minimally invasive techniques

Transcription

1 minimally invasive techniques En Bloc Minimal Laser Resection for T3-Chest Wall Lung Cancer in Patients With Poor Pulmonary Function* Tommaso Claudio Mineo, MD; Vincenzo Amhrogi, MD; Eugenio Pompeo, MD; Italo Nofroni, BS; and Carlo U. Casciani, MD Objective: To analyze the value of en bloc minimal laser resection in patients with marginal function with non-small cell lung cancer invading the chest wall. Design: Retrospective study from March 1987 to December Setting: University teaching hospital. Patients: Study group consists of 10 patients with impaired pulmonary function (FEV 1 :Sl.3 Land forced expiratory flow between 25% and 75% :S0.8 Us) operated on for lung cancer invading the chest wall. There were 7 men and 3 women; ages ranged between 51 and 77 years (mean, 66.2 years). None of the patients had tumors greater than 3 em or involving the first 2 ribs as well as clinical N2 or T4 disease. Interventions: All patients underwent en bloc chest wall combined with minimal resection. Parenchyma dissection was accomplished by Nd: YAG laser encompassing the lesion at distance of 2.0 em. The median number of ribs resected was 1.6 and no patients required chest wall reconstruction. Local postoperative radiation therapy beginning within 1 month after resection was always performed. Results: Tumor resection was considered complete in every case. Four patients had adenocarcinoma, three had squamous cell carcinoma, and three had large cell carcinoma. Currently, 7 patients had NO, 2 had Nl, and 1 had N2 disease. There was no perioperative mortality. Postoperative complications were prolonged air leak (n=2) and atelectasis (n=l). At the present moment, 6 patients are alive, 5 of whom are free from tumor, 2 with a follow-up longer than 5 years. Three patients died: 2 from disseminated disease, after 4 7 months and 32 months, respectively, and the third at 27 months from another cause. One patient was unavailable for follow-up. Only 1 patient had a local recurrence, 15 months later, and he underwent a new, successful, limited resection. Conclusions: These findings suggest that en bloc minimal laser resection can offer an acceptable risk/benefit ratio in the case of patients who cannot tolerate a lobectomy. (CHEST 1996; 110: ) Key words: chest wall; minimal resection; Nd:YAG laser; T3 lung cancer Abbreviations: FEF25%-75%=forced expiratory flow between 25% and 75% eng cancer involving the chest wall has been a ma- ~ o r challenge for thoracic surgeons for a long time. -5 En bloc resection is now considered the treatment of choice.6 7 However, the extent of pulmonary surgery must be balanced with residual lung function. *From the Department of Thoracic Surgery, Postgraduate School of Thoracic Surgery, Tor V e r ~ University, a t a (Drs. Mineo, Ambrogi, Pompeo, and Casciani), and The Department of Medical Statistics and Biometric, La Sapienza University (Mr. Nofroni), Rome, Italy. Manuscript received February 28', 1996; revision accepted June 12. Reprint requests: Dr. Mineo, Ospedale S. Eugenio, Piazzale Umanesimo 10, Rome, Italy Pneumonectomy and lobectomy are the standard procedures for resectable T3-chest wall lung carcinoma, but the patients with impaired pulmonary function cannot be considered candidates for such an invalidating resection. Many investigators have proposed lesser resections as a compromise procedure for patients with stage I lung cancer having limited pulmonary function.8 9 According to the same rationale, minimal lung resection can be associated with en bloc chest wall resection in patients who cannot bear lobectomy. The theoretical

2 advantages of such a combined procedure are represented by preservation of pulmonary function, by scant perioperative complications, and by the ability to tolerate further resections for second primary neoplasms. However, disadvantages could be the incomplete resection and the increased risk of local recurrence. In this study, we evaluated our results with en bloc minimal resection that we have performed with Nd: YAG laser since Long-term survival, recurrence rate, and length of postoperative hospital stay for those patients are analyzed. MATERIALS AND METHODS From March l, 1987 to December 31, 1993, from a total of 24 patients who had undergone intentional curative surgery for T3-chest wall lung cancer, 10 patients with marginal pulmonary function had minimal (wedge) laser resection. There were 7 men and 3 women ranging in age from 51 to 77 years (mean, 66.2 years). Four patients were older than 70 years of age. Chest wall pain was present at time of surgery in eight and it was the initial symptom in six. The patients were considered to have poor lung function on the basis of the following respiratory parameters tested preoperatively: FEY 1less than or equal to 1.3 L and/or forced expiratory flow between 25% and 75% (FEF25%-75%) less than or equal to 0.8 Us. Preoperative staging was routinely