Experiences with retroclavian lymph node biopsy in the diagnosis of certain intrathoracic diseases.

Abstract

The accurate diagnosis of intrathoracic diseases is sometimes difficult. When ordinary routine examination methods fail, differentiation often requires biopsy of enlarged superficial lymph nodes. For cases in which no such nodes can be found Daniels (1949) recommended the histological examination of lymph nodes from the mass of fatty tissue between the M. sternocleidomastoideus and the M. scalenus anterior. These nodes forming part of the mediastinal lymphatic system. He reported five cases: a diagnosis of Boecks sarcoid was established in two, carcinoma in two and silicosis in one. He points out that in one with cancer a major operation was prevented and that, in the other a major exploration of the lung would not have been necessary if biopsy had been carried out first. In 1951 Weiss and alii reported a case of pulmonary sarcoidosis in which a clinical impression of sarcoidosis was confirmed by the method of Daniels. Stimulated by these reports which seem not to have been duly appreciated, and convinced that the chance of getting informative material would be great even in cases in which no lymph nodes could be felt when the subclavicular region was exposed and the above mentioned fat pad explored, we have tried this procedure since January 1952 in a series of 56 cases. In all of them the clinical and/or roentgenological pictures suggested pulmonary or mediastinal disease but the diagnosis was not established with certainty. In none of them could enlarged lymph nodes be found, despite careful palpation. Sometimes preoperative palpation gave the impression of an enlarged lymph node in the supraclavicular space close to the lateral border of the sternocleidomastoideus muscle, but exploration showed the supposed node to be the lateral part of the omohyoideus muscle. The surgical technique is simple and the procedure takes only 10 to 15 minutes. In local anaesthesia an incision of 3 to 4 cm. is made on the side of the lesion or, if both sides are equally ihvolved, the right side about two fingerbreads over and paralleling the clavicle through the skin and the platysma. The lateral border of the sternocleidomastoideus muscle may be devided. This muscle is retracted medially and the fat pad on the anterior surface of the scalenus anterior muscle thereby exposed. This space is crossed by the inferior thyroid and transverse cervical vessels and is bordered by the subclavian and internal jugular veins, the omohyoid and scalenus anterior muscles. The phrenic nerve and-on the left sidethe thoracic ducton the right side-the right lymphatic duct are to be considered. Care should be taken to avoid injuring these structures. This