Videothoracoscopic staging and treatment of lung cancer

Comparison of clinical and oncologic effectiveness between flexible 3-dimensional and bidimensional video-thoracoscopic surgery for lung cancer

BACKGROUND

Three-dimensional (3D) vision systems are available for video-assisted thoracic surgery (VATS). It is unclear whether 3D-VATS is superior to bidimensional (2D) VATS systems.

METHODS

We analyzed patients who received 3D-VATS (n = 171) or 2D-VATS (n = 228) lobectomy in a single institutional retrospective comparative study of 399 patients with resectable lung cancer conducted from June 2012 to December 2017. The operative and perioperative data were compared between the 2 groups.

RESULTS

Operative time, length of hospital stay, number of dissected lymph nodes, and rate of postoperative complications were similar in both groups. In the 3D group, there was no conversion to thoracotomy for intraoperative major vascular injuries, while conversion to an open procedure for uncontrolled bleeding was recorded in 4 (1.7%) patients in the 2D group. Reoperation for hemostasis and/or aerostasis occurred in 6 (2.6%) patients of the 2D group (p = 0.04).

CONCLUSION

Nonrandomized comparison of different surgical approaches is challenging. In our experience, 3D-VATS was safe and effective and offered excellent operative perception and sensitivity, enabling safer dissection of hilar structures. The 3D-VATS system helped skilled surgeons beyond the boundaries of more oncologically aggressive surgery.

Outcomes after Video-assisted Thoracoscopic Lobectomy versus Open Lobectomy for Early-Stage Lung Cancer in Older Adults

RATIONALE

Video-assisted thoracoscopic surgery (VATS) and open lobectomy are both standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC) because of equivalent long-term survival.

OBJECTIVES

To evaluate whether the improved perioperative outcomes associated with VATS lobectomy are explained by surgeon characteristics, including case volume and specialty training.

METHODS

We analyzed the Surveillance, Epidemiology, and End Results-Medicare-linked registry to identify stage I-II NSCLC in patients above 65 years of age. We used a propensity score model to adjust for differences in patient characteristics undergoing VATS versus open lobectomy. Perioperative complications, extended length of stay, and perioperative mortality among patients were compared after adjustment for surgeon's volume and specialty using linear mixed models. We compared survival using a Cox model with robust standard errors.

RESULTS

We identified 9,508 patients in the registry who underwent lobectomy for early-stage NSCLC. VATS lobectomies were more commonly performed by high-volume surgeons (P < 0.001) and thoracic surgeons (P = 0.01). VATS lobectomy was associated with decreased adjusted odds of cardiovascular complications (odds ratio [OR] = 0.65; 95% confidence interval [CI] = 0.47-0.90), thromboembolic complications (OR = 0.47; 95% CI = 0.38-0.58), extrapulmonary infections (OR = 0.75; 95% CI = 0.61-0.94), extended length of stay (OR = 0.47; 95% CI = 0.40-0.56), and perioperative mortality (OR = 0.33; 95% CI = 0.23-0.48) even after controlling for differences in surgeon volume and specialty. Long-term survival was equivalent for VATS and open lobectomy (hazard ratio = 0.95; 95% CI = 0.85-1.08) after controlling for patient and tumor characteristics, surgeon volume, and specialization.

CONCLUSIONS

VATS lobectomy for NSCLC is associated with better postoperative outcomes, but similar long-term survival, compared with open lobectomy among older adults, even after controlling for surgeon experience.

Three-dimensional video-assisted thoracic surgery for pulmonary resections: an update

Video-assisted thoracic surgery (VATS) allows to treat pulmonary and mediastinal diseases although two-dimensional (2D) imaging can make difficult to estimate the morphological and topographical characteristics of a lesion. Some technical aspects have certainly been corrected with the introduction of robot-assisted thoracic surgery (RATS), although not widespread in less economically developed countries. As an emerging imaging system and technique, 3D VATS is an interesting resource for thoracic surgeons and it may be a proper and valid aid in minimally-invasive surgery, but not an alternative or a compromise to the most expensive robotic technology. The purpose of the study was to carefully analyze the different experiences reported in literature in order to evaluate the state of art of 3D VATS method in lung excision.

Lung cancer coexisting with ipsilateral pleural effusion

SUMMARY 

Invasion beyond the elastic layer of the visceral pleura and/or diffuse pleural metastatic spread affects negatively survival in lung cancer. Presence of pleural effusion is also associated with poor prognosis, and image techniques can be of great help for diagnosis. When pleural fluid cytology is negative, thoracoscopy is advisable before attempting tumor resection, in order to detect unsuspected pleural metastases. If widespread pleural malignancy is confirmed, chemical pleurodesis using graded talc (with particles larger than 20 µm in diameter) is the best option, unless the lung is unable to re-expand. In this case, or when a previous pleurodesis has failed, or there is a short life expectancy, placement of a indwelling pleural catheter is the treatment of choice.

Therapeutic modalities for Pancoast tumors

A Pancoast tumor, also called a pulmonary sulcus tumor or superior sulcus tumor, is a tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most Pancoast tumors are non-small cell cancers. The growing tumor can cause compression of a brachiocephalic vein, subclavian artery, phrenic nerve, recurrent laryngeal nerve, vagus nerve, or, characteristically, compression of a sympathetic ganglion resulting in a range of symptoms known as Horner's syndrome. Pancoast tumors are named for Henry Pancoast, a US radiologist, who described them in 1924 and 1932.The treatment of a Pancoast lung cancer may differ from that of other types of non-small cell lung cancer (NSCLC). Its position and close proximity to vital structures may make surgery difficult. As a result, and depending on the stage of the cancer, treatment may involve radiation and chemotherapy given prior to surgery. Surgery may consist of the removal of the upper lobe of a lung together with its associated structures as well as mediastinal lymphadenectomy. Surgical access may be via thoracotomy from the back or the front of the chest and modification. Careful patient selection, improvements in imaging such as the role of PET-CT in restaging of tumors, radiotherapy and surgical advances, the management of previously inoperable lesions by a combined experienced thoracic-neurosurgical team and prompt recognition and therapy of postoperative complications has greatly increased local control and overall survival for patients with these tumors.

