- Email: [email protected]
COMBINED SCALENE FAT PAD BIOPSY AND BRONCHOSCOPY
COMBINED SCALENE FAT P A D BIOPSY
AND
BRONCHOSCOPY Its Value in Suspected Bronchogenic Carcinoma Robert W. Jamplis, M.D., William Glen A. Lillington,
Mills, Jr., M.D., and
M.D., Palo Alto, Calif.
T
HE diagnostic value of biopsy of lower, deep jugular (scalene) lymph nodes was first demonstrated by Daniels 1 in 1949 and has since been amply con firmed by others. When the nodes are clinically palpable, biopsy will provide a pathologic diagnosis in almost all cases,2 and this procedure has become com mon practice. Biopsy of the scalene fat pad when the lymph nodes are not clinically palpable is performed much less commonly, yet it frequently yields a definitive tissue diagnosis.2 It is our present practice to perform this biopsy in conjunction with bronchoscopy in almost all cases of suspected bronchogenic carcinoma, whether supraclavicular lymph nodes are palpable or not. This paper presents an analysis of the cases in which this combined procedure was performed. METHOD
The combined procedure is done using either general or local anesthesia. Bronchoscopy is performed in the usual manner, with endoscopic biopsy of ab normal appearing bronchial mucosa and the collection of bronchial secretions for cytologic study. The supraclavicular area on the appropriate side is then draped after sterile preparation, with the head turned toward the unoperated side, and the shoulder on the operated side pulled downward so as to put the neck structures under tension. An incision through skin and platysma is made about an inch above and parallel to the clavicle, starting over the lateral por tion of the sternoeleidomastoid muscle and extending laterally about 2 inches (Fig. 1). The investing layer of deep cervical fascia is incised longitudinally along the lateral border of the sternoeleidomastoid muscle. This allows that muscle and the internal jugular vein, which presents just beneath it, to be re tracted medially. The external jugular vein is retracted laterally and the omohyoid muscle either laterally or superiorly. This exposes the fat pad over lying the scalenus anticus muscle. When the fascia overlying this is incised, the fat bulges up into the wound and can then be easily grasped with several From the Palo Alto Clinic, Palo Alto, Calif. Received for publication Aug. 18, 1961. 27
28 ^°
JAMPLIS, MILLS, LILLINGTON ' '
J. Thoracic arrd Cardiovas. Surg.
Allis forceps. The dissection of this fat pad is accomplished en bloc with all its nodes from an area bounded medially by the internal jugular vein, su periorly by the omohyoid muscle, and inferiorly by the clavicle and subclavian vein. The lateral border is indefinite, but should extend out at least as far as the external jugular vein can be retracted. On the left, one must be cautious to avoid injuring the thoracic duct. With the index finger one can explore beneath the clavicle, down toward the mediastinum and, often, an individual node can be brought up. Care must be taken to avoid entering the pleura. Before the wound is closed, complete hemostasis is effected. No drains are used and no attempt is made to repair the deep fascia. A dry elastoplast dressing is applied and the patient usually leaves the hospital the following day.
P i g . 1. RESULTS
Scalene fat pad biopsy was performed at the time of bronchoscopy in 61 patients. In 45 patients the presumptive preoperative diagnosis was broncho genic carcinoma. In the other 16 patients, the combined procedure was done for a variety of reasons, most commonly to determine if sarcoidosis was present, but in no instance, was bronchogenic carcinoma the suspected diagnosis. The final diagnosis and the results of node biopsy in these 16 cases are given in Table I. The nodal biopsy established the diagnosis in 8 cases (50 per cent). The bronchial biopsy was positive in one patient (with sarcoidosis) and negative in the other 15. All 45 patients with a preoperative diagnosis of "suspected bronchogenic
Vol. 44, No. 1
SCALENE FAT PAD BIOPSY A N D BRONCHOSCOPY
29
July, 1962
°
carcinoma" (Table II) had clinical and radiographic evidence strongly sug gesting this diagnosis. The average age was 57.4 years (range 40-82); 36 were male and 9 were female. In no instance were the supraclavicular lymph nodes clinically enlarged or palpable. TABLE I.
