Ann Thorac Surg 1997;64:1409-1411
© 1997 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Thoracoscopic Staging of IIIB Non–Small Cell Lung Cancer Before Neoadjuvant Therapy
Tiziano De Giacomo, MD,
Erino A. Rendina, MD,
Federico Venuta, MD,
Giorgio Della Rocca, MD,
Costante Ricci, MD
Departments of Thoracic Surgery and Anesthesiology, University of Rome "La Sapienza," Rome, Italy
Accepted for publication May 2, 1997.
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Abstract
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Background. Bronchoscopy and imaging techniques are the most valuable tools for noninvasive staging of patients with locally advanced non–small cell lung cancer but their overall accuracy is not satisfactory. Neoadjuvant therapy protocols require strict criteria for patient selection and invasive staging should be carried out to establish standardized inclusion criteria and to homogenize posttreatment results. The aim of this prospective study was to evaluate the role of thoracoscopy in the assessment of the real extent of lung cancer in patients with the clinical suspicion of stage IIIB disease.
Methods. From January 1993 to March 1996, we observed 64 patients with suspected IIIB non–small cell lung cancer. Forty-three patients were considered eligible for this study and were divided into three groups: group I, cytologically negative pleural effusion (n = 10); group II, computed tomographic suspicion of mediastinal infiltration (n = 30); and group III, contralateral lymphadenopathy not accessible by mediastinoscopy (n = 3).
Results. No complications related to thoracoscopy occurred. Of 10 patients in group I, thoracoscopy up-staged the disease to IIIB in 6 (60%). Of 30 patients with suspicion of T4 (group II), thoracoscopy confirmed T4 in 15 patients (50%). Nine (30%) were downstaged to stage IIIA and 2 (6.6%) to stage II. In 4 patients (13.4%) thoracoscopy failed to yield definitive staging. In all 3 patients of group III, thoracoscopy confirmed stage IIIB.
Conclusions. Thoracoscopy proved adequate for correct staging in 39 of 43 patients (91%); therefore, it should be considered in the staging work-up of suspected stage IIIB patients.
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Introduction
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In the treatment of locally advanced non–small cell lung cancer neoadjuvant therapy (induction chemotherapy with or without radiation therapy followed by surgical resection) has proved effective for stage IIIA lesions with bulky or multilevel N2 disease [1–3]. The same approach is under evaluation for stage IIIB, which presents direct tumor infiltration of mediastinal structures or neoplastic pleural effusion, and preliminary reports have offered encouraging results [4, 5]. Neoadjuvant therapy protocols require strict criteria for patient selection. Bronchoscopy and imaging techniques are the most valuable tools for noninvasive staging of these patients. If N2 disease is suspected, cervical mediastinoscopy and anterior mediastinotomy can yield positive confirmation. However, when the evaluation of a stage IIIB lesion is concerned, these techniques do not permit a complete evaluation of the real extent of the tumor. Computed tomography or magnetic resonance imaging sometimes may confirm positively or exclude direct tumor infiltration into the mediastinum, but their overall accuracy is not satisfactory [6, 7]. If stage IIIB lesions are to be included in neoadjuvant therapy protocols as in the series of Rusch and co-workers [4], appropriate invasive staging should be carried out. This is indispensable to establish standardized inclusion criteria and to homogenize posttreatment results. Video-assisted thoracoscopy (VAT) offers the possibility of a complete exploration of the chest cavity and therefore, should allow an accurate evaluation of the intrathoracic spread of the tumor. The aim of this prospective study was to evaluate the role of VAT in the assessment of the real extent of lung cancer in patients with the clinical suspicion of stage IIIB disease.
