Multicenter VATS Experience With Mediastinal Tumors

Transcription

1 Multicenter VATS Experience With Mediastinal Tumors Todd L. Demmy, MD, Mark J. Krasna, MD, Frank C. Detterbeck, MD, Gary G. Kline, MD, Leslie J. Kohman, MD, Malcolm M. DeCamp, Jr, MD, and John C. Wain, MD Division of Cardiothoracic Surgery, University of Missouri Hospital and Clinics, Columbia, Missouri; Department of Surgery, University of Maryland Hospital, Baltimore, Maryland; Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Surgery, Long Island Jewish Medical Center, Long Island, New York; Department of Surgery, State University of New York at Syracuse, Syracuse, New York; Department of Surgery, Brigham & Women s Hospital, Boston, Massachusetts; and Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts Background. The use of video-assisted thoracic surgery for diagnosis and treatment of mediastinal tumors in a multiinstitution patient population is not well understood. Methods. We studied 48 cases from Cancer and Leukemia Group B thoracic surgeons. Of 21 men and 27 women, aged years, 22 patients were asymptomatic. In the others, 92% of tumor-related symptoms improved or resolved after treatment. Five tumors involved the anterior compartment, 19 the middle, and 24 the posterior compartment. Diagnoses were typical for each compartment but also included uncommon problems such as superior vena cava hemangioma and a histoplasmosis cyst causing hoarseness. Of the lesions, a biopsy of 12 was done without excision and the rest were excised completely. Fifteen were cystic and 10 were malignant (8 biopsy only). Maximal dimensions were cm. Results. Operations were briefer for 24 posterior (93 41 min) than 5 anterior ( min, p < 0.01) or 19 middle mediastinal tumors ( min, p < 0.01). Although 96% had vital mediastinal relations, only six open conversions were performed because of bleeding (n 3), large size, impaired exposure, or rib attachments, and no patient had morbidity beyond that expected for the thoracotomy. Postoperative stay was shorter for the nonconversion group ( versus days, p 0.05), as was chest tube duration ( days versus days, p 0.03). There were no postoperative deaths or major complications, but 7 patients had minor complications. During a mean of 20 months of surveillance (range, 1 to 52 months), one cyst recurred (asymptomatic) as did one sarcoma that was excised. Conclusions. Video-assisted thoracic surgery is a safe technique for benign mediastinal tumors, typically those in the middle and posterior mediastinum. (Ann Thorac Surg 1998;66:187 92) 1998 by The Society of Thoracic Surgeons Video-assisted thoracic surgery (VATS) has become standard practice for several thoracic problems [1]. For example, VATS is well suited to help diagnosis of pleural disease and interstitial pulmonary disease [2, 3]. However, the use of VATS for the diagnosis and treatment of thoracic tumors is still under investigation. To determine the utility and safety of VATS for selected mediastinal tumors, this retrospective multicenter case review was undertaken. Material and Methods Over 5 years, August 1992 to July 1997, 7 Cancer and Leukemia Group B thoracic surgeons from different institutions submitted their entire experience with mediastinal masses managed by using video-assisted techniques. These 48 patients underwent thoracoscopic Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6 8, Address reprint requests to Dr Demmy, Division of Cardiothoracic Surgery, University of Missouri, 245 Major Hall, Dc119.0, Columbia, MO tumor excisions or incisional biopsies if the lesions were deemed unresectable by radiographic imaging studies. These data were submitted by a data sheet and entered into a computerized database at the University of Missouri. The raw data were printed and submitted back to the investigators for final verification including update of long-term outcomes. This protocol resulted in a 97% complete data collection rate. After induction of general anesthesia, single lung ventilation was performed, and a pneumothorax was created on the operative side. Dual lumen endobronchial tubes were used for selective ventilation, and occasionally bronchus blockers were used for left lung procedures. One institution used CO 2 gas insufflation ( 10 mm Hg using 3 L/min flow) to collapse the lung. The patients were positioned in the lateral decubitus position. A 0 or 30 video telescopic camera was inserted through a port at the midaxillary line in the lower chest (eighth to ninth intercostal space). This allowed internal visualization during creation of thoracoscopy ports at the anterior and posterior axillary lines in the fifth or sixth intercostal spaces by The Society of Thoracic Surgeons /98/$19.00 Published by Elsevier Science Inc PII S (98)

