Eur J Cardiothorac Surg 2002;21:71-73
© 2002 Elsevier Science NL
Cervical mediastinoscopy after total laryngectomy and radiotherapy: its feasibility
Katsuo Yamada,
Pankaj Kumar,
Peter Goldstraw*
Department of Thoracic Surgery, Royal Brompton Hospital, London, UK
Received 11 June 2001;
received in revised form 7 October 2001;
accepted 10 October 2001.
* Corresponding author. Tel.: +44-207-351-8558; fax: +44-207-351-8560
e-mail: p.goldstraw{at}rbh.nthames.nhs.uk
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Abstract
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Objective: The feasibility of cervical mediastinoscopy after total laryngectomy and radiotherapy has not been documented. Methods: We describe our experience with cervical mediastinoscopy in two patients with total laryngectomy and radiotherapy for squamous cell carcinoma and had a Blom–Singer speaking tracheostomy valve in situ. Both patients presented with mediastinal lymphadenopathy and radiographic features suggesting a new pulmonary malignancy. Results: Rigid bronchoscopy and cervical mediastinoscopy were undertaken and paratracheal and subcarinal lymph nodes were biopsied. Both patients made uneventful post operative recovery. Mediastinal lymph node biopsy was definitive in deciding their further care. Conclusion: Cervical mediastinoscopy is feasible in patients with total laryngectomy, tracheostomy and radiotherapy.
Key Words: Cervical mediastinoscopy • Total laryngectomy • Tracheostomy • Radiotherapy
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1. Introduction
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The role of cervical mediastinoscopy in obtaining diagnostic biopsies of mediastinal lymph node and in staging of lung cancer is well established [1,2]. However, the efficacy and safety of cervical mediastinoscopy after total laryngectomy and radiotherapy has not been documented previously.
In patients with previous laryngectomy for carcinoma, there is a higher incidence of lung cancer and a second primary carcinoma is a common cause of death [3,4]. Mediastinum and lungs are common sites of relapse of laryngeal carcinoma [4]. Cervical mediastinoscopy would be helpful in this distinction and in staging of new primary lung malignancy. However some have claimed that previous tracheostomy is a relative contraindication to cervical mediastinoscopy [5]. We report our experience with cervical mediastinoscopy in two patients referred to a single surgeon (PG) in a 1 year period, both patients had undergone total laryngectomy with radiotherapy for squamous cell carcinoma and both had a Blom–Singer prosthesis in situ and presented with radiographic features suggesting new primary lung malignancy.
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2. Material and methods
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Brief clinical summaries of the two patients are presented below and then we discuss our approach.
2.1. Patient 1
A 55-year-old male ex-smoker underwent total laryngectomy for squamous cell carcinoma of the larynx with block dissection of the neck and had a Blom–Singer valve in situ. He had a course of post-operative radiotherapy. At follow up 1 year later, a routine chest radiograph showed a large cavitating lesion in the right lower zone. Significant mediastinal lymphadenopathy was noted on a staging computed tomography (CT) (Fig. 1). Fibre-optic bronchoscopy was not diagnostic. Patient was referred for further assessment of the mediastinum and to assess operability of the lung lesion.
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Fig. 1. (a–c) Computed tomographic scan of the chest of Patient 1. At the tracheostomy stoma level with a Blom–Singer valve. Mediastinal lymphadenopathy compressing the lower trachea and the origin of the right main bronchus. A 9 cm cavitating lesion in the right lower zone.
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Rigid bronchoscopy was negative. Cervical mediastinoscopy was undertaken. A thorough examination of the mediastinum was feasible and lymph nodes in both paratracheal chains and in the subcarinal region were accessible. Histopathology confirmed that mediastinal nodes were involved by squamous cell carcinoma. Thoracotomy was therefore not indicated and the patient was referred to a radiation oncologist.
2.2. Patient 2
A 77-year-old male ex-smoker underwent total laryngectomy for squamous cell carcinoma and had a Blom–Singer valve prosthesis. Post-operatively he had a course of adjuvant radiotherapy and presented 9 years later, with a 7-month history of dyspnoea, productive cough and haemoptysis. Chest radiograph showed collapsed right lower lobe. Computed tomography (CT) of the chest showed pleural thickening together with pleural effusion, marked mediastinal lymphadenopathy and a mass surrounding the intermediate bronchus. Previous fibre-optic bronchoscopy and pleural aspirates were negative.
Open pleural biopsy was performed and showed grossly thickened pleura with an empyema cavity containing thick pus between the lung and the diaphragm. Cervical mediastinoscopy was considered necessary to assess the mediastinal lymph nodes. The findings included marked fibrosis in neck but the area distal to this in the superior mediastinum appeared macroscopically normal. Mediastinal lymph nodes located in the subcarinal and both paratracheal regions were biopsied. The procedure and postoperative course were entirely uneventful. All mediastinal lymph nodes and pleural biopsies showed no evidence of malignancy and the patient was treated conservatively. The clinical course confirmed the diagnosis of empyema. On a repeat CT scan the mass surrounding the bronchus intermedius had regressed markedly and patient remains well 18 months later.