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Material and Methods
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From January 1993 to March 1996, 64 patients with suspected IIIB non–small cell lung cancer were seen at our department. Clinical staging was accomplished by fiberoptic bronchoscopy, total body computed tomography, bone scan, and magnetic resonance imaging in selected patients. Five patients with vocal cord paralysis, 4 with cancer extension in the trachea demonstrated by fiberoptic bronchoscopy, 2 with superior vena cava syndrome, and 10 with malignant pleural effusion with positive cytology were staged as T4 without further invasive staging. Three patients with paratracheal contralateral lymphadenopathy were confirmed as N3 by cervical mediastinoscopy. The 43 remaining patients (28 men and 15 women with a mean age of 58 years, ranging between 38 and 71 years) were considered eligible for this study and were divided into three groups: group I, cytologically negative pleural effusion (n = 10); group II, computed tomographic suspicion of mediastinal infiltration (T4) (n = 30); and group III, contralateral mediastinal lymphadenopathy not accessible to mediastinoscopy (n = 3). Thoracoscopy was carried out in these patients as previously described [8]. The procedures were routinely performed under general anesthesia; however, in 12 patients VAT was carried out under general sedation and local anesthesia keeping the patients in spontaneous breathing. The surgical maneuvres were more difficult, but this approach was used only in patients with high risk for general anesthesia or when the intented procedure was simple pleural biopsy and pleurodesis. In patients with pleural effusion (group I), we obtained large pleural biopsy specimens from at least four sites in the parietal pleura and from the mediastinal, diaphragmatic, and visceral pleura. In addition, biopsy of every single suspicious lesion on the pleural surface was performed. Patients with suspected T4 (group II) are the most difficult to be staged correctly, and therefore, were treated by a standardized approach. The lung is fully mobilized and the site of potential mediastinal infiltration exposed. If the lesion is only adjacent or adherent to the mediastinum, biopsy specimens of the mediastinal pleura and mediastinal tissue are taken. If biopsy results are negative, the tumor is downstaged and the appropriate treatment is instituted (conversion to thoracotomy for resection). If mediastinal infiltration exists, this is confirmed by multiple biopsies. If necessary, the pericardium is opened and the atria explored. Sometimes it has been possible to obtain histologic confirmation of infiltration of mediastinal organs (pericardium, atrium, aortic adventitia, trachea). Sometimes, either because of the bulk of the tumor or because of the technical impossibility or safety of proceeding with the dissection, we accepted mediastinal tissue infiltration as a criterion for staging the lesion as T4. In these cases, careful intraoperative review of computed tomographic images served as a guide to the extension of dissection once histologic confirmation of mediastinal tissue infiltration was obtained. We did not consider conversion to thoracotomy for staging purposes. In patients with mediastinal lymphadenopathies not accessible to mediastinoscopy (group III), VAT was performed as previously described [8].
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Results
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No complications related to VAT occurred (Table 1
). The chest tube was removed 24 to 36 hours after the operation and all VAT patients were discharged from hospital on the first or second postoperative day. In 10 patients in group I, frozen sections showed malignant pleural involvement in 6 patients. Therefore, these patients were referred for chemotherapy and radiation therapy. In the remaining 4 patients, pleural biopsies were negative for cancer infiltration and VAT was converted to thoracotomy for resection (three lobectomies and one bilobectomy). Definitive histologic examination showed no pleural involvement.