2 188 DEMMY ET AL Ann Thorac Surg VATS AND MEDIASTINAL TUMORS 1998;66: All cases generally required 2 working ports (10 mm or greater) in addition to the camera port. Complicated dissection occasionally used 1 to 2 additional 5-mm ports. More detailed port data were not collected for this study. For tumors in the anterosuperior mediastinum, the patients arms were extended over their heads and the ports positioned more anteriorly and apically for better visualization. The dissections were performed either with endoscopic port instruments or standard instruments introduced directly through the chest wall. Sharp and blunt dissection techniques were used to separate tumors from the surrounding organs. Cautery provided hemostasis in areas distant from sensitive structures such as the phrenic nerve. In all but 2 cyst excisions, the cavities were opened and aspirated during their dissection to facilitate removal. In 3 cases, when a cyst was too densely adherent to a vascular or other vital structure (Fig 1A), the nonadherent portion of the cyst was excised and the remaining cyst wall cauterized if lined by epithelium. For all solid masses that could contaminate the chest wall, the working port incisions were extended as needed to accomplish delivery of specimens within extraction sacs. Presenting symptoms, physical findings, and other demographic information were recorded for each patient. Using preoperative radiographic studies and intraoperative findings, we noted the size of the tumors and their relations to vital structures. The postoperative hospital stay, chest tube duration, and change of patient symptoms were recorded. Longer term outcomes included the patients activity levels at the 2- to 6-week postoperative clinic visit, resolution of symptoms, evidence of cyst or neoplastic recurrence, and other late complications. Continuous variables are reported as mean standard deviation, and Student s t test was used to compare their differences. Chi-square testing was used for categorical values. Results The number of patients with presenting symptoms, tumor relations, and general pathologic classifications of the tumors treated using VATS are as follows: Symptom None 22 Dysphagia 7 Pain 5 Dyspnea 3 Cough 2 Hoarseness 1 Anorexia 1 Other 2 Multiple 5 Attachment Vascular 11 Spine 10 Esophagus 6 Pericardium 2 Trachea/bronchus 2 None 2 Fig 1. Unusual middle mediastinal lesions. (A) Computed tomographic scan of patient with symptomatic bronchogenic cyst with coronary artery bypass graft forming part of posterior cyst wall. Inset shows operative photograph. If appropriate, portions of cyst walls were left adherent to vascular and other sensitive structures and their epithelial lining was cauterized. (B) Computed tomographic scan of patient with a histoplasmoma compressing the recurrent laryngeal nerve. Vocal cord paresis resolved after resection. (C) Computed tomographic scan of patient with a rare venous hemangioma of the superior vena cava (SVC). Arrows denote phleboliths. (Ao aorta; PA pulmonary artery; SVG saphenous vein graft.)

3 Ann Thorac Surg DEMMY ET AL 1998;66: VATS AND MEDIASTINAL TUMORS 189 Table 1. Specific Pathologic Diagnoses, Compartment Locations, and Operative Approaches of Excised Mediastinal Lesions Malignancy Anterior Middle Posterior Type No. Type No. Type No. Benign Thymic hyperplasia 1 Cysts 7 Neurogenic 11 Teratoma a 1 Bronchogenic 2 Schwannoma 9 Lipoma 1 Inflammatory 2 Paraganglioma a 1 Enterogenous 1 Ganglioneuroma 1 Pericardial 1 Cysts 7 Unknown etiology 1 Bronchogenic b 4 Benign fibrous tissue c 2 Enterogenous 2 Granuloma 1 Pericardial 1 Nonviable tumor c 1 Benign fibrous tissue c 1 Leiomyoma 1 Leiomyoma a 1 Castleman disease c 1 SVC hemangioma a 1 Malignant Lymphoma c 1 Lymphoma (discrete) 1 Lymphoma c 2 Thymoma 1 Lymphoma c 3 Liposarcoma (myxoid) 1 Liposarcoma (metastatic) 1 Adenocarcinoma a,c 1 (metastatic) Total a Converted to thoracotomy; b One case (of 4) converted to thoracotomy; c Lesion was not excised, only a biopsy was performed. SVC superior vena cava. Encasement 3 Other 5 Multiple 7 Pathologic classification Inflammatory 3 Benign Cyst 15 Solid 20 Malignant 10 Specific pathologic diagnoses for each mediastinal compartment are listed in Table 1. Overall maximal dimensions of the lesion were cm. Symptoms were common in patients with malignancy (70%); however, symptoms were not significantly different than the 50% incidence of symptoms in patients with benign disease. Patients with symptoms had larger masses ( versus cm; p 0.01). The presence of symptoms was associated with a longer hospital stay ( versus days; p 0.03), and longer chest tube drainage ( versus days; p 0.05). One patient had an unusual symptom for benign disease, namely, hoarseness from a laryngoscopically verified right vocal cord paresis. The patient s hoarseness resolved immediately after drainage of a mediastinal histoplasmoma cyst (Fig 1B). Remarkable physical findings were absent in this study except for 2 patients with mediastinal malignancy. One had muscle wasting and the other mild neck vein engorgement from the mediastinal tumor. Tumors were located in the anterosuperior, middle, or posterior compartments in 10%, 40%, and 50% of the patients, respectively. The presence of symptoms, as well as the incidence of conversions or complications, did not differ between compartments. In 12 cases, incisional biopsies of malignancies or benign lesions not warranting resection were performed. Although smaller masses were more likely to be excised rather than undergo incisional biopsy ( versus cm; p 0.02), the excision rate between compartments was not different statistically. Differences in operating room time corresponded to different compartments. The times were briefer for removal of posterior (93 41 minutes) than anterior ( minutes; p 0.01) or middle mediastinal tumors ( minutes; p 0.01). Six patients required conversion to thoracotomy, 1 of whom had a rare venous hemangioma of the superior vena cava. Figure 1C shows the computed tomographic findings of this unusual tumor with phleboliths within this mass. The mass was dissected until a 1-cm stalk remained attached to the superior vena cava. A small tear in the superior vena cava occurred while applying vascular clips to the stalk. Bleeding was controlled by occluding the tear while a thoracotomy was performed to complete the excision above a partial exclusion vascular clamp. