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Transcarinal Bronchoscopic Needle Biopsy
Transcarinal Bronchoscopic Needle Biopsy Robert T. Fox, M.D.,’ William M. Lees, M.D.,+ and Thomas W. Shields, M.D.I
B
KONCHOSCOPIC EXAMINATION has for years been one of the major aids in diagnosis and preoperative evaluation of patients with all types of pulmonary disease, and especially cancer of the lung. In a significant number of patients in whom cancer is suspected, bronchoscopic examination reveals a broad, fixed carina, suggesting the presence of subcarinal lymphadenopathy. Not infrequently, despite exhaustive examination no positive histologic or cytologic proof can be obtained. I n such patients the roentgenographic picture and the bronchoscopic demonstration of a broad, fixed cariiia provide the only evidence on which a clinical diagnosis can be based. Thus, a thoracotomy is necessary in order to establish a positive histologic diagnosis. Many surgeons consider that the presence of metastasis in the subcarinal nodes renders the pulmonary lesion “inoperable” (perhaps a better term is “nonresectable”), especially in a borderline case. Certainly, in the light of recent experience with preoperative irradiation, histologic proof of subcarinal node metastasis could constitute adequate indication for irradiation and subsequent reevaluation for exploration. Inasmuch as many roentgenologists are reluctant to administer radiation therapy without a histologic diagnosis, a simple method of biopsy of enlarged subcarinal nodes is desirable. In August, 1963, Versteegh and Swierenga [8] of Utrecht, the Netherlands, reported on a series of 150 patients with carcinoma of the lung. As part of the bronchoscopic examination they routinely performed transcarinal puncture with a long, thin needle. Only aspiration biopsy was possible with this technique, and they state that in many instances no material was obtained, but a positive histologic diagnosis was reported in 25 (16%) of the patients. Only half of these had a broad carina. Of these 25 patients, 14 were ex*.histant Chief of Surgery, Chicago Municipal Tuberculosis Sanitarium; Assistant Professor of Surgery, Northwestern University Medical School. +Chief of Surgery, Chicago Municipal Tuberculosis Sanitarium; Associate Professor of Surgery, Loyola Stritch School of Medicine. ;Associate Professor of Surgery, Northwestel t i University Medical School. Received for publication Sept. 8, 1964.
92
THE ANNALS OF THORACIC SURGERY
Tmnscarintil Needle Biopsy
FIG. 1. T h e three parts of the long Fox modificntion of the V i m Biegeleisen needle, showing length coinpard with a 40 cin. bronchoscope.
FIG. 2. Magnified view of proximal and distal end of the unit with auger needle in place. VOL. 1, NO. 1, JAN.,
1965
93
FOX, LEES, A N D SHIELDS
plored and only 3 had resections. T h e resections were shown by pathologic examination to be only palliative in nature. Schieppati [S] of Buenos Aires reported on a similar technique in 1949 and 1958. In 1963, unaware of the work of the authors just mentioned, we devised a biopsy technique that has been found to be quite reliable. T h e Vim Biegeleisen biopsy needle has been modified a t our request by the Vim Division of Travenol LaboratoriesX for use through a standard 40 cin. bronchoscope (Figs. 1, 2). It is an auger-type instrument with an outside cutting sheath or cannula, and in almost all instances obtains a very satisfactory core of tissue. It is kept sterile on the “back table” during all bronchoscopic examinations and is ready for immediate use when needed. TECHhlIQUE
During bronchoscopy, in most cases under topical tetracaine anesthesia, thorough routine inspection is accomplished, using the bronchoscopic telescope when indicated. When a broad and/or fixed carina is present, and no other lesion amenable to standard biopsy is seen, then needle biopsy is indicated. (In view of Versteegh and Swierenga’s expe-
FIG. 3. Autopsy specimen showing bmnchoscope in the trcichen, cind the biopsy n e e d k fzrlly introduced into sirbcnrincil nodes. * C o c k #VT37, Travenol Laboratories, Moi t o i i Grobc, I l l .
94
THE ANNALS OF THORACIC SURGERY
TYN nsrtirinti 1 hreedle Biopsy
rience, probably traiiscariiial biopsy should be done on all suspect patients whether the carina is broad or not.) T h e tip of the bronchoscope is positioned just superior to the main carina, and the biopsy needle with beveled obturator in place is introduced through the medial wall of either main bronchus at or just distal to the carinal spur. T h e obturator is removed and the auger biopsy unit introduced and screwed in to the hilt (Fig. 3). T h e outer cannula is then rotated and advanced over the auger biopsy unit to cut off the core of tissue, and the entire unit is withdrawn. If an adequate core of tissue is not obtained, the procedure is repeated. Only minimal oozing of blood is encountered, rarely needing even sponge pressure for control. Since no major vessels are located in the immediate subcarinal region, there is little danger of any significant bleeding. Over 5 0 patients have had this type of biopsy accomplished under topical anesthesia, and there have been no untoward occurrences. In a11 cases a good specimen of tissue was obtained. Recognizable lymph node tissue was present in 65% of the specimens, and carcinoma or lymphoma was found in 40% of all specimens. T h e microscopic picture has iraried froin nonspecific inflammatory reaction or anthracosis to metastatic carcinoma, and in the latter instance thoracotoiny has been avoided on the basis of information provided by this subcarinal node biopsy (Fig. 4). I n recent years several authors [l-5, 71 have described
FlG. -1.