accomplished by total body CT scan and fiberoptic bronchoscopy. Bone scan and mediastinoscopy were performed only in selected cases. At the preoperative staging, none of the patients had positive mediastinal lymph nodes (N2), or tumors greater than 3 em in diameter, or evident invasion of intrathoracic organs (T 4), or neoplasms growing within the first two ribs, or superior sulcus tumors. Preparation for surgery was performed accurately in all patients by tobacco abstinence, physiotherapy, incentive spirometry, bronchodilators, and administration of antibiotics. Each patient gave written informed consent before the operation. The tumors were located in the right upper (n=5), right lower (n=2), left upper (n=2), and left lower (n=l) lobes. Operative technique included posterolateral thoracotomy, intercostal space opening, pleural cavity exploration, benign adhesions dissection, and tumor invasiveness evaluation. The malignant nature of the neoplasm was proved by intraoperative frozen section analysis. After a second intercostal opening, en bloc resection was performed by rib continuity interruption and precise dissection on the parenchymal side, palpating the lesion and encompassing it by Nd:YAG laser. All the tumors, both on the parietal and pulmonary sides, were resected with at least 2.0 em of macroscopically disease-free margin. The laser equipment (Fiberlase 100; Pilkington Medical Systems Ltd; Clyde bank, Scotland) was capable of generating up to 100 W for 0.1 to 9.9 sin 0.1-s increment or extended duration of up to 25 s. Parenchyma was dissected by the noncontact mode delivering 70 W for extended duration; thereafter, bleeding and air leakage from the resection margin were controlled by application of a distance defocused low-powered laser beam. Suture reinforcement was necessary only when bronchi large enough to have a cartilaginous wall (>3 mm) were found. Resection line was always covered by lo ml of fibrin glue. Before closing, mediastinal lymphadenectomy was carried out routinely and air sealant effect was tested by inflating the lung with positive pressure. The maximum number of resected ribs was 2 and the size of the defect never exceeded 5.0x8.0 em. Reconstruction was always performed by a sliding myoplasty of contiguous muscles: due to the minimal loss of chest wall, we did not replace the defect with any prosthetic material. Postoperative pain was controlled by either intercostal nerve block or epidural anesthesia. Since the immediate postoperative period the patients were encouraged to early mobilization and all of them followed a strict program of physiotherapy. All patients, with the partial exception of patient 2, received postoperative radiotherapy restricted to the area of the primary lesion. The doses consisted of approximately 30 to 35 Gy divided into 10 to 20 fractions beginning within 1 month after resection. Two tangential fields were generally preferred, with the use of wedges to improve dose distribution and to limit the dose to remaining lobes. No patients with NO disease receives mediastinal irradiation. In patients with N-positive lymph nodes (n=3), the irradiation was enlarged to hilum and mediastinum. Patients were followed up at 6-month intervals for the first 2 years, and yearly thereafter. Follow-up included clinical evaluation, routine blood test, and chest racliograph. Total body CT or bronchoscopy were performed only when indicated. Pulmonary function tests were performed at 6, 12, and 18 months postoperatively. They included FEV1, FEF25%-75%, and FVC. RESULTS The operation was straightforward and rapid (mean operative time was min). All tumors were confirmed to be T3-chest wall at pathologic examination. Every lesion appeared entirely circumscribed by healthy parenchyma, although resection margin was histologically unclear due to necrotic effect of the laser. Histologic study revealed adenocarcinoma (n=4), squamous cell carcinoma (n=3), and large cell carcinoma (n=3). At postoperative restaging, the tumors of 7 patients were classified as NO, 2 as N1, and 1 as N2 (Table 1). There were no perioperative deaths and no chest flail in the early period. After surgery, no patients required mechanical ventilatory support for a period longer than 6 h. Also, late postoperative complications were minimal. Only one patient developed a lobe atelectasis necessitating bronchoscopy, which was rapidly effective. Prolonged air leakage occurred in two patients. Chest drainage tubes were removed after a minimum of 4 days and a maximum of 13 days (mean, 7.8 days). Hospital stay ranged between 11 and 16 days (average, 14.2 days). Six of eight patients with chest wall pain had significant relief of their symptoms. Despite the described negative effect of the radiotherapy, pulmonary function tests did not disclose significant differences at Student's t test (p value considered significant <0.05) between preoperative and 18-month follow-up. Mean (±SD) FEV 1 (before, 1.22 L; and after, 1.16 L) was reduced 4.5%, with a difference ± and p=0.31. Mean (±SD) FVC (before, 1.74 L; and after, 1.76 L) increased 1.2% from its preoperative value, with a difference of ±0.022 and p=0.88. Mean (±SD) FEF25%-75% (before, 0.83 Us; and after, 0.78 Us) had a reduction of 6.4% with a difference of ± and a p= At the present time, six patients are still alive, five of whom are free of tumor. Two patients now have a follow-up longer than 5 years. Three patients died; 2 of them had disseminated disease after 4 7 and 32 months, CHEST/110/4/0CTOBER,

