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Repeat mediastinoscopy in the assessment of new and recurrent lung neoplasm
Repeat Mediastinoscopy in the Assessment of New and Recurrent Lung Neoplasm Dirk Meersschaut, MD, Frank Vermassen, MD, Aart Brutel de la Riviere, MD, FCCP, Paul J. Knaepen, MD, Jules M. Van Den Bosch, MD, and Roland Vanderschueren, MD, FCCP St. Antonius Hospital, Nieuwegein, The Netherlands
From 1976 to 1990,140 patients (mean age, 66 years; 91% male) underwent repeat mediastinoscopy as a routine staging procedure. The mean interval between first and second mediastinoscopy was 56 months. Owing to adhesions, 26 repeat mediastinoscopies (18%)were considered incomplete. There was no mortality, and 10 complications did not require interventional therapy. The results were positive in 20 patients, thus avoiding an
unnecessary thoracotomy. In 7 patients with negative findings, positive lymph nodes were found at thoracotomy or by transcarinal puncture biopsy. The sensitivity of repeat mediastinoscopy in this series is 74%,and the accuracy 94%.We consider repeat mediastinoscopy a safe and reliable preoperative staging procedure in new or recurrent lung cancer. (Ann Thorac Surg 1992;53:120-2)
I
Thoracic Society’s ”Clinical Staging of Primary Cancer of the Lung” [7, 81. A mediastinoscopy was considered complete if on both sides the tracheobronchial nodes (Naruke 4) and the main carinal node (Naruke 7) were reached.
n 1974, Palva [l] stated that mediastinoscopy is a procedure that, as a rule, should not be repeated. In his series only 1 of the 330 patients underwent repeat mediastinoscopy. Severe fibrosis between the innominate artery and the trachea presented substantial technical difficulty. On the basis of this experience, some writers [2] have gone even further and considered repeat mediastinoscopy as contraindicated. The development of pretracheal fibrosis was confirmed on a histological basis by Balle and Bretlau [3]. Authors of later series [4, 51 considered a previous mediastinoscopy only as a relative contraindication, and stated that repeat mediastinoscopy should be done whenever it could contribute to the diagnosis. We support the opinion that routine mediastinoscopy provides essential information for the staging and management of lung cancer [6]. A previous mediastinoscopy is not considered a contraindication and does not change this policy. In this study we reviewed our experience with 140 repeat mediastinoscopies.
Material and Methods Between 1976 and 1990, repeat mediastinoscopy was performed in 140 patients, 127 men (91%)and 13 women (9%) ranging from 43 to 82 years old. Results were reviewed retrospectively. In all but 1 patient the first mediastinoscopy revealed only benign lymphatic tissue. Twelve patients underwent the first mediastinoscopy for nonmalignant disease. The mean interval between first and second mediastinoscopy was 56 months, ranging from 3 months to 16 years. All accessible lymph nodes were sampled and mapped according to the American Accepted for publication July 24, 1991. Address reprint requests to Dr Brutel de la RviPre, St. Antonius Hospital, Postbus 2500, 3430 EM Nieuwegein, The Netherlands.
