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Ann Thorac Surg 1995;59:971-974
© 1995 The Society of Thoracic Surgeons

Videothoracoscopic Staging and Treatment of Lung Cancer

Department of General Surgery, University of Milan, San Giuseppe Hospital, Milano, Italy

Accepted for publication December 30, 1994.

	Abstract

Top Footnotes Abstract Introduction Material, Methods, and Results Comment References

 
Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate. This is sufficient to justify routine performing of videothoracoscopic operative staging as the first step of operation for lung cancer. Furthermore, videothoracoscopic operative staging permits confirmation of resectability of the lesion and, in selected patients, even direct video-excision. In our experience videothoracoscopic treatment proved a safe and concrete opportunity.

	Introduction

Top Footnotes Abstract Introduction Material, Methods, and Results Comment References

 
Recently introduced minimally invasive techniques found a new field of application in thoracic surgery [1–6]. The role of videothoracoscopy in lung cancer is still very much argued, even if this technique seems to open interesting opportunities for both staging and treatment [7–11].

In regard to staging, each center has its own standardized techniques, such as high-resolution computed tomography, to aid in evaluating the locoregional diffusion of the lesion. However, in many cases, clinical doubts only can be solved by direct surgical exploration. The possibility of carrying out a thoracoscopic assessment opens new possibilities. Concerning the surgical treatment, the feasibility of major thoracoscopic lung resections has been proved, and a number of surgeons now employ this technique also in selected cases of lung cancer [7, 8, 10–15].

Our experience with videothoracoscopy for staging and surgical removal of lung cancer is reported.

	Material, Methods, and Results

Top Footnotes Abstract Introduction Material, Methods, and Results Comment References

 
Between October 1991 and January 1994, 155 patients with lung cancer underwent videothoracoscopy as the initial step of the operation. Videothoracoscopic evaluation of operability does not merely consist of exploring the pleural cavity and the surface of the lung, but also encompasses more complicated maneuvers. We refer to these procedures as videothoracoscopic operative staging (VOS). It can entail lysis of pleural adhesions preventing lung collapse, division of the pulmonary ligament, and freeing of the pulmonary hilum for easier mobilization of the lung; dissection of the fissure to inspect the integrity of the pulmonary artery; opening the pericardium to examine the possibility of carrying out an intrapericardial ligature of the great vessels in case of suspected infiltration in proximity to their mediastinal origin; and section of the azygos vein to explore mediastinal lymph nodes.

Of the 155 patients (Fig 1), videothoracoscopic surgical exploration showed unresectability in 13 (8.3%): because of pleural dissemination without effusion in 7, invasion of mediastinum in 4, partial invasion of esophageal wall in 1, and tumor invasion of the artery in the fissure in 1 (an 80-year-old man who would not have tolerated pneumonectomy). In 10 of them unresectability had not been suspected after conventional preoperative staging, whereas in the other 3 VOS confirmed the suspicion suggested by computed tomography. Eight patients were in stage I, 3 in stage II, and 2 in stage III.

View larger version (19K): [in this window] [in a new window]   Fig 1. . Our personal experience. Every patient with lung cancer, after conventional preoperative staging, is submitted to videoendoscopic operative staging (VOS). The figure reports in schema the outcome of the procedure: in 13 patients (8.3%) VOS detected causes of inoperability thus sparing unnecessary exploratory thoracotomies; patients with compromised respiratory conditions underwent video wedge resection; patients with T1 N0 or T2 N0 disease underwent video or open major pulmonary resection; and patients with stage II or IIIa disease underwent thoracotomy.

Group A consisted of 13 patients with a small, peripheral tumor (diameter, 0.5 to 2.7 cm). They were elderly patients (average age, 70 years), the eldest being 84 years old. In all these patients preoperative function tests had demonstrated severe respiratory insufficiency due to obstructive, restrictive, or combined pulmonary disorder. In all these patients, the preoperative evaluation performed together by the anesthesiologist and surgeon excluded the possibility of performing a major pulmonary resection, due to the operating risk.

Two patients also had coexisting contraindications, namely, dilative ischemic cardiac disease with pericardial effusion and severe bullous emphysema, respectively. Thoracoscopy was undertaken to assess the feasibility of a wedge resection. Videothoracoscopic operative staging confirmed computed tomographic findings that had indicated absence of mediastinal lymphadenopathy preoperatively. In these cases no lymph-node sampling was performed. Videothoracoscopic wedge resection then was carried out as follows: 8 right upper lobe, 1 middle lobe, 2 left upper lobe, and 2 left lower lobe wedge resections. Postoperative course always was uneventful, except in 1 patient with preexisting severe bullous emphysema in whom air leaks persisted until the 22nd postoperative day.

