Ann Thorac Surg 2002;74:1720-1723
© 2002 The Society of Thoracic Surgeons
How to do it
Biopsy of anterior mediastinal masses under local anesthesia
Erino A. Rendina, MDa*,
Federico Venuta, MDa,
Tiziano De Giacomo, MDa,
Anna Maria Ciccone, MDa,
Marco S. Moretti, MDa,
Mohsen Ibrahim, MDa,
G. Furio Coloni, MDa
a Division of Thoracic Surgery, Department of Surgery "Paride Stefanini," University of Rome "La Sapienza," Rome, Italy
* Address reprint requests to Dr Rendina, Division of Thoracic Surgery, Department of Surgery "Paride Stefanini," University "La Sapienza," Roma, Policlinico Umberto I, 00161 Rome, Italy
e-mail: erinoangelo.rendina{at}tin.it
Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
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Abstract
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Treatment of most primary mediastinal tumors is based on positive histological diagnosis; we describe a variation of anterior mediastinoscopy under local anesthesia. After infiltration with local anesthetic, a transverse skin incision is made in the second, third, or fourth interspace. The endothoracic fascia is incised vertically adjacent to the periosteum and a mediastinoscope is inserted in the mediastinum. Between 1995 and 2001, we have employed this technique in 46 patients with anterior mediastinal tumors. Histological diagnosis was obtained in all patients. Pneumothorax (2 patients) was drained by a tube removed at the end of the procedures. No other complications occurred and all patients were discharged from hospital within 24 hours. Mediastinoscopy under local anesthesia proved safe and effective for diagnosing anterior mediastinal tumors.
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Introduction
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The treatment of primary mediastinal tumors is based on positive histological diagnosis. In addition, mediastinal biopsy is indicated in the staging of lung cancer (N2–N3 factors) and for the diagnosis of lymphoproliferative disorders. The ideal technique should allow sampling of adequate tissue specimens with the lowest possible risk and discomfort to the patient. Mediastinoscopy, anterior mediastinotomy, and video-assisted thoracoscopic surgery (VATS) have all been used with specific indications [1] and good diagnostic yield even in an ambulatory setting [2]. After extensive use of those techniques, which require intubation and general anesthesia, we started using a variation of anterior mediastinoscopy under local anesthesia for lesions located in the anterior mediastinum.
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Patients and methods
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Patients
Between 1995 and June 2001, we have seen 46 patients (20 male, 26 female; age range 16 to 63 years, mean 40 years) with anterior mediastinal lesions. Thirty-two patients were symptomatic and 17 had evidence of severe compression of the airway. Tumor size and appearance ranged from large infiltrative tumor (patient 16) to small nodules within normal mediastinal tissue (Fig 1)
(patient 8). In 38 patients, the lesion was confined to the anterior mediastinum, while in 8, the middle mediastinum and paratracheal space was also involved. In 31 patients, anterior mediastinotomy was judged to be the only possible route for biopsy, whereas in 15, cervical mediastinoscopy or VATS could also be performed; however, anterior mediastinoscopy under local anesthesia was preferred because of reduced trauma, operating time, and operative risk.
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Fig 1. Computed tomography showing anterior mediastinal lymphoadenopathy in a patient with bronchogenic carcinoma.
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Surgical technique
The patient is placed supine on the operative table and the appropriate intercostal space is identified by palpation. In case of large masses compressing the airway, the patient can be placed in a semi-sitting position to relieve compression. Each patient receives 1 mg of Midazolam intravenously before entering the operating room.
The second, third, or fourth intercostal space on both sides can be approached, depending on the location and the extension of the lesion as shown by computed tomography. When selecting the intercostal space, it is important to consider that the mediastinoscope can be tilted upward and downward to reach different levels, but that would cause additional pain to the patient. The selected interspace is accurately palpated to identify with precision the sternal insertion of the inferior and superior costal cartilages, and, most importantly, the sternal margin between them. Infiltration with local anesthetic (10 cc of 2% xylocaine plus 10 cc of 5% bupivicaine) is carried out at this level, taking particular care to infiltrate the periosteum of the sternal margin. The tip of the needle is useful to precisely identify the sternal margin as well as to confirm, by intermittent aspiration, the presence of the underlying solid lesion. A transverse (1.5 to 2.0 cm) skin incision is made in the selected intercostal space; the medial end of the incision should be just medial to the sternal margin so that the latter can be readily exposed (Fig 2).
