Thoracoscopic approach to bilateral pulmonary metastasis: is it justified? Kook Nam Han, Chang Hyun Kang*, In Kyu Park and Young Tae Kim Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea * Corresponding author. 101 Daehak-ro Jongno-gu, Seoul 110-744, Korea. Tel: +82-2-20723010; fax: +82-2-7643664; e-mail: [email protected] (C.H. Kang). Received 18 July 2013; received in revised form 17 October 2013; accepted 28 October 2013

Abstract OBJECTIVES: There are few reports on optimal surgical approaches to bilateral pulmonary metastasis and the sequences used in the operation. The aim of this study was to evaluate the feasibility of the thoracoscopic bilateral approach to pulmonary metastasis. METHODS: From June 2006 to February 2013, 61 patients underwent a planned bilateral pulmonary metastasectomy with one- (n = 52) or two-stage (n = 9) thoracoscopic surgery. We retrospectively analysed the outcomes of this group of patients to define the role and limitation of thoracoscopic surgery in bilateral disease. RESULTS: In 17 patients with bilateral single lesions on the computed tomography (CT) scans, we were able to resect more nodules than initially imaged in 7 patients (41.2%), and there were 2 patients (11.8%) who had more true metastatic lesions than expected. Among 44 patients who showed more than two bilateral multiple lesions on the CT scan, we were able to resect more than 10 nodules in 2 patients (4.5%). The overall accuracy rate for resected malignant nodules was 76.6%, and 9 patients (14.8%) actually had the disease confined to the unilateral thorax, with solitary (n = 8) and multiple (n = 1) metastases after bilateral exploration. The prognostic factors for unilateral disease were unilateral lesion on the positron emission tomography (PET) scan (P = 0.024). The values of FVC and FEV1 were, respectively, 14.4 and 15.4% reduction at 6 months postoperatively in patients who had three or more nodules resected. Sarcomatous histology (P = 0.039), a diameter larger than 3 cm (P = 0.042) and bilateral lesion on PET (P = 0.035) were the prognostic factors for intrathoracic recurrences. CONCLUSIONS: Bilateral pulmonary metastasectomy was performed safely with thoracoscopy in patients with bilateral oligo-metastatic sub-pleural lesions and the one-stage approach was a feasible option in bilateral single lesions. Preoperative PET scan could help predict intrathoracic recurrence after thoracoscopic metastasectomy. Keywords: Bilateral metastasis • Thoracoscopy • VATS • Metastasectomy

INTRODUCTION Bilateral presentation of pulmonary metastatic nodules is a common situation for surgeons when they are considering pulmonary metastasectomy. Until now, there have been no definite guidelines for the treatment of bilateral disease except that resectability is the most important factor to improving the outcome but the debate continues about the oncological benefits of aggressive exploration in advanced disease [1–3]. A recent trend in most thoracic surgical fields has been to change to video-assisted thoracoscopic surgery (VATS) [2]. However, the VATS approach is still controversial for metastasectomy because there are 20–50% non-imaged nodules present during open surgery and palpation of the lung has been the standard for detecting non-imaged nodules [4]. In contrast, proponents of the thoracoscopic approach have insisted that the surgical outcomes are not inferior to open surgery and the quality of life of the patients is also an important prognostic factor in long-term survivors as far as having a better postoperative course for VATS surgery [5]. In addition, with the introduction of high-resolution thin-section computed tomography (CT) scans, most metastatic

nodules can be detected and discriminated accurately on preoperative images in certain types of primary tumours [6]. In addition, there has been a lot of controversy over the advantages of routine one-stage bilateral lung exploration [7] and few reports on optimal surgical approaches and sequences specific to bilateral disease for minimizing the operative morbidity related with postoperative quality of life. It has been established that one-stage bilateral exploration by sternotomy or clamshell incision can provide excellent exposure for detecting metastatic nodules even though these open procedures might result in relatively high morbidity [8]. Additionally, there are no proven benefits to one-stage exploration over two-stage operation in terms of survival and intrathoracic recurrences. However, we focused on the potential benefits of VATS, which enable one-stage exploration for oligo-metastatic bilateral disease with less postoperative morbidity and better functional outcomes. The feasibility or indications of this approach for bilateral disease are not fully understood and little is known about the outcomes in the case of VATS resection. In this study, based on our experiences of bilateral VATS, we retrospectively analysed the surgical outcomes of bilateral pulmonary metastasectomy (BPM) with

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

ORIGINAL ARTICLE

ORIGINAL ARTICLE – THORACIC

Interactive CardioVascular and Thoracic Surgery 18 (2014) 615–620 doi:10.1093/icvts/ivt514 Advance Access publication 4 February 2014

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K.N. Han et al. / Interactive CardioVascular and Thoracic Surgery

thoracoscopy with the aim to assess the role and limitation of this procedure in bilateral disease.

MATERIALS AND METHODS Our Institutional Review Board approved this study and waived the requirement for patient consent (IRB No. H-1303-001-470). From our database for the pulmonary metastasectomy registry of 510 patients from June 1998 to February 2013, 174 patients underwent a planned BPM with various approaches, including thoracotomy (n = 81), thoracoscopy (n = 61), combined thoracotomy and thoracoscopy (n = 28), or sternotomy (n = 4). Open surgery for lung palpation had been a standard surgical approach for pulmonary metastasectomy in all patients; however, we adopted bilateral thoracoscopic metastasectomy from 2006 in selected patients. We selected 61 patients who proceeded with a planned thoracoscopic BPM using a one-stage (n = 52) or two-stage operation (n = 9). The most common primary tumour was colorectal cancer (n = 18) as a non-sarcomatous lesion followed by hepatocellular carcinoma (n = 9), breast cancer (n = 5), renal cell carcinoma (n = 5), gynaecological cancer (squamous cell) (n = 5), adenoid cystic cancer (n = 2), biliary cancer (n = 2) and germ cell tumour (n = 1). Sarcomatous lesions, such as osteosarcoma (n = 10), soft tissue sarcoma (n = 3) and chondrosarcoma (n = 2), were included in our series. The median disease interval from the operation time for the primary tumours was 23 (0–156) months (Table 1). All patients had been evaluated by 1-mm cut thin-section chest CT scan and positron emission tomography (PET) scan within 1 month. The surgical decisions for the approach used and the sequence of VATS to the bilateral multiple lesions (BMs) were made based on (i) the peripheral location of the lesions being within the outer one-third

Table 1: Characteristics of the study population (n = 61) Characteristics

Value

Age (years) median (range) Sex, n (%) Male Female Primary tumour histology, n (%) Non-sarcoma Colorectal cancer Hepatocellular carcinoma Breast cancer Renal cell cancer Gynaecological cancer Adenoid cystic cancer Biliary cancer Germ cell tumour Sarcoma Osteosarcoma Soft tissue sarcoma Chondrosarcoma Disease-free interval, n (%)

Thoracoscopic approach to bilateral pulmonary metastasis: is it justified?

There are few reports on optimal surgical approaches to bilateral pulmonary metastasis and the sequences used in the operation. The aim of this study ...
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