Ann Thorac Surg 2000;70:2138-2140
© 2000 The Society of Thoracic Surgeons
Case report
Video-assisted thoracic surgery resection of chest wall en bloc for lung carcinoma
Mark D. Widmann, MDa,
Robert J. Caccavale, MDa,
Jean-Phillipe Bocage, MDa,
Ralph J. Lewis, MDa
a Division of Thoracic Surgery, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey, USA
Accepted for publication April 18, 2000.
Address reprint requests to Dr Widmann, North Jersey Thoracic Surgical Associates, P.C., 111 Madison Ave, Suite 301, Morristown, NJ 07960
e-mail: mdw{at}north-jersey-thoracic.com
 |
Abstract
|
|---|
A video-assisted thoracic surgery approach to en bloc resection of lung cancer invading the chest wall is described. Using a minimally invasive surgical approach combined with neoadjuvant external beam radiotherapy, complete resection of an upper lobe carcinoma invading two rib segments was performed in a manner that permitted complete resection with curative intent and allowed for rapid recovery.
|
Introduction
|
|---|
Chest wall invasion by lung carcinoma is often treated by complete resection of the lung mass en bloc with adjacent segments of ribs. Despite the locally aggressive nature of these lesions, favorable long-term survival has been reported in select patients. Unfortunately, these operative procedures frequently involve a potentially disfiguring resection, lengthy hospitalization, and a long, painful period of recovery. We applied a combination of minimally invasive advanced video-assisted thoracic surgery (VATS) techniques and preoperative external beam radiotherapy to a patient with an invasive T3 lung carcinoma involving the chest wall to achieve complete resection and allow rapid recovery.
A 60-year-old man with a 60 pack-year history of smoking and insulin-dependent diabetes presented with a month long complaint of left upper chest wall pain. The patient reported excellent exercise tolerance and high performance status; his physical examination was unremarkable. Contrast computerized tomography of the thorax demonstrated a 4-cm lesion in the left upper lobe with questionable invasion of ribs 3,4, and 5 and there was no significant hilar or mediastinal lymphadenopathy (Fig 1). A whole body technichium-99 bone scan demonstrated abnormal uptake only in the region of the left posterior rib segments. Computed tomographic-guided needle biopsy of the lung mass yielded a diagnosis of non-small cell carcinoma and a 4,500 cGy course of external beam radiation to the tumor and chest wall was initiated. The patient’s chest wall pain diminished markedly during the next few weeks. Restaging computerized tomography revealed diminished pleural edema and shrinkage of the tumor to approximately 2.5 cm in diameter (Fig 2).
Six weeks after completing radiotherapy the patient underwent left VATS exploration using a standard quadrilateral alignment of port sites [1]. A solitary mass lesion in the posterior segment of the left upper lobe was identified to be adherent to a 2-cm segment of the posterior portions of the third and fourth ribs. Mediastinal exploration and lymph node sampling demonstrated no evidence of metastatic tumor. A wide resection of the lung tumor (5-cm margin) was performed using an Endopath EZ 45 linear stapling device (Ethicon Endo-Surgery, Cincinnati, OH), leaving the tumor attached to the chest wall. Electrocautery dissection of adjacent, intercostal muscles was performed circumferentially; intercostal vessels were coagulated with a harmonic scalpel (Ethicon Endo-Surgery). The anterior margins of the involved ribs (3, 4) were carefully and completely transected with a long-handled osteotome. Posteriorly directed elevation of the chest wall fragment permitted disarticulation of the rib heads from the vertebral bodies and the specimen was freed. The lung and chest wall were removed en bloc and were placed in a sterile specimen bag and removed through a 5-cm anterior, superior VATS incision without rib spreading. Chest wall reconstruction was not necessary as the defect was located posterior to the scapula. The margins of resection were marked with clips and wounds were closed. Postoperatively, the remaining left lung expanded without evidence of air leak and the patient was discharged home on the first postoperative day (Fig 3). Final pathology revealed a 1.5-cm3 moderately differentiated peripheral adenocarcinoma adherent to the chest wall segment with 5.0-cm parenchymal and more than 1.0-cm rib margins without pleural invasion and negative mediastinal lymph nodes T3N0, stage IIB. The patient made a rapid, complete recovery and returned to full physical activity without restrictions in 2 weeks time.
