Ann Thorac Surg 2003;76:876-877
© 2003 The Society of Thoracic Surgeons
Invited commentary
Robert J. Downey, MDa
a Thoracic Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
e-mail: downeyr{at}mskcc.org
Although the authors would disagree [1], I think that there is only one absolute contraindication to mediastinoscopy: the presence of a tracheostomy which, in my opinion, carries an unacceptably high risk of mediastinoscopy wound infection and mediastinitis. There are four relative contraindications to mediastinoscopy, three of which (prior mediastinal irradiation, prior mediastinoscopy, and superior vena caval syndrome) are associated with an increased risk of bleeding during dissection. The fourth relative contraindication is a prior sternotomy, which is distinct from the other three in that because the pretracheal plane has not been entered, there is no increased risk of bleeding nor of injury to vascular grafts, but, should bleeding occur, the presence of grafts and an open pericardium would make exposure for repair more difficult.
In this current publication, Kumar and co-authors retrospectively reviewed the Brompton experience with mediastinoscopy in 28 patients with prior sternotomies, seven of whom also underwent left Chamberlain procedures. The diagnostic yield and completeness of staging were excellent and there were no significant intraoperative or postoperative complications. The authors conclude that "prior sternotomy for cardiac surgery does not compromise the efficacy and safety of mediastinoscopy and mediastinotomy." I agree that efficacy has been demonstrated in that the number of nodes sampled was the same as in patients without sternotomy, but as only 28 patients were available for review, I do not agree that, except in the most limited way, safety has been demonstrated.
The Memorial Sloan-Kettering Cancer Center (MSKCC) experience with mediastinoscopy includes 3341 patients over 12 years, 14 of whom had bleeding which required thoracotomy or sternotomy for control; there were no intraoperative or perioperative deaths after mediastinoscopy and one after an extended mediastinoscopy. Repair of these injuries was almost always difficult and it is not at all clear that the success rate would have been as high had the patients all had prior sternotomies. One of these injuries was in a patient with a patent left internal mammary graft and a prior sternotomy. The innominate artery was mistaken for an involved lymph node and a 2 mm defect created with a biopsy forcep. Repair required piecemeal removal of the manubrium to the level of the innominate vein. Such experiences remain with a surgeon and breed caution. While I perform mediastinoscopy after sternotomy on a relatively routine basis, I make sure of the following:
- That a positive mediastinoscopy will lead to a change in therapy from surgery to induction therapy or definitive chemoradiation therapy.
- Obtain the operative note from the patients prior surgery to determine what vascular grafts may be present.
- Consider a blind biopsy of the supraclavicular fossa lymph nodes particularly if PET imaging suggests nodal involvement. If superior mediastinal lymph nodes are involved with metastatic disease, the supraclavicular nodes are positive in 33% of patients [2].
- Have a reciprocating saw and wire cutters available in the operating room. We do not have cardiopulmonary bypass capability available at MSKCC, but if we did, I would prepare the groins for cannulation.
- Remain patient in waiting for frozen sections to be reported prior to taking additional biopsies. Standard practice to attempt to perform a complete mediastinoscopy by biopsying two right paratracheal lymph nodes, one subcarinal, and one left. In patients with prior sternotomy, I will stop after any positive result that establishes the stage (eg, any positive N3 or a positive N2 with a negative N3 in right-sided disease).
References
- Yamada K., Kumar P., Goldstraw P. Cervical mediastinoscopy after total laryngectomy and radiotherapy: its feasibility. Eur J Cardiothor Surg 2002;21:71-73.[Abstract/Free Full Text]
- Lee J.D., Ginsberg R.J. Lung cancer staging: the value of ipsilateral scalene lymph node biopsy performed at mediastinoscopy. Ann Thorac Surg 1996;62:338-341.[Abstract/Free Full Text]
