Ann Thorac Surg 2006;82:1506-1508
© 2006 The Society of Thoracic Surgeons
Case Reports
Limited Surgery and Radiofrequency Ablation for Recurrent Lung Cancer
Tatsuo Fukuse, MD,
Eiji Ogawa, MD,
Fengshi Chen, MD,
Hiroaki Sakai, MD,
Hiromi Wada, MD*
Department of Thoracic Surgery, Faculty of Medicine, Kyoto University, Kyoto, Japan
Accepted for publication December 20, 2005.
* Address correspondence to Dr Wada, Department of Thoracic Surgery, Faculty of Medicine, Kyoto University, 54 Shogoin, Sakyo-ku, Kyoto, 606-8507 Japan (Email: wadah{at}kuhp.kyoto-u.ac.jp).
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Abstract
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A 72-year-old man who had been diagnosed with second recurrent lung cancer was referred for consideration of a surgical resection. He had undergone a right upper lobectomy with bronchoplasty for the primary lung cancer and stereotactic radiation therapy for the first recurrent tumor. Owing to the comorbid diseases, video-assisted wedge resection and radiofrequency ablation were performed for the second recurrent tumor. The postoperative course was uneventful and the patient was discharged home without complaints. Eighteen months after surgery, he is alive without recurrence. These procedures are minimally invasive and may decrease the local recurrence of lung cancer in properly selected patients.
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Introduction
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Surgical resection is the primary modality offered to patients with early-stage lung cancer and metastatic or recurrent disease to the lungs; however, it is sometimes difficult to perform a lobectomy because of the high incidence of morbidity and loss of quality of life. On the other hand, it is reported that about half of the patients who had lesser resection had recurrence despite complete resection [1]. Radiofrequency ablation (RFA) is a good option for patients at increased risk for resection. Pilot clinical studies have shown that RFA enables the successful treatment of small lung malignancies with a high rate of complete response and acceptable morbidity [2].
As far as we know there has been no report on video-assisted wedge resection with RFA to decrease the local recurrence rate. We herein present a patient with comorbid disease who underwent video-assisted wedge resection with RFA successfully.
A 72-year-old man who was diagnosed with second recurrent lung cancer was referred for consideration of a surgical resection. Computed tomographic scan revealed a 20-mm pulmonary tumor in the left S9 segment. He had undergone right upper lobectomy with bronchoplasty 4 years previously. Two years after the resection, recurrence was identified in the left S6 segment and was treated with stereotactic radiation therapy (SRT) (48 Gy: 4 fractions). One year after the SRT, a second recurrent tumor was identified. Stereotactic radiation therapy was refused by the radiologist because the tumor was too close to the prior SRT lesion (Fig 1). The patient suffered from hypertension, diabetes mellitus, and arteriosclerosis obliterans. Owing to these comorbid diseases, he underwent video-assisted wedge resection with RFA after informed consent was obtained.
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Fig 1. Left: arrow: pulmonary fibrosis due to stereotactic radiation therapy is seen. The first recurrent tumor has disappeared completely. Right: arrow: second recurrent tumor located adjacent to the pulmonary fibrosis.
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Briefly, RFA was performed through a minithoracotomy with the top of the needle electrode placed at the central side of the tumor to ablate the lung tissue within 2 cm central from the tumor. After two cycles of RFA, the tumor was resected with a 2 cm margin with a stapler to allow the lung tissue of the staple line to be ablated (Fig 2).
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Fig 2. Schema of video-assisted wedge resection (VAWR) with radiofrequency ablation (RFA) procedures. Left: RFA was performed with the top of the needle electrode placed at the central side of the tumor to ablate the lung tissue within 2 cm central from the tumor. Right: after two cycles of RFA, VAWR was performed using a stapler with a 2-cm margin to allow the lung tissue along the staple line to be ablated.