RESULTS OP COMBINED PROCEDURE IN 16 P A T I E N T S N O T SUSPECTED OF HAVING BRONCHOGENIC CARCINOMA
FINAL DIAGNOSIS
1
NODES POSITIVE
Sarcoidosis Malignant lymphoma Indeterminate Miscellaneous TABLE I I .
F I N A L DIAGNOSIS
|
NODES NEGATIVE
5 2 0 1 IN
45 P A T I E N T S
WITH
2 0 3 3 SUSPECTED BRONCHOGENIC
Subsequently proved bronchogenic carcinoma Other diseases Pneumonia Lung abscess Tuberculosis Metastatic carcinoma Indeterminate lesion
33 12 3 2 1 2 4
CARCINOMA
cases cases cases cases case cases cases
A further analysis of the studies in 33 patients, finally proved to have bronchogenic carcinoma, is presented in Table III. Significantly, in 5 of the 10 patients with positive scalene nodes, bronchoscopy and sputum studies had failed to reveal evidence of tumor. TABLE I I I .
R E S U L T S OF COMBINED PROCEDURE I N 33 CASES OF PROVED CARCINOMA
Scalene lymph nodes positive Scalene lymph nodes negative Bronchoscopy positive Bronchoscopy negative Cytology positive Cytology negative or inconclusive Cytology not studied
BRONCHOGENIC
10 23 13 20 7 24 2
cases cases cases cases cases cases cases
Right scalene fat pad biopsy was performed in 26 cases, whereas left scalene fat pad biopsy was performed in 7 cases. Because of the lymphatic drainage, the biopsy was done on the left side only when the pulmonary lesion was situated in the left upper lobe. The relationship of the results of the scalene fat pad biopsy to the radiographic appearance and histologic types of the pulmonary lesions in the 33 cases of proved bronchogenic carcinoma was studied. As the number of cases in the subgroups was small, no clear patterns were discernible. The results were compatible with the observation of Beahrs and associates2 that squamous cell carcinomas uncommonly metastasize to the jugular lymph nodes. DISCUSSION
Biopsy of nonpalpable scalene lymph nodes in patients with proved or suspected bronchogenic carcinoma has diagnostic value, prognostic significance,
30
JAMPLIS, MILLS, LILLINGTON
J. Thoracic and Cardiovas. Surg.
and therapeutic implications. Often the diagnostic nodes were small but many times they were large but could not be palpated because of the overlying heavy sternocleidomastoid muscle. In cases in which the diagnosis of bronchogenic carcinoma has already been established, a positive scalene node biopsy is prima-facie evidence of extrathoracic spread. In our opinion this indicates incurability and is a contraindi cation to thoracotomy. Furthermore, when the scalene lymph nodes are in volved with tumor, the likelihood of the lesion being resectable may fall well below 50 per cent. A recent study by Pinkers and Lawrence 3 indicates that pulmonary resection under these circumstances would rarely have palliative value. We have obtained excellent palliation with irradiation and only rarely does pulmonary suppuration develop. In the 33 patients with bronchogenic carcinoma in the present series, the supraclavicular lymph nodes were not palpable and the clinical course and roentgenographic appearance of the chest did not in itself suggest unresectability in any case. ■ The routine use of scalene node biopsy averted an unnecessary thoracotomy in 10 of these patients (30 per cent). For this reason, we believe that thoracotomy should not be performed in a patient with suspected or proved bronchogenic carcinoma unless the scalene lymph nodes have been biopsied and found to be free of tumor. The scalene fat pad biopsy should be done even if the nodes are not palpable. We recognize one expection to the rule of performing the combined pro cedure in all patients with suspected bronchogenic carcinoma. Both bronchoscopy and scalene node biopsy will be negative in most patients with a solitary circumscribed nodule in one lung. It is our practice to proceed directly with exploratory thoracotomy when the benign nature of the " c o i n " lesion cannot be established with reasonable certainty by the usual criteria. 6 Performance of scalene fat pad biopsy at the time of bronchoscopy, rather than as two separate procedures several days apart, has obvious time and finan cial advantages and minimizes the anesthetic risk. The procedure carries little hazard and we have had no complications. SUMMARY
Scalene fat pad biopsy in conjunction with bronchoscopy was performed in 61 patients, in 19 of whom the scalene biopsy proved diagnostic. In 45 pa tients bronchogenic carcinoma was suspected, and this diagnosis was ultimately established in 33. The supraclavicular lymph nodes had not been clinically palpable in any of these 45 patients. The biopsied scalene nodes contained tumor in 10 (30 per cent) of the 33 patients with proved bronchogenic car cinoma. It is concluded that scalene fat pad biopsy should be done prior to thora cotomy in all patients with proved or suspected bronchogenic carcinoma, whether or not the supraclavicular lymph nodes are clinically palpable. The one ex ception is the presence of a solitary " c o i n " lesion not demonstrably benign, in which case thoracotomy must be done. Performance of the scalene node biopsy at the time of bronchoscopy has certain practical advantages.
