Ann Thorac Surg 2002;74:276-277
© 2002 The Society of Thoracic Surgeons
How to do it
Salinoma window technique for mediastinal lymph node biopsy
Brian W. Goodacre, MDa,
Clare Savage, MDb,
Joseph B. Zwischenberger, MDc,d*,
Gerhard R. Wittich, MDd,
Eric vanSonnenberg, MDe
a Medical Imaging, Victoria General Hospital, Victoria, British Columbia, Canada
b Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
c Department of Surgery, The University of Texas Medical Branch, Galveston, Texas, USA
d Department of Radiology, The University of Texas Medical Branch, Galveston, Texas, USA
e Department of Radiology, Brigham and Women’s Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
Accepted for publication February 4, 2002.
* Address reprint requests to Dr Zwischenberger, Division of Cardiothoracic Surgery, Department of Surgery, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0528 USA
e-mail: jzwische{at}utmb.edu
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Abstract
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Computed tomographic-guided transthoracic needle biopsy can access virtually all mediastinal lymph node stations, but is limited by the potential for pneumothorax and bleeding. To avoid these possible complications, the extrapleural "salinoma" technique was used for computed tomographic-guided mediastinal biopsies in 15 patients. Sampling methods were coaxial (8), tandem (5), and single pass (2). Diagnostic yield was 93% with no significant bleeding or pneumothorax. The salinoma technique permits biopsy of deep mediastinal lesions to stage pulmonary malignancies, while providing a technique that limits complications.
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Introduction
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Computed tomographic (CT)-guided transthoracic needle biopsy has the potential to access all mediastinal lymph node stations, with diagnostic yields up to 90%, precluding the need for more expensive and invasive procedures such as mediastinoscopy, video-assisted thoracoscopic surgery, or thoracotomy [1, 2]. Limitations to transthoracic mediastinal access include pneumothorax and bleeding. Pneumothorax is reported to occur in 10% to 60% of all patients, necessitating chest tube placement in 5% to 25% [1, 2]. Hemoptysis is noted in 5% to 10%. Severe hemorrhage or bleeding-related death is exceedingly rare, but has been reported with core biopsy [3]. Langen and colleagues [4] injected saline to displace mediastinal structures establishing an access route in 17 of 20 patients allowing single-pass core biopsies with 2 (12%) pneumothoraces. Rapid diffusion of saline into the surrounding tissues necessitated the single-pass biopsy be performed expeditiously before loss of the saline window [4]. We describe our experience with the salinoma technique to obtain extrapleural access, and avoid injury to blood vessels. Upon creation of a salinoma window, we performed CT-guided fine needle or core biopsy using single pass, tandem, or our preferred coaxial technique. Salinoma provides an unobstructed path for multiple biopsies, increasing diagnostic yield, while decreasing the occurrence of pneumothorax and bleeding.
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Technique
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Retrospective examination of 127 transthoracic mediastinal lymph node biopsies revealed 15 patients in whom the interventional radiologist elected to use the salinoma technique to create an extrapulmonary access route (13 patients), or displace vascular structures (2 patients) to increase the safety of CT-guided needle biopsy. A 22-gauge fine needle was advanced under CT guidance while 10 mL of saline was injected into the extrapleural space, creating a salinoma to displace the lung, pleura, or vascular structures. If a safe biopsy route was not created, additional saline was injected in 10-mL aliquots until a clear path was obtained. Upon creation of the salinoma, one of three techniques (single pass, tandem, or coaxial) was used for biopsy. Using the single-pass technique, the fine needle (20 or 22 gauge) was directly inserted through the chest wall, into the lesion, through the extrapleural/extravascular path created by the salinoma. For the tandem technique, the fine needle used to inject saline was advanced further into the lesion for localization. A second needle placed adjacent to the localizing needle obtained core or fine-needle biopsies, whereas the initial needle remained as a guide should further samples be required. For the coaxial technique, a removable hub system (Cook Inc, Bloomington, IN) allowed initial advancement of the 22-gauge localizing needle used for saline injection into the lesion, over which a 19-gauge guide needle was advanced (Fig 1).
Multiple fine needle aspiration (FNA) and core samples then were obtained through the fixed guide needle without risking loss of the saline window.
