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Video-assisted thoracic surgical resection of malignant lung tumors
General Thoracic Surgery
Video-assisted thoracic surgical resection of malignant lung tumors Forty patients with malignant pulmonary disease underwent evaluation, staging, and a biopsy or resection by means of video-assisted thoracic surgery. There were 20 men and 20 women whose ages ranged from 27 to 82 years. Eight patients had a wedge resection for metastatic carcinoma, three a lobectomy for primary carcinoma, six exploration of the thorax, five biopsy of the aortopulmonary window, and eighteen a sublobar resection for primary carcinoma of the lung. There was no mortality. Three patients had air leaks that lasted an average of 8 days. Video-assisted thoracic surgery seems to be useful for more precise staging of carcinoma of the lung, and, in some patients, resectional operations can be performed. (J 'fHORAC CARDIOVASC SURG 1992;104:1679-87)
Ralph J. Lewis, MD, Robert J. Caccavale, MD (by invitation), Glenn E. Sisler, MD (by invitation), and James W. Mackenzie, MD, New Brunswick, N.J.
Carcinoma of the lung, which has always been a dilemma, continues to challenge the aptitude and surgical skills of the thoracic surgeon.' Despite extraordinary advances in technology and technique, only a rudimentary understanding of this lethal disease has been realized. This is confirmed by an unacceptably low cure rate.? Complicated staging categories merely try to differentiate resectable from nonresectable lesions and, only by inference, attempt to define prognosis, usually with considerable inconsistency.' Until recently, essential information, necessary for making important surgical decisions, could be derived only from a thoracotomy, with its resultant adverse affects." Recently, this same information has become available with video-assisted thoracic surgery (V ATS).5 A reevaluation of various therapeutic From the Section of General Thoracic Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, St. Peter's Medical Center, Robert Wood Johnson University Hospital, New Brunswick, N.J. Read at the Seventy-second Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, Calif., April 26-29, 1992. Address for reprints: Ralph J. Lewis, MD, 185 Livingston Ave., New Brunswick, NJ 08901.
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philosophies and surgical approaches to patients with malignant lung lesions could result from this new knowledge. Patients, methods, and techniques By means of the technique of VATS, 40 patients underwent evaluation and/or treatment for malignant disease of the lung. There were 20 men and 20 women whose ages ranged from 27 to 82 years. Eight patients had a wedge resection for metastatic carcinoma, three had lobectomy for primary carcinoma of the lung, six had exploration of the thorax, five had biopsy of the aortopulmonary window, and eighteen had a sublobar resection for primary carcinoma of the lung (Fig. 1). The technique of VATS has been described previously." Results There was no mortality. Three complications occurred, which consisted of air leaks persisting for an average of 8 days. Lobectomy. Three patients, two women and one man, underwent one left upper lobectomy and two right middle lobectomies. Two patients had adenocarcinoma and one had squamous cell carcinoma. Hospitalization averaged 7 days, and there were no complications. Two patients continue to do well without evidence of recurrence 5 and 7 months after resection. One patient with a
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poorly differentiated adenocarcinoma of the right middle lobe, ulcerating through the visceral pleural with diseased N2 nodes, had a pleural effusion with cells suggestive of malignancy 4 months after the operation. After drainage of the pleural effusion, the patient remains free of symptoms. Exploration of the thorax. Four women and two men had four explorations of the right thoracic cavity and two of the left. Four patients had adenocarcinoma, one squamous cell carcinoma, and one metastatic carcinoma from the colon. After exploration and evaluation by VATS, two patients were judged to have unresectable disease. One had a pneumonectomy and three others had lobectomies. One patient had an air leak lasting 8 days. Metastatic lesions. Eight patients had resection of metastatic lesions, with five lesions occurring in the left lung and three in the right. There were three melanomas, three adenocarcinomas (one rectal, one colon, one bladder), and one malignant paraganglioneuroma. In one patient with a testicular carcinoma and a suspected metastasis I mm in diameter, the metastasis was localized with percutaneously placed barbed wires (Fig. 2). Wedge resection revealed a benign intraparenchymal lymph node. There was one air leak persisting for 9 days. Aortopulmonary window. Five men underwent biopsy of the lymph nodes of the aortopulmonary window because of suspected metastases. There was one melanoma, one squamous cell carcinoma, and one adenocarcinoma. Two patients had benign nodes. One of them had a carcinoma of the lung with a bulging aortopulmonary
window suggestive of metastases on computed tomographic (CT) scan. Biopsy revealed benign lymph nodes, and that patient underwent a curative pneumonectomy. The other patient had had a testicular tumor removed 6 months previously and, at this time, was noted to have an enlarging mass in the aortopulmonary window on CT scan. Biopsy revealed benign nodes and adipose tissue. There were no complications. Sub lobar resection for primary carcinoma. Eighteen patients consisting of eleven women and seven men had twelve adenocarcinomas, four squamous cell carcinomas, and two lymphomatous nodules. Ten lesions were in the right lung and eight in the left. In six patients, sublobar resection was converted to a traditional thoracotomy and lobectomy because of concern regarding the margins of resection. No residual tumor was found in any of these resected lobes. One patient, after having a VATS lobectomy, underwent a thoracotomy and exploration to confirm satisfactory removal of all malignant tissue. Again, no residual tumor was found in the thorax. Despite negative results of a frozen section examination on the excised limited resection, three patients had reresection of the staple line to obtain more ample margins. Results of bronchoscopic study were normal in all 18 patients. Eleven had mediastinoscopy and nine had node biopsies that were negative for malignancy. In two patients, nodes were not found. Because of a CT scan showing no abnormalities, seven patients did not have a mediastinoscopic examination. The size of the lung segment resected averaged 6.2 em in longest dimension, and
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Fig. 2. Percutaneous placement of barbed wire.
the nodules averaged 1.6 cm in diameter. These specimens were more than a wedge but less than a lobectomy. Actually, sublobar resections can be easily accomplished with staplers and the removal of excessive normal tissue can thereby be avoided. Three patients had erosion or ulceration of the visceral pleura. Sublobar resection was performed in each ofthese patients. An air leak persisting for 9 days was the only complication. Each of these patients is now doing well 5 to 7 months after resection without any evidence of recurrence. Discussion Although thoracotomy allows a full exploration, patients have significant postoperative pain and disability from the procedure. The next best technique permitting a complete visual and tactile evaluation of the carcinoma and its surrounding structures is VATS. This causes minimal morbidity to the patient. Because more precise staging seems possible, more beneficial therapeutic interventions may result. Therefore the true extent of primary or metastatic lesions can be accurately evaluated without doing a thoracotomy. Suspected metastatic lesions to the lung can be expeditiously and accurately diagnosed and excised. In selected patients, metastatic lesions can either be sampled for confirmatory diagnosis or completely removed, with the intent of eradication of any residual disease. By means of VATS, bilateral lesions can be approached sequentially during the same operation or at more prolonged intervals.
