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Ann Thorac Surg 1995;59:42-45
© 1995 The Society of Thoracic Surgeons

Thoracoscopic Implantation of Cancer With a Fatal Outcome

Departments of Surgery and Pathology, Evanston Hospital, Northwestern University Medical School, Evanston, Illinois

Accepted for publication May 24, 1994.

	Abstract

Top Footnotes Abstract Introduction Case Presentation Comment References

 
A case is presented in which an indeterminate lung lesion was extracted through an accessory incision during a video-assisted thoracic surgical lung biopsy. The lesion was malignant, and a completion lobectomy was performed. An incisional recurrence developed 5 months later, and this was treated with a wide chest wall resection and reconstruction. However, there was a second massive chest wall recurrence that proved fatal. We believe that tumor seeding to the chest wall occurred at thoracoscopy. To prevent such tumor seeding, thoracoscopic biopsy specimens should be removed in some sort of receptacle when cancer is suspected.

	Introduction

Top Footnotes Abstract Introduction Case Presentation Comment References

 
Though originally described by Jacobaeous more than 80 years ago, thoracoscopy recently has come into expanded use [1, 2]. Initially described for the intrapleural pneumonolysis of adhesions hindering lung collapse in the treatment of pulmonary tuberculosis by artificial pneumothorax, it is now applied in numerous settings, including evaluating pleural disease, treating emphysematous blebs and pneumothoraces, debriding chronic empyemas, extracting foreign bodies, performing pericardiectomies, and performing biopsies of lung tissue and lymph nodes [2, 3]. The indications for thoracoscopy and video-assisted thorascopic surgery (VATS), an obvious variation on the theme, continue to evolve. However, controversy surrounds its use in the resection of known or suspected lung cancer. In light of this, we describe a case of chest wall tumor implantation that occurred after a VATS excision of a small pulmonary adenocarcinoma.

For editorial comment, see page 6.

	Case Presentation

Top Footnotes Abstract Introduction Case Presentation Comment References

 
A 74-year-old man presented because of a 2-cm cavitary density in the left lower lung field that had been found on a screening chest roentgenogram. No abnormality had been noted on a chest roentgenogram obtained 2 years before. The patient denied any weight loss or functional impairment. He had a 40 pack-year smoking history, but had quit 20 years before. He had an extensive travel history, and the result of recent PPD (purified protein derivative) testing was negative. His medical history was noteworthy only for a suprapubic prostatectomy performed for the relief of benign bladder outlet obstruction 2 years before. Physical examination findings were unremarkable.

Further workup included a contrast-enhanced computed tomographic scan that showed a peripheral 2-cm cavitary lesion in the superior segment of the left lower lobe of the lung (Fig 1). There was no evidence of intrathoracic lymphadenopathy or any other lung lesion. Bronchoscopy performed with fluoroscopically guided biopsy and brushing did not yield diagnostic findings. Next, fluoroscopically guided transthoracic needle biopsy using a 22-gauge needle was performed. The specimen findings were also nondiagnostic from both a cytologic and microbial standpoint.

View larger version (94K): [in this window] [in a new window]   Fig 1. . Computed tomographic scan demonstrating a 2-cm cavitary lesion in the left lower lobe of the lung.

The decision was then made to proceed immediately with a completion left lower lobectomy during the same anesthetic session. An axillary thoracotomy was performed, and left lower lobectomy and lymph node sampling were completed without difficulty. No other abnormality was noted. The patient did well after operation and was discharged home on the sixth postoperative day. The final pathologic diagnosis was well-differentiated adenocarcinoma arising from a previous scar. The lesion was 2 cm in diameter, there was no pleural involvement, and none of the 19 lymph nodes submitted for analysis showed evidence of tumor, so the surgical pathologic staging was stage I (T1 N0 M0). Foci of residual cancer were noted at the staple line of the completion lobectomy specimen.

The patient did well until 5 months later, when he noticed a protuberance over his left lateral chest that made it uncomfortable for him to lie on that side (Fig 2). He denied any recent trauma, respiratory compromise, or constitutional symptoms. On physical examination, a 4 x 3-cm, firm, fixed, smooth, nontender mass was noted over the left fifth rib at the midaxillary line. The healed VATS incision, which had been enlarged to extract the original specimen, was less than 1 cm superior to the mass but was not fixed to the mass. There was no obvious skin break or discoloration. The endoscopic port sites and thoracotomy incision had healed well without any obvious abnormality. There was no palpable lymphadenopathy and the rest of the physical examination findings were unremarkable. Examination of the tissue obtained by fine-needle aspiration of the mass (using a 23-gauge needle) revealed adenocarcinoma consistent with the original tumor.

View larger version (149K): [in this window] [in a new window]   Fig 2. . Chest radiogram demonstrating a fullness under the fifth rib anterolaterally (arrow). This was a palpable mass.

View larger version (107K): [in this window] [in a new window]   Fig 3. . (A) The extent of the planned chest wall resection is outlined. (B) The specimen has been removed. There were no adhesions to the remaining upper lobe.