Vol. 44, No. 1 July, 1962
SCALENE FAT PAD BIOPSY A N D BRONCHOSCOPY
31 °
REFERENCES 1. Daniels, A. C.: Method of Biopsy Useful in Diagnosing Certain Intrathoracic Diseases, Dis. Chest 16: 360-366, 1949. 2. Beahrs, O. H., Hunt, O. R., Jr., Storsteen, O. M., and Bernatz, P . E . : The Value of Biopsy of Lower Deep Jugular (Scalene) Nodes as a Diagnostic Procedure, Minnesota Med. 40: 152-155, 1957. 3. Pinkers, L. H., and Lawrence, G. H . : Does Carcinomatous Scalene Node Contraindicate Pulmonary Resection? Dis. Chest 38: 516-518, 1960. 4. Skinner, E. F., Hall, J., Carr, D., and Robbins, S.: Routine Supraclavicular Biopsy in Suspected Bronchogenic Carcinoma, Am. Suigeon 2 1 : 590, 1955. 5. Jamplis, R. W., Hecker, S. P., McNeill, J . I., Mitchell, S. P., North, F . S., and Weigen, J . F . : Circumscribed Pulmonary Lesions, Minnesota Med. 42: 1811, 1959.
AND
BRONCHOSCOPY Its Value in Suspected Bronchogenic Carcinoma Robert W. Jamplis, M.D., William Glen A. Lillington,
Mills, Jr., M.D., and
M.D., Palo Alto, Calif.
T
HE diagnostic value of biopsy of lower, deep jugular (scalene) lymph nodes was first demonstrated by Daniels 1 in 1949 and has since been amply con firmed by others. When the nodes are clinically palpable, biopsy will provide a pathologic diagnosis in almost all cases,2 and this procedure has become com mon practice. Biopsy of the scalene fat pad when the lymph nodes are not clinically palpable is performed much less commonly, yet it frequently yields a definitive tissue diagnosis.2 It is our present practice to perform this biopsy in conjunction with bronchoscopy in almost all cases of suspected bronchogenic carcinoma, whether supraclavicular lymph nodes are palpable or not. This paper presents an analysis of the cases in which this combined procedure was performed. METHOD
The combined procedure is done using either general or local anesthesia. Bronchoscopy is performed in the usual manner, with endoscopic biopsy of ab normal appearing bronchial mucosa and the collection of bronchial secretions for cytologic study. The supraclavicular area on the appropriate side is then draped after sterile preparation, with the head turned toward the unoperated side, and the shoulder on the operated side pulled downward so as to put the neck structures under tension. An incision through skin and platysma is made about an inch above and parallel to the clavicle, starting over the lateral por tion of the sternoeleidomastoid muscle and extending laterally about 2 inches (Fig. 1). The investing layer of deep cervical fascia is incised longitudinally along the lateral border of the sternoeleidomastoid muscle. This allows that muscle and the internal jugular vein, which presents just beneath it, to be re tracted medially. The external jugular vein is retracted laterally and the omohyoid muscle either laterally or superiorly. This exposes the fat pad over lying the scalenus anticus muscle. When the fascia overlying this is incised, the fat bulges up into the wound and can then be easily grasped with several From the Palo Alto Clinic, Palo Alto, Calif. Received for publication Aug. 18, 1961. 27
28 ^°
JAMPLIS, MILLS, LILLINGTON ' '
