why.

Timing

Not including pre-examination and recovery time, a mediastinoscopy can usually be completed in 60 to 75 minutes. It generally takes 45 to 60 minutes to awaken from general anesthesia and about an hour or two more before you are able to get up and dress.

Even though mediastinoscopy is usually performed as an outpatient procedure, you will need to clear the entire day for the procedure plus a couple of days more for recovery.

Location

A mediastinoscopy is performed in an operating room in a hospital.

What to Wear

As you will be asked to undress and put on a hospital gown, wear something comfortable that you can easily remove and put back on. Leave jewelry, hairpieces, or any non-essential items at home.

A locked or secure storage area will be provided to safeguard anything you bring to the hospital.

Food and Drink

You will be asked to stop eating anything, including gum or candy, after midnight the night before the procedure. Up until two hours before your arrival at the hospital, you are allowed to drink a total of 12 fluid ounces of water. After that, you cannot eat or drink anything, including water.

Your healthcare provider will also advise you to stop certain medications that can interfere with blood clotting and lead to excessive bleeding. You would need to stop the following drugs several days in advance of the procedure:

• Ten days beforehand, stop taking vitamin E.
• Seven days beforehand, stop taking aspirin and any herbal remedies, including echinacea, ephedra, garlic, ginger, ginkgo, ginseng, green tea, kava, saw palmetto, St John's wort, and valerian.
• Five days beforehand, stop taking anticoagulants (blood thinners) like Coumadin (warfarin), Plavix (clopidogrel), and Xarelto (rivaroxaban).
• Two days beforehand, stop taking nonsteroidal anti-inflammatory drugs (NSAIDs) like Aleve (naproxen) and Advil or Motrin (ibuprofen).

If you take insulin or diabetes medication, let your healthcare provider know. The dose may need to be adjusted on the morning of the procedure.

Cost and Insurance

As a surgical procedure, a mediastinoscopy is expensive. Depending on your location and the hospital you use, the cost can easily approach or exceed $20,000.

If you have health insurance and the procedure is medically indicated, your carrier should cover some of the expense of a mediastinoscopy. To estimate your out-of-pocket expenses, look at the copay or coinsurance terms in your policy before and after you meet your deductible.

Also, check your out-of-pocket maximum. This is the most you have to pay out of pocket for the policy year, after which all approved treatments are covered 100%.

A mediastinoscopy almost invariably requires prior authorization from your insurer. Make sure approval has been received before proceeding with the procedure. If it hasn't, ask your surgeon to contact your insurer immediately. If approval is not received, you could possibly be faced with having to pay the full bill.

To further reduce costs, only use in-network providers. These are healthcare providers and facilities that are contracted with your insurance company to provide services at a preset fee. Make sure the entire team is in-network, including the hospital and anesthesiologist, each of whom bill individually.

What to Bring

Be sure to bring your insurance card, a driver's license or another official form of identification, and an approved form of payment if needed. (Most hospitals, surgeons, and anesthesiologists will bill directly.)

During the Test

Upon arrival, you will be asked to confirm your insurance and personal information and signed a consent form stating that you understand what the procedure is used for and the risks involved. You will also be provided a medical questionnaire to detail any medications you take and recent or past illnesses or surgical procedures you've had.

Try to arrive no later than 30 minutes before your scheduled appointment to complete these forms.

Either a cardiothoracic surgeon or general surgeon can perform a mediastinoscopy. An anesthesiologist and operating room support staff will also be on hand.

Pre-Test

Once the necessary documents are filled out, you will be led to a changing room and offered a hospital gown to change into. You may be provided slipper socks or allowed to keep your own socks on. You should remove any piercings, contacts, eyewear, dentures, or hearing aids and store them in the designated secure area.

You will then be led to a preoperative room or cubicle to have your blood pressure, pulse, temperature, and weight taken and recorded by a nurse. The nurse will also need to confirm that you have not eaten, have stopped taking the requested medications, and have no symptoms that may contraindicate the procedure. Special attention is paid to respiratory symptoms such as shortness of breath and wheezing.

An anesthesiologist will also arrive to verify whether you have any drug allergies or have reacted adversely to any form of anesthesia in the past. Be sure to ask any questions or share any concerns you have with the anesthesiologist. You may see the surgeon beforehand, although it is more likely you will do so once you enter the operating room.

