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Ultrasound-Guided Video-Assisted Mediastinoscopic Biopsy: A Novel Approach
Ultrasound-Guided Video-Assisted Mediastinoscopic Biopsy: A Novel Approach Jinbai Miao, MD, PhD,* Mei Li, MD,* Yili Fu, MD, Xiaoxing Hu, MD, Bin Hu, MD, PhD, and Hui Li, MD, PhD* Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, Beijing; and Department of Ultrasound Medicine, Beijing HaiDian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China
Video-assisted mediastinoscopy (VAM) is the most commonly used invasive method for the preoperative mediastinal staging of lung cancer and for the diagnosis of other mediastinal diseases. However, VAM has the risk of causing life-threatening bleeding consequent to the specific mediastinal anatomy. We adopted the
ultrasonic technique for VAM biopsies that can easily distinguish the lymph nodes from the surrounding great vessels and thus makes the procedure easier and safer.
I
on all patients. Patients were maintained in the supine position. A small 2- to 3-cm incision was made in the neck approximately 2 cm above the breastbone. The pretracheal fascia just below the isthmus was incised after the muscles were separated. A passage was dissociated from the anterior space of the trachea by using the index finger. After evaluation of the surrounding tissue, VAM was introduced along the surface of the tracheal cartilage rings. 2. Next, by using a metal sucker through the channel of the mediastinoscope, blunt dissociation was performed until the inferior part of the bifurcation and carina of the trachea was reached. 3. Preparation of the ultrasonic probe: The main engine of the ultrasonic apparatus was the Pro Focus 2202 Ultrasound Scanner system with Laparoscopic Transducer Type 8666RF (BK Ultrasound, Peabody, MA) (Fig 1), and the apparatus underwent lowtemperature sterilization. 4. With the ultrasonic instrument, suspicious nodules and masses were examined in the following order: both sides of the trachea, the inferior carina, and near the main bronchus. The lymph nodes and their surrounding great vessels were clearly distinguished using ultrasound and color Doppler imaging, and the size of the lymph nodes was measured (Figs 2, 3). After the site was confirmed, the biopsy tissue was obtained using the sidewalls of the forceps based on the depth provided by the ultrasound image. During this process, the ultrasonic instrument can be applied to examine the thickness of the tissue and its surroundings to obtain the tissue as safely as possible.
n the recent past, video-assisted mediastinoscopy (VAM) has been the gold standard for diagnosing mediastinal lymph node conditions [1, 2]. Currently, the role of VAM in the staging of non–small cell lung cancer may need to be redefined in view of the development of positron emission tomography–computed tomography and ultrasound biopsy (eg, endoscopic ultrasonography [EUS], endobronchial ultrasonography [EBUS]). However, these techniques cannot yet provide an adequate diagnosis, and VAM is still the optimal method for detecting previously undiagnosed enlargement of mediastinal nodes and for investigation in patients who have negative results of EBUS or who require additional tissue biopsy. Thus, improving the safety of VAM is both useful and important because the procedure has a certain degree of risk related to the many large vessels around the mediastinal lymph nodes. Although the risk of hemorrhage is low [3], this complication is life-threatening, and most patients should undergo thoracotomy [4]. Thus, we performed VAM biopsy under the guidance of ultrasound imaging to reduce the risk of injury. This approach has proved successful and useful. The surgeon can make a clear distinction between the lymph nodes and surrounding tissue under the guide of an ultrasonic probe, which ensures that the biopsy is safe beyond the puncture.
Technique 1. A cervical VAM procedure using general anesthesia and a single-lumen endotracheal tube was performed
(Ann Thorac Surg 2016;102:e465–7) Ó 2016 by The Society of Thoracic Surgeons
Accepted for publication March 14, 2016. *Drs Miao and M. Li contributed equally to this work. Address correspondence to Dr H. Li, Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, 8 GongTiNanlu, Chao-Yang District, Beijing 100020, China; email: huilee@ vip.sina.com.
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Comment Compared with traditional mediastinoscopy, VAM biopsy is safe and effective and causes less severe 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.03.047
e466
HOW TO DO IT MIAO ET AL ULTRASOUND-GUIDED MEDIASTINOSCOPIC BIOPSY
Ann Thorac Surg 2016;102:e465–7
Fig 1. (A) and (B) The Pro Focus 2202 Ultrasound Scanner system with Laparoscopic Transducer Type 8666RF.
Fig 2. Ultrasound blood flow of lymph nodes. (A) 4L lymph nodes. (B) 4L lymph nodes after puncture.
