Ann Thorac Surg 2009;87:924. doi:10.1016/j.athoracsur.2008.10.091
© 2009 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).
The intentional creation of a pneumothorax to safely allow a transpleural biopsy of a mediastinal mass was first described by Bressler and Kirkham [1]. In 1994 they reported a series of 36 patients who underwent alternative approaches to the biopsy of mediastinal lesions. Four of these 36 patients were given an iatrogenic pneumothorax to biopsy a mass in the subcarinal space. One patient had a transpleural biopsy of a mediastinal mass through a "protective" pleural effusion. In this patient, position adjustment was used to avoid injuring the lung. Histologic diagnoses were attained in all 5 of these patients and in 34 of the 36 patients (94%) in the series.
The article by Lin and Li [2] describes the method of percutaneous core biopsy of mediastinal lesions using an artificial (iatrogenic) pneumothorax along with position adjustment. Position adjustment was used so that the target lesion could be reached with minimal air injection. In the current series, the target lesion was sampled in all patients, and in 10 of 11 patients (91%) a definitive histologic diagnosis was realized.
The authors theorize that limiting the amount of injected air into the pleural space will minimize the amount of respiratory compromise during the procedure. The mean volume of injected air was 680 mL (range, 400 to 1400 mL). In an earlier report by Scalzetti [3], the mean volume of air injected was 1000 mL. It is not clear if the difference between the volumes of air required to produce the iatrogenic pneumothorax in these two studies is statistically or clinically significant. In addition, the extent of the increased radiation load secondary to repeated scanning during the course of the procedure is not quantified.
Nevertheless, this article highlights a technique that would seem almost intuitive to both thoracic surgeons and interventional radiologists. When a patient presents with a mediastinal mass, the differential diagnosis is broad. Percutaneous core biopsy is often recommended to obtain a tissue diagnosis so that a proper treatment algorithm can be followed. Although this is a small study of 11 patients, the authors should be congratulated for the thorough description of their technique and the results that they reached with almost negligible morbidity.
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References
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- Bressler EL, Kirkham JA. Mediastinal masses: alternative approaches to CT-guided needle biopsy Radiology 1994;191:391-396.[Abstract/Free Full Text]
- Lin Z-Y, Li Y-G. Artificial pneumothorax with position adjustment for computed tomography-guided percutaneous core biopsy of mediastinum lesions Ann Thorac Surg 2009;87:920-924.[Abstract/Free Full Text]
- Scalzetti EM. Protective pneumothorax for needle biopsy of mediastinum and pulmonary hilum J Thorac Imaging 2005;20:214-219.[Medline]
Related Article
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Artificial Pneumothorax With Position Adjustment for Computed Tomography-Guided Percutaneous Core Biopsy of Mediastinum Lesions
- Zheng-Yu Lin and Yin-Guan Li
Ann. Thorac. Surg. 2009 87: 920-924.
[Abstract]
[Full Text]
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