A delay of I to 2 months before proceeding to thoracotomy and resection, to determine if new lesions will develop, is no longer appropriate." Because VATS is minimally invasive, it can be easily repeated with only minimal discomfort to the patient followed by a short hospitalization. Because major resectional operations for certain types of metastases by a traditional thoracotomy may not always improve survival, VATS with its minimal morbidity might be a more reasonable substitute.' This technique has also been beneficial in defining patients with primary malignant tumors who are marginal candidates for resection because of extensive disease. Despite a multitude of preoperative diagnostic invasive and imaging studies, some patients are still found to have unresectable tumors at the time of thoracotomy. If the thorax is initially explored with VATS, the unresectable lesions will become evident, and exploratory thoracotomy can be avoided. On the other hand, patients whose disease has been judged to be unresectable because of x-ray findings have been carefully evaluated by VATS without advanced disease being substantiated. They have then had curative resections. Patients with large tumor burdens, who receive chemotherapy preoperatively, have been extensively evaluated by VATS before the chest was opened and resection done. Currently, in our opinion, this technique seems to be the most accurate modality for staging and definitively distinguishing resectable from nonresectable lesions. Selected patients with favorable anatomy have undergone lobectomy by means of VATS. Although these procedures can be performed at this time, instrumentation,
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Fig. 3. A, Easily resectable lesions. 8, Difficult to resect lesions.
optics, and techniques need improvement for these resections to become more feasible. Tissue-saving resections for primary malignant parenchymallesions have always evoked controversy. In 1950, at the annual meeting of The American Association for Thoracic Surgery, notable thoracic surgeons vigorously participated in a debate concerning pneumonectomy versus lobectomy for malignant lesions." In this era, discussions are beginning to develop concerning lobectomy versus sublobar resection for primary malignancy of the lung. 1O- 12 The recent report by the Lung Cancer Study Group and reports by Pastorino and associatesl'' at the Milan Cancer Institute confirm similar 5-year survivals for either lobectomy or wedge resection for stage I bronchogenic carcinoma. Operative mortality, however, was greater for lobectomy. Although the Lung Cancer Study Group found local recurrence of tumor more common with wedge resection, this was not found by the Milan group.l ' At the present time, there is no universally acceptable standard for wedge resection of malignant lesions. Obvi-
ously, only T1 NO tumors should be managed by sublobar resection, but these lesions can be any size from less than 1 mm to 3 em in diameter. Tumors of different cellular types can have variable virulencies. Anatomic location can have a profound impact on the nature of the resection. Lesions in the lingula, apex, and lung edges are easily approached, whereas lesions in the base of the lung, deep in the fissure, or on the large ovoid surface can be exceedingly difficult to excise (Fig. 3). Size and anatomic site all have a direct relationship to the margins obtained. Presently, there is no uniform recommendation from any source addressing the issue of indications for wedge resection or what would constitute an adequate margin of resection. Because there is no concrete evidence that lobectomy is always superior to limited resection, in certain patients we will continue to perform and accept a sublobar resection as curative if the closest margin exceeds 5 mm. 14• 15 In some patients with advanced pulmonary insufficiency, this might be the only procedure that could be tolerated; however, tissue conservation seems to be even more
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Fig. 4. Inadequate margins for wedge resection in a fissure. Adequatemargins for lingular wedge resection.
important for younger, active patients. If a new second primary lesionsubsequently develops,adequate tissue will be available to permit another potentially curative resection to be performed. As patients age, some will have emphysema, bullous disease, and fibrosis. Ideally, a previous sublobar resection will leave sufficient pulmonary parenchyma to avoid serious dyspnea later in life.'? In our practice, every patient with a coin lesion suspected of being malignant has a CT scan and bronchoscopic examination. If mediastinal lymph nodes on CT scan are greater than I cm in diameter, cervical mediastinoscopy is performed. A mediastinoscopic study revealing malignant disease will usually obviate any further resectional operation. If the mediastinoscopic study does not show malignancy and the bronchoscopic study does not reveal an endobronchial lesion, VATS is performed and the parenchymal tumor is excised. A thoracotomy will have been avoided if the lesion is benign on frozen section. When the tumor is malignant, a search is conducted for N I and N2 nodes. If nodes are found, they are excised and evaluated by frozen section. After consideration of the nodal status, adequacy of the sublobar resection, cellular type of the tumor, and overall general condition of the patient, a decision will be made either to accept the limited resection as a curative procedure or to perform a lobectomy. Currently, we will proceed with a traditional thoracotomy if there is any concern about the adequacy of the sublobar resection. In selected patients with favorable anatomy, a VATS lobectomy will be performed. 5
Numerous controversial issues are surfacing. TI tumors are not always suitable for limited resection because lesions larger than 2 ern can be difficult to excise. Should the T1 category be further stratified so as to better distinguish lesions that can be excised by limited resection from those that cannot? Should limited resection be accepted for only certain cellular types such as well-differentiated tumors rather than poorly differentiated tumors? Should more radical surgery be performed for poorly differentiated tumors? Or should less surgery be done because of the possibility of early metastases in this group of patients? Should patients with lesions in inaccessible anatomic areas undergo lobectomies and those with easily accessible lesions have sublobar resections (Fig. 4). If there is a small malignant tumor ulcerating through visceral pleura, does it benefit the patient to have a lobectomy with sacrifice of abundant proximal normal tissue or will a limited resection be sufficient (Fig. 5)? Some lesions appear to have adequate margins in one plane but are very close to the lung surface in other planes. Would lobectomy add anything more to the resection of these lesions (Fig. 6)? When N2 nodes are found at thoracotomy, many thoracic surgeons will agree that the prognosis becomes dismaI. 17- 19 Yet, because of the magnitude of the thoracotomy incision that is necessary to evaluate the lesion, many thoracic surgeons will still proceed with pulmonary resection and nodal exenteration despite a poor prognosis. If the extent of nodal involvement could be accurately
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Fig. 5. Tumor ulcerating through visceral pleura.
Fig. 6. Margins appearing to be adequate in one plane but close in other planes. determined before thoracotomy, such as N I or N2 nodes, which are small and freely mobile rather than large, matted, fixed, and invasive, could not this important information better assist the surgeon to make a decision more beneficial to the patient? In some of these cases, would
sublobar resection with nodal excision result in survival similar to that of radical pulmonary resection with en bloc node removal? Reviews confirm that surgical mortality would be lower in the limited resection group. 10, 11, 15 Certainly preservation of pulmonary parenchyma, instead of needless sacrifice of healthy lung tissue, seems advantageous if the outcomes are similar. A voluminous and detailed surgical literature can be cited with authority to support the superiority of either limited or radical resection for the treatment of patients with carcinoma of the lung. Obviously, one single course of therapy does not prevail. VATS permits minimally invasive direct evaluation of the tumor and its surrounding structures. This could increase the surgeon's preresectional knowledge and permit each of us to follow our individual philosophies and prejudices when selecting a therapeutic regimen. It seems that more questions are being raised than answered by VATS. Possibly, we should review some of our philosophic approaches to the treatment of carcinoma of the lung. This is never a comfortable situation; however, this new tool could reveal strengths and weaknesses in some of our previous approaches to the treatment of this lesion. VATS will not make any surgeon commit to any specific protocol, but it will provide another option to help in selecting a more appropriate therapeutic procedure. It is not our intention to defend or criticize any particular current therapeutic regimen for carcinoma of the lung. Instead, VATS can be used to
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further define the lesion and to assist the surgeon in implementing the desired therapy. Naturally, there will be differences of opinion, some more vehement than others, and it is anticipated that a debate will ensue. Actually, a renewed and vigorous discussion could advance the treatment of carcinoma of the lung by moving it off the plateau on which it has resided for too long. Radiologists, oncologists, and pulmonologists are diagnosing and treating carcinoma of the lung and, in some cases, even excluding the participation of the thoracic surgeon. It behooves all thoracic surgeons to remain current and familiar with new technology to bring improvements and benefits to patients with carcinoma of the lung. Time, experience, and further patient evaluations will be necessary to determine which protocols will eventually prove to be correct. We hope that, in the near future, thoracic surgeons will be able to determine when limited resection is superior and when radical resection is essential. As we enter the twenty-first century, this entire field deserves a fresh new look. VA TS could assist us in that endeavor. REFERENCES I. Benfield JR. The lung cancer dilemma. Chest 1991; 100:510-1.
