Forty-three of the 65 (66%) surveyed pulmonologists responded. Of these, 30 (70%) favored observation over invasive procedures; of those favoring an invasive procedure, 6 recommended transbronchial lung biopsy, and 2, mediastinoscopy. The remaining five respondents favored an invasive procedure or observation depending on particulars. Thus, about one third of respondents advocated an invasive procedure under some or all circumstances.
HerniaWhether clinically relevant ADs are invariably excluded in persons presenting with ABHL and normal results of physical examination (excluding uveitis and erythema nodosum) is a rhetorical question, answerable either in the negative or not at all. We attempted to resolve the observation vs biopsy controversy by redefining it in quantitative terms and employing explicit assumptions. Our findings are summarized in Figure 1. The risks and costs of mediastinoscopy far outweigh the benefit conferred by early diagnosis of SIS or AD: the likelihood of an AD in a patient presenting with ABHL is only 0.05%—a chance of 1 in 2,000; the risk of major complication of mediastinoscopy, 0.5%, is 10 times the likelihood of an AD; the benefit for SIS is intangible, and for AD, minimal; 12,200 mediastinoscopies in patients with ABHL would be required to prevent a single death from lymphoma at an estimated cost of $37 million. Our conclusion applies only to persons free of constitutional symptoms and with normal results of a physical examination as defined above. No categorical recommendation can be made for individuals with BHL not fitting this classification: the greater the divergence from a typical picture of SIS, the more clinical judgment will be required. It is worth pointing out that in the presence of peripheral lymphadenopathy, the issue of whether to take a biopsy specimen from the mediastinum is nullified, and in patients with lymphoma, extrathoracic physical findings are the rule.
Figure 1. Decision tree for ABHL.
Tags: cost/benefit, hilar adenopathy, Hodgkin’s disease, lymphoma, mediastinoscopy, risk/benefit, sarcoidosis, tuberculosis