3 Table!-Results of Chest Wall En Bloc Resection* No. of Ribs S u n ~ v a l, No./Sex/Age, yr Histology pn Site Resected mo Outcome 1 / ~ 1 / 7 5 Squamous cell :\11 RLL 2 47 DOD 2/F/71 Adenocarcinoma i'\0 RUL 2 78 LRC 3/'vl/69 Adenocarcinoma l\'0 RUL 1 60 NED 4/NI/.51 Large cell NO RUL 2 Unavailable 5/M/77 Adenocarcinoma NO LUL 2 27 DOC 6/M/69 Adenocarcinoma NO RLL 36!\'ED 7/M/62 Large cell :\10 RUL 32 DOD 8/F/70 Squamous cell :\12 LUL 2 24 DR 9/M/55 Large cell l\'1 RUL l 18 NED 10/F/63 Squamous cell NO LLL 2 16 NED *DOD=dead of disease; DOC=dead other cause; NED=not evident disease; DR=dist>mt recurrence; LRC=local recurrence cured; RUL=right upper lobe; RLL=right lower lobe; LUL=Ieft upper lobe; LLL=left lower lobe. respectively. The third patient died at the age of 79 years, 27 months after surgery, from an unrelated cause. Another patient was unavailable for follow-up. The patient with N2 disease is still alive at 20 months, but he has recently developed brain metastases. Only one patient had a recurrence on the excision site. At first she had refused radiation therapy and presented with a local recurrence 15 months later. She underwent a new limited chest wall resection plus radiotherapy and she is alive and well at 63 months after the second operation. DISCUSSION For a long time, the invasion of extrapulmonary structures had been considered the evidence of inoperable advanced bronchogenic carcinoma. 1 2 In 1947, Coleman3 first reported long term-survival after pulmonary and chest wall combined resection for a chest wall invading bronchogenic carcinoma. Twenty years later, studies from two major institutions 4.s definitively stated that a significant percentage of those patients could have some benefit from surgery in long-term survival. The introduction of the new staging system allowed the discrimination \vithin the stage III of a group of patients with potentially resectable disease that is defined as stage IIIA. 6-8 In terms of prognostic results, the most favorable combination in the patients with IliA disease is the T3 (peripheral)-no disease with locally invasive lung cancer. In this case, surgical resection can offer a real chance for long-term survival and even for cure. 8 In our experience, patients with normal respiratory function who have a standard resection for a T3-chest wall lung cancer have a 5-year survival rate of approximately 35% if the disease is NO. The rate decreases to 10% if those patients have mediastinal lymph nodes at histologic examination (pn2). Indeed patients with mediastinal node metastases or unresectable tumors represent the categories with the most unfavorable prognosisjo-l.s Other potential predictor factors oflong-term survival such as age younger than 60 years, squamous cell histotype, and invasion limited to the parietal pleura have been variably interpreted in the literature.l0-16 Controversy also continues as to the extent of parietal resection. Allen et al13 and Albertucci et al14 recommend full-thickness chest wall resection, even in cases where tumor was adherent to the parietal pleura. On the contrary, McCaughan et ap 1 consider the parietal pleura as a barrier to tumor invasion and are confident that extrapleural dissection can achieve adequate oncologic clearance with a lower operative mortality and morbidity rate. Unfortunately, there are no reliable preoperative criteria from the currently available imaging techniques capable of predicting the depth of parietal invasion. 16 We usually prefer an aggressive conduct resecting the chest wall, whenever we find minimal firm adhesions between tumor and parietal pleura. Only in the presence of simple filmy adhesions that are not considered indicators of malignant invasion do we perform extrapleural resection. No patients from the present series fulfilled that prerequisite and therefore, all of them underwent en bloc resection. Apart from long-term results, we deem en bloc resection a successful operation for symptom relief: in six of eight symptomatic patients, resection had a positive effect. Given the limited area of the resected chest wall, no patients required a prosthetic replacement. The defect was often located in the periscapular region and it was easily repaired by a sliding myoplasty. None of our patients developed chest flail postoperatively. We do not consider the prediction of a wide chest wall defect by itself a contraindication for surgery. More recently, because of the increasing interest in lung-conserving operations, 8 9 ) 7 we have focused our attention on the entity of parenchymal resection in these patients. Small peripheral tumors invading the chest wall are frequently excised with en bloc resection of the chest wall, together with a large wedge excision of the tumor. This approach has been popularized in 1094