0 1992 by The Society of
Thoracic Surgeons
Results Twenty (14%)of the 140 remediastinoscopies performed showed positive mediastinal lymph nodes. In 2 of these patients a resection was nevertheless performed: 1 patient with a positive lymph node at the tracheobronchial corner had a right pneumonectomy, and 1patient with a subcarinal lymph node had a left pneumonectomy with canna resection. In both patients the positive result of the mediastinoscopy was confirmed at thoracotomy. In the other 18 patients no thoracotomy was performed. One hundred twenty repeat mediastinoscopies were negative. In 20 patients this was not followed by further operation: in 11 because no evidence of malignancy was found, in 3 because another treatment (chemotherapy or radiotherapy) was chosen, and in 6 because irresectability was confirmed by other techniques. In 2 of these 6 patients the repeat mediastinoscopy was considered incomplete by the surgeon and a transcarinal puncture biopsy was positive. One patient had invasion of the esophagus, 1 patient a metastatic pleural effusion, and 2 patients distant metastases that became clear only after the mediastinoscopy. In 3 of the remaining 100 patients an anterior mediastinotomy showed invasion of the aortopulmonary space, intrapericardial invasion, and invasion of the dorsal mediastinum. Therefore, 97 patients with a negative mediastinoscopy underwent thoracotomy. Six tumors proved to be irresectable at thoracotomy (negative mediastinal lymph nodes, 2; positive mediastinal lymph nodes, 2; no lymph node dissection, 2). Ninety-one patients underwent a resection: 33 pneumectomies, 34 (bi-) 0003-4975/92/$3.50
MEERSSCHAUT ET AL REPEAT MEDlASTlNOSCOPY
Ann Thorac Surg 1992;5312&2
121
Table 1. Cross-Tabulation of the Histology of the First and Second Tumor Second Histolorn Initial Histology
Squamous Cell
Squamous cell Adenocarcinoma Mixed cell
71 1 3
Small cell anaplastic Large cell anaplastic Benign Unknown Hodgkin Total
2 3 7 3
Adenocarcinoma
Mixed Cell
Small Cell
Large Cell
3 1 1
2
1
5 10
Benign
Unknown
8 2
2
92 14 4 5 8 12 4 1
2
140
3
2 1
1
1 1
2 2 1
1 90
18
lobectomies, 14 segmentectomies, 9 wedge resections, and 1 sleeve resection of the left main bronchus. Of the 91 patients who underwent resection, 5 were found to have benign lesions. For the calculation of sensitivity and accuracy we did not take into account the 16 patients in whom no malignancy could be shown (11 without further operation and 5 with operation for a benign lesion). We also did not consider the 4 patients who were not operated on because of the presence of invasion or metastases, the 3 patients in whom no thoracotomy was performed despite a negative mediastinoscopy, the 3 patients with positive anterior mediastinotomy, and 2 patients who underwent thoracotomy but in whom the lesion proved to be irresectable and no additional lymph node dissection was performed. We did include the 2 patients with a positive transcarinal puncture as false-negative results. This gives us a total of 112 patients, of whom 20 had a positive mediastinoscopy and 90 underwent thoracotomy after a negative mediastinoscopy. During this thoracotomy an extensive staging of all accessible lymph nodes was always performed. Eleven of these patients had positive N2 nodes, of which 5 should normally have been in the reach of the mediastinoscopist. In 3 of these patients the mediastinoscopy was considered incomplete by the surgeon. This implies that of a total of 92 negative remediastinoscopies, 7 have to be considered as false negative. Repeat mediastinoscopy can, therefore, in our hands be performed with a sensitivity of 74%, specificity of loo%, and accuracy of 93%. During these 140 repeat mediastinoscopies a total of 381 lymph node stations were biopsied (mean, 2.7). Twentysix explorations (18%)were considered by the surgeon as incomplete: 24 due to adhesions and 2 due to bleeding. In 82%a complete or sufficient exploration of the pretracheal and paratracheal spaces was possible. The mean time between first and second mediastinoscopy for the procedures that were considered incomplete was 42 months, which is less than the 56 months for the group as a whole. There were no deaths due to the procedure. There were no complications necessitating surgical intervention. In 6 patients bleeding occurred, which always stopped by simple tamponade. In 2 patients this bleeding caused premature ending of the procedure. Two esophageal
5
6
3
16
Total
biopsies healed without further treatment. Recurrent nerve palsy occurred once, and there was one wound infection. This means a total of 10 complications (7%),of which none can be considered serious or life-threatening. The histology of the primary and secondary tumors are cross-tabulated in Table 1. Squamous cell carcinoma is the most frequent tumor in both groups. Fifty percent of all patients had a squamous cell carcinoma as both the first and the second tumor. American Joint Committee on Cancer staging of the 92 malignant tumors with negative mediastinoscopy that underwent thoracotomy showed that 2 patients were in stage 0,55 in stage I, 10 in stage 11, 21 in stage IIIa, and 4 in stage 11%.