Microstopic pictiire of metnstcitic mrcinornti i n n n w d l e biopsy sp(v-i-
mcri of szibrtlrintil nod(,s.
VOI.. I , NO. I , JAN.,
1965
FOX, LEES, AND SHIELDS
techniques by which paratracheal nodes may be biopsied by inediastinoscopy. Biopsy of subcarinal nodes by this approach could be done only with considerably increased hazard and would entail an additional surgical procedure, whereas bronchoscopy is, with rare exceptions, part of the routine examination. SUMMARY
A simple technique for performing needle biopsy of subcarinal nodes through a bronchoscope is described. Deiiionstration of metastatic carcinoma by this technique may spare many patients a major thoracotomy. REFERENCES
Mediastinoscopy, a method tor inspection antl tissue biopsy in the superior mediastinum. l h . Chest 36:343, 1959. Harkins, D. E., Black, H., Clauss, K., antl Faranno, K. E. A simple cervicomediastinal exploration for tissue diagnosis of intrathoracic disease. N e w Eng. 1. M e d . 251:1041, 1954. Pa&;, T., and Vikari, S. Mediastinoscopy. J. Thortic. Cnrdiov. Surg. 42:206, 1961. Pearson, F. G. Mediastinoscopy, a method of biopsy in the superior mediash u m . Canad. ]. Surg. 6/4:423, 1963. Keynders, H. Mediastinoscopy in bronchogenic cancer. Dis. Chest 45:606, 1964. Schieppati, E. Mediastinal lymph node puncture through the tracheal carina. Surg. Gynec. Obstet. 107:243, 1958. Steele, J. D., and Marable, S. A. Cervical mediastinotomy for biopsy. J. Thornc. Cardiov. Surg. 37:621, 1959. Versteegh, R. M., and Swieringa, J . Bronchoscopic evaluation of the operability of pulmonary carcinoma. Actn Otolaryng. (Stockholm) 56:603, 1963.
1. Carlens, E.
2. 3.
4. 5. 6.
7. 8.
96
T H E ANNALS OF THORACIC SURGERY
B
KONCHOSCOPIC EXAMINATION has for years been one of the major aids in diagnosis and preoperative evaluation of patients with all types of pulmonary disease, and especially cancer of the lung. In a significant number of patients in whom cancer is suspected, bronchoscopic examination reveals a broad, fixed carina, suggesting the presence of subcarinal lymphadenopathy. Not infrequently, despite exhaustive examination no positive histologic or cytologic proof can be obtained. I n such patients the roentgenographic picture and the bronchoscopic demonstration of a broad, fixed cariiia provide the only evidence on which a clinical diagnosis can be based. Thus, a thoracotomy is necessary in order to establish a positive histologic diagnosis. Many surgeons consider that the presence of metastasis in the subcarinal nodes renders the pulmonary lesion “inoperable” (perhaps a better term is “nonresectable”), especially in a borderline case. Certainly, in the light of recent experience with preoperative irradiation, histologic proof of subcarinal node metastasis could constitute adequate indication for irradiation and subsequent reevaluation for exploration. Inasmuch as many roentgenologists are reluctant to administer radiation therapy without a histologic diagnosis, a simple method of biopsy of enlarged subcarinal nodes is desirable. In August, 1963, Versteegh and Swierenga [8] of Utrecht, the Netherlands, reported on a series of 150 patients with carcinoma of the lung. As part of the bronchoscopic examination they routinely performed transcarinal puncture with a long, thin needle. Only aspiration biopsy was possible with this technique, and they state that in many instances no material was obtained, but a positive histologic diagnosis was reported in 25 (16%) of the patients. Only half of these had a broad carina. Of these 25 patients, 14 were ex*.histant Chief of Surgery, Chicago Municipal Tuberculosis Sanitarium; Assistant Professor of Surgery, Northwestern University Medical School. +Chief of Surgery, Chicago Municipal Tuberculosis Sanitarium; Associate Professor of Surgery, Loyola Stritch School of Medicine. ;Associate Professor of Surgery, Northwestel t i University Medical School. Received for publication Sept. 8, 1964.
92
THE ANNALS OF THORACIC SURGERY
Tmnscarintil Needle Biopsy
FIG. 1. T h e three parts of the long Fox modificntion of the V i m Biegeleisen needle, showing length coinpard with a 40 cin. bronchoscope.