4 the treatment of superior sulcus tumors. 18 The Lung Cancer Study Group 17 has recently demonstrated that the locoregional recurrence rate presents a threefold increase with wedge resection compared to lobectomy in patients with stage I neoplasms. Local recurrence would be originated by incomplete resection or failure to identify microscopic foci and lymphocytic spread of the tumor. The same study has shown that the diameter of the tumor, below 3.0 em, does not seem to affect the recurrence probability. Authors conclude that limited resection is not advisable when patients can tolerate lobectomy. 17 However, in patients with marked pulmonary impairment and with easily circumscribed tumors, even if chest-wall-invading, minimal resection can represent the only alternative to nonoperative treatment. 8 9,1 7 Recent reports suggest a reasonable 5-year survival rate when utilizing lesser resection in a compromised individual, 8 9 despite the extension of the tumor. With minimal resection, we can significantly reduce operative time, perioperative mortality, early postoperative complications, and hospital stay. The expected higher rate of local recurrence becomes an acceptable risk in patients who cannot tolerate a more extensive resection. Our results support the above beliefs: six patients are still alive, five with no evident disease, apart from the histotype and the stage. Air sealant, coagulative, and necrotic effects of Nd:YAG laser are ideal in minimal pulmonary resections for lung cancer Lo Cicero et al19 described the mechanism of laser sealant effect. It is due to the progressive collapse of alveolar septa, producing a thick, multilayer air-proof membrane. This result can be better achieved by either C02 19 or Nd:YAG 20 laser, using a low-power density by defocusing the laser beam on the section line. In addition, Nd:YAG laser is electively absorbed by black structures (anthracotic and hemoglobin pigments), thus allowing specific coagulative activity as much as 4 mm below the surface or in a relatively bloody field. On the contrary, the laser beam is unable to penetrate cartilaginous structures, so that for bronchi greater than 3 mm, it is advisable to use supplementary conventional suture.19 Another important laser issue was hypothesized by Moghissi et al, 20 who attributed to massive coagulative necrosis induced by Nd:YAG laser along the section line, a potential margin of safety in neoplastic cases. It may also have an impact on long-term survival, particularly in patients at high risk of local recurrence. Conventional electrocoagulation might allow bloodless dissection, but it cannot allow either reliable coagulative necrosis or air control. This may be vital in patients with poor lung function who often have disrupted parenchymal architecture and high risk of prolonged postoperative bubbling. Higher cost related to equipment purchase and maintenance can be counterbalanced by reducing the rate of postoperative morbidity and the duration of hospital stay. In some instances, laser resection seems preferable even to stapling. Linear stapler positioning could result in pulmonary distortion with air and blood supply impairment of the lung parenchyma, leading to atelectasis, pleural space problem, infection, and functional worsening. In our experience, 23 we had excellent outcome in pulmonary dissection by laser, especially in the case of neoplastic lesions in patients with poor lung function. All patients in our series were referred to postoperative irradiation as a part of a planned combined treatment. In literature, the indications of radiotherapy after chest wall surgery remain controversial even in patients with normal respiratory function who underwent standard resection. Therefore, in the case of marginal respiratory function, it might potentially reduce or even worsen the functional advantages conferred by minimal resections. As a matter of fact, there is a general agreement for postoperative radiation therapy only in patients with positive margins or lymphatic metastasis Miller 9 proposed routine adjuvant radiotherapy as a technique capable of reducing the rate of local recurrence in those patients undergoing minimal resection, whose lesion had potentially crossed an intersegmental plane. An analogous consideration, the lack of a certain histologic-free margin, compelled us to administer adjuvant radiotherapy in our patients despite their compromised respiratory function. The evidence of healthy parenchyma surrounding the lesion was only macroscopic. In