Mediastinoscopic Ultrasonography (MUS) as a Surgical Adjuvant in Lung Cancer Staging

  • Michael WolfEmail author
  • Biruta Witte
  • Martin Hürtgen


The pretherapeutic assessment of the mediastinal T-status of locally advanced lung carcinoma remains an unsolved problem, whereas mediastinal nodal staging can nowadays be performed with high accuracy. Limitations of non-invasive imaging (CT scan and MRI) favour overstaging of the T-category with the result being that patients receive palliative rather than curative intent therapy. On the other hand, principally presuming a lower stage in centrally located lung tumours inevitably results in an increased number of non-curative exploratory thoracotomies. In this dilemma a valid imaging procedure is clearly needed. Using the artificial pretracheal space created during staging mediastinoscopy in order to introduce sterilizable ultrasound probes, we developed mediastinoscopic ultrasonography (MUS) in an attempt to improve the assessment of the T-status of centrally located lung cancer. Among the ultrasound modalities that offer access to the mediastinum, transesophageal echography and MUS complement one another topographically with regard to mediastinal T-staging.


Lung Cancer Patient Left Pulmonary Artery Thoracic Surgeon Innominate Artery Ultrasonic Probe 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors wish to thank Dr. Ricarda Lachmann, for the re-examination of the CT scans, as well as Dr. S. Herber, PhD, head of the department of radiology of our hospital, for allowing us to use the CT and MRI imaging used in this article. Furthermore, we would like to thank Mr. Alexander Zitzer for his valuable contribution in graphic design (Fig. 8.2) as well as Mr. Stefan Kup (IT department) for his help in the preparation of the videos.

Supplementary material

Video 8.1

MUS radial probe: the intrapericardial left superior pulmonary vein in cross section near the level of the pericardial reflection. It shows free pulsatile movements. No intrapericardial tumour is seen. UVP = left superior pulmonary vein, Tr.pulm. = pulmonary trunk, r.PA. = right pulmonary artery, VCS = superior vena cava (MP4 437 KB)

Video 8.2

CT scan (axial): lung carcinoma of the middle lobe growing centrally along the right superior pulmonary vein. The tumour encases the roof of the left atrium, where the right pulmonary vein drains into the atrial chamber (AVI 23086 kb) (MP4 98 MB)

Video 8.3

Contrast-enhanced axial MRI: middle lobe tumour with suspected intrapericardial invasion of the right superior pulmonary vein (MP4 1.82 MB)

Video 8.4

Contrast-enhanced sagittal MRI: middle lobe tumour with suspected intrapericardial invasion of the right superior pulmonary vein (MP4 1.31 MB)

Video 8.5

Cine MRI (axial): middle lobe tumour growing centrally along the superior pulmonary vein, reaching the roof of the left atrium (MP4 835 KB)

Video 8.6

Cine MRI (short heart axis): middle lobe tumour growing centrally along the superior pulmonary vein, reaching the roof of the left atrium (MP4 1.25 MB)

Video 8.7

Video MUS convex probe: The superior pulmonary vein is invaded within the pericardial reflection, proven by the crescent-shaped pericardial fluid space seen at the left side of the vessel. Colour Doppler shows the filiform configuration of the invaded vessel. UPV = intrapericardial superior pulmonary vein, PERIC. = pericardial fluid, TU = tumour (MP4 584 KB)


