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Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Via Semmola 81, Naples, 80131 Italy
(Email: gaetano.rocco{at}btopenworld.com).
Ultrasonography is becoming increasingly important in the management of lung cancer. Endobronchial ultrasonography has shown unexpected potential in accurately ascertaining mediastinal nodal disease, both in the setting of primary staging and in the re-evaluation of post-induction treatment. In addition, ultrasounds have been used to detect solitary pulmonary nodules prior to video-assisted thoracic surgery resection and for managing chest wall masses and pleural effusions.
As in all fields of human activity, further technological advancements are to be expected. However, a careful analysis of the state-of-the-art technology when introducing such refinements is required.
The interesting article by Sarraf and colleagues [1] describes the intraoperative use of ultrasound technology to determine resection margins in a patient with a centrally located carcinoid tumor requiring a complex reconstruction. The authors used epi-bronchial ultrasonography to demarcate the resection margins, which corresponded to tumor-free margins on frozen section and were more accurate than palpation.
With what should we compare this technique? Short of histologic assessment of tracheobronchial margins with intraoperative frozen section, any method might be fallible for precisely determining tumor-free margins. Palpation is aimed at identifying the edge of the tumor as compared with healthy bronchial structures. Indeed, the surgeon must apply a conservative estimate to spare as much normal airway as possible to ensure a subsequent tension-free anastomosis, especially in patients with central tumors. As a consequence, any margin identified by palpation might be at risk of falling flush with the tumor or slightly into the tumor to yield an inadequate oncologic operation.
To overcome this problem, some surgeons use needle marking, for example, to demonstrate the proximal macroscopic tumor-free margin visualized by bronchoscopy whenever feasible. However, frozen sections remain the gold standard. Thus, epi-bronchial ultrasonography can not replace frozen sections of resection margins, but it can certainly complement palpation.
The procedure proposed by Sarraf and coworkers [1] seems simple and the technology is there to support further developments. However, some issues may limit clinical applicability, especially with regard to the expertise required for using and interpreting epi-bronchial ultrasounds. It is not clear whether this technique can recognize submucosal neoplastic spread, which is fairly common with other nonsmall cell lung cancer histotypes. Possibly, electromagnetic navigational bronchoscopy [2] and optical coherence tomography [3] will further clarify this issue.
Finally, I wonder whether the resolution of this device would be reduced for tumors in larger bronchi or the trachea. Often these tumors are covered with thick fibrinous exudates or mucus. Would these secretions reduce the resolution of the epi-bronchial ultrasound device? Would the size of the ultrasound probe affect the location of resection margins by a few millimeters when the axiom "the farther, the better" may not be acceptable? Some of these questions will certainly be answered in the future, hopefully through acquisition of a larger experience by the authors of this article. For the time being, epi-bronchial ultrasonography seems to be an innovative concept, albeit limited to an extremely selected group of patients.
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