2. Kotlyarov E, Rukosuyev A. Long-term results and patterns of disease recurrence after radical operations for lung cancer. Ann Thorac Surg 1991; 102:24-8. 3. Patterson GA. Lung cancer staging. Chest 1991;100: 520-2.
4. Watanabe Y, Shimizu J, Makoto 0, et al. Aggressive surgical intervention in N z non-small cell cancer of the lung. Ann Thorac Surg 1991;51:253-61. 5. Lewis RJ, Sisler GE, Caccavale RJ. Imaged thoracic lobectomy:Should it be done? Ann Thorac Surg [In press]. 6. Lewis RJ, Caccavale RJ, Sisler GE. Special report: Video endoscopic thoracic surgery. N Engl J Med 1991;88: 473-5.
7. Johnston MR. Median sternotomy for resection ofpulmonary metastases. J THORAC CARDlOVASC SURG 1983; 85:516-22.
8. Moores DWO. Pulmonary metastases revisited. Ann Thorae Surg 1992;52: 178-9. 9. Churchill ED, Sweet R, Soutter L, Scannell JG. The surgical management of carcinoma of the lung: a study of the cases treated' at the Massachusetts General Hospital from 1930 to 1950. J THORAC SURG 1950;20:249-65. 10. Peters RM. The role oflimited resection in carcinoma ofthe lung. Am J Surg 1982;143:706-10. II. Read RC, Yoder G, Schaeffer RC. Survival after conservation resection for TI NO MO non-small cell lung cancer. Ann Thorac Surg 1990;49:391-400. 12. Ginsberg RJ. Limited resection in the treatment of stage I non-small cell lung cancer: an overview. Chest 1989; 96:505-15.
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13. Pastorino U, Valente M, Bedini V, et al. Results of conservative surgery for stage I lung cancer. Tumor 1990;76:3843. 14. Miller J I, Hatcher CR J r. Limited resection of bronchogen-
ic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 1987;44:340-3. 15. Pastorino U, Valente M, Bedini V, et al. Limited resection for stage I lung cancer. Eur J Surg Oncol 1991; 17:42-6. 16. Ginsberg RJ. Surgery for higher-stage lung cancer. In: Pass HI, ed. Chest surgery clinics of north america. Vol I. Adjunctive and alternative treatment of bronchogenic lung cancer. Philadelphia: Saunders, 1991:61-9. 17. Jolly P, Hutchinson C, Detterbeck F, et al. Routine computed tomographis scans, selective mediastinoscopy, and other factors in evaluation of lung cancer. J THORAC CARDlOVASC SURG 1991;102:266-71.
Discussion Dr. John R. Benfield (Sacramento. Calif). After 5 months of experience with modern VATS with current instruments, I rise neither to recount anecdotes nor to try to resolve fundamental issues that pertain to the lung cancer dilemma. I merely intend to try to analyze some of the things that Dr. Lewis has discussed. Among 40 patients, 27% had staging operations. It is therefore clear that hilar and mediastinal exploration can be done wellwith video-assistedmethods. About 53% of the patients had resections of primary cancer and 20% had resections of metastatic cancer. Uncertainty about the adequacy of the resections done with video-assisted methods led to conversion of wedge resections to lobectomies one third of the time and to additional resection about 12% of the time. In no instance was additional cancer found in the secondary resected specimens. In short, the evidence indicates that necessary care was taken not to compromise the ultimate outcome of the operation to preserve the idea of not spreading the ribs. As we learn more about the proper place of video-assisted methods, it is crucial that we all maintain this perspective and that video-assisted methods be evaluated by fully trained thoracic surgeons who are fully equipped to proceed with a thoracotomy. Through VATS one loses a significant portion of the ability to palpate the lung, the hilum, and the mediastinum. Therefore one relies on radiographic diagnosis. For lesions that are relatively small and possibly not near the pleural surface, we have found preoperative localization with injection of methylene blue to be useful. This would be the thoracic analog of the localization of the nonpalpable breast lesion. Dr. Lewis describes a technique whereby a wire was inserted to assist with this problem. Could you describe more about that method and your experience with it? My second question relates to the denominator of the New Jersey experience. During the study period how often and under what circumstances did you consider and then dismiss the use of VATS? In other words, what are the contraindications to using this approach? I believeit is as silly to oppose the use of video-assisted methods as it was to oppose the use of lobectomy for the treatment of lung cancer in 1950. If the video-assisted methods are used by fully trained thoracic surgeons who understand the biologic features of primary and metastatic lung cancers, the use of sub-
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optimum operations and the temptation to use VATS excessively will be avoided. We believe that VATS is a useful reality and I commend Dr. Lewis for his careful approach to the unresolved issues. Dr. Paul Vadasz (Budapest, Hungary). At our institution in the National Lung Institute and Postgraduate Medical University in Budapest, Hungary, an average of 450 lobectomies are performed each year, most of them for cancer. Therefore in the less invasive surgical revolution it became natural for us to investigate how it could be applied to human thoracic surgery. Last year at this meeting, Dr. Romero mentioned the concept and instrumentation developed by Professor Jako, a laryngologist in Boston. In our cancer operations we give the utmost importance to the generally accepted oncology principles and to the patient's safety. When we perform a lobectomy through one 2- to 3-inch intercostal incision, the surgical endoscope provides excellent distal illumination and access to all areas of the thoracic cavity. The visualization is direct, which the thoracic surgeons are accustomed to. An integrated video attachment allows the assistants to view the surgical field on television monitors. The Jako bivalved surgical endoscope incorporates the features of a 2- to 3-inch wide minimally invasive rib retractor and video thoracoscope. It allows good maneuverability with specially developed endoscopic instruments and staplers. In the first phase of our clinical work we have performed over 40 intrathoracic procedures, twoofwhich were left lower lobectomies. We are amazed at the greatly reduced postoperative pain that the patients have after the one 2- to 3-inch incision. In our present lobectomy study our indications are very selective and very careful. Dr. Tea E. Acuff (Dallas, Tex.). After our early experience in December 1990 in Dallas, we began a prospective study of our thoracoscopy procedures in conjunction with Rodney Landreneau of The University of Pittsburgh and Steven Hazelrigg in Milwaukee. At this point we have done about 540 thoracoscopic procedures. About half ofthose we think are related to the role of resection in malignant lung tumors. From these data we propose a list of possible roles of thoracoscopy in the management of malignant lung tumors: The first role is for definitive diagnosis of indeterminant solitary pulmonary nodules. The second is the definitive procedure for lung cancer in patients with poor pulmonary reserve or other medical contraindications. The third is a question mark and is a very selective problem-the question of whether video-assisted lobectomy is appropriate or not. We believe that thoracoscopy has a role in the staging of mediastinal adenopathy, particularly aortopulmonary window and lower esophageal nodes, and we propose it as the treatment of choice for resection of pulmonary metastases. We believe the routine use of thoracoscopy will avoid thoracotomy for unsuspected disease, pleural or otherwise, that cannot be visualized radiographically. Finally, we believe thoracoscopy has a role in the surgical resection of limited stage small-cell cancer before chemotherapy. I have two questions for Dr. Lewis. What do you think is the role of thorcoscopy in the staging of lung cancer? Second, although all of our experiences with video-assisted lobectomy are very early and premature, do you think that VATS has a benefit that we should pursue, trying to develop that technique? Do you think it has advantages over muscle-sparing thoracotomy and epidural anesthesia? Dr. Peter C. Pairolero (Rochester, Minn.). I enjoyed Dr.
