Guidelines for Thoracoscopic Biopsies in Children

Introduction

Thoracoscopy was initially described in 1910 but was not reported for specific use in children until 1975.¹ Thoracoscopy has been utilized for pulmonary biopsy in immunosuppressed children, biopsy of pulmonary masses associated with malignancies, biopsy of mediastinal masses and excision of mediastinal masses and lobectomies.^1-3 Thoracoscopy is also used extensively for treatment of empyema.¹Lung biopsy is an important tool in the diagnosis of interstitial lung disease in immunocompetent children.⁴ Thoracoscopy is useful for the assessment of respectability, staging and evaluation of metastatic disease.⁵ Some of the indications for thoracoscopy include blebectomy, mediastinal biopsy, lung biopsy, excision of intrathoracic masses, including bronchogenic cysts.⁶ Improved technology and decreased morbidity from the thoracoscopic approach allows for a more aggressive approach to obtain tissue for diagnostic purposes in cases of interstitial lung disease and questionable focal lesions.³ Minimally invasive surgery is a safe and accurate means of obtaining tissue in pediatric oncologic patients.^7-9 Potential problems with the use of thoracoscopy for biopsy include the inability to palpate lesions and the development of recurrent disease at the port sites.⁹

Definition

Intersitial lung disease is defined as diffuse interstitial findings on chest x-ray or CT scan. The interstitial disease may be bilateral or unilateral and may be more prominent in one lobe over another. Localized lung disease is described as single lesion or multiple distinct lesions on chest x-ray or CT scan. Mediastinal masses can be found in the anterior, middle or posterior mediastinum and are usually identified by chest x-ray and CT scan.

Diagnosis

Preoperative workup varies based on the procedure performed.⁶ Most intrathoracic lesions require routine radiographs as well as computed tomography (CT) or magnetic resonance imaging (MRI).⁶ Thin cut, high resolution CT scan is particularly useful for identifying the most affected areas with interstitial lung disease.⁶ Occasionally, deep lesions require CT guided needle localization just before the thoracoscopic procedure. This usually involves marking the pleura overlying the lesion with a blood patch or dye and occasionally inserting a wire into the lesion. However, the wire may become dislodged as the lung is collapsed.^{3, 6}

Management

Children with interstitial lung disease are often on the ventilator at the time of consultation for biopsy. Most children with discrete masses are treated by protocol for the underlying tumor. Occasionally, during the initial workup, biopsy of lung masses is needed for staging purposes, to determine the treatment algorithm, and to exclude an infectious process prior to immune suppression.Children with mediastinal masses should be evaluated with pulmonary function and volumetric determination of airway by CT scan prior to performing surgery under general anesthesia. The most important factor in estimating whether tracheal compression will occur after induction of anesthesia is the patient’s preoperative respiratory status, particularly if he/she can lie flat without symptoms. Rarely, avoidance of muscle relaxants is necessary in which case local anesthesia plus mild sedation is used to protect the airway.

Preoperative Work-up

Before undergoing thoracoscopic biopsy, it is recommended that patients undergo chest radiography (preferably anteroposterior and lateral views), and CT or MRI of the chest.The chest x-ray and CT or MRI findings help to localize the lesion and to determine optional patient positioning for the operation.

Indications for Surgery

Interstitial lung disease in immunocompromised patient
Interstitial lung disease in immunocompetent patient
Mediastinal masses – biopsy and excision
Staging in the initial work-up of tumors
Evaluation of residual masses after chemotherapy
Evaluation of new masses after treatment of tumors

Thoracoscopic Biopsy or Intrathoracic or Mediastinal Masses

Lung biopsy is performed with patients in the lateral decubitus position. Posterior pleural biopsies are performed with the patient almost prone and anterior lesions are performed with the patient almost supine. Thus, positioning takes advantage of gravity to allow the lung to fall away from the lesion when the lung is collapsed.^{3, 6, 11-12}

In addition, if necessary, lung biopsy can be obtained by the open technique through a normal posterolateral thoracotomy or small muscle sparing thoracotomy. Mediastinal masses can also be biopsied using thoracotomy, mediastinoscopy, or median sternotomy.

