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J Thorac Cardiovasc Surg 1997;114:300-302
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Tumor dissemination after video-assisted thoracic surgery: What does it mean?

Department of Cardiothoracic Surgery
University Hospital
S-581 85, Linköping, Sweden

To the Editor:

We read with interest the recently published article on tumor dissemination after video-assisted thoracic surgery (VATS) in 21 cases by Downey and colleagues. ¹ The authors conclude that thoracoscopic wedge excision of a lung cancer is an inadequate cancer operation and, should a malignant tumor be diagnosed during thoracoscopy, a thoracotomy and lobectomy should be performed. This recommendation was based on the multicenter trial of the Lung Cancer Study Group. ²

Several comments on the subject seem appropriate.

1. Lobectomy and wedge resection are, obviously, two different operations, regardless of whether they are done by VATS or not. Using the terms VATS lobectomy and VATS wedge resection interchangeably is confusing. These two operations cannot be ascribed to one single entity called just VATS. It is difficult to draw any conclusion from this report because it is unknown which VATS procedure was performed in each of the 21 cases. However, in three cases, in which the actual VATS procedure was specified, it is more likely that dissemination was related to wedge resection and segmentectomy rather than to the method of entering the thoracic cavity. This relationship, indeed, has been clearly shown by the Lung Cancer Study Group. ² In this report lesser resections (wedge and segmentectomy) were compared with lobectomy in the management of stage I non-small-cell lung cancers. A 25% increased risk of local recurrence in patients who had been randomized to a lesser resection was reported.
   
2. Regarding the methods used in this report, authors surveyed 55 members of the Video-Assisted Thoracic Surgery Study Group (VATSSG). The total number of procedures performed by the members of the VATSSG is unknown. Some of the procedures reported were not performed by members of the VATSSG; the operations were performed by other surgeons at the same institution, or else the patients were referred for postoperative consultation from other institutions. We agree with the authors' statement that this is a voluntary reporting based on recollection and should be considered a collection of anecdotes. This report of 21 cases, in fact, represents a description of a rather diverse group of 18 patients and three case reports. Inasmuch as this article was published as an original communication in the Journal, the title of the report could make a misleading impression, that it was a result of a study conducted by the VATSSG, showing interrelation between dissemination and VATS.
   
3. Among these 21 cases, only nine represent primary lung cancers. A detailed report of one of these nine cases has been published before. ³ Five patients had disease metastatic to the lung. This means that these patients had generalized malignant disease and that tumor cells were disseminated by the time of the operation. In these five cases, it is unknown whether further dissemination was related to VATS or rather to an already ongoing generalized malignant process. The site of recurrence in one patient with melanoma was pleura. This might not be related to the actual operation at all. The incision was the site of recurrence in all five patients with mesotheliomas. We agree with the authors that the propensity for mesotheliomas to grow into thoracotomy and chest tube incisions is widely recognized and mesotheliomas should be considered separately from the other cases. The last two patients had small-cell carcinoma and esophageal squamous carcinoma. It is impossible to find any interrelation between tumor dissemination, recurrence, and the VATS procedure in these particular 12 cases.
   
4. Recurrence in a suture line is most likely the result of an inadequate resection and has nothing to do with how the specimen is removed. This can happen after wedge resection performed through thoracotomy, as well as by VATS.
   
5. The authors conclude that should a malignant tumor be diagnosed during thoracoscopy, a thoracotomy and lobectomy should be performed. However, nothing in this report supports the conclusion that thoracotomy is necessary.
   
6. Finally, it is time for all of us to realize that VATS is not thoracoscopy. ⁴ These terms must not be used interchangeably.
   

Similar case reports on tumor dissemination by VATS have been published. ^3,5,6 In all these reports lesser resections were performed. In the majority of these cases no protective plastic bags were used. In all cases the authors blamed VATS rather than its inappropriate application.

We share the opinion that wedge excision is an inadequate cancer operation. This is true regardless of whether VATS or an open technique is used.

On the contrary, we believe that by using special plastic bags and careful handling of the resected tissue, dissemination can be avoided during VATS lobectomy. Once excised, the specimen must be placed in a protective container before removal. We agree with Lewis, Caccavale, and Sisler, ⁷ who adamantly recommend a sealed container for the removal of all malignant tissue.

It is important that authors reporting similar cases specify whether a protective container was used or not and which VATS operation was performed—a lobectomy or wedge resection. It is reasonable to believe that dissemination in these case reports relates to wedge resection and segmentectomy rather than to VATS. To our knowledge, the literature contains no reports refuting the opinion that VATS lobectomy with placement of the specimen in a sealed container before removal is an adequate operation for patients with peripheral T1 N0 M0 non-small-cell lung cancer.

12/8/82098

References

1. Downey RJ, McCormack P, LoCicero J. Dissemination of malignant tumors after video-assisted thoracic surgery: a report of twenty-one cases. J Thorac Cardiovasc Surg 1996;111:954-60.[Abstract/Free Full Text]
   
2. Ginsberg RJ. The comparison of limited resection to lobectomy for T1N0 non-small cell lung cancer: LCSG 821. Chest 1994;106:3185-95.
   
3. Fry WA, Siddiqui A, Pensler JM, Mostafavi H. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;59:42-5.[Abstract/Free Full Text]
   
4. Lewis RJ. VATS is not thoracoscopy. Ann Thorac Surg 1996;62:623-32.[Free Full Text]
   
5. Buhr J, Hurtgen M, Kelm C, Schwemmle K. Tumor dissemination after thoracoscopic resection for lung cancer. J Thorac Cardiovasc Surg 1995;110:855-6.[Free Full Text]
   
6. Walsh GL, Nesbitt JC. Tumor implants after thoracoscopic resection of a metastatic sarcoma. Ann Thorac Surg 1995;59:215-6.[Abstract/Free Full Text]
   
7. Lewis RJ, Caccavale RJ, Sisler GE. Does video-assisted thoracic surgery disseminate tumor? J Thorac Cardiovasc Surg 1996;111:1109-10.
   

This Article 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): Igor E. Konstantinov Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hermansson, U. Articles by Arén, C. Search for Related Content PubMed PubMed Citation Articles by Hermansson, U. Articles by Arén, C.