J Thorac Cardiovasc Surg 2008;136:186-190
© 2008 The American Association for Thoracic Surgery
Rigid bronchoscopy and surgical resection for broncholithiasis and calcified mediastinal lymph nodes
Robert J. Cerfolio, MD, FACS, FCCPa,*,
Ayesha S. Bryant, MSPH, MDa,b,
Lee Maniscalco, BSa
a Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham (UAB), Birmingham, Ala
b Department of Epidemiology, University of Alabama at Birmingham (UAB), Birmingham, Ala
Received for publication June 28, 2007; revisions received August 30, 2007; accepted for publication September 14, 2007.
* Address for reprints: Robert J. Cerfolio, MD, FACS, FCCP, Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham (UAB), 703 19th St S, ZRB 739, Birmingham, AL 35294. (Email: robert.cerfolio{at}ccc.uab.edu).
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Abstract
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Background: Patients with calcified mediastinal lymph nodes who have hemoptysis or lithoptysis represent a challenging therapeutic dilemma.
Methods: We performed a retrospective review of a prospective clinic and operative database between January 1998 and December 2006. All patients had calcified mediastinal lymph nodes, symptoms or complications from these nodes, or both.
Results: There were 50 patients (23 men). Thirty-eight (76%) were symptomatic, which included hemoptysis in 11, persistent cough in 8, and recurrent pneumonia in 5, and all underwent rigid bronchoscopy. Thirty-four (89%) of the 38 symptomatic patients had stones eroding into the airway (broncholiths), and 2 had an airway esophageal fistula. The most common location of the broncholith was in the bronchus intermedius (n = 19). Endoscopic removal of the broncholith was performed in 29 patients and was successful in all. Elective thoracotomy with lymph node curettage, removal, or both was performed in 5 patients. These 5 patients had no significant morbidity and no operative mortality. Patients remained symptom free (median follow-up, 2.3 years; range, 8–42 months). Twelve asymptomatic patients with calcified lymph nodes were followed with serial computed tomographic scans and remain asymptomatic (median follow-up, 3.1 years).
Conclusions: Broncholiths that are not fixed to the airway can be safely removed with rigid and flexible bronchoscopic equipment. Thoracotomy with broncholithectomy is also safe and effective and is reserved for symptomatic lesions that cannot be removed bronchoscopically or for lesions that cause airway esophageal fistulas. Calcified nodes in asymptomatic patients are not an indication for intervention.
Abbreviations and Acronyms CT = computed tomography; Nd:YAG = neodymium-doped yttrium aluminum garnet
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Introduction
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Broncholiths are calcified peribronchial lymph nodes that erode into the adjacent airway and cause clinical and radiographic abnormalities.1
Most broncholiths are a result of fungal infections, often Histoplasmosis capsulatum or mycobacterial granulomatous lymphadenitis, silicosis, or both.2,3 Patients become symptomatic when the calcified lymph node impinges on or erodes into the lumen of the airway. Bronchial distortion, irritation, and erosion by broncholiths can cause chronic cough, hemoptysis, lithoptysis, recurrent pneumonia, and fistulas between the bronchi and mediastinal structures, often the esophagus. Bronchoscopy plays an important diagnostic and therapeutic role. However, many endoscopists have reservations about removal because of the fear of massive hemorrhage, bronchial injury, or both with attempted extraction of broncholiths bronchoscopically. Thus many currently recommend avoiding bronchoscopic broncholithectomy4 and prefer thoracotomy with broncholithotomy.5 In addition to these symptomatic patients, some patients are sent for evaluation of large calcified mediastinal nodes that are asymptomatic. The natural history of these patients has been poorly studied. The purpose of this study was to review our endoscopic and thoracotomy experience in symptomatic patients with broncholithiasis and to evaluate the 3-year natural history of asymptomatic patients with calcified mediastinal lymph nodes.
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Materials and Methods
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Definitions
Broncholithiasis is defined as bronchial inflammation or obstruction caused by broncholiths. A broncholith is defined as a calcified structure or hard concretion that has part of its structure eroding into any part of the tracheobronchial tree.6 It is visible during bronchoscopy, and usually results from the erosion of a tuberculous or other granulomatous lymph node through the bronchial wall into the lumen. Broncholiths were then subdivided as either mobile (also called rockable) or fixed. Mobile broncholiths are defined as a broncholith that is either loose in the airway or moves when probed with bronchoscopic instruments during bronchoscopy. A fixed broncholith (also referred to in this article as an airway stone) is defined as a broncholith that does not exhibit any movement when probed by the bronchoscope or by any instruments placed through it during bronchoscopy.