Extended cervical mediastinoscopy

Surgical exploration of subaortic and para-aortic lymph nodes has traditionally required the combination of standard cervical mediastinoscopy and left anterior mediastinotomy. Video-assisted thoracoscopic surgery is another technique that allows the exploration of these nodal stations. Extended cervical mediastinoscopy is a useful and safe technique for the assessment of para-aortic and subaortic nodal stations through the same incision of the standard cervical mediastinoscopy.

Current and future options for the diagnosis of malignant pleural effusion

INTRODUCTION

Malignant pleural effusion (MPE) is a frequent problem faced by clinicians, but tumor pleural involvement can be seen without effusion.

AREAS COVERED

Imaging, pleural fluid analysis, biomarkers for MPE, needle pleural biopsy and thoracoscopy. To prepare this review, we performed a search using keywords: 'diagnosis' + 'malignant' + 'pleural' + 'effusion' (all fields) in PubMed, and found 4106 articles overall (until 16 January 2013, 881 in the last 5 years).

EXPERT OPINION

Ultrasound techniques will stay as valuable tools for pleural effusions. Biomarkers in pleural fluid do not currently provide an acceptable yield for MPE. In subjects with past history of asbestos exposure, some serum or plasma markers (soluble mesothelin, fibulin) might help in selecting cases for close follow-up, to detect mesothelioma early. Needle pleural biopsy is justified only if used with image-techniques (ultrasound or CT) guidance, and thoracoscopy is better for both diagnosis and immediate palliative treatment (pleurodesis). Animal models of MPE and 'spheroids' are promising for research involving both pathophysiology and therapy. Considering the possibility of direct pleural delivery of nanotechnology-developed compounds-fit to both diagnosis and therapy purposes ('theranostics')-MPE and mesothelioma in particular are likely to benefit sooner than later from this exciting perspective.

Initial experience with a new technique of endoscopic and ultrasonographic access for biopsy of para-aortic (station 6) mediastinal lymph nodes without traversing the aorta

OBJECTIVES

All lymph node stations but the para-aortic are accessible by a combination of endoscopic ultrasound and endobronchial ultrasound. We recently described an echographic-endoscopic technique for the biopsy of para-aortic (station 6) lymph nodes without traversing the thoracic aorta. This study reviewed our initial experience with this new technique.

METHODS

This first-in-human evaluation of the biopsy of station 6 mediastinal lymph nodes with curvilinear endoscopic ultrasound without arterial puncture used a retrospective case series design to study 12 consecutive patients who underwent this new technique. Station 6 lymph nodes were approached with a long fine needle aspiration approach (6-8 cm) through the proximal esophagus. The needle was passed through the esophagus into the mediastinum just medial to the left subclavian artery. It was then directed toward the para-aortic location (6-8 cm trajectory) to reach and enter the para-aortic lymph nodes without piercing the aorta or great vessels.

RESULTS

Successful cytologic diagnoses of station 6 lymph nodes were obtained in all cases (lymphocytes in all samples). No morbidity resulted from the procedure, nor was any observed at 30 days after the procedure. Patient anatomy may preclude safe access in certain situations.

CONCLUSIONS

Endoscopic ultrasound access of para-aortic (station 6) lymph nodes allows complete, minimally invasive mediastinal lymph node staging and diagnosis without traversal of the aorta. This technique, the final piece of the puzzle required for complete staging of the mediastinum with nonsurgical endoscopic techniques, is reproducible and safe.

Video-assisted thoracoscopic surgery versus open lobectomy for stage I lung cancer: A meta-analysis of long-term outcomes

The present study aimed to evaluate the evidence comparing video-assisted thoracoscopic surgery (VATS) and open lobectomy for the treatment of stage I lung cancer using meta-analytical techniques. A literature search was undertaken until July 2011 to identify comparative studies evaluating survival rates, recurrence rates and complications. Pooled odds ratios (OR) and 95% confidence intervals (95% CI) were calculated with either the fixed- or random-effects model. These studies included a total of 1,362 patients: 668 treated with VATS and 694 treated with open lobectomy. The overall survival was significantly higher in patients treated with VATS than with open thoracotomy (OR=2.01, 95% CI 1.44-2.78) at 5 years. However, there was no statistically significant difference in 1.3-year overall survival between the VATS and open lobectomy groups (OR=3.21, 95% CI 0.77-13.40; OR=0.91, 95% CI 0.49-1.70). The data did not demonstrate a significant difference in locoregional recurrence (OR=0.58, 95% CI 0.33-1.03) compared to the open lobectomy group, but suggested a reduced systemic recurrence rate (OR=0.52, 95% CI 0.23-0.82) and complications (OR=0.36, 95% CI 0.23-0.57) of VATS. VATS was superior to open lobectomy for the prognosis of stage I lung cancer. However, the findings have to be carefully interpreted due to the lower levels of evidence.

