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J Thorac Cardiovasc Surg 1995;110:855-0856
© 1995 Mosby, Inc.
BRIEF COMMUNICATIONS |
Giessen, Germany
From the Department of General and Thoracic Surgery, Justus Liebig University, Giessen, Germany.
Many peripheral nodules of the lung that cannot be determined to be benign by means of radiographic assessment require resection to rule out malignancy. The rapid evolution of minimally invasive surgical techniques is stimulating new technical and surgical innovations. Growing enthusiasm for these minimally invasive surgical procedures has led to an expanded role for thoracoscopic or video-assisted thoracic surgery for the solution of many intrathoracic surgical problems. Thoracoscopic surgery has expanded from a rarely used technique for the evaluation of benign diseases to an operative approach used in the treatement of lung cancer. At this writing, there have been reports of nearly 100 thoracoscopic or video-assisted resections in the treatment of lung cancer.
1,2
In January 1990, we began to perform thoracoscopic operations in our Department for General and Thoracic Surgery in Giessen, Germany. Since January 1992, we have elected a thoracoscopic approach for some nodules of the lung because of our good experiences with thoracoscopic wedge resection for such benign diseases as pneumothorax.
Although the decrease in postoperative pain is obvious in the early period after operation, 3 there remains concern about oncologic aspects of this approach. We therefore report on two cases of tumor dissemination after thoracoscopic resection for lung cancer.
In 63 cases, nodules were resected by thoracoscopic wedge resection. In 21 cases, malignancy was demonstrated (14 metastases and seven primary lung cancers). In two of these patients, tumor cell dissemination was observed.
Case 1
In July 1992, we treated a patient who had bad lung function and a peripheral nodule (1.5 cm diameter on computed tomographic scan) of the right upper lobe by means of thoracoscopic wedge resection. The histologic examination showed an adenocarcinoma without infiltration of the pleura visceralis (pathologic classification T1, grade 2). By means of intraoperative pleural lavage, we found tumor cells remaining after the thoracoscopic resection. In February 1994, we detected a metastatic nodule (3 cm in diameter) at the site in the chest wall where the tumor was extracted during the thoracoscopic operation. On computed tomographic scan, we did not find any tumor recurrence in the lung. We performed a curative resection of the tumor located at the thoracic wall. One year after the operation, the patient was in good condition and remained free of any other tumor manifestations.
Case 2
A thoracoscopic wedge resection of a peripheral tumor (2 cm diameter on computed tomographic scan) of a patient's right upper lobe was performed in January 1993. The histologic examination of the frozen section showed a close resection of an adenocarcinoma (only 3 mm distance between tumor and resection). We converted the operation to an open lobectomy and performed additional lymph node dissection. The histologic examination of the formalin-fixed tumor showed an adenocarcinoma with infiltration of the pleural visceralis. The final tumor stage was pathologic classification T2 N0, grade 2. The result of pleural lavage cytologic examination was positive after the thoracoscopic resection. Pleural carcinosis, proved by histologic and cytologic examination, developed in this patient 6 months after the operation. The patient died 14 months after the operation.
Discussion
In our department, we perform thoracoscopic resection only for peripheral lung tumors smaller than 2 cm and in patients with compromised pulmonary reserves. All other patients were treated with open lung operations. In 46 cases, nodules of the lung were resected by thoracoscopic approach. If frozen sections indicated malignancy of the nodule, we converted to open lobectomy and performed formal lymph node dissection. Before and after thoracoscopic resection of the tumor, pleural lavage was performed for cytologic examination. This procedure should detect tumor cell spread before clinical manifestation. We also perform pleural lavage in open operations for lung cancer. 4
These two case reports provide a warning for everyone who performs or tries to perform thoracoscopic operations for patients with from lung cancer. Thoracoscopic surgical methods are not able to adjust adequately to the specific growth pattern and paths of metastatic spread of lung cancer. The loss of palpation and the insufficiency of complete mediastinal lymph node dissection are responsible for the uncertain value of the new method for curative oncologic therapy. It is irresponsible to risk the internationally quite homogenous stage-related results currently obtained in the treatment of lung cancer for the sake of pursuing new technical methods. 5,6 It is not our duty to create a new disease, such as tumor metastasis at the extraction site after thoracoscopic resection of lung cancer. Thoracoscopic resection for potentially malignant diseases should be restricted to superficial lesions smaller than 2 cm. If the medical history or the thoracoscopic aspect suggests primary lung cancer, conversion to an open procedure is absolutely necessary.
Footnotes
J THORAC CARDIOVASC SURG 1995;110:855-6 
References
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