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Lewis's algorithm and I was pleased to see the great care he took in seeing that there was no disseminated cancer during the operation. I also rise to issue a word of caution. VATS is a new and exciting procedure whose full measure has not been realized. Without doubt, thoracoscopy has added to the diagnostic armamentarium of thoracic surgeons. However, adequate diagnosis does not necessarily translate into adequate treatment. Although thoracoscopic resection of benign lesions such as hamartomas and certain types of metastatic lesions is of definite benefit to the patient, this may not necessarily be the situation for the patient with primary lung cancer who is otherwise in good health. Five-year tumor-free survival for patients with Tl NO lesions is about 65% to 70%. It has taken us half a century to achieve this excellent result, and this is the gold standard against which we must measure this procedure, not necessarily our ability to perform it through small incisions. Until this occurs, thoracoscopic resection for primary lung cancer should be limited, as Dr. Benfield has mentioned, to those centers that are dedicated to evaluating this procedure with the patient's long-term interests in mind. Dr. Robert J. Ginsberg (New York, N.Y.). I would like to issue a word of grave caution about Dr. Lewis's recommendation for wedge resection. The Lung Cancer Study Group performed a randomized trial of 276 patients with T I NO tumors. Half of those patients had lobectomy and the other half had either wedge resection or segmental resection. The early results of this trial have been reported at the recent World Conference of Lung Cancer. There was a threefold increase in local recurrence after wedge or segmental resection-the increase with wedge resection being 3.5 fold and the increase with segmental resection 2.5 fold. This was at open thoracotomy. So far there is no significant difference in survival. Many of these patients have had reresections. We are awaiting a little longer follow-up to evaluate survival before we finally report this series. I would warn anybody not to accept wedge resection as the definitive treatment of patients with lung cancer. Dr. Martin F. McKnealIy (Toronto, Ontario, Canada). VATS offers us the opportunity to change or extend staging, to redefine the pulmonary nodule. It creates an opportunity to offer surgery to more debilitated and infirm patients than we currently operate on, an important question to face. It offers an opportunity to make our surgery much more patient friendly, an underemphasized but very important aspect ofthoracic surgery. Finally, with relation to what Dr. Ginsberg has said, it creates an opportunity to change the rules, without preserving the principles. Dr. Lewis, are there some unique complications or problems that you are aware of from your knowledge of the rapidly increasing experience in this new area outside your own institution? How can we best avoid the pitfalls that this patient-driven new technology is going to bring? Dr. James B. D. Mark (Stanford, Calif). I agree that this is an exciting new technology. We share your enthusiasm, but we also want to inject another word of caution. Dr. Lewis and several of the discussants have mentioned the utility of this procedure in resection of metastatic tumors to the lung. Doing that diagnostically is one thing. However, I believe that the ability to palpate the lung and recognize small metastases not otherwise detectable short of palpation makes VATS somewhat limited for metastatic tumors of the lung. Dr. Lewis. I want to thank each of the discussants for rais-
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ing important issues that we and others have been considering. I'll try to give brief answers to each of them. Dr. Benfield asked about barbed wires. Initially, we identified tumors by digital palpation. Patients with smaller and smaller nodules were referred to us, and we began to have problems localizing the nodules. We asked our radiologist to place the same wire used to localize breast lesions into these lung nodules. This method has allowed us to remove lesions as small as I or 2 mm by wedge resection, and some have been malignant. Some companies are trying to develop computers with a type of simulated palpation. Others are exploring the use of ultrasound. Dr. Benfield discussed injection of methylene blue. Since we are in the very early stages of this new technique, I am not sure which method will eventually prove satisfactory for identifying nodules. Dr. Benfield asked when we dismiss the idea of doing a VATS procedure. When we first started, we did these procedures sparingly. As we gained experience and the team became more efficient, we began to perform them more frequently. Currently every anticipated thoracotomy is now preceded by VATS before the chest is opened. Findings such as implants on the parietal pleura or matted, invasive N2 nodes would prevent us from doing a thoracotomy. We are still trying to learn which patients will benefit from VATS and which ones will not. Dr. Vadasz has described a very interesting technique involving direct thoracoscopy. At times, we will combine VATS with direct thoracoscopy, especially when evaluating the aortopulmonary window. VATS, however, is very different from thoracoscopy. Dr. Acuff raises the question of the role of VATS for staging carcinoma ofthe lung. I believe N ael Martini once said that lung cancer is staged correctly before the operation in only 30% of patients, so I think VATS could have a large role in staging malignant tumors. In fact, it might be helpful in defining the N 3 nodes that are frequently being missed. Lobectomy remains a philosophic problem. We probably could have done 12 or 15 lobectomies by this time but stopped after doing 3. We continue to dissect the fissures, skeletonize the vessels, and completely evaluate the hilar area. Weare gaining a great deal of experience with complex video surgery. When it becomes clear that a lobectomy will be necessary, we still open the chest and remove the lobe in the traditional fashion. We will continue to pursue this course of action until optics, techniques, and instruments are improved.
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Dr. Pairolero, I completely agree with everything you said. Caution is the byword. Dr. Ginsberg raises the question of wedge resections. We are using wedge resection for only peripheral NO lesions less than 2 cm. We were doing that with the chest open long before VATS was an option. The Lung Cancer Study Group, to my knowledge, has not yet published any data on wedge resections. It was a multiinstitutional study with many surgeons participating. We have not been told how many lesions were larger than 2 em, whether they crossed the fissures, what kind of margins were accepted, or what the cellular type was. We do not know if most of the recurrences came from one or two institutions or one or two surgeons. We do not even know if they were synchronous tumors, metachronous tumors, or metastases from new, distant primary tumors. The most important information we have not been told is whether these recurrences developed at the line of resection. Once this information is published, we can all make better determinations about when to use a wedge resection. Presently, in carefully selected patients, when appropriate, we will continue to use wedge resection for small peripheral malignant lesions. Dr. McKneally speaks to the problem of complications. I guess any complication can occur that you can think of. We have proceeded slowly and carefully and have had only a few persistent air leaks. We don't hesitate to open the chest if we believe that will help the procedure. We did a VATS lobectomy and then opened the chest to review and study what we did. We are always trying to learn more about this modality and to gain a better understanding of probable indications and contradictions. With regard to pitfalls, when you first begin there can be many frustrations. Video monitors fail, instrumentation is lacking, and operating room personnel are untrained. Weare now approaching 200 patients and have had to open the chest on only one occasion because of a technical problem. The second patient we treated in this manner had bleeding because of a slipped ligature, and we had to perform a thoracotomy to obtain hemostasis. That patient did very well and was discharged on the sixth postoperative day. Since that patient we have used staplers and have had no further problems. I agree with Dr. Mark concerning palpation of tumors. Until now, we have used VATS only for metastatic lesions needing a diagnosis or for confirmation of metastasis. Once again, all of us must carefully evaluate this technique and use it in a cautious and careful manner.
