Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis

Chest
J M ReichM J Edwards

Abstract

To determine whether persons with asymptomatic bilateral hilar lymphadenopathy (ABHL) and normal results of a physical examination should be observed with a presumptive diagnosis of stage 1 sarcoidosis (S1S) (ABHLps), its most frequent cause, or undergo mediastinoscopy to avoid overlooking an alternative diagnosis (AD) requiring treatment. We surveyed the English-language medical literature to estimate the proportion of persons with tuberculosis (TB), Hodgkin's disease (HD), and non-Hodgkin's lymphoma (NHL) who present with ABHL and calculated the number of mediastinoscopies required to identify each AD by computing the following ratio: incidence S1S/incidence of each AD presenting as ABHL (I(S1S)/I[ABHL-AD]). Risks of mediastinoscopy and benefits of earlier ascertainment of AD were derived from the published literature. Cost estimates were based on institutional charges. We conducted a regional survey of practicing pulmonologists to ascertain their diagnostic preferences. We estimate that if 33,000 persons with ABHL underwent mediastinoscopy, 32,982 (99.95%) would be found to have S1S or, very rarely, a disorder not requiring intervention; 407 would require hospitalization for complications at a cost in excess of $1 million; a...Continue Reading

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