Fig 3. Ultrasonic measurement and biopsy of mediastinal lymph nodes. (A) 2R lymph nodes. (B) Measurement. (C) Check after biopsy.
complications because of better visualization. Several vascular landmarks must be identified during the intraoperative period; however, they are not always easily viewed. Thus, before biopsy, it is necessary to determine whether the sample is a blood vessel and identify the circulation around the sample. Without evidence of the lymph node or the vessel behind it, the patient must undergo puncture for a test to reduce the risk of massive hemorrhage. This convenient method is effective, but it also has some limitations. If the target area is the aorta, then even a small puncture can increase the risk of bleeding. Although compression hemostasis is effective,
this step could prolong the time required for the operation and hinder the surgeon’s confidence. Furthermore, with a limited scope, a small amount of bleeding can affect visibility in the site. Moreover, because the field of view of mediastinum endoscopy is limited, it is difficult to master the angle and depth of the puncture needle when puncturing. The accuracy of puncturing thus could be affected. Overall, during the biopsy process, VAM also carries a small but critical risk of potentially significant complications, with morbidity rates between 0.6% and 3% and mortality rates from 0% to 0.3% [1, 5]. Although the rate of hemorrhage is between 0.1% and 0.6% [6], the risk
Ann Thorac Surg 2016;102:e465–7
to the patient is great because of the major vascular structures in the region, including the azygos vein, the brachiocephalic artery, the superior vena cava, and the pulmonary arteries. For this reason, hemorrhage often requires an immediate thoracotomy. Blood vessel injury during operation is one of the main limitations and complications of VAM. Reducing this risk is always the concern of the surgeon. Intracavitary ultrasonic technology has rapidly developed and is widely applied during surgical procedures [7]. Ultrasonic technology is simple and practical to use for distinguishing vessel and substantial tissue. We performed a lymph node biopsy using VAM-guided ultrasound in 10 patients, all of whom had successful surgical procedures. The average operation time was 1.0 0.4 hours, and none of the patients had any complications. We used the ultrasonic instrument during the operation, and it easily passed through the scope. The ultrasonic probe in the front could effectively check the mediastinal lymph nodes and vessel tissues. For the first 3 patients, we performed the ultrasonic check after conventional puncture before performing the biopsy. Although the histomorphologic features of the lymph node could be tested during the subsequent ultrasound examination, local bleeding caused by the puncture inside or outside the lymph nodes could interfere with the ultrasonic and color Doppler imaging. Thus, for the next 7 patients, we directly performed the ultrasonic test and biopsy after accurately ensuring the location, direction, size, and adjacent relationship of the lymph node without puncturing, with good results. The pathologic tests proved that the biopsy tissue was reliable. We initially used ultrasonic technology for VAM to probe lymph nodes (the 2, 4, 7 groups) and tissues. Preliminary results showed that this method accurately revealed substantial lesions in the mediastinum and
HOW TO DO IT MIAO ET AL ULTRASOUND-GUIDED MEDIASTINOSCOPIC BIOPSY
e467
clearly delineated the blood vessels adjacent to the lymph nodes. The limitation of this technique lies in the thick front end of the ultrasonic probe, which has weak flexibility and increases the difficulty of checking the overall status of the lymph nodes under the carina. This study was supported by the Basic and Clinical Cooperation Research Fund of China Capital Medical University (15JL39) and the Clinical Scientific Research Fund of Wu Jieping Medical Foundation (320, 6750, 15052). The authors wish to thank all the participating patients.
References 1. Wei B, Bryant AS, Minnich DJ, Cerfolio RJ. The safety and efficacy of mediastinoscopy when performed by general thoracic surgeons. Ann Thorac Surg 2014;97:1878–83. 2. De Leyn P, Dooms C, Kuzdzal J, et al. Preoperative mediastinal lymph node staging for non-small cell lung cancer: 2014 update of the 2007 ESTS guidelines. Transl Lung Cancer Res 2014;3:225–33. 3. Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011;142:1393–400. 4. Cho JH, Kim J, Kim K, et al. A comparative analysis of videoassisted mediastinoscopy and conventional mediastinoscopy. Ann Thorac Surg 2011;92:1007–11. 5. Defranchi SA, Edell ES, Daniels CE, et al. Mediastinoscopy in patients with lung cancer and negative endobronchial ultrasound guided needle aspiration. Ann Thorac Surg 2010;90: 1753–7. 6. Pop D, Nadeemy AS, Venissac N, Guiraudet P, Mouroux J. Late mediastinal hematoma followed by incisional metastasis after video-assisted mediastinoscopy. J Thorac Oncol 2010;5: 919–20. 7. Joo I. The role of intraoperative ultrasonography in the diagnosis and management of focal hepatic lesions. Ultrasonography 2015;34:246–57.
