Mediastinoscopy in Patients With Presumptive Stage I Sarcoidosis: Non-Hodgkin s Lymphoma
Non-Hodgkin s Lymphoma: Low-grade NHLs, which constitute 40% of cases, are widely disseminated and incurable in 90% of patients. Prognosis in patients with intermediate and high-grade (aggressive) NHL (60%) is correlated with early stage at diagnosis, age younger than 60 years, high performance status, and normal lactate dehydrogenase values, and is curable in half. In contrast to HD, NHL is rarely asymptomatic: among 215 cases reported by Levitt et al, 12 (6%) had disease limited to the mediastinum (with an anterior mediastinal mass) and immediate surrounding structures; in all but 1 (0.5%), there was extensive contiguous extran-odal spread. All presented with symptoms (cough, chest pain, superior vena cava obstruction) of brief duration (average, 3 weeks). In a review of 1,269 cases at Stanford, 3.2% had disease limited to the mediastinum at presentation; “an occasional patient was asymptomatic.
The incidence of NHL at age 20 to 40 years is 2.1X10~D, slightly more than half that of HD. Available information does not permit an estimate of how often BHL-NHL is asymptomatic. Assuming that symptoms in persons with BHL-NHL are five times more likely than with BHL-HD, and the proportion of persons with isolated hilar adenopathy due to NHL is the same as in HD and is bilateral in 25% of cases, the proportion of ABHL-NHL is 0.08X0.03X0.09X0.25=5.4X10.
Iabhl-nhlIs: (2.1X10 )(5.4X 10 °)=11.3X10
WIabhl-nhl is: 3.7X 10-/11.3X 10- = 3.3X 104
To identify one patient with NHL, 33,000 persons with ABHL would require mediastinoscopy—four times the estimated annual US rate of SIS—at a cost of $98 million; 165 persons would experience major morbidity; 330 would require hospitalization at a cost of $729,000.
Risk and Cost Assessment
Mediastinoscopy: The published literature may underestimate the morbidity/mortality of this procedure, which is highly dependent on the experience and skill of the operator, because institutions with a large and favorable experience are more likely to report (these considerations apply equally to trans-bronchial biopsy). Based on a meta-analysis of 16,895 reported procedures, we found the following: the total complications ranged from 1.4 to 2.3% (median, 2%); major complications/deaths ranged from 0 to 1% (median, 0.5%/no deaths); and minor complications ranged from 1 to 2% (median, 1.8%). Under the assumption that the lesser experience of surgeons in community settings will be offset by the better general health of younger patients presenting with ABHL, we estimate the following: 2% complication rate of any type including recurrent laryngeal nerve paralysis; 0.5% complication rate (pneumothorax, bleeding, cardiac arrhythmia) requiring hospitalization (assumed to be in a critical care unit for 24 h at a unit charge of $2,210); and an additional major morbidity rate of 0.5% at the same charge. We excluded the following from the cost computation: medications, tests, respiratory procedures, and professional charges. Also excluded were hospital room charges beyond 1 day and surgical charges for major complications such as mediastinal bleeding and tracheal or esophageal tear requiring mediastinotomy or thoracotomy for repair. The aggregate charge for mediastinoscopy is $3,066 (Kaiser Permanente) and $6,398 (Blue Cross Blue Shield); for 33,000 procedures, it is $101 to $211 million.