Video-assisted thoracic surgical resection of malignant lung tumors Forty patients with malignant pulmonary disease underwent evaluation, staging, and a biopsy or resection by means of video-assisted thoracic surgery. There were 20 men and 20 women whose ages ranged from 27 to 82 years. Eight patients had a wedge resection for metastatic carcinoma, three a lobectomy for primary carcinoma, six exploration of the thorax, five biopsy of the aortopulmonary window, and eighteen a sublobar resection for primary carcinoma of the lung. There was no mortality. Three patients had air leaks that lasted an average of 8 days. Video-assisted thoracic surgery seems to be useful for more precise staging of carcinoma of the lung, and, in some patients, resectional operations can be performed. (J 'fHORAC CARDIOVASC SURG 1992;104:1679-87)
Ralph J. Lewis, MD, Robert J. Caccavale, MD (by invitation), Glenn E. Sisler, MD (by invitation), and James W. Mackenzie, MD, New Brunswick, N.J.
Carcinoma of the lung, which has always been a dilemma, continues to challenge the aptitude and surgical skills of the thoracic surgeon.' Despite extraordinary advances in technology and technique, only a rudimentary understanding of this lethal disease has been realized. This is confirmed by an unacceptably low cure rate.? Complicated staging categories merely try to differentiate resectable from nonresectable lesions and, only by inference, attempt to define prognosis, usually with considerable inconsistency.' Until recently, essential information, necessary for making important surgical decisions, could be derived only from a thoracotomy, with its resultant adverse affects." Recently, this same information has become available with video-assisted thoracic surgery (V ATS).5 A reevaluation of various therapeutic From the Section of General Thoracic Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, St. Peter's Medical Center, Robert Wood Johnson University Hospital, New Brunswick, N.J. Read at the Seventy-second Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, Calif., April 26-29, 1992. Address for reprints: Ralph J. Lewis, MD, 185 Livingston Ave., New Brunswick, NJ 08901.
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philosophies and surgical approaches to patients with malignant lung lesions could result from this new knowledge. Patients, methods, and techniques By means of the technique of VATS, 40 patients underwent evaluation and/or treatment for malignant disease of the lung. There were 20 men and 20 women whose ages ranged from 27 to 82 years. Eight patients had a wedge resection for metastatic carcinoma, three had lobectomy for primary carcinoma of the lung, six had exploration of the thorax, five had biopsy of the aortopulmonary window, and eighteen had a sublobar resection for primary carcinoma of the lung (Fig. 1). The technique of VATS has been described previously." Results There was no mortality. Three complications occurred, which consisted of air leaks persisting for an average of 8 days. Lobectomy. Three patients, two women and one man, underwent one left upper lobectomy and two right middle lobectomies. Two patients had adenocarcinoma and one had squamous cell carcinoma. Hospitalization averaged 7 days, and there were no complications. Two patients continue to do well without evidence of recurrence 5 and 7 months after resection. One patient with a
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poorly differentiated adenocarcinoma of the right middle lobe, ulcerating through the visceral pleural with diseased N2 nodes, had a pleural effusion with cells suggestive of malignancy 4 months after the operation. After drainage of the pleural effusion, the patient remains free of symptoms. Exploration of the thorax. Four women and two men had four explorations of the right thoracic cavity and two of the left. Four patients had adenocarcinoma, one squamous cell carcinoma, and one metastatic carcinoma from the colon. After exploration and evaluation by VATS, two patients were judged to have unresectable disease. One had a pneumonectomy and three others had lobectomies. One patient had an air leak lasting 8 days. Metastatic lesions. Eight patients had resection of metastatic lesions, with five lesions occurring in the left lung and three in the right. There were three melanomas, three adenocarcinomas (one rectal, one colon, one bladder), and one malignant paraganglioneuroma. In one patient with a testicular carcinoma and a suspected metastasis I mm in diameter, the metastasis was localized with percutaneously placed barbed wires (Fig. 2). Wedge resection revealed a benign intraparenchymal lymph node. There was one air leak persisting for 9 days. Aortopulmonary window. Five men underwent biopsy of the lymph nodes of the aortopulmonary window because of suspected metastases. There was one melanoma, one squamous cell carcinoma, and one adenocarcinoma. Two patients had benign nodes. One of them had a carcinoma of the lung with a bulging aortopulmonary
window suggestive of metastases on computed tomographic (CT) scan. Biopsy revealed benign lymph nodes, and that patient underwent a curative pneumonectomy. The other patient had had a testicular tumor removed 6 months previously and, at this time, was noted to have an enlarging mass in the aortopulmonary window on CT scan. Biopsy revealed benign nodes and adipose tissue. There were no complications. Sub lobar resection for primary carcinoma. Eighteen patients consisting of eleven women and seven men had twelve adenocarcinomas, four squamous cell carcinomas, and two lymphomatous nodules. Ten lesions were in the right lung and eight in the left. In six patients, sublobar resection was converted to a traditional thoracotomy and lobectomy because of concern regarding the margins of resection. No residual tumor was found in any of these resected lobes. One patient, after having a VATS lobectomy, underwent a thoracotomy and exploration to confirm satisfactory removal of all malignant tissue. Again, no residual tumor was found in the thorax. Despite negative results of a frozen section examination on the excised limited resection, three patients had reresection of the staple line to obtain more ample margins. Results of bronchoscopic study were normal in all 18 patients. Eleven had mediastinoscopy and nine had node biopsies that were negative for malignancy. In two patients, nodes were not found. Because of a CT scan showing no abnormalities, seven patients did not have a mediastinoscopic examination. The size of the lung segment resected averaged 6.2 em in longest dimension, and
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Fig. 2. Percutaneous placement of barbed wire.
the nodules averaged 1.6 cm in diameter. These specimens were more than a wedge but less than a lobectomy. Actually, sublobar resections can be easily accomplished with staplers and the removal of excessive normal tissue can thereby be avoided. Three patients had erosion or ulceration of the visceral pleura. Sublobar resection was performed in each ofthese patients. An air leak persisting for 9 days was the only complication. Each of these patients is now doing well 5 to 7 months after resection without any evidence of recurrence. Discussion Although thoracotomy allows a full exploration, patients have significant postoperative pain and disability from the procedure. The next best technique permitting a complete visual and tactile evaluation of the carcinoma and its surrounding structures is VATS. This causes minimal morbidity to the patient. Because more precise staging seems possible, more beneficial therapeutic interventions may result. Therefore the true extent of primary or metastatic lesions can be accurately evaluated without doing a thoracotomy. Suspected metastatic lesions to the lung can be expeditiously and accurately diagnosed and excised. In selected patients, metastatic lesions can either be sampled for confirmatory diagnosis or completely removed, with the intent of eradication of any residual disease. By means of VATS, bilateral lesions can be approached sequentially during the same operation or at more prolonged intervals.