Video-assisted mediastinoscopy (VAM) is the most commonly used invasive method for the preoperative mediastinal staging of lung cancer and for the diagnosis of other mediastinal diseases. However, VAM has the risk of causing life-threatening bleeding consequent to the specific mediastinal anatomy. We adopted the
ultrasonic technique for VAM biopsies that can easily distinguish the lymph nodes from the surrounding great vessels and thus makes the procedure easier and safer.
I
on all patients. Patients were maintained in the supine position. A small 2- to 3-cm incision was made in the neck approximately 2 cm above the breastbone. The pretracheal fascia just below the isthmus was incised after the muscles were separated. A passage was dissociated from the anterior space of the trachea by using the index finger. After evaluation of the surrounding tissue, VAM was introduced along the surface of the tracheal cartilage rings. 2. Next, by using a metal sucker through the channel of the mediastinoscope, blunt dissociation was performed until the inferior part of the bifurcation and carina of the trachea was reached. 3. Preparation of the ultrasonic probe: The main engine of the ultrasonic apparatus was the Pro Focus 2202 Ultrasound Scanner system with Laparoscopic Transducer Type 8666RF (BK Ultrasound, Peabody, MA) (Fig 1), and the apparatus underwent lowtemperature sterilization. 4. With the ultrasonic instrument, suspicious nodules and masses were examined in the following order: both sides of the trachea, the inferior carina, and near the main bronchus. The lymph nodes and their surrounding great vessels were clearly distinguished using ultrasound and color Doppler imaging, and the size of the lymph nodes was measured (Figs 2, 3). After the site was confirmed, the biopsy tissue was obtained using the sidewalls of the forceps based on the depth provided by the ultrasound image. During this process, the ultrasonic instrument can be applied to examine the thickness of the tissue and its surroundings to obtain the tissue as safely as possible.
n the recent past, video-assisted mediastinoscopy (VAM) has been the gold standard for diagnosing mediastinal lymph node conditions [1, 2]. Currently, the role of VAM in the staging of non–small cell lung cancer may need to be redefined in view of the development of positron emission tomography–computed tomography and ultrasound biopsy (eg, endoscopic ultrasonography [EUS], endobronchial ultrasonography [EBUS]). However, these techniques cannot yet provide an adequate diagnosis, and VAM is still the optimal method for detecting previously undiagnosed enlargement of mediastinal nodes and for investigation in patients who have negative results of EBUS or who require additional tissue biopsy. Thus, improving the safety of VAM is both useful and important because the procedure has a certain degree of risk related to the many large vessels around the mediastinal lymph nodes. Although the risk of hemorrhage is low [3], this complication is life-threatening, and most patients should undergo thoracotomy [4]. Thus, we performed VAM biopsy under the guidance of ultrasound imaging to reduce the risk of injury. This approach has proved successful and useful. The surgeon can make a clear distinction between the lymph nodes and surrounding tissue under the guide of an ultrasonic probe, which ensures that the biopsy is safe beyond the puncture.
Technique 1. A cervical VAM procedure using general anesthesia and a single-lumen endotracheal tube was performed
(Ann Thorac Surg 2016;102:e465–7) Ó 2016 by The Society of Thoracic Surgeons
Accepted for publication March 14, 2016. *Drs Miao and M. Li contributed equally to this work. Address correspondence to Dr H. Li, Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, 8 GongTiNanlu, Chao-Yang District, Beijing 100020, China; email: huilee@ vip.sina.com.
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Comment Compared with traditional mediastinoscopy, VAM biopsy is safe and effective and causes less severe 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.03.047
e466
HOW TO DO IT MIAO ET AL ULTRASOUND-GUIDED MEDIASTINOSCOPIC BIOPSY
Ann Thorac Surg 2016;102:e465–7
Fig 1. (A) and (B) The Pro Focus 2202 Ultrasound Scanner system with Laparoscopic Transducer Type 8666RF.
Fig 2. Ultrasound blood flow of lymph nodes. (A) 4L lymph nodes. (B) 4L lymph nodes after puncture.
