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Ann Thorac Surg 2003;75:1643-1645
© 2003 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom
Accepted for publication September 27, 2002.
* Address reprint requests to Dr Goldstraw, Department of Thoracic Surgery, Royal Brompton Hospital, London SW3 6NP, United Kingdom.
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A 34-year-old woman had extensive surgery and local radiotherapy for a right thigh monophasic synovial sarcoma. A year later two left pulmonary lesions were discovered on her annual surveillance spiral computed tomography (CT) scan. She was referred to her regional thoracic center where she underwent left VATS and stapled resection to remove the two lesions, with uneventful recovery. It was uncertain if a protective bag was used during the specimen retrieval. Both lesions were subsequently proved to be metastases with clear resection margins on histology.
Five months later the patient became acutely breathless and was readmitted to her thoracic center with radiologic evidence of a large left pleural effusion (Fig 1). She underwent a second left VATS with intraoperative findings of 1.5 L of blood-stained fluid, which was drained; extensive adhesions; and a large left lower lobe lesion that had features of recurrent metastasis and involved the pleura. In view of the intraoperative findings of extensive disease, it was decided not to proceed with further resection or pleurodesis. She was referred for palliative chemotherapy. Over the next 3 months she received three cycles of adriamycin and ifosfamide. Follow-up CT (Fig 2) showed that her large metastasis remained unchanged. She was therefore referred to our unit for a second opinion.
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The patient made an uneventful recovery and was discharged on the eighth operative day. Her postoperative chest and abdomen CT scan 3 months later showed no evidence of recurrence and she remained well 6 months after her last operation.
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The mechanisms of tumor dissemination implicated so far mostly relate to surgical imperfections and poor compliance with oncologic principles [2]. They include tumor disruption during its retrieval especially through a small exit site, direct tumor contact with chest wall, and instrumental contamination. As a result, preventive measures such as the use of a protective impermeable bag for specimen retrieval, an adequate exit port during the tumor removal, and sterile lavage of all port sites and the pleural cavity before the conclusion of the surgery were recommended [2]. When these oncologic principles were respected, the incidence of port site tumor recurrence was low [3]. Unfortunately, we have insufficient information about this patient’s initial VATS metastasectomy to identify whether such technical imperfections contributed to the recurrence we encountered.
The other possibility is that VATS itself may promote intrapleural and intraparenchymal tumor dissemination. Some authors postulated that the limited two-dimensional visualization and tactile examination offered by the VATS might contribute to imprecise definition of tumor margin, unnecessary tumor handling, and hence am increase in the risk of tumor disruption and dissemination [4]. Using carcinoembryonic antigen mRNA expression Yamashita and associates [5] detected a higher transient increase in tumor cells in the blood stream after VATS tumor resection of thoracic malignancies, mainly nonsmall cell lung cancer, when compared with open techniques. They postulated that these cells might increase the risk of subsequent thoracic and hematogenous tumor spread. To date no effective preventive measures are available to cope with this problem. This lack has raised concerns about the controversial role of VATS in pulmonary metastasectomy.
Advocates of VATS in pulmonary metastasectomy recommend its use in patients with small numbers of peripheral lesions identified by the CT imaging. They claim these patients will benefit from the reduced postoperative pain, reduced postoperative morbidity, and better comestic results of avoiding thoracotomy. It has been shown, however, that CT scanning or the use of VATS alone can have a failure rate as high as 56% in detecting additional lesions compared with the bimanual palpation of the collapsed lung during the open technique [6, 7]. If several redo VATS are required for these lesions at a later stage, the cumulative cost and morbidity will eventually outweigh its initial advantage over the open technique.
Incomplete resection may result and these lesions "missed" by VATS can compromise the patient’s overall survival. From a multicenter analysis of 5,206 pulmonary metastasectomies [7], actuarial survival after incomplete metastasectomy was 13% at 5 years and 7% at 10 years, compared with the more favorable figures after complete resection of 36% and 26%, respectively. Even though our patient’s intrapleural tumor was completely excised and she remained well after 6 months, the long-term implications of this complication are unknown.
This case illustrates tumor dissemination as a catastrophic complication of VATS malignant tumor resection. It also highlights the importance of observing the oncologic principles during any tumor resection using VATS. Although preventive measures can reduce port site recurrence, the intrinsic visual and tactile limitation of VATS may be a factor in promoting tumor dissemination. We caution its use in lung malignancy resection, especially in curative pulmonary metastasectomy, where incomplete resection is an additional risk.
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