We performed a retrospective cohort study using a prospective operative database over an 8-year period. In addition, a prospective database of patients evaluated in our clinic was also used. All patients saw one surgeon in the clinic, and patients who underwent surgical intervention were operated on by the same surgeon. The inclusion criteria require patients with calcified mediastinal lymph nodes that we evaluated in our clinic or patients with broncholiths who underwent bronchoscopy or open operations. Patients less than 19 years of age were excluded. This study was approved by the University of Alabama's Institutional Review Board. Patient consent was obtained for entry into the operative and clinic databases, and patients were informed that their data might be used for research purposes.
Technique of Rigid Bronchoscopy
Rigid bronchoscopy was performed as described at length previously.7 Briefly, patients underwent general anesthesia, a tooth guard was placed on the patient's upper teeth, the neck was extended, and, most commonly, a rigid number 8 bronchoscope was inserted through the vocal cords under direct vision with the aid of a hand-held laryngoscope. Conversion from rigid bronchoscopy to formal laryngoscopy with epiglottic suspension is always available. Once the rigid bronchoscope is in the upper trachea, jet ventilation is established. Jet ventilation is carried out through a side channel of the rigid bronchoscope, thus enabling the surgeon more room to work through the end of the scope concomitantly while still oxygenating and ventilating the patient. Ventilation occurs through the open end of the rigid bronchoscope. A flexible bronchoscope can then be easily placed down through the rigid scope, and the entire airway can be evaluated. The offending broncholith is identified and is probed to determine whether it is fixed to the sides of the airway or whether it is mobile. If bleeding occurs from vascular granulation tissue around the airway stone, then a neodymium-doped yttrium aluminum garnet (Nd:YAG) or holmium laser can be used as previously described.8 In addition, an Nd:YAG or holmium laser can be used to directly laser the stone in selected patients. If the stone is loose or becomes loose after manipulation, then it is removed through a 0° lens straight-A head grasper. If it cannot be grabbed and removed, a 4- to 8-mm angioplasty balloon catheter is positioned beyond the stone and then inflated and pulled proximally to pull the stone into the more proximal airway. Irrigation is then used to ensure all small fragments are removed, and the distal airway is then inspected to ensure all subsegments are recruited.
Thoracotomy With Lymph Node Removal or Curettage
Patients who have persistent symptoms, recalcitrant tracheobronchial fistulas, or both to other mediastinal structures often require thoracotomy. The goal of the operation is broncholithectomy through a bronchotomy, repair of the airway and takedown of the fistula, the interposition of a pedicled muscle flap in between the 2 structures (usually we use an intercostal muscle), and removal of all calcified mediastinal (N2) nodes, as well as calcified hilar (N1) nodes, that can be safely removed without the concomitant removal of nondiseased pulmonary parenchyma. Lymph nodes that cannot be safely removed, such as the subcarinal node, because of tenacious attachment to surrounding vital structures (ie, esophagus, carina, and superior vena cava) should be incised, and curettage should be used as previously described.5 This allows for removal of the caseating material, calcified material, or both that fills the lymph node yet leaves the outer shell of the lymph node in place. This technique is safe because the outer wall of the lymph node serves as a protective border to help prevent injury to surrounding structures. The entire material, however, inside the lymph node must be removed so the walls of the lymph node collapse.
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Results
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Between January 1998 and December 2006, there were 50 patients (23 men) who met the eligibility criteria for this study. Twelve (24%) patients were asymptomatic and were referred for calcified mediastinal lymph nodes that were incidentally discovered during computed tomographic (CT) scans performed for other reasons. The remaining 38 (76%) patients were symptomatic.