Comment In earlier discussions about repeat mediastinoscopy, the number of cases was rather limited, making analyses of the data perilous (Palva and associates [9], 6 patients; Lewis and co-workers [4], 12 patients; Balle and Bretlau, 4 patients). It has been reported that mediastinoscopy should never be repeated, because of problems encountered while dissecting the adhesions between the innominate artery and the trachea. In our series the mediastinum could always be reached by direct dissection of the adhesions or by following the left lateral wall of the trachea, thus avoiding the critical innominate artery-tracheal area. In many operative reports, scar tissue was reported to make the exploration more laborious, preventing the complete inspection of the mediastinum in 18% of the procedures. This did result in a loss of sensitivity in our series (74%) compared with an expected sensitivity of about 85% in primary mediastinoscopy. A useless exploration by thoracotomy was avoided in 18 patients (l5%), and the procedure contributed to a successful resection in 86 patients. The procedure reached an accuracy of 93%. Scarring can blur the difference between lymph nodes and other vital structures. Careful dissection resulted in an acceptable complication rate with no major complications and a 7% rate of minor complications. All procedures were performed by a small team of surgeons, increasing the experience and reducing the risks.
122
MEERSSCHAUT ET AL REPEAT MEDIASTINOSCOPY
Once the mediastinum has been opened, tissue planes and interfaces can be changed, as pointed out by Lewis and associates [4]. Therefore computed tomographic scan, unable to distinguish hyperplastic, anthracotic, or granulomatous nodes from malignant nodes, becomes even less reliable after previous mediastinoscopy. For this reason we think repeat mediastinoscopy is even more important as a preoperative staging procedure in patients who have undergone previous mediastinoscopy. It should be performed in every patient with suspicion of a new or recurrent lung carcinoma before thoracotomy is planned.
References 1. Palva T. Mediastinoscopy. Basel: S. Karger, 19741-92. 2. Preciado MC, Duvall AJ, Koop H. Mediastinoscopy: a review of 450 cases. Laryngoscope 1973;83:1300-10.
Ann Thorac Surg 1992;53:12&2
3. Balle VH, Bretlau P. Remediastinoscopy. J Laryngol Otol 1985;99:267-71. 4. Lewis RJ, Sisler GE, Mackenzie JW. Repeat mediastinoscopy. Ann Thorac Surg 1984;37147-9. 5. Swain AJ. Surgical techniques in the diagnosis of pulmonary disease. Clin Chest Med 1987;8:43-51. 6. Luke WP, Pearson FG, Todd TRJ, Patterson GA, Cooper JD. Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung. J Thorac Cardiovasc Surg 1986;91:5%6. 7. Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;76:832-9. 8. Tisi GM, Friedman PJ, Peters RM, et al. Clinical staging of primary lung cancer. Am Rev Respir Dis 1983;127659-64. 9. Palva T,Palva A, Karja J. Re-mediastinoscopy.Arch Otolaryngo1 1975;101:748-50.
INVITED COMMENTARY Because, in my opinion and that of my colleagues, mediastinoscopy has always been considered the most important, definitive staging procedure for carcinoma of the lung, almost all of our patients have this procedure before an anticipated resection. In our experience, the computed tomographic scan does not consistently and accurately reveal the mediastinal contents, so we still rely on mediastinoscopy. In fact, it is not unusual for the computed tomographic scan to present either false-negative or falsepositive findings for lymph nodes in the mediastinum. It cannot differentiate benign anthracotic, hyperplastic, or granulomatous nodes from truly malignant nodes. After a mediastinoscopy has been performed, which results in disruption of tissue planes and scar formation, future computed tomographic scans become even less reliable for the identification of mediastinal nodes. For these reasons and because mediastinoscopy allows bilateral visualization and palpation with direct biopsy, we remain strong advocates of mediastinoscopy. In the past, repeat mediastinoscopy was considered to be contraindicated, because it was purported by prominent thoracic surgeons that it would be too hazardous to
try to dissect the scarred mediastinum. In our experience, once the healed scar was excised and the strap muscles separated, the remainder of the procedure was not very difficult. On occasion, a patient will have a frozen mediastinum barring entry to this area. In the vast majority of repeat mediastinoscopies, however, the mediastinum can be satisfactorily entered and adequately explored, and the lymph nodes can be recovered. We have performed repeat mediastinoscopy since the early 1970s and are in complete agreement with the recommendations of Meersschaut and associates. Dr Meersschaut and colleagues are to be congratulated for their large and excellent series demonstrating the importance and feasibility of this most important staging procedure. Their findings and results continue to emphasize the need for repeat mediastinoscopy to remain a part of the armamentarium of the thoracic surgeon.
