HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Author home page(s): Sybren Meijer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mutsaerts, E. L. Articles by Rutgers, E. J. Search for Related Content PubMed PubMed Citation Articles by Mutsaerts, E. L. Articles by Rutgers, E. J. Related Collections Mediastinum

Ann Thorac Surg 2001;72:230-233
© 2001 The Society of Thoracic Surgeons

---

Original article: general thoracic

Outcome of thoracoscopic pulmonary metastasectomy evaluated by confirmatory thoracotomy

Accepted for publication March 2, 2001.

Address reprint requests to Dr Rutgers, Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
e-mail: erutgers{at}nki.nl

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. The aim of this study was to determine the feasibility, accuracy, and outcome of thoracoscopic resection of peripherally located pulmonary metastases.

Methods. The 28 patients had three or fewer solitary metastases, located in the periphery of the lung, with a diameter 3 cm or less on computed tomography scan. A thoracoscopic resection was performed to remove all identified lesions evaluated by confirmatory thoracotomy.

Results. A thoracoscopic resection was technically impossible in 10 patients. In 1 patient a confirmatory thoracotomy was not performed because the lesion was diagnosed as carcinoid. Among the 17 patients who underwent confirmatory thoracotomy, 12 patients had a complete thoracoscopic resection and 5 patients had residual disease. The success rate appeared to be higher (p = 0.01) in patients with one lesion (11 of 12 patients), than in patients with more than one lesion (1 of 5 patients) found by preoperative computed tomography scan.

Conclusions. Thoracoscopic resection can be considered a viable treatment option for patients who present with a solitary pulmonary metastasis with a diameter of 3 cm or less, when the lesion is located in the periphery of the lung.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Pulmonary metastases are frequently encountered in patients with solid tumors. Some solid tumors tend to produce only a few isolated lung metastases that are usually found peripherally in the lung parenchyma, frequently immediately subpleural [1]. Examples of such tumors are: sarcomas, testicular tumors, renal cell carcinomas, and less frequently, head and neck tumors, colorectal carcinoma, melanoma, and endometrial carcinoma. In these cases, surgical removal of the metastases might be curative. After a total metastasectomy, 5-year survival may be as high as 30% [2–5]. Although these data are derived from studies that were retrospective analyses of selected patient series, these results support the surgical resection of isolated lung metastases. A long-term remission will seldom be achieved when more than three metastases are found preoperatively [3–6].

Unilateral located metastases are usually removed by a posterolateral thoracotomy. Bilateral tumors are excised either by a two-stage bilateral thoracotomy or sternotomy. Peripherally located metastases enable complete removal by wedge resection with the stapling technique. Developments in thoracoscopic/laparoscopic instruments enable tissue stapling using a 12-mm port system. Unfortunately, thoracoscopic resection makes it impossible to examine the lung by palpation. Small lesions may then be difficult to find, and, if not seen on computed tomography (CT) scan, may easily be missed.

It is not uncommon that more metastatic sites are found during a thoracotomy than anticipated by preoperative imaging techniques [7]. When the disease is disseminated extensively, a cure will not be achieved by surgical procedures alone. A decision must then be made to resect if palliative goals can be met.

The advantage of thoracoscopic removal of solitary metastases is the limited surgical trauma, which results in an improved postoperative recovery, shorter hospital stay, and decreased long-term morbidity. These effects should be counterbalanced by the risk of incomplete resection of metastatic disease that is assured by thoracotomy and direct palpation [8–10].

This study determined the feasibility, accuracy, and outcome of thoracoscopic resection of solitary peripherally located pulmonary metastases.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Between November 1992 and October 1996, 28 patients (12 men and 16 women) with pulmonary nodules (found during follow-up by routine chest roentgenograms) that were considered to be metastases from the primary tumor, and for whom resection was considered as a therapeutic option, were eligible for this study. This study included thoracoscopic resection of all identified lesions evaluated by confirmatory thoracotomy. This study design was chosen because in 1992, thoracotomy with wedge resections of all suspicious lesions after careful palpation of the lung was considered standard treatment for pulmonary metastases. Furthermore, at the time, video-assisted operations were new and experimental. Further selection criteria included three or fewer solitary lesions with a diameter of 3 cm or less, located in the periphery of the lung. No specific attempts were undertaken to obtain preoperative cytologic diagnosis. Patients were required to be fit enough to undergo the intended thoracotomy and pulmonary resection. If a pulmonary nodule appeared to be technically unresectable during the thoracoscopy, or if the nodules were benign or carcinoid, patients underwent a thoracotomy and were registered for this study but not included in the analysis.