View larger version (147K): [in this window] [in a new window]   Fig 4. . (A and B) Gross surgical specimen. (C) Nests of adenocarcinoma can be seen in areas of skeletal muscle. (Hematoxylin and eosin; x20 before 50% reduction.) (D) Parietal pleural surface showing smooth surface with no tumor. (Hematoxylin and eosin; x10 before 50% reduction.)

View larger version (126K): [in this window] [in a new window]   Fig 5. . Fine-need aspiration specimen from chest wall showing adenocarcinoma. (Papanicolaou stain; x40 before 50% reduction.)

	Comment

Top Footnotes Abstract Introduction Case Presentation Comment References

Early chest wall metastasis is very unusual for stage I adenocarcinoma of the lung. It should not be considered part of the natural history or progression of the disease in this patient. Complete resection is usually curative.

To date, there has been only one other report, in the form of a letter, of chest wall incisional metastasis arising after a VATS procedure [9]. Rare cases of metastasis related to transthoracic needle biopsy have been reported. The exact mechanics responsible for the seeding remain controversial [5, 8, 10].

The crucial question regards the risk associated with the removal of malignant lesions through a small incision. The wedge resection specimen measured 7.7 x 3.6 x 0.6 cm and came out easily through the enlarged port site. Interestingly, this problem is not unique to thoracic surgery. A similar scenario was described for the seeding of a gallbladder carcinoma extracted through a periumbilical port [11].

In addition to a good operative technique, modifications or precautions may need to be taken when dealing with endoscopic tumor retrieval. One should use a tissue receptacle, such as a condom, glove, or sheath, to remove the resected tissue if malignancy is suspected and the tissue mass is larger than the port. There may also be dilutional and tumoricidal benefits conferred by copious irrigation of the chest cavity and incision with sterile water. The low incidence of this problem makes prospective or even retrospective analysis of any precautionary modifications difficult. Interestingly, tumor implantation is not restricted to minimally invasive procedures. Tumors have also implanted in conventional incisions [12, 13]. This problem may therefore have less to do with the incision size than with the biologic nature of the tumor [14]. Further research into the biologic behavior of tumors may yield answers to this question.

Video-assisted thoracoscopic surgery is an effective and valuable addition to the armamentarium of thoracic procedures. This case is presented to point up the possible risk of a fatal complication that may become more frequent as minimal-access surgical procedures become more commonplace in all surgical disciplines. An understanding of the principles of endoscopic surgical procedures, good operative technique, awareness of potential problems, and vigilance at follow-up will perhaps limit the morbidity and mortality associated with VATS. We recommend the extraction of possible cancer-containing lung tissue through some form of protective sheath.

	Footnotes

Top Footnotes Abstract Introduction Case Presentation Comment References

 
Address reprint requests to Dr Fry, 2500 Ridge Ave, Suite 105, Evanston, IL 60201.

	References

Top Footnotes Abstract Introduction Case Presentation Comment References

 

1. Jacobaeus VHC. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:289–94.
2. Mack MJ, Aronoff RJ, Acuff TE, Douthit MB, Bowman RT, Ryan WH. Present role of thoracoscopy in the diagnosis and treatment of diseases of the chest. Ann Thorac Surg 1992;54:403–8.[Abstract]
3. Wakabayashi A. Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;102:721–3.[Abstract]
4. Seyfer AE, Walsh DS, Graeber GM, Nuno IN, Eliasson AH. Chest wall implantation of lung cancer after thin-needle aspiration biopsy. Ann Thorac Surg 1989;48:284–6.[Abstract]
5. Moloo Z, Finley RJ, Lefcoe MS, Turner-Smith L, Craig ID. Possible spread of bronchogenic carcinoma after transthoracic fine needle aspiration biopsy. Acta Cytol 1985;29:167–9.[Medline]
6. Voravud N, Shin DM, Dekmezian RH, Dimery I, Lee JS, Hong WK. Implantation metastasis of carcinoma after fine-needle aspiration biopsy. Chest 1992;102:313–5.[Abstract/Free Full Text]
7. Muller NL, Bergin CJ, Miller RR, Ostrow DN. Seeding of malignant cells into the needle tract after lung and pleural biopsy. J Can Assoc Radiol 1986;37:570–5.
8. Sinner WN, Zajiek J. Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn 1976;17:473–80.
9. Thurer RL. Video-assisted thoracic surgery. Ann Thorac Surg 1993;56:199–200.[Medline]
10. Murthy SM, Goldschmidt RA, Rao LN, Ammirati M, Buchman T, Scanlon EF. The influence of surgical trauma on experimental metastasis. Cancer 1989;64:2035–44.[Medline]
11. Clair DG, Lautz DB, Brooks DC. Rapid development of umbilical metastases after laparoscopic cholecystectomy for unsuspected gallbladder carcinoma. Surgery 1993;113:355–8.[Medline]
12. Fortner JG, Lawrence W. Implantation of gastric cancer in abdominal wounds. Ann Surg 1960;134:789–94.
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14. Ackerman LV, Myron WW. The implantation of cancer-an avoidable surgical risk. Surgery 1955;37:341–55.[Medline]

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