Ann Thorac Surg 2007;84:1000
© 2007 The Society of Thoracic Surgeons
New Technology
Invited commentary
Keith D. Mortman, MD
Section of Thoracic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331
(Email: mortmak{at}ccf.org).
Mediastinoscopy has been an accepted procedure to biopsy mediastinal lymph nodes and stage the mediastinum for more than half a century. As surgeons gain experience with specific procedures, the indications for its use tend to multiply. The role of mediastinoscopy has expanded to include treating bronchogenic [1] and pericardial [2] cysts, as well as performing pericardial windows [3]. Improved technology and fiberoptics now allow the thoracic surgeon to perform video mediastinoscopy. The magnification provided by the video mediastinoscope allows for safer biopsies and is useful for teaching students, residents, and other members of the operating room team. Advanced computer software has enabled three-dimensional (3-D) reconstructions of chest and abdominal computed tomography (CT) and has ushered in the era of virtual bronchoscopy and virtual colonoscopy. Now, multi-detector CT provides even greater resolution 3D-volume datasets creating such tools as virtual coronary angiography. "Fly through" sequences of luminal structures and "fly around" sequences of other anatomic structures are graphically recreated.
The article by Shiono and colleagues [4] describes the use of virtual mediastinoscopy as an adjunct to cervical mediastinoscopy. Previous reports of virtual mediastinoscopy have been presented at meetings [5] and appeared in the literature [6]. The authors theorized that virtual mediastinoscopy would make mediastinal exploration safer and more accurate. Five patients with mediastinal adenopathy (determined by CT or positron emission tomography [PET]-CT) underwent virtual mediastinoscopy using reformatted CT and PET-CT images. Standard cervical mediastinoscopy was performed while the virtual images were simultaneously viewed in the operating room. An assistant was required to scroll through the computer-generated images as the surgeon manipulated the video mediastinoscope.
Presently the combination of CT and PET-CT is useful in identifying patients with mediastinal adenopathy and in determining which patients require cervical mediastinoscopy prior to pulmonary resection, even in the absence of mediastinal adenopathy (ie, T2N0 tumor). Although virtual mediastinoscopy is a fascinating imaging modality, I do not believe that it currently adds true value to standard video mediastinoscopy, which is already a safe and accurate operation in experienced hands. The authors suggest that virtual mediastinoscopy may further improve safety and accuracy and reduce operative blood loss and operative time. Perhaps this may be true as both software and hardware continue to evolve, but these conclusions can not be supported by the current series of 5 patients. For the present time, virtual mediastinoscopy, like video mediastinoscopy, may be limited to the role of educating general and thoracic surgery residents about the important anatomic relationships in the mediastinum.
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References
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- Urschel JD, Horan TA. Mediastinoscopic treatment of mediastinal cysts Ann Thorac Surg 1994;58:1698-1700.[Abstract]
- Sarin CL. Pericardial cyst in the superior mediastinum treated by mediastinoscopy: a case report Br J Surg 1970;57:232-233.[Medline]
- Rana BS, Jones RA, Simpson IA. Recurrent pericardial effusion: the value of polymerase chain reaction in the diagnosis of tuberculosis Heart 1999;82:246-247.[Abstract/Free Full Text]
- Shiono H, Okumura M, Sawabata N, et al. Virtual mediastinoscopy for safer and more accurate mediastinal exploration Ann Thorac Surg 2007;84:995-1000.[Abstract/Free Full Text]
- Takada A, Hirayama A, Nitadori J, et al. "PET-CT virtual mediastinoscopy" aided the mediastinal lymph node biopsy. Abstract presented at the Radiological Society of North America, 2005 conference.
- Quon A, Napel S, Beaulieu CF, Gambhir SS. "Flying through" and "flying around" a PET/CT scan: pilot study and development of 3D integrated 18F-FDG PET/CT for virtual bronchoscopy and colonoscopy J Nucl Med 2006;47:1081-1087.[Abstract/Free Full Text]
Related Article
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Virtual Mediastinoscopy for Safer and More Accurate Mediastinal Exploration
- Hiroyuki Shiono, Meinoshin Okumura, Noriyoshi Sawabata, Tomoki Utsumi, Masayoshi Inoue, Masato Minami, Noriyuki Tomiyama, Hikaru Matsuda, and Yoshiki Sawa
Ann. Thorac. Surg. 2007 84: 995-999.
[Abstract]
[Full Text]
[PDF]
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