The fibers of the pectoralis major muscle are separated and the insertion of the intercostal muscle to the sternal margin is divided vertically by the cautery beside the bone. Adherence to the bone avoids injury to the internal mammary vessels which do not require exposure. The gap is now enlarged by a pledget dissector and the anterior mediastinum is entered. Proceeding obliquely in a lateral-medial direction prevents entering the pleural cavity (Fig 3).
Also, it allows palpating the mediastinum behind the sternum and it helps in identifying the tumor mass. Needle aspiration is also useful at this stage to rule out mediastinal vessels. If the tumor abuts the anterior chest wall, there is no need to insert the mediastinoscope in the mediastinum. After careful needle aspiration, multiple biopsies can be taken inserting the mediastinoscopic biopsy forceps directly through the incision. In case of smaller lesions within the mediastinal tissue (lymphnodes, small tumor nodules), the mediastinoscope is inserted and the dissection is carried out in the usual fashion. After frozen section histology confirms that the biopsy material is sufficient for diagnosis, the fibers of the pectoralis major muscle are approximated by one figure-of-eight suture, and the skin incision is closed. A control roentgenogram of the chest is taken and the patient can be discharged from hospital.
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Fig 2. Anterior mediastinotomy incisions. The skin incision extends over the sternal margin to facilitate the vertical incision of the intercostal muscles (dotted line).
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Results
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Histological diagnosis was obtained in all 46 patients (Table 1); in no patient did the incision have to be enlarged or converted to another technique. We had two complications (4.3%) and no mortality. In 1 patient, pneumothorax developed on the side of the operation and, in another patient, it occurred contralaterally. In neither patient did pneumothorax interfere with spontaneous breathing; it was treated by the insertion of a catheter through the surgical incision and was removed before leaving the operating room. No patient required intubation nor ventilatory assistance. Patients with severe compression of the airway tolerated the procedure well with no sequelae. Sixteen patients were discharged from hospital in the afternoon following the procedure, and 30 on the following morning, without need for pharmacological pain control.
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Comment
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Biopsy of anterior mediastinal masses can be performed by a variety of techniques [1] ranging from fine-needle aspiration biopsy (FNAB) [3] to surgical procedures allowing biopsy as well as resection [4]. It is, however, important to consider that the first priority in this setting is to provide positive histological diagnosis with the lowest possible risk. The "risk of the procedure" should be considered in a rather wider perspective in these patients; repeated biopsy because of inadequacy of the histological material delays the onset of therapy and increases the risk no less than a truly surgical approach or a prolonged hospital stay. In addition, anterior mediastinal lesions differ markedly from lung cancer, where FNAB is usually sufficient, because the diagnosis may be challenging and large tissue specimens are necessary. Therefore, an apparently less-invasive procedure may entail an increased overall risk when compared to surgical biopsy.
Core needle biopsy (CNB) may provide sufficient material for histology and immunohistochemistry with a diagnostic accuracy of approximately 80% [5]. Data in the literature indicate that CNB may be an alternative to standard surgical techniques, although a second biopsy should be anticipated in as much as 20% of patients. Higher accuracy may be expected for large lesions, but CNB can be hazardous as well as inaccurate for small nodules. Whether CNB should be occasionally considered preferable is a matter of personal choice; in general, we prefer the exposure of a truly surgical approach.
The operation itself is not new [6, 7], yet it has the advantage of being feasible under local anesthesia without limitations of its versatility and indications. Spontaneous breathing and potential patient motion were not a problem in our series. Key points to our technique are the accuracy in assuring hemostasis and adherence to the sternal margin; this prevents injury to the internal mammary vessels and mediastinal pleura. The opening through the chest wall invariably seems too small at this stage, but the access can safely be enlarged once the mediastinal tissue is identified.
An important subset of patients with anterior mediastinal masses have severe compression of the airway, usually not only limited to the trachea but also extended to the main bronchi. In these patients, induction of general anesthesia and myorelaxation may cause dramatic airway collapse distal to the end of the endotracheal tube. We believe that mediastinal biopsy under local anesthesia should be considered the procedure of choice in these patients.