Group B consisted of 63 patients affected by a peripheral lung neoplasm preoperatively staged as T1 N0 and T2 N0, with negative bronchoscopy. Thoracoscopy was undertaken to ascertain whether a major thoracoscopic pulmonary resection could be carried out. Videothoracoscopic operative staging confirmed resectability and feasibility of major videothoracoscopic pulmonary resections. Fifty-two lobectomies and 4 pneumonectomies were carried out entirely through the videothoracoscopic approach. There were 13 right lower lobectomies, 14 left lower lobectomies, 14 right upper lobectomies, 4 middle lobectomies, 1 right segmentectomy of the right apical lower lobe segment, and 6 left upper lobectomies.

Videothoracoscopic lobectomies and pneumonectomies were performed following the same steps of traditional open operations, with separate isolation and ligature of venous, arterial, and bronchial elements and with accurate hilar and mediastinal lymphadenectomy, as recommended by oncology protocols.

In 7 patients conversion to open procedure was necessary due to bleeding during dissection in 3 cases and to absence of the fissure in 4 cases.

In patients who underwent lobectomy, histologic examination revealed 21 adenocarcinomas, 27 squamous cell carcinomas, 2 undifferentiated carcinomas, 1 small cell lung cancer, and 1 carcinoid. Postoperative staging revealed 20 T1 N0 M0, 18 T2 N0 M0, 6 T1 N1 M0, 7 T2 N1 M0, and 1 T1 N2 M0. Among the 4 pneumonectomized patients, 2 had small epidermoid carcinoma invading the secondary carina of the left main bronchus, another had a small epidermoidal cancer invading the pulmonary artery within the fissure, and the last had an atypical carcinoid tumor involving the intermediate bronchus and the secondary carina with the right upper bronchus. No sleeve procedure, neither bronchial nor arterial, was possible. Postoperative staging revealed 2 T2 N0 and 2 T2 N1 tumors.

Postoperative course was uneventful in 51 patients (91%). Five patients with preexisting emphysema had prolonged air leakage. One of them who had undergone right upper lobectomy needed positive-pressure ventilation starting from the third postoperative day for severe respiratory failure, and on the seventh postoperative day a bronchopleural fistula developed, which healed with conservative treatment.

Group C consisted of 66 patients with lung tumor preoperatively staged II or IIIa. Thoracoscopy was undertaken to obtain definitive evaluation of operability by an open conventional approach. Four patients were found to have inoperable disease; the remaining 62 patients underwent 4 tracheal sleeve pneumonectomies, 23 pneumonectomies, 34 lobectomies, and 1 right upper sleeve lobectomy.

	Comment

Top Footnotes Abstract Introduction Material, Methods, and Results Comment References

 
The goal of preoperative lung cancer staging is to exclude distant metastases and local causes of inoperability. A few methods of staging are well standardized: plain chest roentgenography, bronchoscopy, computed tomography of brain, chest, and abdomen, and bone scintigraphy are performed commonly in almost all centers. Other investigations, such as mediastinoscopy or the Chamberlain procedure, are adopted in many centers only in selected cases [15, 16].

Mediastinoscopy or the Chamberlain procedure for staging are performed in our department only when computed tomographic scan or bronchoscopy suggests extracapsular lymphadenopathy or N3 disease, as we do not consider intracapsular N2 lymphadenopathy a contraindication to surgical removal. Technical causes of inoperability (invasion of the great vessels, of the mediastinum, or of endothoracic organs) in our opinion are not detected by mediastinoscopy.

The sensitivity of the aforementioned investigations is not absolute, and metastases missed by preoperative staging sometimes can be observed a few months later. Similarly, there is still a high incidence of merely exploratory thoracotomies for conditions missed by preoperative staging or only suspected on computed tomographic scan. The incidence has decreased progressively in recent years, but rates of about 10% to 15% [17, 18] and only occasionally lower figures [19] are reported in the scientific literature.

Videothoracoscopy offers a direct view of the lesion and a means of thoroughly exploring the thoracic cavity. It allows detection of unsuspected pleural invasion when the pleural nodules are very small and when there is no pleural effusion.

Furthermore, by using dissecting maneuvers, VOS can allow for a better exploration of the mediastinum, particularly in evaluating operability when the lesion is suspected to be in contact with, to compress, or to invade hilar or mediastinal structures. In these cases, only direct surgical exploration can solve the uncertainty and VOS allows the surgeon to accomplish the same operative maneuvers conventionally required by thoracotomy. Videothoracoscopic operative staging ensures that the integrity of pulmonary artery, upper and lower pulmonary veins, and bronchus is assessed. In addition, it not only permits surgical exploration of the upper and lower paratracheal lymph nodes (levels 1, 2, 3, and 4) but also of carinal (level 7) and paraesophageal lymph nodes (level 8), not easily accessible to cervical mediastinal exploration or the Chamberlain procedure. Finally, VOS detects possible infiltration of the artery in the fissure and, consequently, unfeasibility of lobectomy, avoiding thoracotomy in patients unable to tolerate a pneumonectomy.