  1. 1.
    Quint LE. Staging non-small cell lung cancer. Cancer Imaging. 2007;7:148–59.PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    DiPierna CA, Wood DE. Surgical management of T3 and T4 lung cancer. Clin Cancer Res. 2005;11(13 Suppl):5038s–44.CrossRefGoogle Scholar
  3. 3.
    Catarino PA, Goldstraw P. The future in diagnosis and staging of lung cancer. Respiration. 2006;73:717–32.PubMedGoogle Scholar
  4. 4.
    Garcia-Aguilar J, Pollock J, Lee SH, Hernandez de Anda E, Mellgren A, et al. Accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. Dis Colon Rectum. 2002;45(1):10–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Herth F, Ernst A, Schulz M, Becker H. Endobronchial ultrasound reliably differentiates between airway infiltration and compression by tumor. Chest. 2003;123(2):458–62.PubMedCrossRefGoogle Scholar
  6. 6.
    Puli SR, Reddy JB, Bechthold ML, Antillon D, Ibdah JA, Antillon MR. Staging accuracy of esophageal cancer by endoscopic ultrasound: a meta-analysis and systematic review. World J Gastroenterol. 2008;14(10):1479–90.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Puli SR, Batapati Krishna Reddy J, Bechtold ML, Antillon MR, Ibdah JA. How good is endoscopic ultrasound for TNM staging of gastric cancers? A meta-analysis and systematic review. World J Gastroenterol. 2008;14(25):4011–9.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Goldberg BB. Suprasternal sonography. JAMA. 1971;15:245–50.CrossRefGoogle Scholar
  9. 9.
    Herth FJF. The mediastinum. In: Bolliger CT, Herth FJF, Mayo PH, Miyazawa T, Beamis JF, editors. Clinical chest ultrasound, Progress in respiratory research, vol. 37. Basel: Karger; 2009. p. 51–8.CrossRefGoogle Scholar
  10. 10.
    Hagenmüller F, Classen M. Ultrasonic tomography by means of an ultrasonic fiberendoscope. Endoscopy. 1980;12:241–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Hürther TH, Hanrath P. Endobronchiale Sonographie zur Diagnostik pulmonaler und mediastinaler Tumoren. Dtsch Med Wochenschr. 1990;115:1899–905. German.CrossRefGoogle Scholar
  12. 12.
    Pedersen BH, Vilmann P, Folke K, Jakobsen GK, Krasnik M, Milman N, et al. Endoscopic ultrasonography and real-time guided fine needle aspiration biopsy of solid lesions of the mediastinum suspected of malignancy. Chest. 1996;110(2):539–44.PubMedCrossRefGoogle Scholar
  13. 13.
    Krasnik M, Vilmann P, Larsen SS, Jakobsen GK. Preliminary experience with a new method of endoscopic transbronchial real time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions. Thorax. 2003;58:1083–6.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Klotter HJ, Rückert K, Kümmerle E. Intraoperative Ultraschalluntersuchungen bei Pankreaseingriffen. Dtsch Med Wochenschr. 1983;108:1463–8. German.PubMedCrossRefGoogle Scholar
  15. 15.
    Castaing D, Edmond J, Kunstlinger E, Bismuth H. Utility of operative ultrasound in the surgical management of liver tumors. Ann Surg. 1986;204:600–5.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Huertgen M, Metzler B, Friedel G, Toomes H. Mediastinoscopic ultrasonography (MUS). Eur J Cardiothorac Surg. 2004;26:842–4.CrossRefGoogle Scholar
  17. 17.
    Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest. 2009;136(1):260–71.Google Scholar
  18. 18.
    Sobin LH, Gospodarowicz MK, Wittekind C, editors. TNM classification of malignant tumours. 7th ed. Oxford: Wiley-Blackwell; 2009.Google Scholar
  19. 19.
    Wernecke K. Mediastinale Sonographie: Untersuchungstechnik, diagnostische Effizienz und Stellenwert in der bildgebenden Diagnostik des Mediastinums. 1st ed. Heidelberg: Springer; 1991. p. 4. Fig. 5. German.CrossRefGoogle Scholar
  20. 20.
    Wittekind C, Compton CC, Brierley J, Sobin LH, editors. TNM supplement: a commentary on uniform use. 4th ed. Oxford: Wiley-Blackwell; 2009.Google Scholar
  21. 21.
    Hassan H, Vilmann P, Sharma V, Holm J. Initial experience with a new laparascopic ultrasound probe for guided biopsy in the staging of upper gastrointestinal cancer. Surg Endosc. 2009;23:1552–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Vilmann P, Ortiz-Moyano C. Laparascopic ultrasound scanning. In: Dietrich CF, editor. Endoscopic ultrasound: an introductory manual and atlas. Stuttgart/New York: Thieme; 2011. p. 509–22.Google Scholar