Our experience shows that the surgical biopsy of anterior mediastinal lesions can be performed under local anesthesia through an intercostal parasternal access. The advantages of this technique over needle biopsy are better control and exposure of the tumor, larger biopsy specimens, and 100% diagnostic yield with only moderately increased invasiveness. On the other hand, the approach which we have used is evidently less traumatic than the standard surgical techniques while yielding comparable results.
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Discussion
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DR F. GRIFFITH PEARSON (Mansfield, Ontario, Canada): Doctor Rendina, I enjoyed your paper and very clear presentation.
The whole technique described here brings me back many years to our early days with mediastinoscopy, and use of a very similar approach to the anterior mediastinum for the specific investigation of patients with primary lung cancer in the left upper lobe and left hilum. You made note of the use of anterior mediastinotomy for N2 disease, and I do not know that we ever specifically published or described the technical approach that we used in those patients. These cases were obviously initially done under general anesthesia, and most or all of them in those days would have had a mediastinoscopy first. If the mediastinoscopy was found to be negative, we then made that very same little incision in the second or third intercostal space, divided the muscle, just as you did, staying right against the lateral margin of the sternum and avoiding the internal mammary vessels. We stayed out of the pleural space, and the only difference in technique was that we used an index finger to palpate the anterior mediastinum before introducing the mediastinoscope for biopsy. In these cases, of course, we were looking for nodes. Subsequently, we did use this approach many times for evaluation and biopsy of anterior mediastinal tumors—thymoma, lymphoma, and other mediastinal lesions—and would select the level of the interspace or the side, depending entirely on location, as you have described. Most of my own cases were done under general anesthesia, maybe more from habit than anything else in earlier years. I am sitting here today beside Dr Tom Todd, who told me that he used this technique fairly frequently in patients with compression of their upper airway; he did it under local anesthesia in order to obviate the problem of airway obstruction under general anesthesia. He was obviously very happy with it. There is no question that it provides easy access and an infinitely more certain biopsy than a needle; it is safe, and it seems to me preeminently logical that you are doing these under local anesthesia and achieving a short hospital stay—particularly in the patients with airway tracheal compression.
I really enjoyed the paper. Thank you.
DR RENDINA: Thank you, Dr Pearson. I am pleased with your interest and honored.
This technique not only has no claim for technical originality, but I have learned now that it has no originality whatsoever, even for the indication. As a matter of fact, we started using this technique precisely because we were very alarmed by complications that we had in 2 patients who had huge tumors compressing the airway. We found that putting them in a semi-sitting position on the operating table, and doing the biopsy as quickly as we could under local anesthesia, would prevent all the harm and risk to the patient of myorelaxation. Other than that, I am pleased to acknowledge that you have found the extensive use of this procedure under local anesthesia interesting and indicated in several patients. Thank you.
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References
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- Rendina E.A., Venuta F., De Giacomo T., et al. Comparative merits of thoracoscopy, mediastinoscopy and mediastinotomy for mediastinal biopsy. Ann Thorac Surg 1994;57:992-995.[Abstract]
- Venuta F., Rendina E.A., Pescarmona E., et al. Ambulatory mediastinal biopsy for hematologic malignancies. Eur J Cardiothorac Surg 1997;11:218-221.[Abstract]
- Moinuddin S.M., Lee L.H., Montgomery J.H. Mediastinal needle biopsy. AJR Am J Roentgenol 1984;143:531-532.[Abstract/Free Full Text]
- Kern J.A., Deniel T.N., Trible C.G., et al. Thoracoscopic diagnosis and treatment of mediastinal masses. Ann Thorac Surg 1993;56:92-96.[Abstract]
- Ben-Yehuda D., Polliack A., Okon E., et al. Image-guided core needle biopsy in malignant lymphoma: experience with 100 patients that suggests the technique is reliable. J Clin Oncol 1996;14:2431-2434.[Abstract]
- McNeill T.M., Chamberlain J.M. Diagnostic anterior mediastinotomy. Ann Thorac Surg 1966;4:532-539.[Medline]
- Kirby T.J., Fell S.C. Mediastinoscopy. In: Pearson F.G., Deslauriers J., Ginsberg R.J., et al. , eds. Thoracic surgery. New York: Churchill Livingstone, 1995:835-840.
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Abstract
Introduction