The Future in Diagnosis and Staging of Lung Cancer

Surgical techniques remain central to the diagnosis and staging of lung cancer. Clinical situations which invoke the role of surgery include the diagnosis of solitary pulmonary masses, staging of the mediastinum, restaging of the mediastinum and the assessment of resectability. The techniques available include cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy and different procedures for intra-operative mediastinal lymph node assessment including systematic nodal dissection, lobe-specific nodal dissection and sentinel node mapping. The staging of lung cancer is continuously evolving as technological advances combine with clinical advances to better stratify patients into treatment and prognostic categories and alter pre-operative investigation algorithms. Although most of the surgical techniques have been around for many years, it is their application in future which is likely to change. The increasing use of positron emission tomography/computed tomography fusion imaging is raising the proportion of patients being shown to have additional lesions that could contraindicate surgical treatment but which require tissue confirmation to exclude a false-positive examination. Many such lesions are amenable to the expanding techniques available to the interventional endoscopist. The relationship between the surgeon and the endoscopist must become closer to ensure that the appropriate technique is used at each point in the patient's pathway. The future of surgical techniques will be driven by: (1) developments in screening and imaging, with a likelihood that more early stage cancers will present and may be amenable to minimally invasive surgical approaches with the possibility of a role for robotics and nanotechnology; (2) improvements in neoadjuvant therapies which will demand flawless mediastinal staging and restaging; (3) advances in molecular biology which, whilst currently requiring that surgery provide samples of tumour and lymph node tissue to fully characterize the disease, do hold the promise that ever smaller amounts of tissue will be required and that eventually the genetic fingerprint will provide a biological ultrastaging to perhaps supersede anatomical staging.

Diagnostische videoassistierte Thorakoskopie

Modern radiologic diagnostics show a variety of pathological changes in the mediastinum, pleura, and lung but no evidence on their histogenesis. Transbronchial and transthoracal fine-needle aspiration biopsy usually cannot yield detailed diagnostic results because of its small size. Sufficient and representative material can be obtained by thoracoscopy. Video-assisted thoracoscopy allows safe and fast diagnosis of diffuse lung diseases, pleural diseases including malignant mesothelioma, indeterminate peripheral lung nodule, and mediastinal masses. This gentle diagnostic method can give invaluable information guiding further management of the thoracic injury. Video-assisted thoracoscopy is a safe and effective guiding tool if performed by experienced thoracic surgeons able to convert to thoracotomy. It is to be noted that interpretation of intraoperative findings plays a decisive role in interdisciplinary diagnostics of intrathoracal diseases.

Tracheal sleeve pneumonectomy: Long-term outcome

Selected primary lung cancers less than 2cm from the carina or invading the tracheo-bronchial angle, formerly considered inoperable, can be amenable to tracheal sleeve pneumonectomy (TSP). Such a delicate technique, can entail remarkable post-operative morbidity and mortality, and only few clinical series are reported. Purpose of this paper is to examine complications and long-term survival of our personal series and those reported in literature. At our academic department from 1983 to December 2004, out of 99 patients with NSCLC less than 2cm from the carina, 35 (35.4%) were deemed inoperable after conventional staging; the remaining 64 underwent surgery. Since 1993 in every patient with lung cancer we perform a thoracoscopic exploration as the first step of the intervention. Unexpected causes of inoperability were found at thoracotomy in nine patients (14.1%) and at thoracoscopy in two other patients. Of the remaining 53 patients, 52 had a right TSP and one a left TSP. Intraoperative mortality was nil. Perioperative mortality was 7.5%. Major complications occurred in 11.3% of the patients. Thirty (56.6) patients are alive and disease-free 23-97 months after surgery; for 18 (33.4%) of these, more than 5 years have elapsed after the operation. TSP is the only concrete option for treating lung cancer originating less than 2 cm from the carina. The review of our experience and of other reported series suggests that, with careful selection of patients and meticulous surgical technique, operative mortality and complications are acceptable. Long-term survival and prognosis are encouraging.

Feasibility of Imprint Cytology for Evaluation of Mediastinal Lymph Nodes in Lung Cancer

BACKGROUND

Intraoperative evaluation of mediastinal lymph nodes is a necessary step which helps us to decide whether or not to continue the operation of lung cancer. Imprint cytology (IC) can be used as an alternative method in staging. It is a more rapid and simpler procedure than frozen section (FS) analysis. Therefore, we compared the diagnostic accuracy of IC with permanent section on 1050 mediastinal lymph nodes.

METHODS

A total of 255 non-small cell lung cancer patients who underwent surgical procedure between January 1995 and April 2004 were included. There were 236 males and 19 females with a mean age of 54.2 years (range 26-79 years). In order to obtain lymph node samples mediastinoscopy was performed in 232 (91%), anterior mediastinotomy in 50 (20%) and video-assisted thoracoscopic surgery in 16 (6.3%) patients. During final pathological diagnosis, both imprint and permanent section slides were compared.

RESULTS

There were five false-positive and eight false-negative results. The sensitivity, specificity and the predictive values for positive and negative results were 93.1, 99.5, 95.6 and 99.1%, respectively. The overall efficiency was 98.8%.

CONCLUSIONS

The diagnostic IC is an accurate, reliable, simple and less time-consuming method for evaluation of mediastinal lymph nodes in lung cancer, compared with FS method.

Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery

STUDY OBJECTIVES

Controversy regarding the most suitable surgical approach for treating malignancies of the lung is a matter of continuous discussions. "Complete" video-assisted thoracic surgery (VATS) that is performed using only the vision of a monitor is generally limited to lung resections of minimal difficulty. With the great interest in minimally invasive techniques for treating various pathologies, we have widely applied an integrated surgical approach that combines muscle-sparing minithoracotomy (incision, 4 to 10 cm) and video assistance using mainly direct visualization of the lung resection, which we have called hybrid VATS. The aim of this study is to evaluate the usefulness of hybrid VATS.

DESIGN

Retrospective single-center study.