Safe techniques have been identified for thoracoscopic procedures in children. Single lung ventilation is useful in infants and children, but it is difficult to place dual lumen tubes in small children.^{1, 3, 6, 11-12} Instead, the patient may undergo selective contralateral lung ventilation using ipsilateral bronchial blockers or Fogarty balloon catheters. Use of CO2 insufflation creates a pneumothorax and further collapses the ipsilateral lung. Pressures of 4-6 mm should be utilized.

Entry to the thoracic cavity should be at the fourth interspace as the collapsed lung from single lung ventilation may elevate the ipsilateral diaphragm.

Deep-seated lesions should be localized as previously described. Because the lesion cannot be palpated, the specimen should be sent for frozen section examination and the presence of the lesion should be confirmed before removing the ports.^{3, 6}

Usually three ports are used for biopsy. In larger children, placement of a 12 mm port is recommended for the use of endoscopic staplers. Smaller children can be biopsied with biopsy forceps or after placement of endoloops surrounding the tissue. However, the loops may dislodge and the biopsy site can be secured by sutures.

Mediastinal masses can be approached by thoracoscopy. Single lung ventilation should be achieved by the same methods used for pleural and lung biopsies. For anterior mediastinal masses, a modified supine position is helpful. The positioning allows gravity to keep the lung out of the operative field. Thoracosopy allows visualization of the lesion and determination of the exent of the lesion. The lesion may be biopsied or resected.¹³

Bleeding can be controlled with cautery, laser, ultrasonic shears or the Ligasure. Reexpansion of the lung frequently controls bleeding.

Placement of tube thoracostomy at the end of the procedure is procedure directed, and is often based on the extent of ventilatory support the patient will require.

Summary

Children with interstitial lung disease and isolated lesions associated with tumor frequently need diagnostic procedures. When appropriate preoperative screening is performed, children benefit from the performance of these procedures via thoracoscopy. The development of smaller instruments and decreased morbidity have led to use of minimally invasive surgery for these diagnostic procedures.

References

Rodgers, BM. Thoracoscopic Procedures in Children. Seminars Pediatr Surg 2(3): 182-189, 1993.
Rodgers, BM. Pediatric Thoracoscopy: Where have we Come and What Have We Learned? Ann. Thorac Surg 56:704-707, 1993.
Rothenberg SS. Thoracoscopy in Infants and Children. Sem Pediatr Surg 7(4): 194-201, 1998.
Fan LL, Kozinetz CA, Wojtczak HA et al. Diagnostic value of transbronchial, thoracoscopic and open lung biopsy in immunocompetent children with chronic interstitial lung disease. J Pediatrics 131(4): 565-569, 1997.
Holcomb GW, Tomita SS, Haase GM, et al. Minimally Invasive Surgery in Children with Cancer. Cancer 76:121-128, 1995.
Lobe TE. Pediatric Thoracoscopy. Sem Thoracic Cardiovasc Surg 5(4): 298-302, 1993.
Waldhausen JHT, Tapper D, Sawin RS. Minimally invasive surgery and clinical decision-making for pediatric malignancy. Surg Endosc 14(3):250-253, 2000.
Saenz NC, Conlon KCP, Aronson DC, LaQuaglia MP. The Application of Minimal Access Procedures in Infants, Children and Young Infants with Pediatric Malignancies. J Lap & Adv Surg Tech 7(5): 289-294, 1997.
Milanez de Campos JR, Filho LOA, Werebe EC, et al. Thoracoscopy in Children and Adolescents. Chest 111: 494-497, 1997.
Sartorelli KH, Partrick D and Meagher DP. Port-Site Recurrence After Thoracoscopic Resection of Pulmonary Metastasis Owing to Osteogenic Sarcoma. J Ped Surg 31(10): 1443-1444, 1996.
Rogers DA, Philippe PG, Lobe TE, et al. Thoracoscopy in Children: An Initial Experience with an Evolving Technique. J Laparendoscopic Surg 2(1): 7-14, 1992.
Holcomb III GW. Minimally Invasive Surgery for Solid Tumors. Sem Surgical Oncology 16:184-192, 1999.
Smith TJ, Rothenberg SS, Brooks M et al. Thoracoscopic Surgery in childhood Cancer. J Ped Hem/Onc 24:429-435, 2002

This guideline was prepared by the IPEG Guidelines Committee and was reviewed and approved by the Executive Committee of the International Pediatric Endosurgery Group (IPEG) July, 2004.

International Pediatric Endosurgery Group (IPEG)

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International Pediatric Endosurgery Group