In 30 group II patients (Table 2), stage T4 was confirmed pathologically in 15 patients and they proceeded to neoadjuvant therapy. In 11 patients, thoracoscopic exploration of the chest ruled out the direct mediastinal extent of the tumor; 9 patients were staged as IIIA and 2 as stage II. Of these 11 patients, 7 underwent lung cancer resection after conversion of VAT to thoracotomy. The remaining 4 patients presented multiple level N2 disease and underwent neoadjuvant therapy. In 4 patients (13.3% of group II and 9.3% of the entire group) we were not able to obtain positive histologic staging by VAT. In 3 patients this was attributable to a very large tumor mass hampering thoracoscopic maneuvres. The last patient had extended infiltration of the pericardium associated with pericardial effusion and any attempt to mobilize the lung to expose the mediastinum induced severe arrhythmias and the procedure had to be discontinued. As stated in Material and Methods we did not proceed to thoracotomy for staging only. These patients were considered as T4 and underwent neoadjuvant therapy. In 3 patients with N3 lymph nodes in the aortopulmonary window (group III), VAT confirmed stage IIIB disease (Table 1
). Overall, in 10 patients with cytologically negative pleural effusion (group I), VAT up-staged the disease to IIIB in 6 patients (60%). In 30 patients with a computed tomographic suspicion of T4 (group II), VAT confirmed T4 in 15 patients (50%). Nine patients (30%) were staged to stage IIIA and 2 (6.6%) to stage II. In 4 patients (13.4%), VAT failed to yield definitive staging. In all 3 patients with a computed tomographic suspicion of N3 not accessible to mediastinoscopy (group III), VAT confirmed stage IIIB. Therefore, VAT proved inadequate for correct staging in 4 of 43 patients (9.3%).
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Comment
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Neoadjuvant therapy has become a well-accepted approach for stage IIIA non–small cell lung cancer. Its efficacy is being evaluated for stage IIIB, which is usually considered to be locally advanced lung cancer, incurable, and not surgically treated. However, it is often difficult to assess and compare the outcome of stage IIIB patients if they are only clinically staged. In fact, the lack of histologic confirmation of the real extent of the tumor makes it difficult to distinguish which patients have real stage IIIB lesions and which present a different stage of disease. We used VAT to perform many surgical thoracic procedures and we applied this technique to the assessment of the real extent of lung cancer in patients with clinical suspicion of stage IIIB disease. The possibility of a complete exploration of the pleural cavity and the ipsilateral mediastinum, with low invasiveness and morbidity, makes this procedure preferable to other surgical staging techniques [9, 10]. Cervical mediastinoscopy allows assessment of paratracheal nodes but it is not useful for the evaluation of other lymphatic stations [11]. In addition, mediastinoscopy is of no value for the detection of direct mediastinal tumor infiltration. Anterior mediastinotomy is a well-known procedure but offers a very limited field of view; if the latter has to be widened, frequently the pleural space is entered, thus requiring a chest drain. Furthermore, the anterior chest wound can delay the beginning of radiation therapy.
In our experience, VAT correctly staged the disease in more than 90% of patients. Six of 10 patients with cytologically negative pleural effusion were found to have pleural malignancy. At the present time, the number of patients is too small to draw any conclusion. A prospective study is in progress at our institution to verify this finding. Patients with suspect T4 are the most difficult to stage correctly. Video-assisted thoracoscopy was inadequate for this purpose in 4 of 30 patients (13%).
In the presence of a large tumor mass, VAT can be technically difficult because of the limited working space and the impossibility of thoroughly mobilizing the lung. In these conditions, the exploration of the mediastinum can be hazardous or impossible. In our study, in 4 patients we were not able to assess the mediastinal status by VAT and arbitrarily we considered those patients as stage IIIB. This should be regarded as a limit of VAT. In the evaluation of paratracheal N3 disease, mediastinos-copy still plays an important role and should be considered the procedure of choice. Nevertheless, the presence of lymphadenopathy in the aortopulmonary window can be better approached by VAT.
In conclusion, stage IIIB non–small cell lung cancer includes a heterogeneous group of patients with locally advanced tumor. Accurate staging is necessary to decide whether initial surgical resection or neoadjuvant chemotherapy is indicated. Video-assisted thoracoscopy proved safe and effective for this purpose and in our experience it provided correct staging of 39 of 43 patients (91%).
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Footnotes
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Address reprint requests to Dr De Giacomo, Department of Thoracic Surgery, University of Rome "La Sapienza," II Surgical Clinic-Policlinico Umberto I, V.le Policlinico, 00164 Rome, Italy.
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References
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Abstract
Introduction