INTERVENTIONS

From January 1998 to October 2004, 405 of 678 lobectomies (60%) and 165 of 226 segmentectomies (73%) were performed for primary lung cancer using hybrid VATS.

RESULTS

Bronchoplasty was performed in 93 of the 678 patients (14%) who underwent lobectomy and in 11 of the 226 patients (5%) who underwent segmentectomy. Hybrid VATS was utilized in 33% of sleeve lobectomy procedures and in 27% of sleeve segmentectomy procedures. The mean (+/- SD) surgical time using hybrid VATS was 164 +/- 48 min for lobectomy and 158 +/- 35 min for segmentectomy, and the mean blood loss was 166 +/- 120 and 109 +/- 80 mL, respectively. There was one operative mortality (0.2%) secondary to cardiogenic shock. Postoperative complications developed in 11% of patients with p-stage IA disease after undergoing hybrid VATS, in contrast to 19% of patients after undergoing open thoracotomy. The prognosis of patients treated by hybrid VATS was equivalent to that obtained with open thoracotomy.

CONCLUSIONS

Minithoracotomy combined with video support that is performed predominantly via direct visualization is a secure, integrated, minimally invasive approach to performing major resection for lung cancer, including atypical procedures such as bronchoplasty. This hybrid VATS can be an acceptable and satisfactory option whenever the performance of complete VATS is considered to be challenging.

Subtle pleural metastasis without large effusion in lung cancer patients: preoperative detection on CT

Objective

We wanted to describe the retrospective CT features of subtle pleural metastasis without large effusion that would suggest inoperable lung cancer.

Materials and Methods

We enrolled 14 patients who had open thoracotomy attempted for lung cancer, but they were proven to be inoperable due to pleural metastasis. Our study also included 20 control patients who were proven as having no pleural metastasis. We retrospectively evaluated the nodularity and thickening of the pleura and the associated pleural effusion on the preoperative chest CT scans. We reviewed the histologic cancer types, the size, shape and location of the lung cancer and the associated mediastinal lymphadenopathy.

Results

Subtle pleural nodularity or focal thickening was noted in seven patients (50%) having pleural metastasis and also in three patients (15%) of control group who were without pleural metastasis. More than one of the pleural changes such as subtle pleural nodularity, focal thickening or effusion was identified in eight (57%) patients having pleural metastasis and also in three patients (15%) of the control group, and these findings were significantly less frequent in the control group patients than for the patients with pleural metastasis (p = 0.02). The histologic types of primary lung cancer in patients with pleural metastasis revealed as adenocarcinoma in 10 patients (71%) and squamous cell carcinoma in four patients (29%). The location, size and shape of the primary lung cancer and the associated mediastinal lymphadenopathy showed no significant correlation with pleural metastasis.

Conclusion

If any subtle pleural nodularity or thickening is found on preoperative chest CT scans of patients with lung cancer, the possibility of pleural metastasis should be considered.

Combined Video-Assisted Mediastinoscopy and Thoracoscopy in the Management of Lung Cancer: A Five-Year Experience

OBJECTIVE

The aim of this study was to assess the usefulness of combined video-assisted mediastinoscopy (VM) and video-assisted thoracoscopy (VT) in the management of patients with lung cancer.

METHODS

A prospective observational study was performed over a 5-year period. Indications for combined VM and VT included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain a histologic diagnosis with a single technique.

RESULTS

An indication for combined exploration was established in 30 patients, representing 2.6% of all the patients referred to us for diagnosis, staging, and/or resection of lung cancer. Combined VM and VT was completed in 28 patients, as pleural carcinosis was found at VT in 2 cases. There was no mortality or morbidity in our series. Histologic diagnosis was obtained in 12/13 patients without preoperative histologic typing. In all the evaluated patients, combined VM and VT was useful in clinical decision-making, leading to immediate surgery (n=10), induction treatments (n=8), or nonsurgical therapy (n=12). Among the patients who underwent immediate surgery, combined VM and VT never failed to assess the T factor. The N factor was correctly evaluated in 8/10 patients, and in 2 patients it failed to recognize a minimal N2 disease.

CONCLUSION

Combined VM and VT is a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread can be thoroughly evaluated.

Thoracoscopic Localization Techniques for Patients With Solitary Pulmonary Nodule and History of Malignancy

BACKGROUND

Our aim was to evaluate the best intrathoracoscopic localization technique in patients with single pulmonary nodule and a history of malignancy.

METHODS

We divided 50 patients in two groups, well matched for diameter and depth of the pulmonary lesion. In 25 patients we performed intrathoracoscopic ultrasound to locate the pulmonary nodule (group A), whereas in the other 25 patients the radio-guided technique was adopted (group B). In both group A and group B, the localization techniques were compared with finger palpation. In group A, 12 nodules were in the left lung and 13 in the right one; in group B, 11 lesions were in the left and 14 in the right lung. In both groups, the distance of the nodule from the pleural surface was 2.6 +/- 0.5 cm (2 to 2.5 cm in 14 patients, and >2.5 cm for the remaining 11). The diameter of the nodule was 1.26 +/- 0.22 (< or =1 cm in 10 patients, and 1 to 1.5 cm in 15) in both groups. All patients underwent thoracoscopic wedge resection, and 10 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy.

RESULTS

In group A, ultrasound localized the nodule in 24 of 25 patients (96%) whereas finger palpation localized it in 19 of 25 (76%; not significant). In group B, both the radio-guided and finger palpation techniques localized the nodule in 20 of 25 patients (80%; not significant). No complications were recorded with the ultrasound technique; however, 10 cases of pneumothorax were detected after the radio-guided technique (p < 0.01).

CONCLUSIONS

Both the ultrasound and radio-guided techniques are accurate to detect solitary pulmonary nodules, but the radio-guided method yields complications as compared with the ultrasound.