2.3. Surgical technique
The surgical technique differs little from standard mediastinoscopy. The incision is sited 0.5–1.0 cm caudal to the stoma. Dissection continues until the trachea is reached. Once the trachea has been located at the thoracic inlet, the mediastinal dissection continues routinely and cervical radiotherapy does not add to the problems of dissection presumably as this is focussed on the neck area. The pretracheal plane is developed towards the mediastinum taking particular care with dissection the region of the innominate artery which may be more vulnerable after laryngectomy and radiotherapy. No drains were used and the incision was closed in two layers using continuous sutures.
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3. Results
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Cervical mediastinoscopy was performed with no procedure related complications. Thorough assessment of the mediastinum was feasible in both patients and lymph nodes in the paratracheal and subcarinal regions were accessible. Both patients made an uncomplicated recovery. The incision healed satisfactorily and there were no problems with infection at the incision or at the tracheostome site.
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4. Discussion
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The presence of mediastinal lymphadenopathy after total laryngectomy presents significant diagnostic dilemma. Mediastinal lymphadenopathy may represent local recurrence of the laryngeal carcinoma, be related to a new primary carcinoma of the tracheobronchial tree, oesophagus or the pharynx or may represent additional unrelated pathology. A definitive histological diagnosis is necessary in all cases. If a new primary malignancy is suspected, accurate mediastinal staging enables appropriate management decisions to be made.
Non-invasive assessment of the mediastinal lymph nodes including CT scanning and positron emission tomography (PET) in staging of lung carcinoma has been evaluated in numerous studies. A meta-analysis evaluating mediastinal nodal metastasis from non-small cell lung cancer (NSCLC), showed the mean sensitivity and specificity to be 60 and 77% for CT and 79 and 91% for PET scan respectively [6]. For a definitive tissue diagnosis, fine-needle aspiration biopsy of the mediastinal lymph nodes has been shown to have a sensitivity and specificity of 87–88% for the detection of neoplasm and 82–83% for distinguishing benign from malignant disease [7]. On the other hand the sensitivity of transbronchial fine-needle aspiration biopsy from the mediastinal lymph node for the staging of NSCLC ranged from 60–77% [8–10]. No technique is sensitive or specific enough to change the current gold standard of cervical mediastinoscopy for mediastinal lymph node staging in NSCLC [11].
Cervical mediastinoscopy is also of value in the determination of mediastinal lymphadenopathy in other conditions, such as tuberculosis, sarcoid and lymphoma [1]. It will provide reliable histology allowing effective treatment in tuberculosis or other infectious diseases as well as obtaining bacteriological specimens for culture. The presence of sarcoid type reactions in mediastinal lymph nodes draining primary pulmonary carcinoma may be present in 2.2% of cases and therefore a definitive tissue diagnosis of the lymph nodes is helpful [12].
Previously reported series document a high incidence of primary lung cancer in patients with laryngeal carcinoma as similar aetiological factors (smoking and atmospheric irritants) are important in both these malignancies [3]. In a series of 286 patients with total laryngectomy and tracheostomy for laryngeal carcinoma, the incidence of primary lung carcinoma was reported to be 12.5% (36 of 286) but only a small fraction 19% (7 of 36) of these primary lung carcinomas were suitable for surgical resection [3]. Lung is also the most common site of distant metastasis in laryngeal carcinoma [4]. Therefore if the histology of the lung lesion is the same as histology of the laryngeal carcinoma then it is difficult to distinguish between a primary lung carcinoma and metastasis from the laryngeal carcinoma. However in practice this makes little difference as one report has suggested that pulmonary resection for metastatic laryngeal carcinoma is associated with improved outcome [13]. Therefore if patients with laryngectomy present with a lung lesion associated with mediastinal lymphadenopathy, cervical mediastinoscopy reliably provides a tissue diagnosis enabling appropriate staging and optimal treatment.
This report describes our experience of performing cervical mediastinoscopy after total laryngectomy and radiotherapy with tracheostomy in two patients. We have described our surgical approach and we did not experience any difficulties with wound healing or infection. We believe that cervical mediastinoscopy after laryngectomy and radiotherapy is feasible and it is a safe and a definitive diagnostic procedure in this setting that enables the clinicians to make appropriate management decisions.
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R. J. Downey
Invited commentary
Ann. Thorac. Surg.,
September 1, 2003;
76(3):
876 - 877.
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Abstract
1. Introduction