J. Thoracic arrd Cardiovas. Surg.
Allis forceps. The dissection of this fat pad is accomplished en bloc with all its nodes from an area bounded medially by the internal jugular vein, su periorly by the omohyoid muscle, and inferiorly by the clavicle and subclavian vein. The lateral border is indefinite, but should extend out at least as far as the external jugular vein can be retracted. On the left, one must be cautious to avoid injuring the thoracic duct. With the index finger one can explore beneath the clavicle, down toward the mediastinum and, often, an individual node can be brought up. Care must be taken to avoid entering the pleura. Before the wound is closed, complete hemostasis is effected. No drains are used and no attempt is made to repair the deep fascia. A dry elastoplast dressing is applied and the patient usually leaves the hospital the following day.
P i g . 1. RESULTS
Scalene fat pad biopsy was performed at the time of bronchoscopy in 61 patients. In 45 patients the presumptive preoperative diagnosis was broncho genic carcinoma. In the other 16 patients, the combined procedure was done for a variety of reasons, most commonly to determine if sarcoidosis was present, but in no instance, was bronchogenic carcinoma the suspected diagnosis. The final diagnosis and the results of node biopsy in these 16 cases are given in Table I. The nodal biopsy established the diagnosis in 8 cases (50 per cent). The bronchial biopsy was positive in one patient (with sarcoidosis) and negative in the other 15. All 45 patients with a preoperative diagnosis of "suspected bronchogenic
Vol. 44, No. 1
SCALENE FAT PAD BIOPSY A N D BRONCHOSCOPY
29
July, 1962
°
carcinoma" (Table II) had clinical and radiographic evidence strongly sug gesting this diagnosis. The average age was 57.4 years (range 40-82); 36 were male and 9 were female. In no instance were the supraclavicular lymph nodes clinically enlarged or palpable. TABLE I.
RESULTS OP COMBINED PROCEDURE IN 16 P A T I E N T S N O T SUSPECTED OF HAVING BRONCHOGENIC CARCINOMA
FINAL DIAGNOSIS
1
NODES POSITIVE
Sarcoidosis Malignant lymphoma Indeterminate Miscellaneous TABLE I I .
F I N A L DIAGNOSIS
|
NODES NEGATIVE
5 2 0 1 IN
45 P A T I E N T S
WITH
2 0 3 3 SUSPECTED BRONCHOGENIC
Subsequently proved bronchogenic carcinoma Other diseases Pneumonia Lung abscess Tuberculosis Metastatic carcinoma Indeterminate lesion
33 12 3 2 1 2 4
CARCINOMA
cases cases cases cases case cases cases
A further analysis of the studies in 33 patients, finally proved to have bronchogenic carcinoma, is presented in Table III. Significantly, in 5 of the 10 patients with positive scalene nodes, bronchoscopy and sputum studies had failed to reveal evidence of tumor. TABLE I I I .
R E S U L T S OF COMBINED PROCEDURE I N 33 CASES OF PROVED CARCINOMA
Scalene lymph nodes positive Scalene lymph nodes negative Bronchoscopy positive Bronchoscopy negative Cytology positive Cytology negative or inconclusive Cytology not studied
BRONCHOGENIC
10 23 13 20 7 24 2
cases cases cases cases cases cases cases
Right scalene fat pad biopsy was performed in 26 cases, whereas left scalene fat pad biopsy was performed in 7 cases. Because of the lymphatic drainage, the biopsy was done on the left side only when the pulmonary lesion was situated in the left upper lobe. The relationship of the results of the scalene fat pad biopsy to the radiographic appearance and histologic types of the pulmonary lesions in the 33 cases of proved bronchogenic carcinoma was studied. As the number of cases in the subgroups was small, no clear patterns were discernible. The results were compatible with the observation of Beahrs and associates2 that squamous cell carcinomas uncommonly metastasize to the jugular lymph nodes. DISCUSSION
Biopsy of nonpalpable scalene lymph nodes in patients with proved or suspected bronchogenic carcinoma has diagnostic value, prognostic significance,
