Ann Thorac Surg 2000;70:318-319
© 2000 The Society of Thoracic Surgeons
How to do it
Thoracoscopic localization of nonpalpable rib tumors for excisional biopsy
Jerome M. McDonald, MDa,
Richard K. Freeman, MDa
a Department of Surgery, Bremerton Naval Hospital, Bremerton, Washington, USA
Address reprint requests to Dr Freeman, Division of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235
e-mail: rkfreeman{at}pol.net
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Abstract
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Nonpalpable tumors of the rib can be difficult to localize accurately at the time of excisional biopsy. Furthermore, the ability of current imaging techniques to assess pleural or pulmonary involvement is not reliable. An intraoperative localization method using single port thoracoscopy is discussed which allows optimal placement of a biopsy incision and provides an accurate assessment of any tumor invasion into the adjacent pleura or lung.
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Introduction
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Primary bone tumors of the chest wall originate from a rib in 85% of cases [1]. Because the incidence of malignancy in such rib lesions approaches 90%, excisional biopsy is considered the preferred method of diagnosis [2]. However, the excisional biopsy of nonpalpable, posterior-based rib tumors can present a challenge. Such tumors are often difficult to localize topographically and their extension into adjacent structures such as the pleura and lung is not reliably predicted by modern imaging modalities [3]. This report describes our experience using single port video thoracoscopy to localize nonpalpable rib tumors at the time of excisional biopsy.
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Technique
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After the induction of anesthesia using a double lumen endotracheal tube, patients undergoing excisional biopsy of a nonpalpable rib tumor are positioned in a modified lateral decubitus position allowing access to the entire anterolateral or posterolateral hemithorax depending on the location of the lesion (Fig 1). After the initiation of single lung ventilation, a 15 mm thoracoscopic port is inserted into the pleural space through the sixth intercostal space in the midaxillary line. Using a 30-degree thoracoscope and video camera, the chest wall tumor is inspected and any involvement of the adjacent pleura or lung is assessed. The tumor is then transilluminated allowing the biopsy skin incision to be made with extreme accuracy. Muscles overlying the tumor are split in the direction of their fibers to expose the affected rib. Direct observation using the thoracoscope during excision of the mass ensures adequate margins of resection and avoids injury to the unaffected pleura.
If the tumor is found to involve a portion of adjacent pleura, the lesion and pleura are resected in continuity. Similarly, lung that is found to be densely adherent to the tumor is resected en bloc with a portion of parietal pleura. This is readily accomplished by performing a pulmonary wedge resection using thoracoscopic stapling devices after placement of a second 20 mm thoracoscopic port.
After excision of the tumor and all involved structures, a 20F straight chest tube is placed into the pleural space through the port incision in the midaxillary line. Suction is applied to the tube as the biopsy incision is closed in layers with absorbable suture. The ipsilateral lung is then inflated and the chest tube withdrawn on suction before termination of anesthesia. If the pleura is violated during the resection or if a pulmonary resection is required, the chest tube is left in place in the immediate postoperative period.
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Results
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Since 1994, thoracoscopic localization has been used as an adjunct to excisional biopsy in 5 patients with posterior, nonpalpable tumors of the chest wall originating from a rib. Patients were treated at Bremerton Naval Hospital (Bremerton, WA). Mean patient age was 25.6 ± 8 years (range, 18 to 35 years) and included 4 men. All of the lesions were well visualized through the parietal pleura using the thoracoscope. Transillumination of the mass altered the skin incision site predicted by imaging studies in 4 of 5 cases. Involvement of the underlying pleura and lung occurred in 1 patient. This was well visualized by the thoracoscope allowing for an en bloc resection but had not been identified by preoperative magnetic resonance or computed tomographic imaging.
Mean operative time for the series was 48 ± 27 minutes (range, 28 to 95 minutes). Histologic evaluation of the specimens revealed chondroma (2), osteochondroma (1), chondrosarcoma (1), or osteosarcoma (1) with all resection margins free of tumor. Only the patient who underwent a pulmonary wedge resection required a tube thoracostomy postoperatively resulting in a hospital stay of 2 days. All other patients were discharged home the day of the surgical procedure. There were no readmissions, significant complications, or operative mortalities in this series of patients.
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Comment
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Nonpalpable chest wall tumors originating from a rib can be difficult to localize topographically at the time of excisional biopsy. Inappropriately placed skin incisions resulting in the violation of extraneous tissue planes or the underlying pleura can compromise exposure, result in incomplete tumor excision, and significantly complicate a subsequent wide local excision if required [4]. Furthermore, tumor extension into the adjacent pleura or lung is not reliably predicted from current imaging techniques. Other techniques have been utilized including methylene blue injection from skin down to periosteum at the target lesion using nuclear medicine-guided bone scan and gamma probe-directed biopsy [5, 6]. These techniques are particularly effective if the rib abnormality is only visualized on bone scan, however, both require coordination with nuclear medicine on the day of operation. Additional difficulties with these techniques include methylene blue diffusion, requiring prompt excision of the rib, and only subtle differences in the "hot spot" activity compared with background with the gamma probe-directed biopsy.
Single port video thoracoscopy can minimize many of the technical challenges associated with the excisional biopsy of nonpalpable rib tumors. By localizing and transilluminating the lesion, this technique allows a small, accurate biopsy incision to be made. Direct visualization also allows for immediate recognition of the involvement of adjacent structures and, in the case of tumor extension into the lung, provides a method for accomplishing an en bloc resection. The ability to observe the tumor during resection also ensures excision of the entire tumor with adequate margins and avoids injury to the unaffected pleura. This often eliminates the need for a postoperative tube thoracostomy, allowing the majority of procedures to be performed without overnight admission to the hospital.
Although the thoracoscopic ports used in these patients were 15 and 20 mm in size, 5 mm 30-degree thoracoscopes are now readily available and could be used through a 5 mm port, generating less postoperative pain and scarring from the port site.
In summary, the addition of single port thoracoscopic localization to the excisional biopsy of nonpalpable rib tumors appears to be both safe and effective. By improving visualization of the lesion and its adjacent structures, complete tumor excision is ensured and hospital length of stay, morbidity, and mortality are not increased. Extrapolation of the potential benefits of this technique to other tumors of the chest wall continues to be investigated.
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References
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Accepted for publication January 13, 2000.
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Abstract
Introduction