Long-term Survival After Videothoracoscopic Lobectomy for Stage I Lung Cancer

STUDY OBJECTIVES

The aim of this study was to evaluate our personal experience and survival curves after video-assisted thoracic surgery (VATS) lobectomies for stage I lung cancer, in comparison with the results reported in existing literature.

DESIGN

Retrospective analysis of our experience and an overview of literature.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milan.

PATIENTS

From October 1991 to December 2001, of 257 patients with clinical stage I lung cancer, 193 patients underwent VATS lobectomy, 7 patients were declared inoperable at thoracoscopic exploration, and 57 patients were converted (18 patients for oncologic reasons and 39 patients for technical reasons).

RESULTS

We observed no intraoperative mortality and no recurrence. Survival data were analyzed with the Kaplan-Meier method along with a log-rank test for statistical significance. The global survival rates at 3 years and 5 years were 77.7% and 63.64%, respectively. T1N0 patients had a better survival curve at 3 years and 5 years (83.50% and 70.21%, respectively) compared to T2N0 patients (71.13% and 56.12%). Patients < 70 years of age had better 3-year and 5-year survival rates (82.37% and 73.32%, respectively) than those > 70 years of age (57.49% and 37.09%). This difference was statistically significant (p < 0.01).

CONCLUSIONS

Our results after the VATS approach match the "best" results reported in literature following conventional surgery. Minimally invasive surgery seems to imply reduced tissue damage and decreased impairment of immunologic function. VATS lobectomy permits radical oncology as accurately as lobectomy by thoracotomy, provided that long-established standards are respected. In spite of technical difficulties, it could therefore become a valid alternative in treating stage I lung cancer.

Lung cancer staging

The staging of lung cancer is a continuously progressing field, with advances in technology not only improving prognostic accuracy, but fundamentally changing pre-operative investigation algorithms. Noninvasive staging is currently undergoing revolutionary developments with the advent of Positron Emission Tomography, whereas Video-Assisted Thoracic Surgery has already been established as an essential, minimally invasive diagnostic tool for invasive histological staging. Molecular staging may transform future lung cancer staging, promising extremely accurate substaging, and potentially prompting a revision of our anatomically based conceptualization of lung cancer spread. This review presents an appraisal of current lung cancer staging modalities, and presents an overview of recent developments in molecular staging.

Postoperative Respiratory Complications of Video-assisted Thoracic Surgery for Lung Cancer

PURPOSE

We analyzed the risk factors predisposing patients to develop postoperative respiratory complications (PRCs) in VATS lobectomy and segmentectomy for lung cancer, retrospectively.

METHODS

Both univariate and multivariate analyses of PRCs were performed in seventy-five patients who had undergone VATS lobectomy and segmentectomy for lung cancer from November 1994 to December 2000.

RESULTS

Univariate analysis of the development of PRCs revealed that the significant risk factors were age, ppo%VC, ppo%FEV, ppoFEV, poor pulmonary function, and duration of surgery. Multivariate logistic regression test in regard to the development of PRCs revealed that duration of surgery was the most significant risk factor. On the basis of the receiver operator characteristic analysis, duration of surgery more than 297 min had a sensitivity of 70% and a specificity of 66% for the development of PRCs.

CONCLUSIONS

The duration of surgery should be less than five hours not to lose advantages of VATS lobectomy and segmentectomy. Therefore, if the duration of surgery is more than five hours for any reasons, conversion to limited thoracotomy or muscle-sparing methods is recommended.

Thoracoscopic Localization Techniques for Patients with a Single Pulmonary Nodule and Positive Oncological Anamnesis: A Prospective Study

INTRODUCTION

Our aim was to evaluate the best intrathoracoscopic localization technique in patients with a single pulmonary nodule and a history of malignancy.

METHOD

We divided 30 patients into two groups, well matched for diameter and depth of the pulmonary lesion. In 15 patients (group A) we performed intrathoracoscopic ultrasound (US) to locate the pulmonary nodule, while in the other 15 patients (group B) intrathoracoscopic radioguided occult lesion localization (ROLL) was used. In both groups, the localization technique was compared to finger palpation. In group A, 6 nodules were in the left lung and 9 in the right; in group B, 7 lesions were in the left and 8 in the right lung. In each group, the distance of the nodule from the pleural surface was 2-2.5 cm in 8 patients, and > 2.5 cm in the remaining 7. In both groups, the diameter of the nodule was </= 1 cm in 6 patients, and 1-1.5 cm in 9 patients. All patients underwent thoracoscopic wedge resection, and 6 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy.

RESULTS

In group A, US localized the nodule in 15 of 15 patients (100%) while finger palpation located the nodule in 11 of 15 (73%) (P = NS). In group B, both ROLL and finger palpation localized the nodule in 12 of 15 patients (80%) (P = NS).

CONCLUSION

Intrathoracoscopic US seems superior to radioguided and finger palpation localization techniques for single pulmonary nodules. Thus, we are now routinely using intraoperative US to identify single pulmonary nodules.

The use of surgery to treat lung cancer in elderly patients

Lung cancer is a leading cause of cancer death and its cure depends on an adequate surgical approach. More than half of all lung cancers are diagnosed in patients aged 65 years or over. However, surgical risk increases in patients over 65 years old. Therefore, surgical procedures for lung cancer are far less frequent in elderly patients. Many clinicians avoid surgery, or minimise surgical procedures on the basis of age but recent advances in preoperative risk assessment and surgical and anaesthetic techniques have resulted in a significant decrease in operative mortality and morbidity for older patients. The treatment of lung cancer in elderly patients should no longer be based on the premise that surgery is too risky for elderly patients. Every effort should be made to assess risk and optimise treatment for this large and expanding proportion of the population.