Ralph J. h i s , M D 185 Livingston Ave
New Brunswick, NJ
08901
From 1976 to 1990,140 patients (mean age, 66 years; 91% male) underwent repeat mediastinoscopy as a routine staging procedure. The mean interval between first and second mediastinoscopy was 56 months. Owing to adhesions, 26 repeat mediastinoscopies (18%)were considered incomplete. There was no mortality, and 10 complications did not require interventional therapy. The results were positive in 20 patients, thus avoiding an
unnecessary thoracotomy. In 7 patients with negative findings, positive lymph nodes were found at thoracotomy or by transcarinal puncture biopsy. The sensitivity of repeat mediastinoscopy in this series is 74%,and the accuracy 94%.We consider repeat mediastinoscopy a safe and reliable preoperative staging procedure in new or recurrent lung cancer. (Ann Thorac Surg 1992;53:120-2)
I
Thoracic Society’s ”Clinical Staging of Primary Cancer of the Lung” [7, 81. A mediastinoscopy was considered complete if on both sides the tracheobronchial nodes (Naruke 4) and the main carinal node (Naruke 7) were reached.
n 1974, Palva [l] stated that mediastinoscopy is a procedure that, as a rule, should not be repeated. In his series only 1 of the 330 patients underwent repeat mediastinoscopy. Severe fibrosis between the innominate artery and the trachea presented substantial technical difficulty. On the basis of this experience, some writers [2] have gone even further and considered repeat mediastinoscopy as contraindicated. The development of pretracheal fibrosis was confirmed on a histological basis by Balle and Bretlau [3]. Authors of later series [4, 51 considered a previous mediastinoscopy only as a relative contraindication, and stated that repeat mediastinoscopy should be done whenever it could contribute to the diagnosis. We support the opinion that routine mediastinoscopy provides essential information for the staging and management of lung cancer [6]. A previous mediastinoscopy is not considered a contraindication and does not change this policy. In this study we reviewed our experience with 140 repeat mediastinoscopies.
Material and Methods Between 1976 and 1990, repeat mediastinoscopy was performed in 140 patients, 127 men (91%)and 13 women (9%) ranging from 43 to 82 years old. Results were reviewed retrospectively. In all but 1 patient the first mediastinoscopy revealed only benign lymphatic tissue. Twelve patients underwent the first mediastinoscopy for nonmalignant disease. The mean interval between first and second mediastinoscopy was 56 months, ranging from 3 months to 16 years. All accessible lymph nodes were sampled and mapped according to the American Accepted for publication July 24, 1991. Address reprint requests to Dr Brutel de la RviPre, St. Antonius Hospital, Postbus 2500, 3430 EM Nieuwegein, The Netherlands.
0 1992 by The Society of
Thoracic Surgeons
Results Twenty (14%)of the 140 remediastinoscopies performed showed positive mediastinal lymph nodes. In 2 of these patients a resection was nevertheless performed: 1 patient with a positive lymph node at the tracheobronchial corner had a right pneumonectomy, and 1patient with a subcarinal lymph node had a left pneumonectomy with canna resection. In both patients the positive result of the mediastinoscopy was confirmed at thoracotomy. In the other 18 patients no thoracotomy was performed. One hundred twenty repeat mediastinoscopies were negative. In 20 patients this was not followed by further operation: in 11 because no evidence of malignancy was found, in 3 because another treatment (chemotherapy or radiotherapy) was chosen, and in 6 because irresectability was confirmed by other techniques. In 2 of these 6 patients the repeat mediastinoscopy was considered incomplete by the surgeon and a transcarinal puncture biopsy was positive. One patient had invasion of the esophagus, 1 patient a metastatic pleural effusion, and 2 patients distant metastases that became clear only after the mediastinoscopy. In 3 of the remaining 100 patients an anterior mediastinotomy showed invasion of the aortopulmonary space, intrapericardial invasion, and invasion of the dorsal mediastinum. Therefore, 97 patients with a negative mediastinoscopy underwent thoracotomy. Six tumors proved to be irresectable at thoracotomy (negative mediastinal lymph nodes, 2; positive mediastinal lymph nodes, 2; no lymph node dissection, 2). Ninety-one patients underwent a resection: 33 pneumectomies, 34 (bi-) 0003-4975/92/$3.50
