Ann Thorac Surg 2005;79:1780-1782
© 2005 The Society of Thoracic Surgeons
Case report
Videopericardioscopy Using Endothoracic Sonography for Lung Cancer Staging
Kiyoshi Ohno, MD*,a,
Tomoki Utsumi, MDa,
Yoshiaki Sasaki, MDb,
Yuko Suzuki, MDb
a Department of Surgery, Osaka, Japan
b Department of Internal Medicine, Osaka Kosei-Nenkin Hospital, Osaka, Japan
Accepted for publication October 24, 2003.
* Address reprint requests to Dr Ohno, Department of Surgery, Osaka Kosei-Nenkin Hospital, 4-2-78, Fukushima, Fukushima-ku, Osaka 553-0003, Japan
ok8926{at}okn.gr.jp
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Abstract
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We performed videopericardioscopy using an endothoracic sonographic probe for the staging of left hilar nonsmall cell lung cancer. This method will be useful for an accurate diagnosis of direct tumor invasion into the intrapericardial great vessels and lead to the institution of appropriate treatment.
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Introduction
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Accurate staging is fundamental to institution of appropriate treatment for nonsmall cell lung cancer. The accuracy of diagnostic imaging techniques (ie, computed tomography or magnetic resonance imaging, or both) remains unsatisfactory. Video-assisted thoracoscopy is generally useful for the determination of T factors, but it is inadequate for diagnosing direct invasion of huge hilar masses into the intrapericardial great vessels. Accordingly, we performed transthoracic videopericardioscopy using endothoracic sonography for hilar lung cancer staging.
A 63-year-old man with a chief complaint of coughing visited our hospital, because a chest roentgenogram had detected a left hilar mass shadow. Enhanced chest computed tomographic scan showed a 35 x 25 mm left hilar mass shadow adjacent to the pulmonary arterial trunk and left pulmonary artery (Fig 1). The left tracheobronchial lymph node was swollen with a short diameter of 1 cm or more. Bronchoscopic biopsy at the orifice of the upper bronchus revealed squamous cell carcinoma. Brain magnetic resonance imaging, bone scintigram, and upper abdominal computed tomography showed no evidence of metastasis. The clinical stage was T4N2M0 and IIIB. The patient was admitted for more accurate staging and evaluation of the tumor resectability. Standard cervical mediastinoscopy under general anesthesia revealed a metastasis in a left tracheobronchial lymph node (single station N2). Bilateral scalene lymph node biopsies simultaneously performed at mediastinoscopy were negative. Then video-assisted thoracoscopy was performed to investigate the direct tumor invasion into the intrapericardial great vessels. Three port-access incisions were used at the left sixth intercostal space on the anterior axillary line for thoracoscopy, the left fourth intercostal space on the parasternal line, and the fourth intercostal space on the anterior axillary line. The diameters of thoracoports used were 12, 12, and 5 mm. A hilar tumor mass adjacent to the pericardium was found by thoracoscopy, but the existence of intrapericardial tumor invasion was unclear. A small opening was made in the pericardial sac just over the pulmonary arterial trunk using electrocautery. The incision was enlarged with endoforceps and endoshears to approximately 5 cm toward the pulmonary arterial bifurcation. The pulmonary arterial trunk proved to be free of tumor invasion. Traction was applied to the pericardial margin, and the thoracoscope was introduced to determine the resectability of the left pulmonary artery. The intrapericardial left pulmonary artery also seemed to be intact, but it was unclear whether there was tumor invasion into the posterior wall of the pulmonary artery. Therefore, an endothoracic sonographic probe was inserted through the thoracoport at the left fourth intercostal space on the parasternal line (Fig 2). An Aloka SSD-2000 (Aloka, Tokyo, Japan) apparatus was used at a frequency of 7.5 MHz. The probe included a linear type I (intraoperative electronic linear probe UST-5536-7.5). Ultrasonography revealed the left pulmonary artery to be free of tumor invasion, because the presence of a repeated contraction and dilation of the left pulmonary artery showed synchronization with a cardiac rhythm (Fig 3).
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Fig 1. Computed tomographic scan shows possible tumor invasion of the pulmonary arterial trunk and left pulmonary artery. (T = tumor.)
