Mediastinoscopy near the end

In the current edition of the Thoracic Surgery News, published by the AATS, a note addresses the issue of mediastinoscopy vs. EBUS-TBNA. It’s a study presented at the last AATS meeting, done at the Toronto General Hospital in which EBUS-TBNA was found equally effective as mediastinoscopy when staging lung cancer. They enrolled 153 patients and performed EBUS-TBNA followed by mediastinoscopy in every patient and found EBUS-TBNA having 81% sensitivity, 91% negative predictive value and 93% diagnostic, and mediastinoscopy having 79% sensitivity, 90% negative predictive value, and 93% accuracy. Specificity and positive predictive was 100% for both methods.

EBUS-TBNA has become an essential part of the minimally invasive staging of the mediastinum. Mediastinoscopy has been done less frequently in patients with lung cancer for two reasons: the first one is the increased use of PET-CT; patients with small peripheral pulmonary nodules and negative mediastinum in PET-CT do not go routinely through mediastinoscopy. The second reason is that many other patients are diagnosed with mediastinal disease during EBUS-TBNA; these patients do not need mediastinoscopy because as shown by this study the EBUS-TBNA’s PPV is 100%. As a result, mediastinoscopy is left for those patients with suspicion of mediastinal disease in CT or PET-CT and a negative EBUS-TBNA. We have published about EBUS-TBNA vs. mediastinoscopy in the ATS.

I don’t think in terms of EBUS-TBNA replacing mediastinoscopy, but rather consider these two as complementary. EBUS-TBNA and mediastinoscopy complement each other in some situations as in the restaging of the mediastinum in patients with N2 disease that undergo neoadjuvant therapy. EBUS-TBNA can be use initially to stage the mediastinum and after neoadjuvant therapy mediastinoscopy used for restaging. Hiliar lymph node stations represent a spot which mediastinoscopy does not reach, but EBUS-TBNA can. Even though, it does not make a difference in treatment approach, in certain cases might be useful to know about these nodes.

Finally, Endoscopic Ultrasound with Fine Needle Aspiration (EUS-FNA) can add lymph node stations to the staging done by mediastinoscopy or EBUS-TBNA. Despite the infrequent involvement of stations #8 and #9 in lung cancer, EUS-FNA can sample these stations through the esophagus and also access the most posterior part of the subcarinal nodes.

I consider mediastinoscopy is still the gold standard in the invasive staging of the mediastinum, but we should get use to read reports favouring EBUS-TBNA and EUS-FNA to mediastinoscopy, based on better sensitivity and less complications. For us, as thoracic surgeons, the most important thing is to know how these techniques can complement each other, which ones are their limitations and flaws and based in this knowledge, tailor the best diagnostic strategy for every single patient.

Sebastian

¿Es la videotoracoscopía la mejor forma de realizar una timectomía?

Hay varios trabajos publicados que muestran que la videotoracoscopía es un abordaje efectivo para hacer una timectomía para resecar un timoma. A mí nunca me gustó mucho la idea de remover el timo por videotoracoscopía; no creo poder remover toda la grasa tímica de esta forma. La disección de la grasa mediastinal, al menos en mis manos, no es igual que cuando realizo una timectomía por estereotomía. Cuando tenemos que realizar una timectomía, nosotros elegimos una estereotomía. Con este abordaje disecamos toda la grasa tímica desde un nervio frénico de un lado hasta el del lado opuesto, y desde la vena innominada resecando los cuernos tímicos superiores, hasta el diafragma incluyendo toda la grasa pericárdica. De ninguna manera, en nuestra experiencia esto se puede lograr con la videotoracoscopía. Lamentablemente, no tenemos demasiada experiencia con el Da Vinci, que parece hacer una diferencia en este tipo de cirugía. Los timomas son tumores de lento crecimiento, muchas veces son pequeños y hasta podría ser lo mismo removerlo con un margen de tejido sano sin disecar toda la grasa mediastinal. No conozco estudios que comparen estos dos tipos de resecciones, posiblemente porque está muy aceptado que remover toda la grasa mediastinal es el tratamiento de elección. De todas maneras, no creo que desde un punto de vista oncológico sea correcto remover solamente el tumor. Nuestra experiencia resecando timomas por estereotomía es muy buena, los pacientes se recuperan de manera rápida y el dolor habitualmente no es un problema. Además, creemos que este vaciamiento radical es la cirugía oncológicamente correcta. Arriba les muestro un caso en el que removimos toda la grasa tímica por estereotomía mediana y estoy seguro que nunca podría obtener el mismo resultado con videotoracoscopía. ¿Qué hacés vos usualmente en estos pacientes? Sebastián

Defining the optimal treatment for empyema

There are many ways to treat a patient with an empyema that goes from a chest tube insertion to a thoracostomy window. Different options lay in between these two extremes. For many of us a chest tube insertion is the first measure in a patient with empyema. However, I found many times, no matter how well positioned is the chest tube, that I couldn’t drain all the fluid from the pleural space. This situation leads to a discussion about what to do next, a CT guided pigtail catheter? A new chest tube? Alteplase infusion through the chest tube? VATS? Thoracotomy? If an option different than surgery is chosen, new CT scans are performed to make sure no significant amount of fluid is left and few days are lost in the process. So, what is the best first approach?

In 2009 Wozniak et al. published in the ATS a paper that shows that chest tube insertion is associated with treatment failure when it is the first intervention in patients with advanced empyema. The best results were achieved with VATS and thoracotomy. Although they address the topic in patients with advanced empyemas, I think that also in early stage empyemas the first intervention is critical. As I said, chest tubes failed many times in patients with empyemas and a quick VATS that cleans up the pleural space is many times a more wise option. After VATS you are completely sure that you drained everything, that you freed up the entire lung and the chest tube or tubes are placed where they should be. This saves time, usually offers a one-time intervention and carries a very low complication rate. There are cases that VATS is not enough and an open thoracotomy is needed, specially in those advanced empyemas, where a true and extensive decorticacion is needed.

I don’t mean with this that VATS is the treatment of choice in every patient with empyema, but I do mean that VATS should be always considered as a possible first option. If CT shows the fluid is free in the pleural space, no loculations are seen, you face a very sick patient or a patient that for some reason would no tolerate general anesthesia –and we found this last one to be a very infrequent event-, you may want to consider a chest tube insertion or a CT guided pigtail placement. A recent work by Dr. Feins’ team also published in the Annals, showed very good results with the use of intrapleural alteplase through the chest tube. This is an excellent choice, but we reserved it for those patients that wouldn’t tolerate surgery and have an empyema that didn’t resolve with just a chest tube.

The best option to treat an empyema patient is the one that you think will fix the problem with the minimum number of interventions and days of hospitalization weighted against the risks of the intervention itself, no matter which one is that procedure for you. In our hands this procedure is usually VATS.

What is the practice at your place?

Sebastian

PS: by the way the case of the picture actually needed an open thoracotomy decortication.