Figure 1 shows the results for these symptomatic patients. The most common presenting symptoms included hemoptysis (11 patients), persistent cough (8 patients), and recurrent pneumonia (5 patients). Other symptoms included chest pain in 4 patients, dyspnea in 4 patients, dysphagia in 2 patients, and malaise, hemoptysis, excessive sputum, and wheezing in 1 patient each. All patients underwent rigid bronchoscopy with a flexible bronchoscope placed through the rigid scope, as described in the Materials and Methods sections. We found broncholiths eroding into the airway in 32 patients, an esophageal fistula in 2 patients (both on the right bronchial tree), and calcified mediastinal lymph nodes compressing parts of the airway in the remaining 4 symptomatic patients. These 4 patients underwent bronchoscopic dilation and 3-month therapy with itraconazole (Sporonax; Janssen–Ortho, Toronto Ontario, Canada) because all 4 had extensive bilateral mediastinal and hilar disease. One patient required the placement of percutaneously placed stents in the right pulmonary veins and a stent in the bronchus intermedius. He has required 2 rigid bronchoscopies and lasering because of some mild granulation tissue over the past 1.5 years.
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Figure 1. Treatment results for the 38 symptomatic patients. *Recommended length of treatment is 3 months.
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The location of the broncholiths is shown in
Figure 2. The most common location was the bronchus intermedius (n = 19). Twenty-nine broncholiths were mobile, as defined in the Materials and Methods section, during endoscopic evaluation, and 14 were immobile. Endoscopic stone removal was successful without significant bleeding in all 29 patients. These 29 patients have a median follow-up of 4.2 years and have had no significant recurrences of broncholiths, although 3 required subsequent procedures to remove other broncholiths that moved into their airway. Elective thoracotomy with lymph node curettage, removal, or both was performed in 5 patients. These 5 patients had no significant morbidity or operative mortality and remain symptom free (median follow-up, 2.3 years; range, 8–42 months). The 12 asymptomatic patients with calcified lymph nodes were followed with serial CT scans and also remain asymptomatic (median follow-up, 3.1 years).
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Discussion
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This retrospective study describes results on 4 different subsets of patients with calcified mediastinal lymph nodes. First, it demonstrates the safe and successful endoscopic management of broncholiths in a subset of patients who have broncholiths that are not fixed in the airway. Second, it shows the safe and effective results of thoracotomy in a subset of patients who have fixed broncholiths that are not safely removable endoscopically and who have persistent symptoms or fistulas caused by the broncholith. These patients can undergo broncholithectomy with good short- and long-term results through a thoracotomy. The third group includes patients whose calcified lymph nodes have not eroded into the airway. We have shown that the 3-year natural history of these patients seems to be benign, and prophylactic surgical resection might not be warranted because of the mere presence of enlarged calcified lymph nodes. However, the fourth group of patients is the most challenging. These are patients with large hilar and mediastinal lymph nodes that are compressing but not invading the airway. These patients probably represent a spectrum of mediastinal scarring that can culminate into full-blown idiopathic mediastinal fibrosis, which is also referred to as chronic fibrosis mediastinitis or chronic mediastinal fibrosis. This inflammatory and devastating disease is a process of not just calcified mediastinal lymph nodes but can become, in selected patients, a slow, progressive, insidious growth of fibrotic tissue that progressively envelopes all mediastinal structures. It has the potential to constrict or occlude any mediastinal structure and can be fatal in otherwise young healthy patients. These patients are often managed with dilation (and/or stenting of the appropriate constricted structures).
The key to success to most surgical procedures is patient selection. Brantigan in 19784 concluded that bronchoscopic broncholithectomy should be avoided in all patients because of the high risk of massive hemoptysis. Trastek and colleagues5 from the Mayo Clinic in 1985 stated that "broncholithectomy via thoracotomy is the preferred treatment." Hence many thoracic surgeons have been trained to avoid attempts at removal of airway broncholiths. However, 15 years later, the same institution updated their practice on patients with broncholiths and included 26 patients who underwent endoscopic removal.9 In the more recent series they reported that endoscopic removal is safe in properly selected patients. Similarly, Manivale and Deslee in 200510 reported the successful endoscopic removal of loose broncholiths in 2 patients, and Olsen and associates in 199611 concluded that "bronchoscopy is a safe and effective therapeutic option for the management of loose broncholiths." Yet despite these reports, many surgeons suggest that endoscopic removal should not be attempted because of the risk of massive hemoptysis and other complications.12 We believe the best treatment depends on the characteristic of the broncholith, its size, its location, its proximity to the pulmonary artery on the chest CT scan, and the patient's symptoms.