  23. 23.
    Huertgen M, Wolf M, Witte B. Mediastinoscopic ultrasonography. J Thorac Oncol. 2007;2:362–4.CrossRefGoogle Scholar
  24. 24.
    Wolf M, Witte B, Hillebrand H, Lachmann R, Herber S, Hürtgen M. Ultrasound criteria applied with intraoperative mediastinoscopic ultrasound (MUS) in pretherapeutic T-staging of lung tumors show superior correlation with pathologic T-stage than staging with computed tomography. 18th European Conference on General Thoracic Surgery; 30 May–2 June 2010; Abstract F-048, Valladolid, Spain.Google Scholar
  25. 25.
    Schaefer-Prokop C, Prokop M. New imaging techniques in the treatment guidelines for lung cancer. Eur Respir J. 2002;19(Suppl35):71s–83.CrossRefGoogle Scholar
  26. 26.
    Cangemi V, Volpino P, Drudi FM, D’Andrea N, Cangemi R, Piat G. Assessment of the accuracy of diagnostic chest CT scanning. Impact on lung cancer management. Int Surg. 1996;81:77–82.PubMedGoogle Scholar
  27. 27.
    Gdeedo A, Van Schil P, Cohouts B, Van Mieghem F, Van Meerbeek J, Van Marck E. Comparison of imaging TNM [(i)TNM] and pathologic TNM [pTNM] in staging of bronchogenic carcinoma. Eur J Cardiothorac Surg. 1997;12:224–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Cetinkaya E, Turna A, Yildiz P, Dodurgali R, Bedirhan M, Gürses A, Yilmaz V. Comparison of clinical and surgical-pathologic staging of the patients with non-small cell lung carcinoma. Eur J Cardiothorac Surg. 2002;22:1000–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Rankin SC. Advances in radiological staging of non-small cell lung cancer (NSCLC). Cancer Imaging. 2004;4:S22–4.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Ohtsuka T, Minami M, Nakajima J, Kohno T, Yagyu K, Furuse A. Cine computed tomography for evaluation of tumors invasive to the thoracic aorta: seven clinical experiences. J Thorac Cardiovasc Surg. 1996;112:190–2.PubMedCrossRefGoogle Scholar
  31. 31.
    Seo JS, Kim YJ, Choi BW, Choe KO. Usefulness of magnetic resonance imaging for evaluation of cardiovascular invasion: evaluation of sliding motion between thoracic mass and adjacent structures on cine MR images. J Magn Reson Imaging. 2005;22(2):234–41.PubMedCrossRefGoogle Scholar
  32. 32.
    Schröder C, Schönhofer B, Vogel B. Transesophageal echographic determination of aortic invasion by lung cancer. Chest. 2005;127:438–42.PubMedCrossRefGoogle Scholar
  33. 33.
    Varadarajulu S, Schmulewitz N, Wildi SF, Roberts S, Ravenel J, Reed CE, et al. Accuracy of EUS in staging of T4 lung cancer. Gastrointest Endosc. 2004;59:345–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Caterino U, Dialetto G, Covino FE, Mazzarela G, Grella E, Massimo M. The usefulness of transesophageal echocardiography in the staging of locally advanced lung cancer. Monaldi Arch Chest Dis. 2007;67:39–42.PubMedGoogle Scholar
  35. 35.
    Pass HI. Mediastinal staging 2005: pictures, scopes, and scalpels. Semin Oncol. 2005;32:269–78.PubMedCrossRefGoogle Scholar
  36. 36.
    Shen RK, Meyers BF, Larner JM, Jones DR. Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3Suppl):290S–305.PubMedCrossRefGoogle Scholar
  37. 37.
    Ahmad US, Blum MG. Invasive diagnostic procedures. In: Shields TW, LoCicero J, Reed CE, Feins RH, editors. General thoracic surgery. 7th ed. Philadelphia: Lippincott, Williams, and Wilkins; 2009. p. 301–12.Google Scholar
  38. 38.
    Hürtgen M, Friedel G, Toomes H, Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results. Eur J Cardiothorac Surg. 2002;21:348–51.PubMedCrossRefGoogle Scholar
  39. 39.
    Witte B, Wolf M, Hürtgen M, Toomes H. Video-assisted mediastinoscopic surgery: clinical feasibility and accuracy of mediastinal lymph node staging. Ann Thorac Surg. 2006;82:1821–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Klinik für ThoraxchirurgieKatholisches Klinikum KoblenzKoblenzGermany

Personalised recommendations