Fig 3. Ultrasonic measurement and biopsy of mediastinal lymph nodes. (A) 2R lymph nodes. (B) Measurement. (C) Check after biopsy.
complications because of better visualization. Several vascular landmarks must be identified during the intraoperative period; however, they are not always easily viewed. Thus, before biopsy, it is necessary to determine whether the sample is a blood vessel and identify the circulation around the sample. Without evidence of the lymph node or the vessel behind it, the patient must undergo puncture for a test to reduce the risk of massive hemorrhage. This convenient method is effective, but it also has some limitations. If the target area is the aorta, then even a small puncture can increase the risk of bleeding. Although compression hemostasis is effective,
this step could prolong the time required for the operation and hinder the surgeon’s confidence. Furthermore, with a limited scope, a small amount of bleeding can affect visibility in the site. Moreover, because the field of view of mediastinum endoscopy is limited, it is difficult to master the angle and depth of the puncture needle when puncturing. The accuracy of puncturing thus could be affected. Overall, during the biopsy process, VAM also carries a small but critical risk of potentially significant complications, with morbidity rates between 0.6% and 3% and mortality rates from 0% to 0.3% [1, 5]. Although the rate of hemorrhage is between 0.1% and 0.6% [6], the risk
Ann Thorac Surg 2016;102:e465–7
to the patient is great because of the major vascular structures in the region, including the azygos vein, the brachiocephalic artery, the superior vena cava, and the pulmonary arteries. For this reason, hemorrhage often requires an immediate thoracotomy. Blood vessel injury during operation is one of the main limitations and complications of VAM. Reducing this risk is always the concern of the surgeon. Intracavitary ultrasonic technology has rapidly developed and is widely applied during surgical procedures [7]. Ultrasonic technology is simple and practical to use for distinguishing vessel and substantial tissue. We performed a lymph node biopsy using VAM-guided ultrasound in 10 patients, all of whom had successful surgical procedures. The average operation time was 1.0 0.4 hours, and none of the patients had any complications. We used the ultrasonic instrument during the operation, and it easily passed through the scope. The ultrasonic probe in the front could effectively check the mediastinal lymph nodes and vessel tissues. For the first 3 patients, we performed the ultrasonic check after conventional puncture before performing the biopsy. Although the histomorphologic features of the lymph node could be tested during the subsequent ultrasound examination, local bleeding caused by the puncture inside or outside the lymph nodes could interfere with the ultrasonic and color Doppler imaging. Thus, for the next 7 patients, we directly performed the ultrasonic test and biopsy after accurately ensuring the location, direction, size, and adjacent relationship of the lymph node without puncturing, with good results. The pathologic tests proved that the biopsy tissue was reliable. We initially used ultrasonic technology for VAM to probe lymph nodes (the 2, 4, 7 groups) and tissues. Preliminary results showed that this method accurately revealed substantial lesions in the mediastinum and
HOW TO DO IT MIAO ET AL ULTRASOUND-GUIDED MEDIASTINOSCOPIC BIOPSY
e467
clearly delineated the blood vessels adjacent to the lymph nodes. The limitation of this technique lies in the thick front end of the ultrasonic probe, which has weak flexibility and increases the difficulty of checking the overall status of the lymph nodes under the carina. This study was supported by the Basic and Clinical Cooperation Research Fund of China Capital Medical University (15JL39) and the Clinical Scientific Research Fund of Wu Jieping Medical Foundation (320, 6750, 15052). The authors wish to thank all the participating patients.
References 1. Wei B, Bryant AS, Minnich DJ, Cerfolio RJ. The safety and efficacy of mediastinoscopy when performed by general thoracic surgeons. Ann Thorac Surg 2014;97:1878–83. 2. De Leyn P, Dooms C, Kuzdzal J, et al. Preoperative mediastinal lymph node staging for non-small cell lung cancer: 2014 update of the 2007 ESTS guidelines. Transl Lung Cancer Res 2014;3:225–33. 3. Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011;142:1393–400. 4. Cho JH, Kim J, Kim K, et al. A comparative analysis of videoassisted mediastinoscopy and conventional mediastinoscopy. Ann Thorac Surg 2011;92:1007–11. 5. Defranchi SA, Edell ES, Daniels CE, et al. Mediastinoscopy in patients with lung cancer and negative endobronchial ultrasound guided needle aspiration. Ann Thorac Surg 2010;90: 1753–7. 6. Pop D, Nadeemy AS, Venissac N, Guiraudet P, Mouroux J. Late mediastinal hematoma followed by incisional metastasis after video-assisted mediastinoscopy. J Thorac Oncol 2010;5: 919–20. 7. Joo I. The role of intraoperative ultrasonography in the diagnosis and management of focal hepatic lesions. Ultrasonography 2015;34:246–57.