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Fig 2. Left videopericardioscopy demonstrates no tumor (T) invasion of the pulmonary arterial trunk (PATr). Endothoracic sonographic probe (ESP) evaluating tumor invasion of the left pulmonary artery.
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Fig 3. Endothoracic sonography shows no tumor invasion of the pulmonary arterial trunk (A) and the left pulmonary artery (B). (AAo = ascending aorta; DAo = descending aorta; Lt PA = left pulmonary artery; PATr = pulmonary arterial trunk.)
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The clinical stage was T2N2 (single station N2) M0, and IIIA. We have performed induction chemoradiotherapy before surgery for patients with mediastinoscopy-proven multilevel N2 and positive scalene lymph node biopsy. As treatment, the left pneumonectomy with lymphadenectomy was selected rather than induction chemoradiotherapy. The postoperative course was uneventful. The postoperative pathologic stage was p-t2n2 (left tracheobronchial lymph node metastasis) m0, and IIIA.
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Comment
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Recently trials of combined modality treatment including induction chemotherapy or chemoradiotherapy followed by surgery have been performed for selected stage III nonsmall cell lung cancers [1–3]. For evaluation of the therapeutic effects, accurate staging in the pretreatment period is necessary. However, the accuracy of diagnostic imaging techniques such as computed tomography and magnetic resonance imaging remain unsatisfactory.
We have performed mainly mediastinoscopic lymph node biopsies and bilateral scalene lymph node biopsies to evaluate the N factors, and we have used video-assisted thoracoscopy to determine the T factors.
Video-assisted thoracoscopy is of great value in diagnosing mediastinal lymph node metastasis when mediastinoscopy is not feasible, and also in diagnosing T4 factors such as cytology-negative pleural effusion, tumor invasion into mediastinal tissue, and intrapulmonary metastasis in the same lobe as the main tumor. Unfortunately, on the other hand, video-assisted thoracoscopy is less worthy in diagnosing direct invasion of the intrapericardial great vessels by huge hilar tumors [4].
Loscertales and colleagues [5] reported using transthoracic videopericardioscopy to evaluate the resectability of hilar lung cancer. We have put their method into practice for staging huge hilar-type lung cancers, but tumor invasion of the posterior wall of the great vessels has been obscure. Our staging procedure using an endothoracic sonographic probe in addition to their method is thought be useful for diagnosing direct invasion of hilar nonsmall cell carcinoma into the intrapericardial great vessels.
To evaluate direct invasion of the intrapericardial great vessels by huge hilar tumors, transesophageal sonography does not allow the probe to be applied over the desired location from a variety of angles. Furthermore, in some cases the presence of air in the lung tissue during transesophageal sonography may preclude an accurate evaluation [6]. Magnetic resonance imaging has been a valuable diagnostic tool for detecting invasion of the intrapericardial great vessels by huge hilar tumors [7]. However, videopericardioscopy can evaluate the relationship between the tumor and intrapericardial great vessels directly and obtain more accurate diagnosis by using sonography at the same time. Videopericardioscopy using sonography should be performed for patients in whom the magnetic resonance imaging is not conclusive.
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References
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- Albain KS, Rusch VW, Crowley JJ, et al. Concurrent cisplatin/etoposide plus chest radiotherapy followed by surgery for stages III A (N2) and III B non-small cell lung cancer: mature results of southwest oncology group phase II study 8805. J Clin Oncol. 1995;13:1880–1892[Abstract/Free Full Text]
- Stamatis G, Eberhardt W, Stüben G, et al. Preoperative chemoradiotherapy and surgery for selected non-small cell lung cancer III B subgroups: long-term results. Ann Thorac Surg. 1999;68:1144–1149[Abstract/Free Full Text]
- Grunenwald DH, André F, Péchoux C, et al. Benefit of surgery after chemoradiotherapy in stage III B (T4 and/or N3) non-small cell lung cancer. J Thorac Cardiovasc Surg. 2001;122:796–802[Abstract/Free Full Text]
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- Loscertales J, Jiménez-Merchán R, Congregado-Loscertales M, et al. Usefulness of videothoracoscopic intrapericardial examination of pulmonary vessels to identify respectable clinical T4 lung cancer. Ann Thorac Surg. 2002;73:1563–1566[Abstract/Free Full Text]
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Abstract
Introduction