MEERSSCHAUT ET AL REPEAT MEDlASTlNOSCOPY
Ann Thorac Surg 1992;5312&2
121
Table 1. Cross-Tabulation of the Histology of the First and Second Tumor Second Histolorn Initial Histology
Squamous Cell
Squamous cell Adenocarcinoma Mixed cell
71 1 3
Small cell anaplastic Large cell anaplastic Benign Unknown Hodgkin Total
2 3 7 3
Adenocarcinoma
Mixed Cell
Small Cell
Large Cell
3 1 1
2
1
5 10
Benign
Unknown
8 2
2
92 14 4 5 8 12 4 1
2
140
3
2 1
1
1 1
2 2 1
1 90
18
lobectomies, 14 segmentectomies, 9 wedge resections, and 1 sleeve resection of the left main bronchus. Of the 91 patients who underwent resection, 5 were found to have benign lesions. For the calculation of sensitivity and accuracy we did not take into account the 16 patients in whom no malignancy could be shown (11 without further operation and 5 with operation for a benign lesion). We also did not consider the 4 patients who were not operated on because of the presence of invasion or metastases, the 3 patients in whom no thoracotomy was performed despite a negative mediastinoscopy, the 3 patients with positive anterior mediastinotomy, and 2 patients who underwent thoracotomy but in whom the lesion proved to be irresectable and no additional lymph node dissection was performed. We did include the 2 patients with a positive transcarinal puncture as false-negative results. This gives us a total of 112 patients, of whom 20 had a positive mediastinoscopy and 90 underwent thoracotomy after a negative mediastinoscopy. During this thoracotomy an extensive staging of all accessible lymph nodes was always performed. Eleven of these patients had positive N2 nodes, of which 5 should normally have been in the reach of the mediastinoscopist. In 3 of these patients the mediastinoscopy was considered incomplete by the surgeon. This implies that of a total of 92 negative remediastinoscopies, 7 have to be considered as false negative. Repeat mediastinoscopy can, therefore, in our hands be performed with a sensitivity of 74%, specificity of loo%, and accuracy of 93%. During these 140 repeat mediastinoscopies a total of 381 lymph node stations were biopsied (mean, 2.7). Twentysix explorations (18%)were considered by the surgeon as incomplete: 24 due to adhesions and 2 due to bleeding. In 82%a complete or sufficient exploration of the pretracheal and paratracheal spaces was possible. The mean time between first and second mediastinoscopy for the procedures that were considered incomplete was 42 months, which is less than the 56 months for the group as a whole. There were no deaths due to the procedure. There were no complications necessitating surgical intervention. In 6 patients bleeding occurred, which always stopped by simple tamponade. In 2 patients this bleeding caused premature ending of the procedure. Two esophageal
5
6
3
16
Total
biopsies healed without further treatment. Recurrent nerve palsy occurred once, and there was one wound infection. This means a total of 10 complications (7%),of which none can be considered serious or life-threatening. The histology of the primary and secondary tumors are cross-tabulated in Table 1. Squamous cell carcinoma is the most frequent tumor in both groups. Fifty percent of all patients had a squamous cell carcinoma as both the first and the second tumor. American Joint Committee on Cancer staging of the 92 malignant tumors with negative mediastinoscopy that underwent thoracotomy showed that 2 patients were in stage 0,55 in stage I, 10 in stage 11, 21 in stage IIIa, and 4 in stage 11%.