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Fig 1. Salinoma window technique for mediastinal lymph node biopsy. (A) Twenty-two-gauge needle at the anterior aspect of the pleural reflection in position to begin injecting saline, to allow extrapulmonary approach; (B) 22-gauge needle within the widened mediastinal space, after injection of 10 mL of saline, creating a safe window; (C) insertion of 22-gauge needle into the mass for localization; (D) 22-gauge needle fully advanced into mass with 19-gauge coaxial needle being advanced; and (E) 22-gauge needle withdrawn, allowing coaxial passes with a variety of intraluminal needles within the 19-gauge needle. (Bx = biopsy; FNA = fine needle aspiration.)
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In 13 of 15 (87%) patients, the salinoma created an extrapulmonary (11 of 13) or extravascular (2 of 2) biopsy route to the mediastinal target. Mean volume of injected saline was 38 mL (range, 10 to 170 mL). The coaxial technique was used in 8 of 15 biopsies, or 53%. The tandem technique (5 of 15 biopsies; 33%) and the single-pass technique (2 of 15 biopsies; 13%) were used less frequently. A diagnosis was made in 14 of 15 patients (93% diagnostic yield) with 12 of 14 malignant. All major lymph node stations were accessed. One nondiagnostic aspirate subsequently proved to be Hodgkin’s disease. Two patients in whom a tongue of the lung could not be displaced from the azygoesophageal recess by salinoma, underwent transpulmonary access with a 19-gauge guide needle permitting several coaxial biopsy needle passes. Both patients developed a tiny pneumothorax visible on CT scan, but not seen on postprocedure chest roentgenograms and did not require a chest tube.
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Comment
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Despite careful planning of the optimal needle route, complications from CT-guided transthoracic biopsy occur predominantly due to laceration of the pulmonary parenchyma (causing pneumothorax) or vessels (causing bleeding) [5]. Many mediastinal lesions have lung interposed between the chest wall and the biopsy target, necessitating a transpulmonary approach with transgression of the visceral pleura twice, risking pneumothorax. Salinoma can temporarily displace lung or vascular structures, creating a window of access for sampling mediastinal lymph nodes.
We have combined creation of a salinoma with the coaxial biopsy technique, permitting multiple samples to be obtained before the saline diffuses into adjacent tissues and the safe access route is lost. Once the biopsy pathway is secured with the guide needle, fine-needle and core biopsies can be obtained through it, increasing yield for histology, cytology, flow cytometry, or culture. With the single-pass approach, each salinoma may allow only a single biopsy, particularly if a delay ensues as the sample is being fixed and examined by a cytopathologist. If the initial tissue sample is inadequate, saline must be reinjected to obtain access for additional tissue. Similarly, with the tandem technique, biopsy is dependent on maintenance of the temporary salinoma access window. We use the coaxial technique, which allows multiple needle passes, for lesions that are small, difficult to access, or those that require more tissue for diagnosis (ie, infection or lymphoma). Our 13% rate of pneumothorax is similar to Langen and colleagues [4], but no patients required a chest tube.
Salinomas can displace lung parenchyma and small vessels from the biopsy needle path, minimizing the risk of pneumothorax and bleeding. Our combined use of salinoma and coaxial biopsy technique results in a high diagnostic yield from CT-guided FNA or core biopsy of major mediastinal lymph node stations, with a lower risk of complications than traditional image-guided methods, and decreased cost compared with surgical alternatives.
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References
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- Zwischenberger J.B., vanSonnenberg E., Alpard S.K., Goodacre B.W. Interventional radiology in the chest. In: Yim A.P.C., ed. Minimal access cardiothoracic surgery. Philadelphia: WB Saunders, 2000:388-397.
- Morrissey B., Adams H., Gibbs A.R., Crane M.D. Percutaneous needle biopsy of the mediastinum: review of 94 procedures. Thorax 1993;48:632-637.[Abstract/Free Full Text]
- Moore E.H. Needle-aspiration lung biopsy: a comprehensive approach to complication reduction. J Thorac Imaging 1997;12:259-271.[Medline]
- Langen H.J., Klose K.C., Keulers P., Adam G., Jochims M., Gunther R.W. Artificial widening of the mediastinum to gain access for extrapleural biopsy: clinical results. Radiology 1995;196:703-706.[Abstract/Free Full Text]
- Glassberg R.M., Sussman S.K., Glickstein M.F. CT anatomy of the internal mammary vessels: importance in planning percutaneous transthoracic procedures. AJR Am J Roentgenol 1990;155:397-400.[Abstract/Free Full Text]
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Abstract
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