Our findings indicate that performing VOS as the initial step of the intervention in all cases of lung cancer can reduce the incidence of exploratory thoracotomies dramatically. In our experience of 155 cases, VOS revealed causes of inoperability and avoided an exploratory thoracotomy in 13 patients (8.3%). In 10 of these the finding was absolutely unexpected. In the other 3 patients, preoperative computed tomography had suggested unresectability but was unable to distinguish whether the tumor simply adhered to or infiltrated the neighboring structure. Direct inspection by VOS confirmed that local extension of the tumor prevented removal. In these cases the commonly adopted staging techniques (mediastinoscopy, Chamberlain procedure) would not have revealed inoperability.

In 142 patients, VOS showed no conditions of inoperability. Nevertheless we still recorded 4 exploratory thoracotomies (2.6% of patients). In some cases, VOS cannot be employed because pleural adhesions are too diffuse, preventing lung collapse and maneuverability. In our 4 exploratory thoracotomies VOS was not carried out adequately. In 2 cases it was technically impossible to mobilize the lung and explore the mediastinum. In the other 2 cases, early in our experience, the mediastinum had not been explored completely so that enlargement of the aortopulmonary window lymph nodes was discovered only at thoracotomy. In both cases mediastinoscopy undoubtedly would have showed lymphadenopathy but so would VOS, had we adequately searched for any involvement of these lymph nodal stations. However, all surgical procedures have a learning curve.

In our experience of more than 2,000 operations for lung cancer from 1967 to 1990, the rate of exploratory thoracotomies was 19%, but during the last few years the incidence has decreased to 12% due to improvement of staging and operating techniques. In this VOS series the rate of exploratory thoracotomies was 2.6%. Without VOS, the 13 patients who were found to have inoperable disease through videothoracoscopy would have undergone an exploratory thoracotomy, thereby increasing our rate of exploratory thoracotomies from 2.6% to 11%. This suggests that, as experience increases, the number of exploratory thoracotomies probably could be limited to those cases in which VOS is not technically feasible. Nevertheless, the margin of error of this procedure must be taken into account and requires conclusive evaluation in larger series.

In selected cases not only correct staging but also surgical removal of the tumor can be carried out by the thoracoscopic approach. Wedge resection commonly is not recommended for treating primary lung cancer [20, 21]. Nevertheless, it is acceptable for very compromised patients. Feasibility of video-assisted wedge resections further extends the indication due to the minimal trauma and functional impairment. Videothoracoscopic operation also allows carrying out major pulmonary resections (lobectomies and pneumonectomies). To date we have had no intraoperative or postoperative mortality, just as there are no such reports in the literature by other authors.

We believe the indication for videothoracoscopic major resection is limited to patients with negative bronchoscopy preoperatively staged T1 N0 and T2 N0, in which the procedure is completed with locoregional lymphadenectomy as in open procedures. Regional lymphadenectomy has modified staging in 16 cases (29%): 15 N1 cases and 1 N2 case. In the latter case, unexpectedly, histologic examination revealed small cell lung cancer with lymph node involvement (N2).

Videothoracoscopic pneumonectomy was performed in only 4 patients (3 left and 1 right pneumonectomies), accounting for 7% of major videothoracoscopic resections, but needs to be considered separately. In these cases videothoracoscopic pneumonectomy is easier to perform than lobectomy. The main pulmonary hilum is anatomically less complex than lobar or secondary hilar structures, and is therefore easy to isolate when there is no invasion of mediastinal structures or fibrosis.

Videothoracoscopic pneumonectomy must never be an alternative to a difficult thoracoscopic lobectomy; in these cases, conversion to thoracotomy is mandatory.

In conclusion, in our experience operative videothoracoscopy has proved to be useful in obtaining decisive evaluation of lung cancer resectability. Videothoracoscopic operative staging allowed us to minimize the number of exploratory thoracotomies. In spite of the great accuracy provided by conventional imaging techniques for staging lung cancer, only direct exploration can provide definitive assessment of and information on the locoregional extension of the tumor. In our opinion, VOS is capable of providing information equal to any obtained by open thoracotomy. Minimal invasivity of VOS offers many advantages that a widespread adoption of the procedure is predicted.

Videothoracoscopic removal of lung cancer in selected patients is an important innovation. Performing videothoracoscopic atypical wedge resections in compromised patients allows surgeons to extend indications for surgical removal in patients unable to tolerate thoracotomy. Additionally, thoracoscopy has been successful in major anatomic pulmonary resections with adequate mediastinal and hilar lymphectomy as performed in the open approach.

	Footnotes

Top Footnotes Abstract Introduction Material, Methods, and Results Comment References

 
Address reprint requests to Dr Roviaro, Divisione di Chirurgia Generale, Ospedale S. Giuseppe, Via San Vittore 12, 20123 Milano, Italy.

	References

Top Footnotes Abstract Introduction Material, Methods, and Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Roviaro, G. Articles by Gozi, G. Search for Related Content PubMed PubMed Citation Articles by Roviaro, G. Articles by Gozi, G.