Current concepts in the staging of non-small cell lung cancer

When evaluating a patient diagnosed with non-small cell lung cancer (NSCLC), staging helps define the extent of disease. The main goals of staging are to assist in determining appropriate treatment options (surgery versus non-surgical) and in predicting prognosis. Based on the recommendation of the American Joint Committee for Cancer (AJCC), a TNM (tumor, node, and metastases) staging system is used for NSCLC. Clinical staging (cTNM) is determined using non-invasive techniques such as clinical assessment and radiologic testing. Pathologic staging (pTNM) is determined using invasive techniques such as bronchoscopy, mediastinoscopy, and video-assisted thoracoscopic surgery, or at the time of thoracotomy. Recently, new staging modalities such as positron emission tomography and intraoperative sentinel node mapping have been used with promising results. In the near future, these techniques, as well as molecular and serum tumor markers, will likely be used to more accurately determine the burden of disease and allow for more appropriate treatment.

Diagnosis and management of early lung cancer

Bronchogenic carcinoma remains the leading cause of cancer deaths in the United States. Approximately 80% of newly diagnosed cases are non-small cell lung cancer (NSCLC); 80% of these present with disseminated or locally advanced disease. Unfortunately, only 10% are potentially surgically curable patients with early-stage disease (T1N0/T2N0). Most patients with early-stage disease are asymptomatic, with their lung cancer detected as a result of non-cancer related procedures. Studies have shown that chest radiography as a screening modality resulted in a higher discovery of early disease, but did not translate to a significant reduction in lung cancer mortality. Recent work on low-dose helical CT, however, has renewed interest in the challenge of detecting early-stage lung cancer.

Video-assisted thoracic surgery (VATS) resection for lung cancer

VATS is a relatively new technology that has become the standard of care for basic procedures such as drainage of pleural effusion and blebectomy. VATS anatomic lung resection is more controversial. Published studies demonstrate several advantages of VATS over a standard posterolateral thoracotomy. A minimally invasive approach causes less inflammatory reaction. Acute and chronic pain are diminished. As a result, the length of hospitalization is shorter. Early and late shoulder dysfunction is less and return to work time is shorter. Taken together, these factors suggest a better overall outcome using a VATS approach. From an oncologic standpoint, lymph node dissection can be accomplished and locoregional recurrence is low. The validity of VATS for lung cancer will be determined by long-term data. A phase III national (intergroup) protocol is being drafted and will help to answer these questions.

Usefulness of videothoracoscopic intrapericardial examination of pulmonary vessels to identify resectable clinical T4 lung cancer

BACKGROUND

Discrepancies in predicting resectability by imaging techniques (computed tomography and magnetic resonance imaging) compared with actual intraoperative findings have persuaded us to perform systematic exploratory videothoracoscopy (EVT) as the first step in the surgical evaluation of patients with lung cancer. Resectability of centrally located primary tumors with intrapericardial extension (clinical T4), however, can be established only by direct examination of the pericardial sac contents. Therefore, in these instances, videopericardioscopy (VPC) has been added to our protocol.

METHODS

From April 1993 to December 2000, members of our department used EVT to assess 620 patients with lung cancer. Of them, 27 patients, 25 men and 2 women, were seen with pericardial tumor extension. The mean age of the group was 62 years (range, 41 to 77 years). To be properly evaluated, these patients underwent VPC. We used three and, occasionally, four incisions to perform EVT. The same incisions were used to enter the pericardial cavity during VPC.

RESULTS

In 15 of the 27 patients, hilar and vascular invasion was correctly predicted by imaging techniques. The other 12, however, were correctly staged only during EVT. The tumor was deemed unresectable by VPC in 6 patients (5 with invasion at the origin of the pulmonary artery and 1 with involvement of the left inferior pulmonary vein and left atrium), and exploratory thoracotomy was obviated. There was no morbidity or mortality in these 6 patients, and their mean length of hospital stay was 48 hours. The remaining 21 patients underwent thoracotomy and intrapericardial lung resection. Six of them had been considered to have unresectable disease on the basis of computed tomographic findings or magnetic resonance imaging studies. An average of 22 minutes (range, 16 to 33 minutes) was added to the operation when VPC was used.

CONCLUSIONS

This study suggests that EVT is superior to imaging techniques (computed tomography or magnetic resonance imaging) in detecting tumor extension into the pericardium. In addition, short of an exploratory thoracotomy, VPC seems to be the most definitive study to establish resectability of centrally located tumors with pericardial invasion. Unnecessary exploratory thoracotomies can thus be avoided.

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of lung cancer

BACKGROUND

This study seeks to assess the safety and usefulness of combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of patients with lung cancer.

METHODS

Ten consecutive patients with lung neoplasms were evaluated. Indications for this combined approach included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain histologic diagnosis by a single technique. RESULTS; Histologic diagnosis was obtained in 6 patients without preoperative histologic typing. In 3 patients, in contrast with preoperative imaging studies, combined thoracoscopy and mediastinoscopy showed the resectability of the primary tumor and the absence of metastatic mediastinal lymph nodes. These findings were confirmed at thoracotomy. In 3 other patients prevascular lymph nodes metastases were found. They underwent neoadjuvant chemotherapy; at subsequent operation, a complete resection was possible. In the remaining four cases combined exploration proved definitive contraindications for operation (recognition of oat-cell carcinoma, n = 2; T4 status, n = 1; T3N2, n = 1).

CONCLUSIONS

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy seems to be a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread may be exhaustively evaluated. In patients with left lung cancer a complete exploration of the aortopulmonary window is possible.