|
Comment
|
|---|
A recent thorough review has concluded that survival of patients with lung cancer invading the chest wall after resection with curative intent is dependent on completeness of resection and extent of nodal involvement [2]; en bloc resection of the involved lung and adjacent chest wall is often recommended in this setting [3]. Adjuvant preoperative radiation therapy is controversial but has been reported to favor excellent (> 50%) survival rates, diminish local recurrence rates, and may allow improved tumor localization and limit extent of resection in properly selected patients [4, 5]. Unfortunately, a traditional thoracotomy and chest wall resection in these patients can be associated with high rates of morbidity (> 20%) [6] and mortality (4% to 15%) [2, 3, 7] and frequently can involve a prolonged, painful period of recovery.
Although some groups have advocated VATS for staging of chest wall invasion by lung carcinoma [8], VATS resection of the lung en bloc with the chest wall has not been previously described. We have found that the magnification and improved visual field provided by VATS has facilitated parietal pleurectomy for superficial invasion by lung cancer. As our experience has increased, we have been able to perform more radical and complex en bloc resections of lung and chest wall tumors. Neoadjuvant radiotherapy in combination with a true VATS approach in carefully selected patients can present an opportunity for complete curative resection in a minimally invasive manner. In this patient, after radiotherapy, chest wall edema and the primary tumor diminished significantly, pain was quickly controlled, and excellent functional status was maintained before operation. Follow-up computed tomographic scanning was helpful in determining the anticipated margins of resection. VATS exploration permitted full staging of the mediastinum and pleura in the least traumatic and invasive manner in the event that metastatic tumor was found and major resectional operation would unexpectedly not be performed. The VATS approach permitted accurate, controlled, and complete dissection and resection of lung and chest wall structures while avoiding the morbidity of major chest wall trauma associated with thoracotomy and traditional rib resection techniques. The patient’s complete resection, early discharge, rapid recovery, and return to full activity are evidence of the potential for further application of VATS approaches to properly selected patients with lung carcinoma with chest wall involvement.
|
References
|
|---|
-
Lewis R.J., Sisler G.E., Caccavale R.J. Imaged thoracic lobectomy; should it be done?. Ann Thorac Surg 1992;54:80-83.[Abstract]
-
Piehler J.M., Pairolero P.C., Weiland L.H., Offord K.P., Payne W.S., Bernatz P.E. Bronchogenic carcinoma with chest wall invasion: factors affecting survival following en bloc resection. Ann Thorac Surg 1982;34:684-691.[Abstract]
-
Paulson D.L. Carinomas in the superior pulmonary sulcus. J Thorac Cardiovasc Surg 1975;70:1095-1104.[Abstract]
-
Downey R.J., Martini N., Rusch V.W., Bains M.S., Korst R.J., Ginsberg R.J. Extent of chest wall invasion and survival in patients with lung cancer. Ann Thorac Surg 1999;68:188-193.[Abstract/Free Full Text]
-
Patterson G.A., Ilves R., Ginsberg R.J., Cooper J.D., Todd T.J., Pearson F.G. Combined pulmonary and chest wall resection for carcinoma of the lung: benefits of adjuvant radiotherapy. Ann Thorac Surg 1982;34:692-697.[Abstract]
-
Shah S.S., Goldstraw P. Combined pulmonary and thoracic wall resection for stage III lung cancer. Thorax 1995;50:782-784.[Abstract/Free Full Text]
-
McCaughan B.C., Martini N., Bains M.S., McCormack P.M. Chest wall invasion in carcinoma of the lung. Therapeutic and prognostic implications. J Thorac Cardiovasc Surg 1985;89:836-841.[Abstract]
-
Waller D., Clarke S., Tsang G., Rajesh P. Is there a role for video-assisted thoracoscopy in the staging of non-small cell lung cancer?. Eur J Cardiothorac Surg 1997;12:214-217.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
H. Matsuoka, W. Nishio, M. Okada, T. Sakamoto, M. Yoshimura, and N. Tsubota
Resection of chest wall invasion in patients with non-small cell lung cancer
Eur. J. Cardiothorac. Surg.,
December 1, 2004;
26(6):
1200 - 1204.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. P.C. Yim
VATS major pulmonary resection revisited--controversies, techniques, and results
Ann. Thorac. Surg.,
August 1, 2002;
74(2):
615 - 623.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
