Mediastinoscopy in Patients With Presumptive Stage I Sarcoidosis: Results
Unspecified Lymphoma: Among 100 consecutive cases of lymphoma reported from the Mayo Clinic, 9 had BHL; how often it was an isolated finding was not stated. All were “ill of serious progressive disease and all had obvious extrathoracic disease, most often palpable lymph nodes. Of 212 patients with lymphomas described by Winterbauer et al, only 1, who had constitutional symptoms, presented with BHL unaccompanied by extrathoracic abnormalities on physical examination. Because of their diversity with respect to major clinical features, we analyzed HD and NHL separately.
Hodgkins Disease: The most common malignancy in young adults has a bimodal age distribution, the earlier peak of which overlaps the peak age incidence of sarcoidosis. It frequently presents as regional disease and is often curable; prognosis is adversely affected by increasing number of lymph node regions involved and the presence of “B symptoms”— ie, fever, night sweats, or weight loss. In a CT analysis of 77 patients with intrathoracic HD, the authors found an orderly pattern of lymphatic spread, retrograde and contiguous, invariably originating in the anterior mediastinal/paratracheal area. Johnson et al reported on 1,470 patients with HD: 41% were asymptomatic; 44 (3%) had isolated mediastinal involvement, of whom 40 (91%) had an anterior mediastinal mass. The presentation of the data lacks sufficient detail to ascertain how many of the four patients (0.27%) free of anterior mediastinal involvement exhibited isolated hilar nodal involvement. Kaplan reported on 426 patients with HD: the percent who were asymptomatic was not provided; 7 (1.6%) had isolated mediastinal involvement, 6 (86%) of whom had an anterior mediastinal mass; none presented with isolated BHL (95% Cl: 0, 0.7%). Stein reported no cases of HD in which involvement was limited to BHL. The number of cases reviewed was not specified. Based on the Johnson et al study, and assuming that all four cases with hilar adenopathy were free of other thoracic involvement and the likelihood of B symptoms is independent of the site of involvement, the proportion of persons with HD exhibiting isolated asymptomatic hilar adenopathy is as follows: 0.41X0.03X0.09=1.1 X10-3. Hilar adenopathy in HD is characteristically unilateral; we assumed bilaterality in 25%, 2.8X10-4. The incidence of HD at age 20 to 40 years is 3.7X10-5
Iabhl-hd is: (2.8X 10)(3.7X 10) = 10.4X 10
WIabhl-hd is: 3.7X 10/10.4X 10 = 3.6X 103
To identify one case of stage IIA HD mimicking BHLps, 3,600 patients with ABHL would have to undergo mediastinoscopy at a cost of $10.8 million; 18 persons would experience major morbidity; 36 persons would require hospitalization at a cost of $80,000.