Complications of tracheal sleeve pneumonectomy: personal experience and overview of the literature

OBJECTIVES

Tracheal sleeve pneumonectomy, although technically demanding, is considered the choice for tracheobronchial angle cancers. Complications in our 49 tracheal sleeve pneumonectomies are reviewed. Results, complications, and technical aspects are critically discussed. Although series in the literature differ in selection of patients and surgical techniques and extend over long periods, we attempt to compare our experience with results from the literature.

METHODS

From 1983 to September 1999, 60 patients eligible for tracheal sleeve pneumonectomy after conventional staging underwent operation. A Sybilla Fome-Cuf ventilation tube (Bivona, Inc, Gary, Ind) was used starting in 1987 to facilitate anastomosis. Since 1993, all patients have undergone video-assisted thoracoscopy immediately before the operation.

RESULTS

There were 11 (18.3%) exploratory thoracotomies, 48 right tracheal sleeve pneumonectomies, and 1 left tracheal sleeve pneumonectomy. Among the tracheal sleeve pneumonectomies, we recorded 4 (8.2%) perioperative deaths (myocardial infarction, n = 1; heart failure, n = 1; pulmonary edema, n = 1; gastric ulcer hemorrhage, n = 1; and anastomotic fistula in a patient who received high-dose radiation before the operation, n = 1). We observed 5 (10.2%) complications (lung edema, n = 1; transitory recurrent nerve palsy, n = 2; empyema without fistula cured conservatively, n = 1; and pneumonia, n = 1). Anastomotic stenosis did not occur. Twenty-six (53%) patients are alive 14 to 87 months postoperatively, 12 (24.5%) of these more than 5 years postoperatively. Five (10.2%) died of mediastinal recurrence at 6 and 54 months. Two others (4.1%) died in road accidents.

CONCLUSIONS

Tracheal sleeve pneumonectomy is a demanding operation with a high risk of complications. Analysis of literature and personal experience shows that complications can be greatly reduced through accurate selection of patients, precise technique, and optimal postoperative care. Long-term survival equals that obtained after standard pneumonectomy.

Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma

BACKGROUND

Extended cervical mediastinoscopy (ECM) is a technique in the staging of bronchogenic carcinoma described first by Ginsberg in 1984. To update our experience we have prospectively evaluated our results on 106 patients who underwent the technique from 1985 to 1998.

METHODS

The ECM technique is performed once the operability of the patient has been evaluated, according to the computed tomography findings. The intervention is carried out at the same time as a standard cervical mediastinoscopy through the same incision following the same technique as previously published. The ECM is considered positive when metastatic nodes or tumor involvement directly in the paraaortic or subaortic regions is detected and confirmed histologically. Negative cases of ECM and positive cases of standard cervical mediastinoscopy are excluded from this study. A false-negative ECM is defined as the presence of infiltrated adenopathies at the paraortic level detected on postoperative histologic study.

RESULTS

We had performed ECM in 106 patients, and a total of 13 were subsequently excluded for the reasons stated above. Of the remaining cases, 26 were positive, 61 negative and 6 had false-negative results with no false-positive results. Sensitivity was 81.2%, specificity 100%, accuracy 93.3%, positive predictive value 100%, and negative predictive value 91%. There were no complications with the technique.

CONCLUSIONS

We conclude that ECM is a useful technique for staging bronchogenic carcinoma that allows samples to be taken from paraortic and subaortic regions with minimally invasive techniques.

Thoracoscopic evaluation and treatment of pulmonary disease

VATS wedge resection and lobectomy can be performed with reasonable morbidity and mortality. A cautious approach is appropriate for VATS lobectomy with proper patient selection, and the completeness of the cancer surgery should not be compromised. Only surgeons with the VATS skills that allow them to perform complex procedures should perform the procedure.

Mini-invasive surgery may be advised in oncology

In the last decade mini-invasive surgery has consistently developed with good results, but also with some unjustified clinical applications. This review is aimed at defining evidence based indications and procedures ('clinical practice') and those still worthy of controlled studies in oncologic centers with expertise in mininvasive surgery ('clinical research'). At present, diagnostic and staging laparoscopy and thoracoscopy represent the 'standard' for different tumors. Conversely, therapeutic indications according to evidence based medicine criteria are still limited. Tumors treatment by mini-invasive surgery requires 'expertise' on the part of the surgical team; this can be achieved by extensive training of a correct use of instruments and methods following the general surgical principles of traditional 'open surgery'.

Semi-invasive and invasive procedures for the diagnosis and staging of lung cancer. II. Bronchoscopic and surgical procedures

Each of the various techniques used for the diagnosis and staging of lung cancer has its advantages and limitations (Table 1). Imaging has a major role in guiding these procedures and deciding which of them is most appropriate in a given clinical setting. A CT examination by which the size and location of the parenchymal lesion and the presence and location of enlarged lymph nodes can be determined is a prerequisite for all sampling procedures. As a general rule, when attempting to diagnose a solitary pulmonary nodule or mass, central lesions are more easily approached by the bronchoscopic route, whereas a transthoracic route is preferred for peripheral lesions. Bronchoscopy is often performed using fluoroscopic guidance, and the recently developed CT fluoroscopy and endoscopic ultrasound have the potential to facilitate transbronchial needle aspiration. A recent advent in imaging of lung cancer has been the introduction of positron emission tomography to the diagnostic work-up of lung cancer. Although this technique has been shown to be highly accurate in determining the malignant or benign nature of lesions, it does not enable histologic diagnosis. In each case, the most appropriate diagnostic procedure should be tailored to suit the specific requirements determined by the characteristics of the disease process, institutional availability of the various diagnostic procedures, and patient preferences, when possible.

