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Ann Thorac Surg 2002;73:1563-1566
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

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

^a Department of General and Thoracic Surgery, University Hospital Virgen Macarena, Seville, Spain

Accepted for publication December 19, 2001.

* Address reprint requests to Dr Loscertales, Hospital Universitario Virgen Macarena, Avda Dr. Fedriani 1, 41071 Seville, Spain
e-mail: jloscert{at}us.es

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
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.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Preoperative staging of non–small cell lung cancer is necessary to establish appropriate therapy. Currently, clinical staging of the primary tumor is accomplished chiefly by computed tomography. On the basis of the discrepancies between clinical staging and intraoperative findings, Gdeedo and associates [1] pointed out that the computed tomographic (CT) findings alone should not contraindicate thoracotomy in patients with bronchogenic carcinoma.

In 1993, Wain [2] demonstrated the value of exploratory videothoracoscopy (EVT) in the accurate staging of lung cancer. Roviaro and colleagues [3, 4] and our group [5, 6] support systematic performance of EVT as the first surgical step in patients with lung cancer. As a result, the number of exploratory thoracotomies may decrease, mainly at the expense of patients with unsuspected pleural carcinomatosis or those with questionable invasion of the pulmonary vessels revealed by imaging techniques.

On the other hand, pericardioscopy was initially performed with a mediastinoscope through a subxiphoid pericardial window [7–9]. This approach allows visualization and biopsy of the pericardium and epicardium. Later studies [10–12] explored the possibility of performing pericardioscopy with a flexible fiberscope. This method of diagnosing and treating diverse types of pericardial effusions has been validated in large series [13–16].

Examination of the intrapericardial contents is a natural extension of EVT, and we have named this procedure videopericardioscopy (VPC). We have used it for patients with invasion of the pericardium and present the results of our exprience with VPC here.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Since July 1992, members of our department have performed EVT as the first surgical step in the management of patients with resectable lung cancer. When pericardial tumor extension (clinical T4) was suspected by EVT, patients underwent VPC. Until March 1993, we performed a thoracotomy on these patients to confirm the VPC findings. From April 1993 to December 2000, 620 EVT were done. During that time, exploratory thoracotomies were avoided except in patients found unsuitable for EVT, such as those with dense pleural adhesions.

During this 7-year period, 27 patients underwent VPC. There were 25 men and 2 women, and the mean age was 62 years (range, 41 to 77 years). In 15 of them, hilar or pericardial invasion by the tumor had been suggested by a CT scan or magnetic resonance imaging study. In the other 12 patients, EVT established the presence of unsuspected tumor involvement of the pulmonary hilum or pericardium.

Technical aspects of EVT have been described previously [5, 6]. In brief, we use three to four port-access incisions, and VPC is performed through the same incisions. A small opening is made in the pericardial sac with an electrocautery, and the incision is enlarged with endoforceps and endoshears to 4 to 5 cm (Fig 1). Traction is applied to the pericardial margin, and the thoracoscope is introduced to examine the contents of the pericardial sac and determine resectability (Fig 2). To decide whether there is enough length to ligate the vessels, we use an instrument with a predetermined diameter. In this case, the suction tip used measures 5 mm. The left pulmonary vessels (Fig 3) are usually easier to examine than those on the right (Fig 4). Whenever there is a need to perform a biopsy or a brushing of the pulmonary artery, the risks have to be carefully weighed against the benefits. When the tumor is resectable, we proceed immediately with thoracotomy.

View larger version (73K): [in this window] [in a new window]   Fig 1. Technical aspects of videopericardioscopy. (A) Traction on the pericardium is applied with endoforceps, and (B) the incision is made with endoshears.

View larger version (79K): [in this window] [in a new window]   Fig 2. (A) Right videopericardioscopy (VPC) in patient with tumor invasion of right pulmonary artery. The superior vena cava is retracted anteriorly. (B) Right VPC showing tumor invasion of left inferior pulmonary vein and left atrium.

View larger version (86K): [in this window] [in a new window]   Fig 3. (A) Magnetic resonance imaging of possible tumor invasion (arrow) of left pulmonary artery and (B) left videopericardioscopy showing no such invasion (arrow).

View larger version (70K): [in this window] [in a new window]   Fig 4. (A) Computed tomographic scan showing possible tumor invasion of right pulmonary artery and (B) right videopericardioscopy demonstrating no such invasion.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Since its inception in 1986, pericardioscopy had been used exclusively to establish the diagnosis and the appropriate treatment of pericardial effusions. In 1999, Stephens and Fichtner [17] reported its use for treating hemopericardium. A subxiphoid approach was always used. Wain [2] was the first to point out the possibility of applying EVT as a preoperative staging tool. Roviaro and co-workers [3, 4] believed that EVT should be performed systematically in all patients with potentially resectable disease. In their 1995 study [3], these authors proposed the use of a pericardial incision to evaluate tumor extension, but no specific reference was made regarding the performance of VPC in any of the 155 patients involved. In 1997, our group [6] published the results of VPC in 5 patients. We emphasized that 3 patients who had been rejected by other hospitals because of pulmonary artery invasion diagnosed by imaging techniques had undergone successful resection. In the other 2 patients, massive invasion of the pulmonary artery precluded resection.

A correlation between clinical and pathological staging of only 35% found by Gdeedo and colleagues [1] persuaded them to proceed with thoracotomies despite CT scan findings indicating unresectability. In their study, 54.1% of the primary tumors (clinical T) were correctly staged by CT scan, 27% were overstaged, and 18.9% were understaged. Takahashi and coauthors [18] used thin-section electron-beam computed tomography to evaluate hilar and mediastinal tumor invasion. The accuracy, sensitivity, and specificity of this technique in evaluating invasion of the pulmonary vessels were 75%, 77.8%, and 71.4%, respectively.

Of the 620 patients we evaluated with EVT, 27 had hilar invasion. In 15 of these patients, tumor invasion was predicted by imaging techniques. However, 14 of them had resectable tumors, including 6 patients whose disease had been considered unresectable at other hospitals. This shows the inaccuracy of current methods used to establish pericardial tumor invasion and emphasizes the need of systematic performance of EVT. The other 12 patients had unsuspected tumors, and 7 underwent resection. Resectability was established in all instances with VPC.

Thus, 6 patients were found to have unresectable tumors by VPC, 5 of whom had previously been considered candidates for resection on the basis of CT scans. None of them died or experienced morbidity, and their mean length of hospital stay was 48 hours. These patients were referred to the medical and radiation oncology services for therapy on the third postoperative day. It is unlikely they would have been seen this early those services had they undergone a thoracotomy. Although we are aware of no reports to support our hypothesis regarding the experiences of VPC, our results clearly confirm that VPC is a useful examining tool with a high degree of sensitivity and specificity.

In conclusion, we found VPC to be an accurate tool to establish resectability in the case of questionable clinical T4 tumors. With this method, patients can be spared an unnecessary thoracotomy, and surgeons can proceed with resection in patients whose lesions had been considered unresectable on the basis of imaging techniques.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Dr Eduardo Tovar for editing this manuscript.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) 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 Loscertales, J. Articles by Ayarra, J. Search for Related Content PubMed PubMed Citation Articles by Loscertales, J. Articles by Ayarra, J. Related Collections Lung - cancer