Ann Thorac Surg 2008;86:1339-1341. doi:10.1016/j.athoracsur.2008.04.115
© 2008 The Society of Thoracic Surgeons
New Technology
Clinical Application of Direct Bronchial Ultrasound to Visualize and Determine Endobronchial Tumor Margins for Surgical Resection
Khaled M. Sarraf, MRCSb,
Elizabeth Belcher, FRCSb,
Susanna Price, FRCPa,
Eric Lim, FRCS, (C-Th)a,*
a Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom
b Department of Intensive Care Medicine, Royal Brompton Hospital, London, United Kingdom
Accepted for publication April 23, 2008.
* Address correspondence to Dr Lim, Department of Thoracic Surgery, Royal Brompton Hospital, Sydney St, London, SW3 6NP, United Kingdom (Email: e.lim{at}rbht.nhs.uk).
 |
Abstract
|
|---|
Purpose: We describe the first experience of direct bronchial (epi-bronchial) ultrasound to visualize and determine the endobronchial tumor margins for surgical resection.
Description: An ultrasound probe was applied onto the membranous portion of the right main bronchus directly over a pedunculated tumor. The tumor was visualized due to the water content, with a total loss of signal (air-tumor interface) at the tumor edge. A sterile marker was used to outline the air-tumor interface.
Evaluation: Traditionally, surgical technique involves palpation of the tumor with an incision to inspect the endobronchial lumen determining the position of the pedicle, thus estimating the amount of airway to resect. Using direct bronchial ultrasound, the right main palpated margin was 0.5-cm proximal to the ultrasound margin, which correctly identified the tumor margin. The upper lobe palpated margin was 1 cm proximal to the ultrasound margin, which correctly identified the tumor margin. In the intermediate bronchus, the palpated and ultrasound margin were the same and correct.
Conclusions: By using the air-tumor interface, epi-bronchial ultrasound scanning can accurately demarcate the base of endobronchial tumors for surgical resection and reconstruction.
|
Technology
|
|---|
Typical carcinoid tumors are rare, low-grade tumors that are often well-circumscribed and rarely metastasize. There is a slight preponderance of growth within the central airways leading to symptoms and signs of airways obstruction. Our institution has considerable experience with airways resection and reconstruction [1, 2], and we describe the first experience of the application of direct bronchial (epi-bronchial) ultrasound to visualize and determine the endobronchial tumor margins to facilitate surgical resection.
|
Technique
|
|---|
A 24-year-old camera man presented with hemoptysis and despite a previous diagnosis of asthma, never experienced an asthma attack nor gained any symptom relief from bronchodilators. An initial fiber-optic bronchoscopy was performed for hemoptysis and a vascular pedunculated tumor was noted in his right main bronchus four rings from the carina (Fig 1). A computed tomographic scan confirmed a tumor in the right main bronchus, but the distal extent was not discernable. Subsequently rigid bronchoscopy and biopsies were performed that confirmed the tumor to be a carcinoid without any atypical features.
The patient underwent a right posterolateral thoracotomy with an intended sleeve resection of the bronchus. A standard ultrasound probe (Vivid 7; GE Healthcare, Piscataway, NJ) was applied through a sterile sheath filled with aqua gel directly onto the membranous portion of the bronchi. It was possible to visualize the tumor (Fig 2) due to the water content, however, at the tumor edge, where only air was present within the bronchial lumen, there was a total loss of signal (air-tumor interface). Using this information, a sterile marker pen was used to outline the margins of the air-tumor interface (Fig 3). The right main palpated margin was approximately 0.5 cm proximal (in relation to the carina) to the ultrasound margin, which was incised and found to correspond exactly to the edge of the tumor. The upper lobe palpated margin was 1 cm proximal to the ultrasound margin, which was correct (an initial incision into the palpated margin was found to be within tumor) (Fig 4). In the intermediate bronchus, the palpated and ultrasound margin were the same and corresponded to the exact edge of the tumor (Fig 5). Frozen sections were sent from the main, upper, and intermediate bronchi, and reported back with no microscopic evidence of tumor. After bronchial resection, an end-to-end anastomosis between the main and intermediate bronchi was performed and a "D"-shaped incision was used to create a neo-secondary carina in the main bronchus and an end-to-side anastomosis performed between the upper lobe and main bronchi (Fig 6).
View larger version (118K):
[in this window]
[in a new window]
|
Fig 3. Ultrasound margins: image orientated by head, feet, posterior (Pos), anterior (Ant), right main bronchus (MB), bronchus intermedius (BI), and right upper lobe bronchus (ULB). The initial purple marker pen margins determined by ultrasound have been isolated within the purple rectangles.
|
|
View larger version (115K):
[in this window]
[in a new window]
|
Fig 4. Initial cuts on the bronchus. (Ant = anterior; BI = bronchus intermedius; Pos = posterior; RMB = right main bronchus; ULB = upper lobe bronchus.)
|
|
View larger version (113K):
[in this window]
[in a new window]
|
Fig 5. Excised tumor with the right main, upper lobe, and bronchus intermedius. (Ant = anterior; BI = bronchus intermedius; Pos = posterior; RMB = right main bronchus; ULB = upper lobe bronchus.)
|
|
View larger version (117K):
[in this window]
[in a new window]
|
Fig 6. Completed resection and re-anastomosis. (Ant = anterior; BI = bronchus intermedius; Pos = posterior; RMB = right main bronchus; ULB = upper lobe bronchus.)
|
|
|
Comment
|
|---|
Because of their benign nature, centrally placed carcinoid tumors can be confidently treated with airway resection and reconstruction, especially when the lung distal to the obstruction is normal. Traditionally, the surgical technique involves palpation of the tumor and an initial incision to inspect the endobronchial lumen to determine the position and extent of the pedicle and to estimate the amount of airway to resect. This technique may not always be reliable, and imprecision in the estimation that leads to excessive loss of bronchial airway can result in difficulties in reconstruction and tension within the anastomosis, both factors that predispose to failure of the surgical procedure. An alternative may be the intraoperative use of a flexible bronchoscope; however, this may not be ideal if the tumor fills the entire lumen.
This technique may not be suitable in other subtypes of tumor such as nonsmall cell lung cancer with submucosal spread, as it is best used in defined polypoid tumors of the airway.
We believe this to be the first epi-bronchial ultrasound image and use of the air-tumor interface to accurately demarcate endobronchial tumors for surgical resection and reconstruction.
|
Disclosures and Freedom of Investigation
|
|---|
No funding was used to perform the evaluation, and the tested technology was not purchased, borrowed, or donated to the study. In addition, the authors had full control of the design of the study, methods used, outcome measurements, analysis of data, and production of the written report.
|
Footnotes
|
|---|
Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
|
References
|
|---|
- El Jamal M, Nicholson AG, Goldstraw P. The feasibility of conservative resection for carcinoid tumors: is pneumonectomy ever necessary for uncomplicated cases? Eur J Cardiothorac Surg 2000;18:301-306.[Abstract/Free Full Text]
- Lim E, Yap YK, De Stavola BL, Nicholson AG, Goldstraw P. The impact of stage and cell type on the prognosis of pulmonary neuroendocrine tumors J Thorac Cardiovasc Surg 2005;130:969-972.[Abstract/Free Full Text]
Related Article
-
Invited Commentary
- Gaetano Rocco
Ann. Thorac. Surg. 2008 86: 1342.
[Extract]
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
G. Rocco
Invited Commentary
Ann. Thorac. Surg.,
October 1, 2008;
86(4):
1342 - 1342.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Technology