A delay of I to 2 months before proceeding to thoracotomy and resection, to determine if new lesions will develop, is no longer appropriate." Because VATS is minimally invasive, it can be easily repeated with only minimal discomfort to the patient followed by a short hospitalization. Because major resectional operations for certain types of metastases by a traditional thoracotomy may not always improve survival, VATS with its minimal morbidity might be a more reasonable substitute.' This technique has also been beneficial in defining patients with primary malignant tumors who are marginal candidates for resection because of extensive disease. Despite a multitude of preoperative diagnostic invasive and imaging studies, some patients are still found to have unresectable tumors at the time of thoracotomy. If the thorax is initially explored with VATS, the unresectable lesions will become evident, and exploratory thoracotomy can be avoided. On the other hand, patients whose disease has been judged to be unresectable because of x-ray findings have been carefully evaluated by VATS without advanced disease being substantiated. They have then had curative resections. Patients with large tumor burdens, who receive chemotherapy preoperatively, have been extensively evaluated by VATS before the chest was opened and resection done. Currently, in our opinion, this technique seems to be the most accurate modality for staging and definitively distinguishing resectable from nonresectable lesions. Selected patients with favorable anatomy have undergone lobectomy by means of VATS. Although these procedures can be performed at this time, instrumentation,
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Fig. 3. A, Easily resectable lesions. 8, Difficult to resect lesions.
optics, and techniques need improvement for these resections to become more feasible. Tissue-saving resections for primary malignant parenchymallesions have always evoked controversy. In 1950, at the annual meeting of The American Association for Thoracic Surgery, notable thoracic surgeons vigorously participated in a debate concerning pneumonectomy versus lobectomy for malignant lesions." In this era, discussions are beginning to develop concerning lobectomy versus sublobar resection for primary malignancy of the lung. 1O- 12 The recent report by the Lung Cancer Study Group and reports by Pastorino and associatesl'' at the Milan Cancer Institute confirm similar 5-year survivals for either lobectomy or wedge resection for stage I bronchogenic carcinoma. Operative mortality, however, was greater for lobectomy. Although the Lung Cancer Study Group found local recurrence of tumor more common with wedge resection, this was not found by the Milan group.l ' At the present time, there is no universally acceptable standard for wedge resection of malignant lesions. Obvi-
ously, only T1 NO tumors should be managed by sublobar resection, but these lesions can be any size from less than 1 mm to 3 em in diameter. Tumors of different cellular types can have variable virulencies. Anatomic location can have a profound impact on the nature of the resection. Lesions in the lingula, apex, and lung edges are easily approached, whereas lesions in the base of the lung, deep in the fissure, or on the large ovoid surface can be exceedingly difficult to excise (Fig. 3). Size and anatomic site all have a direct relationship to the margins obtained. Presently, there is no uniform recommendation from any source addressing the issue of indications for wedge resection or what would constitute an adequate margin of resection. Because there is no concrete evidence that lobectomy is always superior to limited resection, in certain patients we will continue to perform and accept a sublobar resection as curative if the closest margin exceeds 5 mm. 14• 15 In some patients with advanced pulmonary insufficiency, this might be the only procedure that could be tolerated; however, tissue conservation seems to be even more
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Fig. 4. Inadequate margins for wedge resection in a fissure. Adequatemargins for lingular wedge resection.
important for younger, active patients. If a new second primary lesionsubsequently develops,adequate tissue will be available to permit another potentially curative resection to be performed. As patients age, some will have emphysema, bullous disease, and fibrosis. Ideally, a previous sublobar resection will leave sufficient pulmonary parenchyma to avoid serious dyspnea later in life.'? In our practice, every patient with a coin lesion suspected of being malignant has a CT scan and bronchoscopic examination. If mediastinal lymph nodes on CT scan are greater than I cm in diameter, cervical mediastinoscopy is performed. A mediastinoscopic study revealing malignant disease will usually obviate any further resectional operation. If the mediastinoscopic study does not show malignancy and the bronchoscopic study does not reveal an endobronchial lesion, VATS is performed and the parenchymal tumor is excised. A thoracotomy will have been avoided if the lesion is benign on frozen section. When the tumor is malignant, a search is conducted for N I and N2 nodes. If nodes are found, they are excised and evaluated by frozen section. After consideration of the nodal status, adequacy of the sublobar resection, cellular type of the tumor, and overall general condition of the patient, a decision will be made either to accept the limited resection as a curative procedure or to perform a lobectomy. Currently, we will proceed with a traditional thoracotomy if there is any concern about the adequacy of the sublobar resection. In selected patients with favorable anatomy, a VATS lobectomy will be performed. 5
Numerous controversial issues are surfacing. TI tumors are not always suitable for limited resection because lesions larger than 2 ern can be difficult to excise. Should the T1 category be further stratified so as to better distinguish lesions that can be excised by limited resection from those that cannot? Should limited resection be accepted for only certain cellular types such as well-differentiated tumors rather than poorly differentiated tumors? Should more radical surgery be performed for poorly differentiated tumors? Or should less surgery be done because of the possibility of early metastases in this group of patients? Should patients with lesions in inaccessible anatomic areas undergo lobectomies and those with easily accessible lesions have sublobar resections (Fig. 4). If there is a small malignant tumor ulcerating through visceral pleura, does it benefit the patient to have a lobectomy with sacrifice of abundant proximal normal tissue or will a limited resection be sufficient (Fig. 5)? Some lesions appear to have adequate margins in one plane but are very close to the lung surface in other planes. Would lobectomy add anything more to the resection of these lesions (Fig. 6)? When N2 nodes are found at thoracotomy, many thoracic surgeons will agree that the prognosis becomes dismaI. 17- 19 Yet, because of the magnitude of the thoracotomy incision that is necessary to evaluate the lesion, many thoracic surgeons will still proceed with pulmonary resection and nodal exenteration despite a poor prognosis. If the extent of nodal involvement could be accurately
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Fig. 5. Tumor ulcerating through visceral pleura.
Fig. 6. Margins appearing to be adequate in one plane but close in other planes. determined before thoracotomy, such as N I or N2 nodes, which are small and freely mobile rather than large, matted, fixed, and invasive, could not this important information better assist the surgeon to make a decision more beneficial to the patient? In some of these cases, would
sublobar resection with nodal excision result in survival similar to that of radical pulmonary resection with en bloc node removal? Reviews confirm that surgical mortality would be lower in the limited resection group. 10, 11, 15 Certainly preservation of pulmonary parenchyma, instead of needless sacrifice of healthy lung tissue, seems advantageous if the outcomes are similar. A voluminous and detailed surgical literature can be cited with authority to support the superiority of either limited or radical resection for the treatment of patients with carcinoma of the lung. Obviously, one single course of therapy does not prevail. VATS permits minimally invasive direct evaluation of the tumor and its surrounding structures. This could increase the surgeon's preresectional knowledge and permit each of us to follow our individual philosophies and prejudices when selecting a therapeutic regimen. It seems that more questions are being raised than answered by VATS. Possibly, we should review some of our philosophic approaches to the treatment of carcinoma of the lung. This is never a comfortable situation; however, this new tool could reveal strengths and weaknesses in some of our previous approaches to the treatment of this lesion. VATS will not make any surgeon commit to any specific protocol, but it will provide another option to help in selecting a more appropriate therapeutic procedure. It is not our intention to defend or criticize any particular current therapeutic regimen for carcinoma of the lung. Instead, VATS can be used to
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further define the lesion and to assist the surgeon in implementing the desired therapy. Naturally, there will be differences of opinion, some more vehement than others, and it is anticipated that a debate will ensue. Actually, a renewed and vigorous discussion could advance the treatment of carcinoma of the lung by moving it off the plateau on which it has resided for too long. Radiologists, oncologists, and pulmonologists are diagnosing and treating carcinoma of the lung and, in some cases, even excluding the participation of the thoracic surgeon. It behooves all thoracic surgeons to remain current and familiar with new technology to bring improvements and benefits to patients with carcinoma of the lung. Time, experience, and further patient evaluations will be necessary to determine which protocols will eventually prove to be correct. We hope that, in the near future, thoracic surgeons will be able to determine when limited resection is superior and when radical resection is essential. As we enter the twenty-first century, this entire field deserves a fresh new look. VA TS could assist us in that endeavor. REFERENCES I. Benfield JR. The lung cancer dilemma. Chest 1991; 100:510-1.