FIG. 2. Magnified view of proximal and distal end of the unit with auger needle in place. VOL. 1, NO. 1, JAN.,
1965
93
FOX, LEES, A N D SHIELDS
plored and only 3 had resections. T h e resections were shown by pathologic examination to be only palliative in nature. Schieppati [S] of Buenos Aires reported on a similar technique in 1949 and 1958. In 1963, unaware of the work of the authors just mentioned, we devised a biopsy technique that has been found to be quite reliable. T h e Vim Biegeleisen biopsy needle has been modified a t our request by the Vim Division of Travenol LaboratoriesX for use through a standard 40 cin. bronchoscope (Figs. 1, 2). It is an auger-type instrument with an outside cutting sheath or cannula, and in almost all instances obtains a very satisfactory core of tissue. It is kept sterile on the “back table” during all bronchoscopic examinations and is ready for immediate use when needed. TECHhlIQUE
During bronchoscopy, in most cases under topical tetracaine anesthesia, thorough routine inspection is accomplished, using the bronchoscopic telescope when indicated. When a broad and/or fixed carina is present, and no other lesion amenable to standard biopsy is seen, then needle biopsy is indicated. (In view of Versteegh and Swierenga’s expe-
FIG. 3. Autopsy specimen showing bmnchoscope in the trcichen, cind the biopsy n e e d k fzrlly introduced into sirbcnrincil nodes. * C o c k #VT37, Travenol Laboratories, Moi t o i i Grobc, I l l .
94
THE ANNALS OF THORACIC SURGERY
TYN nsrtirinti 1 hreedle Biopsy
rience, probably traiiscariiial biopsy should be done on all suspect patients whether the carina is broad or not.) T h e tip of the bronchoscope is positioned just superior to the main carina, and the biopsy needle with beveled obturator in place is introduced through the medial wall of either main bronchus at or just distal to the carinal spur. T h e obturator is removed and the auger biopsy unit introduced and screwed in to the hilt (Fig. 3). T h e outer cannula is then rotated and advanced over the auger biopsy unit to cut off the core of tissue, and the entire unit is withdrawn. If an adequate core of tissue is not obtained, the procedure is repeated. Only minimal oozing of blood is encountered, rarely needing even sponge pressure for control. Since no major vessels are located in the immediate subcarinal region, there is little danger of any significant bleeding. Over 5 0 patients have had this type of biopsy accomplished under topical anesthesia, and there have been no untoward occurrences. In a11 cases a good specimen of tissue was obtained. Recognizable lymph node tissue was present in 65% of the specimens, and carcinoma or lymphoma was found in 40% of all specimens. T h e microscopic picture has iraried froin nonspecific inflammatory reaction or anthracosis to metastatic carcinoma, and in the latter instance thoracotoiny has been avoided on the basis of information provided by this subcarinal node biopsy (Fig. 4). I n recent years several authors [l-5, 71 have described
FlG. -1.
Microstopic pictiire of metnstcitic mrcinornti i n n n w d l e biopsy sp(v-i-
mcri of szibrtlrintil nod(,s.
VOI.. I , NO. I , JAN.,
1965
FOX, LEES, AND SHIELDS
techniques by which paratracheal nodes may be biopsied by inediastinoscopy. Biopsy of subcarinal nodes by this approach could be done only with considerably increased hazard and would entail an additional surgical procedure, whereas bronchoscopy is, with rare exceptions, part of the routine examination. SUMMARY
A simple technique for performing needle biopsy of subcarinal nodes through a bronchoscope is described. Deiiionstration of metastatic carcinoma by this technique may spare many patients a major thoracotomy. REFERENCES
Mediastinoscopy, a method tor inspection antl tissue biopsy in the superior mediastinum. l h . Chest 36:343, 1959. Harkins, D. E., Black, H., Clauss, K., antl Faranno, K. E. A simple cervicomediastinal exploration for tissue diagnosis of intrathoracic disease. N e w Eng. 1. M e d . 251:1041, 1954. Pa&;, T., and Vikari, S. Mediastinoscopy. J. Thortic. Cnrdiov. Surg. 42:206, 1961. Pearson, F. G. Mediastinoscopy, a method of biopsy in the superior mediash u m . Canad. ]. Surg. 6/4:423, 1963. Keynders, H. Mediastinoscopy in bronchogenic cancer. Dis. Chest 45:606, 1964. Schieppati, E. Mediastinal lymph node puncture through the tracheal carina. Surg. Gynec. Obstet. 107:243, 1958. Steele, J. D., and Marable, S. A. Cervical mediastinotomy for biopsy. J. Thornc. Cardiov. Surg. 37:621, 1959. Versteegh, R. M., and Swieringa, J . Bronchoscopic evaluation of the operability of pulmonary carcinoma. Actn Otolaryng. (Stockholm) 56:603, 1963.
1. Carlens, E.
2. 3.
4. 5. 6.
7. 8.
96
T H E ANNALS OF THORACIC SURGERY