Patients underwent the after standard workup for surgery: CT scan (Siemens Somaton Plus CT scanner, Munich, Germany, single slice technique with slices of 7 mm without contrast), bronchoscopy, pulmonary function tests, and investigations to exclude locoregional relapse or metastasis at other sites.

The end points for this study were the number of successful procedures, that is, the number of thoracoscopic resections for all lesions found on CT scan when no residual disease was demonstrable at confirmation thoracotomy; the number of technical failures; reoccurrence of the disease, either pulmonary or elsewhere; and survival.

The study was approved by the medical ethical committees of both The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital (NCI-AvL) and the Academic Hospital Free University (AHFU). Patients were entered in the study after informed consent. Twenty-three patients were treated at the NCI/AvL and 5 at the AHFU.

Surgical technique
The 28 operations were performed by three surgeons (E.R., F.Z., S.M.). After the induction of general anesthesia, patients were ventilated through a double-lumen endotracheal tube that allowed contralateral ventilation and ipsilateral collapse of the lung. Patients were positioned in a stable lateral position. Depending on the location of the metastases, three to four ports were introduced, usually 12 mm. After a careful inspection, all visible or "palpable" (by instrumentation) lesions were removed by the GIA stapling technique. Special care was taken not to clamp or sever the lesion. The specimen was then removed through one of the ports in a sterile bag and sent for frozen section analysis.

After the removal of all the recognized lesions and a histologic examination by frozen section, a confirmatory thoracotomy was performed. The lung was then carefully examined for residual disease. Any suspicious palpable abnormality was excised, usually by GIA stapling technique. If the lesion was considered to be a second primary after frozen section histology, a formal lobectomy including lymph node sampling from the mediastinum was performed. Hemostasis was assured and air leaks were corrected before closure. Thoracotomy was closed over a chest tube.

Statistical analysis
The Fisher’s exact test was used to determine the relationship between the number of pulmonary metastases on CT scan and the result of thoracoscopic resection. An overall survival curve was constructed with the Kaplan–Meier method. The Clopper–Pearson [11] method was used to determine the confidence interval of percentages.

All statistical analyses were performed with the Statistical Package for the Social Sciences software, version 8.0 (SPSS, Chicago, IL).

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Table 1 lists patient characteristics. Table 2 shows the perioperative findings of all patients. It appeared technically impossible to perform a thoracoscopic metastasectomy in 10 patients (36%). In 7 patients the lesion was not visible because of pleural adhesions or a central location. In the 3 remaining patients, the lesion was visualized but complete thoracoscopic resection was impossible because of either the location or size of the lesion. These 10 patients underwent a thoracotomy.

Seventeen of the 28 patients underwent a subsequent confirmatory thoracotomy. In 12 patients (71%) no visible or palpable abnormality was found after the thoracoscopic resection. In 5 patients (29%) residual disease (one to three nodules, range 2 to 5 mm) was found and removed. No residual tumor was found at the site of any of the thoracoscopic wedge resections.

Considering preoperative CT findings, the probability of a thoracoscopic resection being complete was higher in patients with one metastasis (11 of 12, 92%) than in patients with two or three metastases (1 of 5, 20%) (p = 0.010; Fisher’s exact test) (Table 2). In patients with one solitary metastasis the Clopper–Pearson confidence interval, which predicts the probability of a successful thoracoscopic resection, was 62% to 99%. The mean diameter of the lesions resected by thoracoscopy was 17 mm (range 7 to 30 mm).