Comment In earlier discussions about repeat mediastinoscopy, the number of cases was rather limited, making analyses of the data perilous (Palva and associates [9], 6 patients; Lewis and co-workers [4], 12 patients; Balle and Bretlau, 4 patients). It has been reported that mediastinoscopy should never be repeated, because of problems encountered while dissecting the adhesions between the innominate artery and the trachea. In our series the mediastinum could always be reached by direct dissection of the adhesions or by following the left lateral wall of the trachea, thus avoiding the critical innominate artery-tracheal area. In many operative reports, scar tissue was reported to make the exploration more laborious, preventing the complete inspection of the mediastinum in 18% of the procedures. This did result in a loss of sensitivity in our series (74%) compared with an expected sensitivity of about 85% in primary mediastinoscopy. A useless exploration by thoracotomy was avoided in 18 patients (l5%), and the procedure contributed to a successful resection in 86 patients. The procedure reached an accuracy of 93%. Scarring can blur the difference between lymph nodes and other vital structures. Careful dissection resulted in an acceptable complication rate with no major complications and a 7% rate of minor complications. All procedures were performed by a small team of surgeons, increasing the experience and reducing the risks.
122
MEERSSCHAUT ET AL REPEAT MEDIASTINOSCOPY
Once the mediastinum has been opened, tissue planes and interfaces can be changed, as pointed out by Lewis and associates [4]. Therefore computed tomographic scan, unable to distinguish hyperplastic, anthracotic, or granulomatous nodes from malignant nodes, becomes even less reliable after previous mediastinoscopy. For this reason we think repeat mediastinoscopy is even more important as a preoperative staging procedure in patients who have undergone previous mediastinoscopy. It should be performed in every patient with suspicion of a new or recurrent lung carcinoma before thoracotomy is planned.
References 1. Palva T. Mediastinoscopy. Basel: S. Karger, 19741-92. 2. Preciado MC, Duvall AJ, Koop H. Mediastinoscopy: a review of 450 cases. Laryngoscope 1973;83:1300-10.
Ann Thorac Surg 1992;53:12&2
3. Balle VH, Bretlau P. Remediastinoscopy. J Laryngol Otol 1985;99:267-71. 4. Lewis RJ, Sisler GE, Mackenzie JW. Repeat mediastinoscopy. Ann Thorac Surg 1984;37147-9. 5. Swain AJ. Surgical techniques in the diagnosis of pulmonary disease. Clin Chest Med 1987;8:43-51. 6. Luke WP, Pearson FG, Todd TRJ, Patterson GA, Cooper JD. Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung. J Thorac Cardiovasc Surg 1986;91:5%6. 7. Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;76:832-9. 8. Tisi GM, Friedman PJ, Peters RM, et al. Clinical staging of primary lung cancer. Am Rev Respir Dis 1983;127659-64. 9. Palva T,Palva A, Karja J. Re-mediastinoscopy.Arch Otolaryngo1 1975;101:748-50.
INVITED COMMENTARY Because, in my opinion and that of my colleagues, mediastinoscopy has always been considered the most important, definitive staging procedure for carcinoma of the lung, almost all of our patients have this procedure before an anticipated resection. In our experience, the computed tomographic scan does not consistently and accurately reveal the mediastinal contents, so we still rely on mediastinoscopy. In fact, it is not unusual for the computed tomographic scan to present either false-negative or falsepositive findings for lymph nodes in the mediastinum. It cannot differentiate benign anthracotic, hyperplastic, or granulomatous nodes from truly malignant nodes. After a mediastinoscopy has been performed, which results in disruption of tissue planes and scar formation, future computed tomographic scans become even less reliable for the identification of mediastinal nodes. For these reasons and because mediastinoscopy allows bilateral visualization and palpation with direct biopsy, we remain strong advocates of mediastinoscopy. In the past, repeat mediastinoscopy was considered to be contraindicated, because it was purported by prominent thoracic surgeons that it would be too hazardous to
try to dissect the scarred mediastinum. In our experience, once the healed scar was excised and the strap muscles separated, the remainder of the procedure was not very difficult. On occasion, a patient will have a frozen mediastinum barring entry to this area. In the vast majority of repeat mediastinoscopies, however, the mediastinum can be satisfactorily entered and adequately explored, and the lymph nodes can be recovered. We have performed repeat mediastinoscopy since the early 1970s and are in complete agreement with the recommendations of Meersschaut and associates. Dr Meersschaut and colleagues are to be congratulated for their large and excellent series demonstrating the importance and feasibility of this most important staging procedure. Their findings and results continue to emphasize the need for repeat mediastinoscopy to remain a part of the armamentarium of the thoracic surgeon.
Ralph J. h i s , M D 185 Livingston Ave
New Brunswick, NJ
08901