The similar characteristics of most patients who undergo successful endoscopic removal is a broncholith that is not fixed in the airway (or at least partially mobile on bronchoscopic probing), is small enough to be removed endoscopically, is proximal enough in the airway to facilitate removal, and is not contiguous with the pulmonary artery on the CT scan. If a broncholith is contiguous with the pulmonary artery, aggressive manipulation can be dangerous; however, if it is near any large vascular structures, a more aggressive probing and perhaps even lasering might be safe. In 2006, Ferguson and colleagues13 reported the use of a laser and lithotripsy to help break apart a broncholith, and as seen in this series, we too have used the Nd:YAG and holmium lasers for airway stones. However, the CT scan must be carefully evaluated, the proximity of the pulmonary artery or other vessels must be carefully considered, and the amount of broncholith outside the airway must also be considered.
Unlike many other surgical series, this study also includes a nonoperative clinic database. Although we did not start the clinic database at the same time as the surgical database, we have been able to track patients who did not come to the surgical arena. This allows us to report the total number of patients, as opposed to only those who underwent a surgical intervention. Importantly, there have been no previous reports on the natural history of calcified mediastinal and hilar lymph nodes in asymptomatic patients. Patients have been referred to us for prophylactic thoracotomy because of the fear of progression of disease. However, this article shows that the 3-year natural history of these patents appears to be benign. The nodes do not necessary rub their way into the airway or cause a fistula between mediastinal structures or lead to superior vena cava syndrome. We found that asymptomatic patients seem to have no progression of disease, either radiologically or by the development of symptoms over a median of 3.1 years. This suggests these patients can be followed on a yearly basis or perhaps even less stringently with CT scans. Intervention might not be warranted unless patients become symptomatic. These comments are for patients without active inflammatory disease and reserved for those with burnt-out calcified nodal disease. However, symptomatic patients who have superior vena cava syndrome or progressive pulmonary venous obstruction probably are better given diagnoses of idiopathic mediastinal fibrosis as opposed to broncholithiasis. Their treatment is quite different, and their disease is more aggressive, with greater morbidity, and can be fatal.
Based on our experience, we have presented an algorithm for the current management of patients with broncholiths, as shown in
Figure 3. As seen, the major determining factor is the patient's symptoms. Patients who have a fistula that is caused by the stone require intervention but not necessarily thoracotomy. Stone removal and observation is one option, and stone removal with temporary stenting of the airway or esophagus (if the fistula is between the airway and the esophagus) is another. However, open thoracotomy with broncholithectomy and buttressing of the airway closure with a muscle flap to interpose pedicled muscle between the 2 structures is the most conservative therapy and offers definitive and complete repair.
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Figure 3. Our preferred algorithm for the care of patients with broncholiths in the airway, calcified mediastinal lymph nodes abutting the airway, or both.
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In conclusion, despite previous reports, broncholiths that are not fixed in the airway can be safely removed with rigid and flexible bronchoscopic equipment. Thoracotomy with broncholithectomy appears safe and effective and is reserved for symptomatic lesions that cannot be removed bronchoscopically or for lesions that cause airway esophageal fistula. The removal of other ipsilateral calcified lymph nodes during that operation is safe. Calcified nodes in asymptomatic patients are not an indication for intervention.
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Footnotes
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Read at the Thirty-third Annual Meeting of the Western Thoracic Surgical Association, Santa Ana Pueblo, NM, June 27–30, 2007.
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References
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- Brantigan CO. Endoscopy for broncholith. JAMA 1978;240:1483.[Medline]
- Trastek VF, Pairolero PC, Ceithaml EL, Piehler JM, Payne WS, Bernatz PE. Surgical management of broncholithiasis. J Thorac Cardiovasc Surg 1985;90:842-848.[Abstract]
- Stedman's Medical Dictionary for the Health Professions and Nursing. 5th ed. New York, NY: Lippincott Williams & Wilkins; 2005209.
- Cerfolio RJ. Hemoptysis for benign disease. In: Bland KI, Sarr MG, Coffee WG, editors. The practice of general surgery. Philadelphia, PA: W.B. Saunders; 2002. pp. 877-881.
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- Olsen EJ, Utz JP, Prakas UBS. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med 1999;160:766-770.[Abstract/Free Full Text]
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Abstract
Introduction