An intravenous (IV) line will be inserted into a vein in your arm and probes placed on your chest to connect to an electrocardiogram (ECG) machine used to monitor your heart rate. You will then be wheeled into the operating room.

Throughout the Procedure

Once in the operating room, you will be transferred to an operating table and connected to the ECG machine. Your blood oxygen levels will be measured with a pulse oximeter that clamps onto your finger.

General anesthesia most commonly involves both inhaled and IV agents. Once anesthesia is injected into the IV line and you are asleep, you will be intubated. Intubation involves inserting a tube into your mouth and trachea to keep the airway open to deliver oxygen, medicine, or anesthesia. A muscle relaxant will also be injected to prevent sudden movements during the operation.

The surgeon will then make a small incision just above the sternum (breastbone) and introduce the mediastinoscope through the opening. This is a long, thin, flexible tube with a fiberoptic light cable.

In addition to checking for masses or enlarged lymph nodes, the surgeon can also obtain tissue samples by inserting a narrow biopsy forceps through the same opening.

After removing the mediastinoscope, a few stitches or adhesive strips will be applied to close the incision. A small gauze dressing will be placed to cover the wound. The anesthesiologist will also remove the breathing tube before you are wheeled to the post-anesthesia care unit (PACU).

After the Test

When you awaken in PACU, you will be drowsy for a while from the anesthesia. You may have some discomfort from the incision, and it is not uncommon to experience hoarseness and a mild sore throat from the intubation.

You may also be provided oxygen through a thin tube that rests below the nose called a nasal cannula. Food and drink will also be given.

To ensure that your lungs are unharmed and haven't collapsed, a chest X-ray will be taken after the surgery. Mobile chest X-ray machines are now used in many hospitals so that you don't have to be wheeled to a separate radiology unit.

Until your vital signs are normalized, the nursing staff will keep you under monitored care. You will only be released when the chest X-ray is clear and the staff is sure that you have means to return home safely, as the effects of the anesthesia can last for several hours.

Managing Side Effects

Once at home, you will be asked to take it easy and avoid harm by:

• Lifting no more than five to 10 pounds
• Limiting strenuous activity
• Taking pain medication, such as Tylenol (acetaminophen), as directed by your healthcare provider
• Returning to work and driving a car only when your healthcare provider says that it's OK

If you develop a high fever, chills, and/or increased redness, swelling, pain, or drainage from the wound, call your healthcare provider immediately. While uncommon, post-surgical infection can occur.

Interpreting Results

Following a mediastinoscopy, your healthcare provider will set up an appointment to discuss the results. If a biopsy was taken during your procedure, it usually takes five to seven days for the lab to return a report.

With lung cancer, the result of your mediastinoscopy can either determine if you have cancer or provide important information in determining the stage of your cancer.

If the purpose of the test was to check suspicious findings, the report will offer details about any masses or enlarged lymph nodes that were found. The primary findings are generally categorized as being either:

• Negative, meaning the biopsy did not find any abnormal cells
• Positive, meaning that abnormal cells were found

It is important to remember that not all abnormal cells are cancer. There may be other causes for the abnormalities that have not been diagnosed, such as sarcoidosis or tuberculosis. If cancer cells are found, the lab report will say so.

If the purpose of the test was to stage cancer, the report will detail if any cancer cells were found in the lymph nodes and/or what the characteristic of the primary tumor are.

The lab pathologist may also be able to grade the tumor from 1 to 4, which helps predict how slowly or aggressively the cancer will spread based on the characteristics of the cells.

If you don't understand what the findings mean for you, ask your healthcare provider.

Follow-Up

If you have lung cancer, you may be referred to one or more cancer specialists for further testing, including a medical oncologist, radiation oncologist, or surgical oncologist.

Other evaluations may be needed, including a PET/CT scan to ascertain if lung cancer has spread (metastasized) to distant parts of the body. This and other tests can provide the information needed to develop the best treatment plan for you.

Possible treatments include more surgery, chemotherapy, radiation therapy, immunotherapy, and targeted therapies.

A Word From Verywell

Mediastinoscopy is a valuable tool in the detection and staging of cancer but one that ultimately has risks you need to consider seriously. In the end, mediastinoscopy involves surgery no matter how "minor" it may seem.

If your healthcare provider has recommended a mediastinoscopy, talk about possible alternatives. There may be good reasons for this test, but the increased accuracy of less risky options often make them equally viable for some people.