30
JAMPLIS, MILLS, LILLINGTON
J. Thoracic and Cardiovas. Surg.
and therapeutic implications. Often the diagnostic nodes were small but many times they were large but could not be palpated because of the overlying heavy sternocleidomastoid muscle. In cases in which the diagnosis of bronchogenic carcinoma has already been established, a positive scalene node biopsy is prima-facie evidence of extrathoracic spread. In our opinion this indicates incurability and is a contraindi cation to thoracotomy. Furthermore, when the scalene lymph nodes are in volved with tumor, the likelihood of the lesion being resectable may fall well below 50 per cent. A recent study by Pinkers and Lawrence 3 indicates that pulmonary resection under these circumstances would rarely have palliative value. We have obtained excellent palliation with irradiation and only rarely does pulmonary suppuration develop. In the 33 patients with bronchogenic carcinoma in the present series, the supraclavicular lymph nodes were not palpable and the clinical course and roentgenographic appearance of the chest did not in itself suggest unresectability in any case. ■ The routine use of scalene node biopsy averted an unnecessary thoracotomy in 10 of these patients (30 per cent). For this reason, we believe that thoracotomy should not be performed in a patient with suspected or proved bronchogenic carcinoma unless the scalene lymph nodes have been biopsied and found to be free of tumor. The scalene fat pad biopsy should be done even if the nodes are not palpable. We recognize one expection to the rule of performing the combined pro cedure in all patients with suspected bronchogenic carcinoma. Both bronchoscopy and scalene node biopsy will be negative in most patients with a solitary circumscribed nodule in one lung. It is our practice to proceed directly with exploratory thoracotomy when the benign nature of the " c o i n " lesion cannot be established with reasonable certainty by the usual criteria. 6 Performance of scalene fat pad biopsy at the time of bronchoscopy, rather than as two separate procedures several days apart, has obvious time and finan cial advantages and minimizes the anesthetic risk. The procedure carries little hazard and we have had no complications. SUMMARY
Scalene fat pad biopsy in conjunction with bronchoscopy was performed in 61 patients, in 19 of whom the scalene biopsy proved diagnostic. In 45 pa tients bronchogenic carcinoma was suspected, and this diagnosis was ultimately established in 33. The supraclavicular lymph nodes had not been clinically palpable in any of these 45 patients. The biopsied scalene nodes contained tumor in 10 (30 per cent) of the 33 patients with proved bronchogenic car cinoma. It is concluded that scalene fat pad biopsy should be done prior to thora cotomy in all patients with proved or suspected bronchogenic carcinoma, whether or not the supraclavicular lymph nodes are clinically palpable. The one ex ception is the presence of a solitary " c o i n " lesion not demonstrably benign, in which case thoracotomy must be done. Performance of the scalene node biopsy at the time of bronchoscopy has certain practical advantages.
Vol. 44, No. 1 July, 1962
SCALENE FAT PAD BIOPSY A N D BRONCHOSCOPY
31 °
REFERENCES 1. Daniels, A. C.: Method of Biopsy Useful in Diagnosing Certain Intrathoracic Diseases, Dis. Chest 16: 360-366, 1949. 2. Beahrs, O. H., Hunt, O. R., Jr., Storsteen, O. M., and Bernatz, P . E . : The Value of Biopsy of Lower Deep Jugular (Scalene) Nodes as a Diagnostic Procedure, Minnesota Med. 40: 152-155, 1957. 3. Pinkers, L. H., and Lawrence, G. H . : Does Carcinomatous Scalene Node Contraindicate Pulmonary Resection? Dis. Chest 38: 516-518, 1960. 4. Skinner, E. F., Hall, J., Carr, D., and Robbins, S.: Routine Supraclavicular Biopsy in Suspected Bronchogenic Carcinoma, Am. Suigeon 2 1 : 590, 1955. 5. Jamplis, R. W., Hecker, S. P., McNeill, J . I., Mitchell, S. P., North, F . S., and Weigen, J . F . : Circumscribed Pulmonary Lesions, Minnesota Med. 42: 1811, 1959.