The pathologic diagnosis of the resected lesions were benign (hamartoma; n = 1), carcinoid (n = 1), a second primary (n = 6), and metastases of known primary (n = 20). Five patients with a second primary were included in the 11 solitary deposits in which thoracoscopy was considered accurate. The hamartoma could be visualized but not resected through a thoracoscopy because of its central location in the nondeveloped fissure between the right upper and middle lobe.

There was no mortality associated with the procedure and there were no perioperative complications. Postoperatively, four complications occurred in 28 patients. These included pneumonia (n = 1), prolonged air leak (n = 1), subcutaneous emphysema (n = 1), and transient respiratory failure (n = 1).

Of the 20 patients with metastases, 6 have died to date, 7 are alive with disease, and 7 are alive without demonstrable disease. The median follow-up of the 14 patients still alive is 42.5 months (range 2 to 71 months). Survival at 5-years is estimated to be 59% (SE 14%) (Fig 1).

View larger version (14K): [in this window] [in a new window]   Fig 1. Kaplan-Meier plot of overall survival of 20 patients with completely removed metastases.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
This study shows that thoracoscopic resection of solitary metastasis in the periphery of the lung is feasible. We demonstrated evidence that the success rate of the thoracoscopic resection is associated with the number of lesions found on CT.

This finding is in contrast with a comparable study by McCormack and colleagues [12]. In their series, additional malignant tumors were found at thoracotomy in 10 of 18 patients (56%) as compared with 5 of 17 patients (29%) in the present study. Even in patients with one lesion detected on CT, 7 of 14 patients (50%) had additional metastases found (one of 12 in this study). McCormack and colleagues concluded that cancer will be missed if thoracoscopy is used as the only technique because of the discrepancy between radiographic and surgical findings.

CT scan is known to underestimate the number of lesions found at thoracotomy. McCormack and colleagues [7] demonstrated that 42% of lesions were not identified by CT scan. Lesions smaller than 1 cm are especially difficult to detect on CT. Munden and colleagues [13] reported that these small lesions, missed by CT scan but found during operation, may not be ignored because many are malignant (58%). The current generation of helical CT screening [14] and positron emission tomography [15, 16] may identify nodules in the 2 to 3-mm range and could be helpful in identifying metastases more accurately.

This study showed that known metastases could be resected with adequate margins by the video-assisted thoracoscopic wedge resection. However, lesions occult on CT scan but otherwise palpable may be easily missed by the thoracoscopic technique alone. The clinical consequence of this outcome is uncertain, as multiple lung metastases from solid tumors are very rarely cured by surgical procedures alone. A long-term remission will seldom be achieved when more than three metastases are found preoperatively [3, 6]. Secondly, those "missed" nodules will emerge during follow-up by chest roentgenogram or CT scan, and if solitary or limited in number they will be accessible for surgical resection.

In our study, 10 of 28 patients (36%) underwent a thoracotomy because thoracoscopic resection was deemed technically impossible. This is in agreement with the experience from other series [17, 18].

The favorable 5-years survival rate of 59% may be due to patient selection and the small numbers of patients. The two-stage procedure—thoracoscopy followed by a confirmatory thoracotomy—does not seem to have a negative effect on the outcome.

In this series, 1 patient had a port site recurrence diagnosed 20 months after thoracoscopic resection. This patient is described elsewhere [19]. Port site recurrence is an uncommon but feared complication of thoracoscopy for malignant lesions. A number of precautions need to be taken to avoid port site recurrences. The use of thoracoports instead of tab incisions, atraumatic tissue handling, and the use of endoscopic specimen retrieval bags are factors that may reduce the risk of port site recurrence [19].

The advantage of thoracoscopy over resection through a thoracotomy is the limited surgical trauma with consequently reduced postoperative morbidity and pain. Additional benefits are an improved postoperative recovery, shorter hospital stay, and reduced medical costs [9, 10, 20].

Although this study was small, our evidence shows that the probability of a thoracoscopic resection being complete seems to be at least 62% for patients with a single metastasis on CT scan, given our selection criteria.

