Ann Thorac Surg 2000;69:1255-1257
© 2000 The Society of Thoracic Surgeons
CASE REPORTS
Cervical mediastinoscopy incisional metastasis
Medhat Al-Sofyani, MDa,
Donna E. Maziak, MDCMa,
Farid M. Shamji, MDa
a Division of Thoracic Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
Address reprint requests to Dr Maziak, Ottawa Hospital—Civic Campus, 1053 Carling Ave, CPC Room 162, Ottawa, ON, Canada K1Y 4E9
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Abstract
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Tumor deposit in the cervical mediastinoscopy incision is a rare complication of this operation when it is done to stage lung cancer. The etiology of this complication remains unclear. We present the case of a patient with this condition, discuss the cause and management, and review the literature.
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Introduction
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Cervical mediastinoscopy has become a routine staging operation for the assessment of mediastinal nodes in lung cancer. One of the rare complications of mediastinoscopy is tumor metastasis in the neck incision. We report such a case and review the literature.
A 51-year-old man was seen with cough, hemoptysis, and fatigue. Chest roentgenographic examination revealed a right lower lobe mass. A computed tomographic scan of the chest confirmed the presence of a 6 x 6 cm mass in the right lower lobe abutting the minor fissure and the absence of mediastinal lymphadenopathy. Metastatic workup included a computed tomographic scan of the head, a computed tomographic scan of the abdomen, and a bone scan, all of which were negative. Flexible bronchoscopy revealed an endobronchial tumor at the origin of the right lower lobe bronchus. Biopsy results and brushings were consistent with large cell carcinoma. At staging cervical mediastinoscopy, a biopsy specimen from the right tracheobronchial lymph node was negative for malignancy.
At the time of resection, the tumor in the right lower lobe was found to involve the middle lobe and the inferior pulmonary vein, thus necessitating a right pneumonectomy. The tumor proved to be undifferentiated large cell carcinoma. Subcarinal lymph nodes were resected and showed absence of tumor involvement. However, on histologic examination, the subcarinal fatty tissue contained tumor cells. The postoperative recovery was uneventful, and the patient was discharged home on the tenth postoperative day. Because of tumor deposit in the subcarinal fatty tissue, the stage was upgraded to IIIA, and adjuvant chemotherapy and radiotherapy were planned.
Two months after cervical mediastinoscopy and after the patient had received the first cycle of cisplatin-based chemotherapy, a 1.2 x 1.0-cm lesion was noted along the superior aspect of the cervical mediastinoscopy scar. The results of fine-needle aspiration biopsy were negative for malignancy. The lesion was excised with the patient under local anesthesia, and a diagnosis of metastatic large cell carcinoma was made on histologic examination. The thoracotomy had healed well.
The patient finished four cycles of cisplatin-based chemotherapy and received 4,000 cGy to the right hemithorax and mediastinum, including the area surrounding the cervical mediastinoscopy incision. Both chemotherapy and radiotherapy were well tolerated by the patient, and there were no serious complications. Fifteen months after pneumonectomy, the patient shows no evidence of local recurrence or distant metastasis.
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Comment
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Cervical mediastinoscopy is routinely done for staging lung cancer. A rare complication of this operation is tumor deposit in the incision. In a metaanalysis of cervical mediastinoscopy cases, incisional deposit occurred in eight of 6,490 cases, an incidence of 0.12% [1].
The mechanism remains uncertain. Direct implantation of malignant cells in the cervical mediastinoscopy tract at the time of biopsy seems a reasonable explanation, but it does not explain the cause of metastasis arising after negative mediastinoscopies, as in our patient and the patient of Hoitsma and colleagues [2]. Other possible explanations include lymphatic dissemination and hematogenous spread followed by implantation in the hyperemic wound in the early stages of healing.
A review of the literature showed that four studies [2–5] have discussed the management of five cases of cervical incisional metastasis (Table 1). Adenocarcinoma was reported as the primary lung cancer in 2 patients, squamous cell carcinoma in 2, and small cell carcinoma in 1 patient. Three patients had stage IIIA disease at mediastinoscopy; 1 patient had stage II disease; and for 1, the stage was not given. Cellular differentiation was reported twice: it was moderate in 1 of the patients and poor in the other. For all 3 patients with stage IIIA disease at mediastinoscopy, there was no information about the location of the lymph nodes sampled at biopsy. In the case report of Rate and Solin [4], cervical mediastinoscopy was performed 52 months after lobectomy because of bilateral lung infiltrates and mediastinal lymphadenopathy on computed tomographic scan. Three patients received radiation therapy as definitive treatment of the primary lung cancer [3, 5]. The radiation field did not include the neck incision in 2 of them [5], and the exact radiation field was not mentioned for the other [3]. Of these patients, 1 received adjuvant chemotherapy [5].
The time interval from cervical mediastinoscopy to appearance of the tumor nodule in the incision ranged between 6 and 24 weeks (mean, 13.4 weeks) [2–5]. The treatment of the tumor deposit in 4 of the 5 patients was local radiation therapy [3–5]. One patient received chemotherapy as well [5], and for 1 patient, the treatment was not mentioned [2]. Hoyer and associates [5] did not discuss the outcome of treatment in their first patient, and that patient was lost to follow-up. Their other patient was receiving chemotherapy and radiotherapy when the nodule was noticed. The nodule disappeared with the second cycle of chemotherapy, and the patient received additional radiotherapy to the area. No follow-up was provided. Sullivan and Passamonte [3] found that the nodule in their patient initially disappeared in response to radiation therapy but recurred 5 months after local radiation treatment. Rate and Solin [4] reported that in their patient, the nodule partially responded with a reduction in size, but the patient died of metastatic disease.
In summary, in this small series, it seems that neither the pathologic cell type of the primary lung cancer nor the degree of cellular differentiation has any relationship to the development of cervical mediastinoscopy incisional metastasis. Whether or not there is a connection between the stage of the disease and this condition remains unclear. In our patient, excision of the tumor nodule in the neck incision combined with adjuvant radiation therapy to the area appears to have controlled the local disease. Whether recurrence at the cervical mediastinoscopy scar signifies a more aggressive tumor is yet to be determined.
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References
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Ashbaugh D.G. Mediastinoscopy. Arch Surg 1970;100:568-573.[Abstract/Free Full Text]
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Hoitsma H.F., Tjho E.T.T., Cuesta M.A. A late complication of a diagnostic mediastinoscopy. Thorax 1978;33:115-116.[Abstract/Free Full Text]
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Sullivan W.D., Passamonte P.M. Mediastinoscopy incision site metastasis. South Med J 1982;75:1428.[Medline]
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Rate W.R., Solin L.J. Mediastinoscopy incision metastasis. Cancer 1989;63:68-69.[Medline]
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Hoyer E.R., Leonard C.E., Hazuka M.B., Wechsler-Jentzsch K. Mediastinoscopy incisional metastasis. Cancer 1992;70:1612-1615.[Medline]
Accepted for publication September 30, 1999.
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Invited commentary
- John R. Benfield
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Abstract
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