Ann Thorac Surg 2003;75:1643-1645
© 2003 The Society of Thoracic Surgeons
Case report
Intrapleural tumor dissemination after video-assisted thoracoscopic surgery metastasectomy
Keng Leong Ang, MRCSa,
Carol Tan, MRCSa,
Michael Hsin, FRCSa,
Peter Goldstraw, MD, FRCSa*
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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Abstract
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In a 34-year-old woman extensive intrapleural disease developed within 1 year of video-assisted thoracoscopic surgery (VATS) removal of two pulmonary metastases from a previously treated synovial sarcoma. She underwent a successful complete pleurectomy through a left thoracotomy to excise the pleural tumor and remains well 6 months later. This case highlights tumor dissemination as one of the pitfalls of VATS metastasectomy and raises concerns about using VATS in this situation.
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Introduction
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Since its advent video-assisted thoracoscopic surgery (VATS) has replaced conventional techniques in the investigation and treatment of many thoracic conditions, including malignant disease. However, many thoracic surgeons remain concerned as to its use when surgery is undertaken with curative intent for malignant disease especially lung cancer and metastasectomy. The reservations expressed by such surgeons include the risk of port-site implantation during VATS procedures. We present a case in which extensive pleural recurrence occurred after VATS metastasectomy but was fortunately salvaged by thoracotomy.
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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Fig 1. Spiral computed tomography of the thorax demonstrating a large left pleural effusion and posterior lateral intrathoracic lesion.
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Fig 2. Spiral computed tomography of the thorax taken after palliative chemotherapy showing resolution of left pleural effusion and an unchanged posterior lateral intrathoracic lesion.
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Further investigations at our unit established the presence of a large left-sided intrathoracic lesion but excluded other metastatic lesions on CT and magnetic resonance imaging (MRI). Routine workup confirmed the patient’s operability and she underwent a bronchoscopy and left thoracotomy. At bronchoscopy there was severe distortion and extrinsic compression of the left lower lobe bronchus. At thoracotomy, five of the six previous VATS port sites (three from the first VATS procedure and the remainder from the repeated procedure) were excised and found to contain scar tissue on paraffin section. There was a large, 12 cm, encapsulated tumor mass in the pleura adherent to the lung surface in the region of the staple lines but without macroscopic evidence of lung parenchymal invasion. After extrapleural mobilization, pleurectomy and pleural metastasectomy were performed while preserving the lung. Histology of the pleural mass showed features of monophasic synovial sarcoma, confirming its metastatic origin.
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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Comment
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Tumor implantation and dissemination is a rarely reported yet devastating complication of VATS when used for resecting lung malignancies. A recent literature review of this subject yielded fewer than 10 case reports. A retrospective collection of anecdotal cases based on the experience from surgeons of the VATS study group (VATSSG) [1] suggested significant morbidity and even mortality associated with this uncommon complication. Common sites of tumor implantations were VATS port sites, resection margin, other lung parenchyemal sites, or pleura, or a combination of the above. Extensive isolated pleural implantation as demonstrated by this case was reported in two instances [1].
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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References
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- Downey R.J., McCormack P., LoCicero J., III Dissemination of malignant tumors after video-assisted thoracic surgery: a report of twenty-one cases. The Video-Assisted Thoracic Surgery Study Group. J Thorac Cardiovasc Surg 1996;111:954-960.[Abstract/Free Full Text]
- Collard J.M., Reymond M.A. Video-assisted thoracic surgery (VATS) for cancer. Risk of parietal seeding and of early local recurrence. Int Surg 1996;81:343-346.[Medline]
- Parekh K., Rusch V., Bains M., Downey R., Ginsberg R. VATS port site recurrence: a technique dependent problem. Ann Surg Oncol 2001;8:175-178.[Medline]
- Downey RJ. Complications after video-assisted thoracic surgery. Chest Surg Clin North Am 1998;8:907–17
- Yamashita J.I., Kurusu Y., Fujino N., Saisyoji T., Ogawa M. Detection of circulating tumor cells in patients with non-small cell lung cancer undergoing lobectomy by video-assisted thoracic surgery: a potential hazard for intraoperative hematogenous tumor cell dissemination. J Thorac Cardiovasc Surg 2000;119:899-905.[Abstract/Free Full Text]
- McCormack P.M., Bains M.S., Begg C.B., et al. Role of video-assisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial. Ann Thorac Surg 1996;62:213-216.[Abstract/Free Full Text]
- Pastorino U., Buyse M., Friedel G., et al. Long-term results of lung metastasectomy. prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg 1997;113:37-49.[Abstract/Free Full Text]
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Abstract
Introduction