In conclusion, a thoracoscopic resection and a "wait & see" policy can be considered a viable treatment option for patients with solitary metastasis smaller than 3 cm, located in the periphery of the lung. Patients with multiple or centrally located lesions should be treated with thoracotomy because that technique allows palpation of the lung tissue and provides a better overview. Second primary tumors should be treated accordingly.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Financial support was given by The Netherlands Cancer Institute.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Crow J., Slavin G., Kreel L. Pulmonary metastasis: a pathologic and radiologic study. Cancer 1981;47:2595-2602.[Medline]
2. Van Coevorden F., Van Geel A.N. Pulmonary metastasectomy for soft tissue sarcomas. Treatment with curative intent. Eur J Surg Oncol 1992;18(Suppl 1):5-6.
3. Casson A.G., Putnam J.B., Natarajan G., et al. Five year survival after pulmonary metastasectomy for adult soft tissue sarcoma. Cancer 1992;69:662-668.[Medline]
4. Takita H., Edgerton F., Karakousis C., Douglass H.O., Vincent R.G., Beckley S. Surgical management of metastases to the lung. Surg Gyn Obstet 1981;152:191-194.
5. Van Halteren H.K., Van Geel A.N., Hart A.A.M., Zoetmulder F.A.N. Pulmonary resection for metastases of colorectal origin. Chest 1995;107:1526-1531.[Abstract/Free Full Text]
6. Pastorino U., Buyse M., Friedel G., et al. Long-term results of lung metastasectomy: prognostic analysis based on 5206 cases. J Thorac Cardiovasc Surg 1997;113:37-49.[Abstract/Free Full Text]
7. McCormack P.M., Ginsberg K.B., Bains M.S., et al. Accuracy of lung imaging in metastases with implications for the role of thoracoscopy. Ann Thorac Surg 1993;56:863-866.[Abstract]
8. Förster R., Heinecke A., Leschber G., Linder A., Kästel M., Stamatis G. Thoracoscopy versus thoracotomy. The dilemma of the comparison and its meaning for quality assurance in thoracic surgery. Zentralbl chir 1999;124:120-127.[Medline]
9. Landreneau R.J., Wiechmann R.J., Hazelrigg S.R., Mack M.J., Keenan R.J., Ferson P.F. Effect of minimally invasive thoracic surgical approaches on acute and chronic postoperative pain. Chest Surg Clin N Am 1998;8:891-906.[Medline]
10. Hazelrigg S.R., Nunchuck S.K., Landreneau R.J., et al. Cost analysis for thoracoscopy: thoracoscopic wedge resection. Ann Thorac Surg 1993;56:633-635.[Abstract]
11. Clopper C.J., Pearson E.S. The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrica 1934;26:404-413.
12. 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;62:213-217.[Abstract/Free Full Text]
13. Munden R.F., Pugatch R.D., Liptay M.J., Sugarbaker D.J., Le L.U. Small pulmonary lesions detected at CT: clinical importance. Radiology 1997;202:105-110.[Abstract/Free Full Text]
14. Kaneko M., Eguchi K., Ohmatsu H., et al. Peripheral lung cancer: screening and detection with low-dose spiral CT versus radiography. Radiology 1996;201:798-802.[Abstract/Free Full Text]
15. Graeber G.M., Gupta N.C., Murray G.F. Positron emission tomographic imaging with fluorodeoxyglucose is efficacious in evaluating malignant pulmonary disease. J Thorac Cardiovasc Surg 1999;117:719-727.[Abstract/Free Full Text]
16. Maublant J., Vuillez J.P., Talbot J.N., et al. [Positron emission tomography (PET) and [F-18]-fluorodeoxyglucose in (FDG) cancerology]. Bull Cancer 1998;85:935-950.[Medline]
17. Suzuki K., Nagai K., Yoshida J., et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules. Indications for preoperative marking. Chest 1999;115:563-568.[Abstract/Free Full Text]
18. Rusch V.W., Bains M.S., Burt M.E., McCormack P.M., Ginsberg R.J. Contribution of videothoracoscopy to the management of the cancer patient. Ann Surg Oncol 1994;1:94-98.[Abstract]
19. Mutsaerts ELAR, Zoetmulder FAN, Rutgers EJT. Port site metastasis as a complication of thoracoscopic metastasectomy. Eur J Surg Oncol 2001; in press.
20. Giudicelli R., Thomas P., Lonjon T., et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994;58:712-718.[Abstract]