2. Kotlyarov E, Rukosuyev A. Long-term results and patterns of disease recurrence after radical operations for lung cancer. Ann Thorac Surg 1991; 102:24-8. 3. Patterson GA. Lung cancer staging. Chest 1991;100: 520-2.
4. Watanabe Y, Shimizu J, Makoto 0, et al. Aggressive surgical intervention in N z non-small cell cancer of the lung. Ann Thorac Surg 1991;51:253-61. 5. Lewis RJ, Sisler GE, Caccavale RJ. Imaged thoracic lobectomy:Should it be done? Ann Thorac Surg [In press]. 6. Lewis RJ, Caccavale RJ, Sisler GE. Special report: Video endoscopic thoracic surgery. N Engl J Med 1991;88: 473-5.
7. Johnston MR. Median sternotomy for resection ofpulmonary metastases. J THORAC CARDlOVASC SURG 1983; 85:516-22.
8. Moores DWO. Pulmonary metastases revisited. Ann Thorae Surg 1992;52: 178-9. 9. Churchill ED, Sweet R, Soutter L, Scannell JG. The surgical management of carcinoma of the lung: a study of the cases treated' at the Massachusetts General Hospital from 1930 to 1950. J THORAC SURG 1950;20:249-65. 10. Peters RM. The role oflimited resection in carcinoma ofthe lung. Am J Surg 1982;143:706-10. II. Read RC, Yoder G, Schaeffer RC. Survival after conservation resection for TI NO MO non-small cell lung cancer. Ann Thorac Surg 1990;49:391-400. 12. Ginsberg RJ. Limited resection in the treatment of stage I non-small cell lung cancer: an overview. Chest 1989; 96:505-15.
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13. Pastorino U, Valente M, Bedini V, et al. Results of conservative surgery for stage I lung cancer. Tumor 1990;76:3843. 14. Miller J I, Hatcher CR J r. Limited resection of bronchogen-
ic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 1987;44:340-3. 15. Pastorino U, Valente M, Bedini V, et al. Limited resection for stage I lung cancer. Eur J Surg Oncol 1991; 17:42-6. 16. Ginsberg RJ. Surgery for higher-stage lung cancer. In: Pass HI, ed. Chest surgery clinics of north america. Vol I. Adjunctive and alternative treatment of bronchogenic lung cancer. Philadelphia: Saunders, 1991:61-9. 17. Jolly P, Hutchinson C, Detterbeck F, et al. Routine computed tomographis scans, selective mediastinoscopy, and other factors in evaluation of lung cancer. J THORAC CARDlOVASC SURG 1991;102:266-71.
Discussion Dr. John R. Benfield (Sacramento. Calif). After 5 months of experience with modern VATS with current instruments, I rise neither to recount anecdotes nor to try to resolve fundamental issues that pertain to the lung cancer dilemma. I merely intend to try to analyze some of the things that Dr. Lewis has discussed. Among 40 patients, 27% had staging operations. It is therefore clear that hilar and mediastinal exploration can be done wellwith video-assistedmethods. About 53% of the patients had resections of primary cancer and 20% had resections of metastatic cancer. Uncertainty about the adequacy of the resections done with video-assisted methods led to conversion of wedge resections to lobectomies one third of the time and to additional resection about 12% of the time. In no instance was additional cancer found in the secondary resected specimens. In short, the evidence indicates that necessary care was taken not to compromise the ultimate outcome of the operation to preserve the idea of not spreading the ribs. As we learn more about the proper place of video-assisted methods, it is crucial that we all maintain this perspective and that video-assisted methods be evaluated by fully trained thoracic surgeons who are fully equipped to proceed with a thoracotomy. Through VATS one loses a significant portion of the ability to palpate the lung, the hilum, and the mediastinum. Therefore one relies on radiographic diagnosis. For lesions that are relatively small and possibly not near the pleural surface, we have found preoperative localization with injection of methylene blue to be useful. This would be the thoracic analog of the localization of the nonpalpable breast lesion. Dr. Lewis describes a technique whereby a wire was inserted to assist with this problem. Could you describe more about that method and your experience with it? My second question relates to the denominator of the New Jersey experience. During the study period how often and under what circumstances did you consider and then dismiss the use of VATS? In other words, what are the contraindications to using this approach? I believeit is as silly to oppose the use of video-assisted methods as it was to oppose the use of lobectomy for the treatment of lung cancer in 1950. If the video-assisted methods are used by fully trained thoracic surgeons who understand the biologic features of primary and metastatic lung cancers, the use of sub-
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optimum operations and the temptation to use VATS excessively will be avoided. We believe that VATS is a useful reality and I commend Dr. Lewis for his careful approach to the unresolved issues. Dr. Paul Vadasz (Budapest, Hungary). At our institution in the National Lung Institute and Postgraduate Medical University in Budapest, Hungary, an average of 450 lobectomies are performed each year, most of them for cancer. Therefore in the less invasive surgical revolution it became natural for us to investigate how it could be applied to human thoracic surgery. Last year at this meeting, Dr. Romero mentioned the concept and instrumentation developed by Professor Jako, a laryngologist in Boston. In our cancer operations we give the utmost importance to the generally accepted oncology principles and to the patient's safety. When we perform a lobectomy through one 2- to 3-inch intercostal incision, the surgical endoscope provides excellent distal illumination and access to all areas of the thoracic cavity. The visualization is direct, which the thoracic surgeons are accustomed to. An integrated video attachment allows the assistants to view the surgical field on television monitors. The Jako bivalved surgical endoscope incorporates the features of a 2- to 3-inch wide minimally invasive rib retractor and video thoracoscope. It allows good maneuverability with specially developed endoscopic instruments and staplers. In the first phase of our clinical work we have performed over 40 intrathoracic procedures, twoofwhich were left lower lobectomies. We are amazed at the greatly reduced postoperative pain that the patients have after the one 2- to 3-inch incision. In our present lobectomy study our indications are very selective and very careful. Dr. Tea E. Acuff (Dallas, Tex.). After our early experience in December 1990 in Dallas, we began a prospective study of our thoracoscopy procedures in conjunction with Rodney Landreneau of The University of Pittsburgh and Steven Hazelrigg in Milwaukee. At this point we have done about 540 thoracoscopic procedures. About half ofthose we think are related to the role of resection in malignant lung tumors. From these data we propose a list of possible roles of thoracoscopy in the management of malignant lung tumors: The first role is for definitive diagnosis of indeterminant solitary pulmonary nodules. The second is the definitive procedure for lung cancer in patients with poor pulmonary reserve or other medical contraindications. The third is a question mark and is a very selective problem-the question of whether video-assisted lobectomy is appropriate or not. We believe that thoracoscopy has a role in the staging of mediastinal adenopathy, particularly aortopulmonary window and lower esophageal nodes, and we propose it as the treatment of choice for resection of pulmonary metastases. We believe the routine use of thoracoscopy will avoid thoracotomy for unsuspected disease, pleural or otherwise, that cannot be visualized radiographically. Finally, we believe thoracoscopy has a role in the surgical resection of limited stage small-cell cancer before chemotherapy. I have two questions for Dr. Lewis. What do you think is the role of thorcoscopy in the staging of lung cancer? Second, although all of our experiences with video-assisted lobectomy are very early and premature, do you think that VATS has a benefit that we should pursue, trying to develop that technique? Do you think it has advantages over muscle-sparing thoracotomy and epidural anesthesia? Dr. Peter C. Pairolero (Rochester, Minn.). I enjoyed Dr.