fact, the wide necrotic effect of the laser avoids a 100% reliable evaluation of the resection margin. However, the same necrotic effect is described to have a sterile action on the neoplastic cell, preventing local relapse of the tumor. In our experience, local fractioned radiotherapy had excellent results and it did not significantly affect pulmonary function. On the contrary, the only patient from our group who at the beginning refused radiotherapy developed a local recurrence 15 months later. In this case, the mass was slightly more than 3 em and despite the macroscopic evidence of tumor-free margin, resection was probably inadequate. The patient underwent a second chest wall-minimal resection plus radiotherapy with good results at a 5-year distance. In conclusion, en bloc minimal laser resection appears to be a less time-consuming and more effective pain-relief procedure, with low operative mortality and morbidity rates. We consider it possible to offer an acceptable risk/benefit ratio for limited lung cancer invading the chest wall in patients with poor lung function. To reduce the possibility of local recurrence and prolong long-term survival, we suggest the following mandatory prerequisites: functional impos- CHEST /110 I 41 OCTOBER,

5 sibility to tolerate a lobectomy, tumor less than 3 em in diameter with margins easily encompassed by resection, and no clinical lymph nodal involvement. All these criteria should be researched and clearly stated in the preoperative functional testing and staging process. En bloc minimal laser resection will extend its indications by the development of innovative techniques in the definition of lung function and the entity of chest wall involvement. REFERENCES 1 Gebauer PW. The differentiation of bronchogenic carcinoma. J Thorac Surg 1941; 10:156 2 Graham EA. Indications for total pneumonectomy. Dis Chest 1944; 10: Coleman FP. Primary carcinoma of lung with invasion of the ribs: pneumonectomy and simultaneous block resection of chest wall. Ann Surg 1947; 126: Grillo HC, Greenberg JJ, Wilkins EW Jr. Resection of bronchogenic carcinoma involving thoracic wall. J Thorac Cardiovasc Surg 1966; 51:417 5 Geha AS, Bematz FE, Woolner LB. Bronchogenic carcinoma involving the thoracic wall: surgical treatment and prognostic significance. J Thorac Cardiovasc Surg 1967; 54: Mountain CF. A new international staging system for lung cancer. Chest 1986; 86:225S-33S 7 Naruke T. Prognosis and survival based on the new staging system. J Thorac Cardiovasc Surg 1988; 96: Ginsberg RJ. Lung sparing operations for cancer. In: Roth JA, Cox JD, Hong WI, eds. Lung cancer. Boston: Blackwell. 1993: Miller JI. Limited resection ofbronchogenic carcinoma in patient with impaired pulmonary function. Ann Thorac Surg 1993; 56: Trastek VF, Pairolero PC, Piehler JM, et al. En bloc (chest wall) resection for bronchogenic carcinoma with parietal fixation: factor affecting survival. J Thorac Cardiovasc Surg 1984; 87: Me Gaughan BC, Martini N, Bains MS, et al. Chest wall invasion in carcinoma of the lung: therapeutic and prognostic implications. J Thorac Cardiovasc Surg 1985; 89: Casillas M, Paris F, Tarrazona V, et al. Surgical treatment oflung carcinoma involving the chest wall. Eur J Cardiothorac Surg 1989; 3: Allen SM, Mathisen JD, Grillo HC, et al. Bronchogenic carcinoma with chest wall invasion. Ann Thorac Surg 1991; 51: Albertucci M, De Meester TR, Rothberg M. et al. Surgery and the management of peripheral lung tumors adherent to the parietal pleura. J Thorac Cardiovasc Surg 1992; 103: Lopez L, Lopez Pujol J, Varela A, et al. Surgical treatment of stage III non-small cell bronchogenic carcinoma involving the chest wall. Scand J Thorac Cardiovasc Surg 1992; 26: Ratto GB, Piacenza G, Frola C, et al. Chest wall involvement by lung cancer: computed tomographic detection and result of the operation. Ann Thorac Surg 1991; 51: Lung Cancer Study Group. Randomized trial of lobectomy versus limited resection for T1 NO non-small cell lung cancer. Ann Thorac Surg 1995; 60: Dartevelle P, Marzelle J, Chapelier A, et al. Extended operations for T3-T4 primary lung cancers: indications and results. Chest 1989; 96(suppi):51S-3S 19 Lo Cicero J III, Hartz RS, Frederiksen JW, et al. New application of the laser in pulmonary resection: hemostasis and sealing of air leak. Ann Thorac Surg 1985; 40: Moghissi K, Dench M, Neville E. Effect of the non-contact mode ofyag laser on pulmonary tissues and its comparison with electrocliathem1y: an anatomic-pathological study. Laser Med Sci 1989; 4: Landreneau RJ, Hazelrigg SR, Johnson JA, et al. Neodymium: yttrium-aluminum garnet laser -assisted pulmonary resections. Ann Thorac Surg 1991; 51: Kodama K, Doi 0, Yasuda T, et al. Radical laser segmentectomy for TlNO lung cancer. Ann Thorac Surg 1992; 54: Mineo TC, Cristina B, Ambrogi V, et al. Usefulness of the Nd:YAG laser in parenchyma-sparing resection of pulmonary nodular lesions. Tumori 1994; 80: