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Ann Thorac Surg 1996;62:352-355
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Staging of Primary Lung Cancer by Computed Tomography-Guided Percutaneous Needle Cytology of Mediastinal Lymph Nodes

Departments of Respiratory and Cardiovascular Surgery and Internal Medicine, Niigata Cancer Center Hospital, Niigata, Japan

Accepted for publication March 14, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. The necessity of an easy and noninvasive technique to evaluate mediastinal node status cytopathologically is considered.

Methods. Eighteen cases of clinical N2 primary lung cancer were examined. Under local anesthesia, the lymph node was punctured with a 19-gauge needle using intermittent computed tomographic monitoring, and samples were studied cytologically. Subcarinal (no. 7) nodes and lower paratracheal (no. 4) nodes were sampled using the paraspinal posterior approach. Anterior mediastinal (no. 6) nodes were sampled using the parasternal anterior approach. Node status was diagnosed pathologically at operation.

Results. Number 7 nodes were examined in 11 cases, no. 4 nodes in 5 cases, and no. 6 nodes in 2 cases. Malignant cells were detected in 14 cases. Fourteen cases were diagnosed as true positive, 2 cases as true negative, and 2 cases as false negative. The sensitivity, specificity, and accuracy of this method were 88%, 100%, and 89%, respectively. Pneumothorax developed in 4 cases (22%).

Conclusions. Computed tomography-guided percutaneous needle cytology of mediastinal lymph nodes is useful for staging primary lung cancer. Because this is a small series, additional studies are necessary.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
In primary lung cancer, it is very important to establish the TNM stage for deciding operability. Node status in particular is directly connected with the prognosis. Many reports say that operation for N2 disease produces a low survival rate, and the prognosis is worse in those cases diagnosed preoperatively by mediastinoscopy [1–3]. Because surgical resection after induction chemotherapy is recommended instead of operation alone for N2 cases, accurate diagnosis of node status preoperatively is necessary. From the viewpoint of easiness and noninvasiveness, we have chosen computed tomography (CT) as the guidance for percutaneous needle cytology of mediastinal lymph nodes. We describe the technique and the results of this procedure for staging primary lung cancer.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Each patient had primary lung cancer diagnosed pathologically by bronchoscopic biopsies or percutaneous needle biopsies and had enlarged mediastinal lymph nodes (>12 mm in short-axis diameter) detected by chest CT. All patients provided informed consent before the examination.

After supine or prone positioning, CT was performed with a 2-mm thickness and a 3-mm interval. A paraspinal posterior approach in the prone position was selected for subcarinal (no. 7), right upper paratracheal (no. 2R), and right lower paratracheal (no. 4R) nodes; a parasternal anterior approach in the supine position was used for anterior mediastinal (no. 6), left upper paratracheal (no. 2L), left lower paratracheal (no. 4L), and aortopulmonary (no. 5) nodes (Fig 1). Mediastinal nodes were numbered according to the nodal classification of the American Thoracic Society [4]. On the monitoring view, the depth and angle of the lymph node from the chest wall were calculated, and the appropriate (9, 12, or 15 cm) 19-gauge needle was chosen. Under local anesthesia, the needle was directed through the intercostal space toward the lymph node using intermittent CT monitoring. When the needle was confirmed at the lymph node, sampling was performed. After removing the stylet, the lymph node was brushed by a Tokyo Medical University needle and aspirated with a 10-mL syringe. The material was sent for cytologic examination. To diagnose pneumothorax, we checked the CT again at the end of the examination, and a chest roentgenogram was performed the next day.

View larger version (53K): [in this window] [in a new window]   Fig 1. . Schema of computed tomography shows the location of mediastinal lymph nodes (solid circles) and the approach to puncture these lymph nodes. Numbers 2R, 4R, and 7 nodes can be punctured through a paraspinal posterior approach. Numbers 2L, 4L, 5, and 6 nodes can be punctured through a parasternal anterior approach. The name of nodal station is referred to in the text. (Ao = aorta; BCA = brachiocephalic artery; BCV = brachiocephalic vein; CCA = common carotid artery; lt = left; MB = main bronchus; PA = pulmonary artery; rt = right; SCA = subclavian artery; SVC = superior vena cava; Tr = trachea.)

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

View larger version (29K): [in this window] [in a new window]   Fig 2. . Computed tomograms of a subcarinal node show the needle (large arrow) puncturing the subcarinal node (short arrow) through a paraspinal posterior approach.

View larger version (39K): [in this window] [in a new window]   Fig 3. . Computed tomograms of a right lower paratracheal node show the needle (large arrow) puncturing the paratracheal node (short arrow) through a paraspinal posterior approach.

View larger version (45K): [in this window] [in a new window]   Fig 4. . Computed tomograms of an anterior mediastinal node show the needle (large arrow) puncturing the anterior mediastinal node (short arrow) through a parasternal anterior approach.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Pathologically, N2 primary lung cancer has a poor prognosis even if postoperative chemotherapy is performed [2]. As the necessity of induction chemotherapy has been reported recently [5, 6], the evaluation of mediastinal node status is important. We performed CT-guided percutaneous needle cytology of mediastinal lymph nodes as a relatively noninvasive and easy procedure for these evaluations. Although CT-guided percutaneous needle biopsy is an established procedure for the diagnosis of mediastinal tumors [7, 8], there are no reports of this technique for the diagnosis of metastatic mediastinal lymph nodes.

There are several merits to this technique. First, using a paraspinal posterior approach, nos. 2R, 4R, and 7 nodes can be examined, and using a parasternal anterior approach, nos. 2L, 4L, 5, and 6 nodes can be examined. Although we did not have a chance to examine any other mediastinal lymph nodes, in this series, sampling of almost all mediastinal lymph nodes would be feasible using both the posterior and anterior approaches. Second, enlarged mediastinal lymph nodes are well detected by plane thin-slice CT monitoring, even in obese patients. Intermittent CT monitoring makes needle puncture of the lymph node easy. Third, this method is performed under local anesthesia noninvasively.

The disadvantage of this technique is the occurrence of pneumothorax. Although this complication occurred in 4 cases (22%), the rate of this complication is acceptable because these cases were easily treated conservatively. However, one must be careful not to overlook the possibility of pneumothorax after the examination. Bleeding or hemoptysis, another possible complication, did not occur in our cases. Although the internal thoracic artery was detected through thin-slice CT on examination of the no. 6 node, some reports refer to color Doppler ultrasonographic imaging as appropriate guidance to avoid vascular injury [9]. Chest-wall implantation of cancer after percutaneous needle biopsy is a rare complication [10].

There are many procedures to evaluate mediastinal node status. Although CT is the most common staging procedure, its sensitivity ranges widely from 50% to 90%, and specificity and accuracy are about 80% [11, 12]. Because CT has a low positive predictive accuracy (true positive/true positive + false positive), which is about 70%, when compared with its high negative predictive accuracy (true negative/true negative + false negative) [11, 12], pathologic evaluation of enlarged mediastinal lymph nodes will be necessary. Although enlarged lymph nodes that were actually not metastatic in our 2 cases might have been evaluated accurately with CT combined with mediastinoscopy, CT examination alone may not be enough to diagnose accurately as CT is no more than a procedure for evaluating node station morphologically. As a diagnostic procedure, mediastinoscopy has high sensitivity, specificity, and accuracy [13]. However, this examination requires general anesthesia, is quite invasive, and causes severe adhesion of mediastinal structures, which makes it difficult to dissect lymph nodes at pulmonary resection. Furthermore, access to no. 7 lymph nodes is difficult by mediastinoscopy. Although biopsy of mediastinal lymph nodes under thoracoscopy has been performed recently, this procedure also requires general anesthesia [14]. A preoperative staging examination should be minimally invasive and performed under local anesthesia. Although transbronchial needle aspiration cytology is a good procedure and is performed under local anesthesia, it is difficult except for the no. 7 lymph nodes [15]. Cervical and supraclavicular lymph nodes are easily detected by ultrasonography [16], but this method is not suitable for the diagnosis of intrathoracic tumors. Transesophageal ultrasound-guided needle aspiration biopsy is another new technique to evaluate mediastinal node status cytologically under local anesthesia, and this technique is useful for selected patients [17].

As for the cytologic diagnosis, some problems occur in its process. When the cytologic examination is negative for malignant cells, either the lymph node was not metastatic or the sample was inadequate. Although several punctures may decrease the false-negative rate, the test becomes increasingly invasive. An additional technique to improve sampling would be helpful. Those patients suspected of N2 disease with negative results by our method should receive the next procedure, ie, biopsy of lymph nodes using mediastinoscopy or thoracoscopy. Because the 2 false-negative cases by our method might be evaluated accurately with mediastinoscopy, it is reasonable to perform mediastinoscopy only for negative cases. This process would be less invasive for evaluating node status for most cases compared with performing mediastinoscopy for all cases.

As for the cost, this examination carries a small rate of complications and is less expensive than mediastinoscopy, which requires general anesthesia. Although we performed this procedure only for inpatients, it is possible to examine outpatients to reduce costs further.

This method is feasible for many mediastinal lymph nodes using both the anterior and posterior approaches and is easily performed under local anesthesia. The rate of pneumothorax, the main complication, is acceptable. This method appears very useful for staging primary lung cancer. Because this is a small series, we hope that this examination will be tested in other institutions.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We acknowledge Dr Akira Yokoyama for his helpful suggestions.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Akamatsu, Department of Cardiothoracic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113, Japan.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Akamatsu, H. Articles by Kurita, Y. Search for Related Content PubMed PubMed Citation Articles by Akamatsu, H. Articles by Kurita, Y.