Clinical and surgical staging of non-small cell lung cancer

The necessity for a compulsive attitude toward preoperative assessment of lung cancer is to be emphasized, since rational treatment and prognosis depend largely on the stage of disease at the time of diagnosis. In the preoperative setting, the techniques used should be sequential, logical, and help to identify patients suitable for treatment with curative intent. With regard to the primary tumor (T status), the accuracy of CT or MRI to predict the need for extended resections is limited. Similarly, all noninvasive methods to determine the nodal status (N) are valuable, but mediastinoscopy has a greater sensitivity and specificity than either CT or MRI. The role of routine organ screening for the detection of distant occult metastasis in the asymptomatic patient is still controversial. Ultimately, the prognosis of the resected patient with lung cancer is based on complete intraoperative staging, which can be done by either systematic node sampling or complete lymphadenectomy. At present, neither of these techniques has been shown to improve the quality of staging or survival.

Diagnosis and staging of lung cancer

Lung cancer is the biggest cancer killer among men and women in the United States. Lung cancer can present in a myriad of ways and the goal of prompt diagnosis and staging requires that the clinician be able to knowledgeably choose from a variety of tools available for such purpose. Review of some of these tools and general strategies with regard to staging is provided. Many new technologies are becoming available and much evaluation needs to be done before their proper roles become well defined. Little has changed with regard to staging of small cell lung cancer in recent years. The International System for Staging Non-Small-Cell Lung Cancer was revised for a second time in 1997. Although the revisions have largely corrected the shortcomings of the 1985 version, some controversies persist. Whenever possible, a multidisciplinary approach to diagnosis, staging, and therapy should be utilized. This should include incorporating the services of the pulmonologist, the thoracic surgeon, the medical oncologist, the radiologist, the radiation therapist, the pathologist, the respiratory therapist, and the social worker.

Video-assisted thoracoscopic lobectomy reduces cytokine production more than conventional open lobectomy

OBJECTIVE

We studied cytokine changes after video-assisted thoracoscopic lobectomy and conventional lobectomy in patients with stage IA lung cancer.

METHODS

From June, 1997, 20 consecutive patients with stage IA non small-cell lung carcinoma underwent either conventional lobectomy via an open thoracotomy (n = 10) or video-assisted thoracoscopic lobectomy (n = 10). The cytokine concentration in serum and pleural fluid were measured for 6 days postoperatively.

RESULTS

Interleukin-6 and interleukin-8 leads peaked at 3 h or 1 day after surgery. Cytokine levels in pleural fluid were more than 100 times higher than corresponding systemic levels. The increase of interleukin-6 in pleural fluid 3 hours after surgery was significantly smaller in video-assisted thoracoscopic lobectomy (3971 +/- 2793 pg/mL for video-assisted thoracoscopic lobectomy vs. 23274 +/- 8426 pg/mL for open lobectomy). There were no significant differences in the serum interleukin-6 and interleukin-8 concentrations between the 2 groups.

CONCLUSION

The thoracoscopic approach lessened the increase of cytokines in pleural fluid, but benefits of reduced cytokine production in video-assisted thoracoscopy remain to be clarified.

Lung Cancer Found Unresectable at Thoracotomy: Reappraisal of an Old Problem

We review our experience with unresectable non-small cell lung cancer, after adoption of a more aggressive surgical approach, including mediastinal lymph node dissection. Cases with enlarged mediastinal lymph nodes (MLNs, cN2) that were predicted to be resectable were included. Our objective was to identify preoperative findings to prevent unnecessary thoracotomy. In 1988–1997, 192 patients had thoracotomy for non-small cell lung cancer. Fifteen cases (7.7%) were found unresectable at thoracotomy. CT scans demonstrated enlarged MLNs in 7 of 15 and enlarged hilar lymph nodes in 6 of 15 cases. The tumor abutted the hilum in 5 of 15, chest wall in 2 of 15, and mediastinal structures in 7 of 15 cases. Atelectasis was seen in 3 of 15 cases. During the same period, 63 patients with stage III disease, including 39 patients with enlarged MLNs, were resected. The unresectability rate for cN2 patients was 15.2 per cent. Five (33%) patients were physiologically unable to tolerate the required pneumonectomy [forced expiratory volume in 1 second, 1.65 liters (range, 1.15–2.07)]. There were three (20%) esophageal invasions, two (13.3%) mediastinal invasions, two (13.3%) aortic invasions, two (13.3%) metastases to the diaphragm, and one (6.6%) invasion of proximal pulmonary artery. Median survival was 4 months. Two-year actuarial survival was 8 per cent. We conclude that careful palpation and dissection were required to establish unresectability. Preliminary thoracoscopy would have prevented thoracotomy in two cases (13.3%) of diaphragmatic metastases but would not reliably establish unresectable invasion of mediastinal structures.

Thoracoscopic procedures for intrathoracic diseases: the present status

Thoracoscopic operations, alternatively termed as video-assisted thoracic surgery (VATS), are replacing the variety of surgical procedures which have been otherwise performed by open thoracotomy. The minimally invasive nature of the procedure, reduced postoperative pain, shortened hospital stay, and reduced cost, are the potential advantages of VATS. While these merits are being proven, the limits to this technique are also getting clearer. In fact, VATS has already become a standard treatment of choice in several diseases, such as bullectomy for spontaneous pneumothorax and biopsy for indeterminate nodule and diffuse interstitial lung disease, while others, such as major video-assisted lung resection for lung carcinoma and resection of metastatic lung tumour, await further evaluation of their roles in terms of oncological and technical aspects. Three issues that currently need to be addressed as the present role of thoracoscopy evolves are instrumentation, economics, indication, and end results in certain procedures.