This article has been cited by other articles:

				D. Gossot, C. Radu, P. Girard, A. Le Cesne, S. Bonvalot, M. S. Boudaya, P. Validire, and P. Magdeleinat Resection of Pulmonary Metastases From Sarcoma: Can Some Patients Benefit From a Less Invasive Approach? Ann. Thorac. Surg., January 1, 2009; 87(1): 238 - 243. [Abstract] [Full Text] [PDF]

				J. Nakajima, T. Murakawa, T. Fukami, and S. Takamoto Is thoracoscopic surgery justified to treat pulmonary metastasis from colorectal cancer? Interactive CardioVascular and Thoracic Surgery, April 1, 2008; 7(2): 212 - 217. [Abstract] [Full Text] [PDF]

				M. C. Kang, C. H. Kang, H. J. Lee, J. M. Goo, Y. T. Kim, and J. H. Kim Accuracy of 16-channel multi-detector row chest computed tomography with thin sections in the detection of metastatic pulmonary nodules Eur. J. Cardiothorac. Surg., March 1, 2008; 33(3): 473 - 479. [Abstract] [Full Text] [PDF]

				P. E. Van Schil, J. M. Hendriks, B. P. van Putte, B. A. Stockman, P. R. Lauwers, P. W. ten Broecke, M. J. Grootenboers, and F. M. Schramel Isolated lung perfusion and related techniques for the treatment of pulmonary metastases Eur. J. Cardiothorac. Surg., March 1, 2008; 33(3): 487 - 496. [Abstract] [Full Text] [PDF]

				H. I. Pass and C. S. Bizekis Surgical Treatment of Sarcomatous Lung Metastases ASCO Educational Book, January 1, 2008; 2008(1): 519 - 522. [Abstract] [Full Text] [PDF]

				J. Nakajima, T. Murakawa, T. Fukami, A. Sano, M. Sugiura, and S. Takamoto Is Finger Palpation at Operation Indispensable for Pulmonary Metastasectomy in Colorectal Cancer? Ann. Thorac. Surg., November 1, 2007; 84(5): 1680 - 1684. [Abstract] [Full Text] [PDF]

				J. Pfannschmidt, H. Dienemann, and H. Hoffmann Surgical Resection of Pulmonary Metastases From Colorectal Cancer: A Systematic Review of Published Series Ann. Thorac. Surg., July 1, 2007; 84(1): 324 - 338. [Abstract] [Full Text] [PDF]

				A. M. Parsons, F. C. Detterbeck, and L. A. Parker Accuracy of Helical CT in the Detection of Pulmonary Metastases: Is Intraoperative Palpation Still Necessary? Ann. Thorac. Surg., December 1, 2004; 78(6): 1910 - 1918. [Abstract] [Full Text] [PDF]

				R. H.V. Reddy, B. Kumar, R. Shah, S. Mirsadraee, K. Papagiannopoulos, P. Lodge, and J. A.C. Thorpe Staged pulmonary and hepatic metastasectomy in colorectal cancer--is it worth it? Eur. J. Cardiothorac. Surg., February 1, 2004; 25(2): 151 - 154. [Abstract] [Full Text] [PDF]

				S. Margaritora, V. Porziella, A. D'Andrilli, A. Cesario, D. Galetta, G. Macis, and P. Granone Pulmonary metastases: can accurate radiological evaluation avoid thoracotomic approach? Eur. J. Cardiothorac. Surg., June 1, 2002; 21(6): 1111 - 1114. [Abstract] [Full Text] [PDF]

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 Author home page(s): Sybren Meijer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mutsaerts, E. L. Articles by Rutgers, E. J. Search for Related Content PubMed PubMed Citation Articles by Mutsaerts, E. L. Articles by Rutgers, E. J. Related Collections Mediastinum