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A skin incision of 7 cm in length was made at the mid-axillary line in the fifth intercostal space. Two thoracoports were placed, one at the midaxillary line in the eighth intercostal space, and the other at the posterior axillary line in the seventh intercostal space. After the lung was deflated, under ultrasound guidance and by palpation, a 15-gauge expandable LeVeen needle electrode (size 3.0 cm) (Boston Scientific Japan, Tokyo, Japan) was introduced and stabilized by hand (Fig 3). The top of the needle was placed at the central side of the tumor to ablate the lung tissue within 2 cm central from the tumor. The RF3000 Generator (Boston Scientific Japan) was used. The output algorithm was initially set at 10 W, which was increased stepwise and was applied in a roll-off manner in which the level of impedance rapidly increases, showing that ablation is sufficient to achieve thermal coagulation. To achieve as much thermal coagulation as possible, RFA was performed twice. The total RFA time was 18 minutes. The tumor was then resected with a 2-cm margin using a stapler; however, the margin on the central side of the tumor was not sufficient because of the organization and hyalinization of the lung due to prior radiation. The ablated lung tissue was reinforced by mattress sutures with absorbable felt. The total operation time was 144 minutes, and bleeding volume was less than 10 mL. The tumor was diagnosed as a second recurrent squamous cell carcinoma. The postoperative course was uneventful, and the patient was discharged home without complaints. Eighteen months after surgery the patient is alive without recurrence.
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Fig 3. (Left) After the lung was deflated, a 15-gauge needle electrode was introduced under ultrasound guidance and was stabilized by hand. (Right) Wedge resection for the tumor was performed using an endo-stapler after radiofrequency ablation.
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Comment
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Recently the opportunity for limited surgery for early, recurrent, or metastatic lung cancer has been increasing. However, in this surgical mode, narrow resection margins remain a concern. Usually limited surgery is performed to maintain a macroscopically safe margin, and frozen-section histologic examination is routinely performed. However, the resected line of limited surgery cannot always be sufficiently wide owing to anatomic, physiologic, or technical reasons, especially when the patient has comorbid conditions [3, 4]. Shennib and colleagues [3] reported that only 46% of patients undergoing limited resection had a surgically wide (>1 cm) resection margin. Moreover, Martini and colleagues [1] reported that 31 of 62 patients (50%) who had wedge resection or segmentectomy had recurrence despite complete resection. To decrease the local recurrence rate, Higashiyama and colleagues [4] reported a lavage cytologic technique for the surgical margin, and Santos and colleagues [5] reported intraoperative brachytherapy after sublober resection in high-risk lung cancer patients.
Recently SRT has been introduced as a new modality that allows the delivery of higher doses of radiation to the targeted tumor [6]. This patient had previously received SRT with good control; however, the new lesion was relatively close to the irradiated area and SRT was not used this time.
Generally RFA is most suitable for tumors smaller than 4 cm and for peripheral nodules. The reported local regression rate for lung cancer is 8.6% to 38% [2]. Radiofrequency ablation has the benefit of low morbidity and low cost, and it is a mobile system that can be repeated; moreover it can be easily used in the operation theater with only 10 to 20 minutes of additional time. Consequently, limited resection with RFA is a novel minimally invasive method for local control, especially in a compromised host. Further studies are necessary to evaluate the local control rate of this novel method.
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References
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- Martini N, Bains MS, Burt ME, et al. Incidence of local recurrence and second primary tumors in resected stage I lung cancer J Thorac Cardiovasc Surg 1995;109:120-129.[Abstract/Free Full Text]
- Fernando HC, De Hoyos A, Landreneau RJ, et al. Radiofrequency ablation for the treatment of non-small cell lung cancer in marginal surgical candidates J Thorac Cardiovasc Surg 2005;129:639-644.[Abstract/Free Full Text]
- Shennib H, Bogart J, Herndon JE, et al. Video-assisted wedge resection and local radiotherapy for peripheral lung cancer in high-risk patients: the cancer and leukemia group B (CALGB) 9335, a phase II, multi-institutional cooperative group study J Thorac Cardiovasc Surg 2005;129:813-818.[Abstract/Free Full Text]
- Higashiyama M, Kodama K, Takami K, Higaki N, Nakayama T, Yokouchi H. Intraoperative lavage cytologic analysis of surgical margins in patients undergoing limited surgery for lung cancer J Thorac Cardiovasc Surg 2003;125:101-107.[Abstract/Free Full Text]
- Santos R, Colonias A, Parda D, et al. Comparison between sublobar resection and 125Iodine brachytherapy after sublobar resection in high-risk patients with stage I non-small-cell lung cancer Surgery 2003;134:691-697.[Medline]
- Timmerman R, Papiez L, McGarry R, et al. Extracranial stereotactic radioablation: results of a phase I study in medically inoperable stage I non-small cell lung cancer Chest 2003;124:1946-1955.[Abstract/Free Full Text]
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Abstract
Introduction