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Lewis's algorithm and I was pleased to see the great care he took in seeing that there was no disseminated cancer during the operation. I also rise to issue a word of caution. VATS is a new and exciting procedure whose full measure has not been realized. Without doubt, thoracoscopy has added to the diagnostic armamentarium of thoracic surgeons. However, adequate diagnosis does not necessarily translate into adequate treatment. Although thoracoscopic resection of benign lesions such as hamartomas and certain types of metastatic lesions is of definite benefit to the patient, this may not necessarily be the situation for the patient with primary lung cancer who is otherwise in good health. Five-year tumor-free survival for patients with Tl NO lesions is about 65% to 70%. It has taken us half a century to achieve this excellent result, and this is the gold standard against which we must measure this procedure, not necessarily our ability to perform it through small incisions. Until this occurs, thoracoscopic resection for primary lung cancer should be limited, as Dr. Benfield has mentioned, to those centers that are dedicated to evaluating this procedure with the patient's long-term interests in mind. Dr. Robert J. Ginsberg (New York, N.Y.). I would like to issue a word of grave caution about Dr. Lewis's recommendation for wedge resection. The Lung Cancer Study Group performed a randomized trial of 276 patients with T I NO tumors. Half of those patients had lobectomy and the other half had either wedge resection or segmental resection. The early results of this trial have been reported at the recent World Conference of Lung Cancer. There was a threefold increase in local recurrence after wedge or segmental resection-the increase with wedge resection being 3.5 fold and the increase with segmental resection 2.5 fold. This was at open thoracotomy. So far there is no significant difference in survival. Many of these patients have had reresections. We are awaiting a little longer follow-up to evaluate survival before we finally report this series. I would warn anybody not to accept wedge resection as the definitive treatment of patients with lung cancer. Dr. Martin F. McKnealIy (Toronto, Ontario, Canada). VATS offers us the opportunity to change or extend staging, to redefine the pulmonary nodule. It creates an opportunity to offer surgery to more debilitated and infirm patients than we currently operate on, an important question to face. It offers an opportunity to make our surgery much more patient friendly, an underemphasized but very important aspect ofthoracic surgery. Finally, with relation to what Dr. Ginsberg has said, it creates an opportunity to change the rules, without preserving the principles. Dr. Lewis, are there some unique complications or problems that you are aware of from your knowledge of the rapidly increasing experience in this new area outside your own institution? How can we best avoid the pitfalls that this patient-driven new technology is going to bring? Dr. James B. D. Mark (Stanford, Calif). I agree that this is an exciting new technology. We share your enthusiasm, but we also want to inject another word of caution. Dr. Lewis and several of the discussants have mentioned the utility of this procedure in resection of metastatic tumors to the lung. Doing that diagnostically is one thing. However, I believe that the ability to palpate the lung and recognize small metastases not otherwise detectable short of palpation makes VATS somewhat limited for metastatic tumors of the lung. Dr. Lewis. I want to thank each of the discussants for rais-
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ing important issues that we and others have been considering. I'll try to give brief answers to each of them. Dr. Benfield asked about barbed wires. Initially, we identified tumors by digital palpation. Patients with smaller and smaller nodules were referred to us, and we began to have problems localizing the nodules. We asked our radiologist to place the same wire used to localize breast lesions into these lung nodules. This method has allowed us to remove lesions as small as I or 2 mm by wedge resection, and some have been malignant. Some companies are trying to develop computers with a type of simulated palpation. Others are exploring the use of ultrasound. Dr. Benfield discussed injection of methylene blue. Since we are in the very early stages of this new technique, I am not sure which method will eventually prove satisfactory for identifying nodules. Dr. Benfield asked when we dismiss the idea of doing a VATS procedure. When we first started, we did these procedures sparingly. As we gained experience and the team became more efficient, we began to perform them more frequently. Currently every anticipated thoracotomy is now preceded by VATS before the chest is opened. Findings such as implants on the parietal pleura or matted, invasive N2 nodes would prevent us from doing a thoracotomy. We are still trying to learn which patients will benefit from VATS and which ones will not. Dr. Vadasz has described a very interesting technique involving direct thoracoscopy. At times, we will combine VATS with direct thoracoscopy, especially when evaluating the aortopulmonary window. VATS, however, is very different from thoracoscopy. Dr. Acuff raises the question of the role of VATS for staging carcinoma ofthe lung. I believe N ael Martini once said that lung cancer is staged correctly before the operation in only 30% of patients, so I think VATS could have a large role in staging malignant tumors. In fact, it might be helpful in defining the N 3 nodes that are frequently being missed. Lobectomy remains a philosophic problem. We probably could have done 12 or 15 lobectomies by this time but stopped after doing 3. We continue to dissect the fissures, skeletonize the vessels, and completely evaluate the hilar area. Weare gaining a great deal of experience with complex video surgery. When it becomes clear that a lobectomy will be necessary, we still open the chest and remove the lobe in the traditional fashion. We will continue to pursue this course of action until optics, techniques, and instruments are improved.
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Dr. Pairolero, I completely agree with everything you said. Caution is the byword. Dr. Ginsberg raises the question of wedge resections. We are using wedge resection for only peripheral NO lesions less than 2 cm. We were doing that with the chest open long before VATS was an option. The Lung Cancer Study Group, to my knowledge, has not yet published any data on wedge resections. It was a multiinstitutional study with many surgeons participating. We have not been told how many lesions were larger than 2 em, whether they crossed the fissures, what kind of margins were accepted, or what the cellular type was. We do not know if most of the recurrences came from one or two institutions or one or two surgeons. We do not even know if they were synchronous tumors, metachronous tumors, or metastases from new, distant primary tumors. The most important information we have not been told is whether these recurrences developed at the line of resection. Once this information is published, we can all make better determinations about when to use a wedge resection. Presently, in carefully selected patients, when appropriate, we will continue to use wedge resection for small peripheral malignant lesions. Dr. McKneally speaks to the problem of complications. I guess any complication can occur that you can think of. We have proceeded slowly and carefully and have had only a few persistent air leaks. We don't hesitate to open the chest if we believe that will help the procedure. We did a VATS lobectomy and then opened the chest to review and study what we did. We are always trying to learn more about this modality and to gain a better understanding of probable indications and contradictions. With regard to pitfalls, when you first begin there can be many frustrations. Video monitors fail, instrumentation is lacking, and operating room personnel are untrained. Weare now approaching 200 patients and have had to open the chest on only one occasion because of a technical problem. The second patient we treated in this manner had bleeding because of a slipped ligature, and we had to perform a thoracotomy to obtain hemostasis. That patient did very well and was discharged on the sixth postoperative day. Since that patient we have used staplers and have had no further problems. I agree with Dr. Mark concerning palpation of tumors. Until now, we have used VATS only for metastatic lesions needing a diagnosis or for confirmation of metastasis. Once again, all of us must carefully evaluate this technique and use it in a cautious and careful manner.