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J Thorac Cardiovasc Surg 1996;111:1110-1111
© 1996 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of General and Thoracic Surgery
Justus Liebig University
Rudolf-Buchheim-Strasse 7
D-35392 Giessen, Germany
Reply to the Editor:
Thoracoscopy and video-assisted thoracic surgery (VATS) have been characterized as minimally invasive operations. Both techniques seems to decrease operative trauma.
1-3 The indications for thoracoscopy and VATS, an obvious variation on the theme, continue to evolve. The growing enthusiasm for these minimally invasive surgical procedures has led to an expanded role in the diagnosis and staging of lung cancer. However, the role of thoracoscopy and VATS in the treatment of primary thoracic tumors or lung metastases is still undefined.
Chest wall metastasis (case 1 in our brief communication) or pleural carcinosis (case 2 in our brief communication) are very unusual for stage I lung cancer. In our first case we did not place the resected specimen in a bag. I think that tumor cells were squeezed into the chest wall during the extraction procedure. For this reason, 1
years after the thoracoscopic resection, we detected a metastasis at the port site, the site of tumor extraction. After curative resection of the tumor located at the thoracic wall, the patient is still free of any other tumor manifestation. Meanwhile, the second operation was nearly 2 years ago and we did not find any other widespread metastases. Therefore, I think the metastasis at the thoracic wall was induced by thoracoscopic surgery, because we could not detect any signs of hematogenous dissemination.
In our second case we performed a closed resection of an adenocarcinoma with infiltration of the pleural surface. These two factors may induce subsequent pleural carcinosis. Of course, tumors with infiltration of the pleural surface have a poorer prognosis than tumors without ulceration of the pleural viscera. However, complete resection of these stage I tumors by open thoracic operations is usually curative. In our case of pleural carcinosis the result of pleural lavage cytology was positive after thoracoscopic resection. In the first lavage fluid (before thoracoscopic resection) we did not find any tumor cells. The dissemination of tumor cells into the pleural cavity with subsequent pleural carcinosis was the result of the close resection of the lung cancer by the thoracoscopic approach.
To the present, we have performed intraoperative pleural lavage 4,5 in 319 patients with lung cancer before (lavage I) and after (lavage II) open resection. Tumor cells were found in 122 cases (38.2%) in the lavage I group. In 24.8% we detected tumor cells in stage I (pT1 NO, pT2 NO) lung cancers. The cumulative survival of non-small-cell lung cancer in stage I (n = 154) was 22.1% if the results of lavage were positive (n = 44) and 67.9% if lavage results were negative (n = 110) (p < 0.05). The biologic behavior of lung cancer and the irregular patterns of spread determine this finding. In our two cases of tumor dissemination after thoracoscopic resection of lung cancer, the cytologic result of pleural lavage was positive only after the resection.
Several reports of tumor implants after thoracoscopic resection of malignant tumors have been published. 6-8 In all cases the authors suspected a relation between VATS and tumor dissemination.
We have performed thoracoscopic resection of nodules of the lung in 108 cases. In 42 cases, malignancy was demonstrated (25 metastases and 17 primary lung cancers). In most cases of lung cancer we converted to open lung surgery with lobectomy or pneumonectomy and additional lymph node dissection, which could not be performed sufficiently by a thoracoscopic approach. 9,10 In our opinion thoracoscopic resection for potentially malignant lesions should be restricted to superficial lesions smaller than 2 cm. If the thoracoscopic appearance suggests primary lung cancer with infiltration of the pleural surface, conversion to open procedure is absolutely necessary.
References
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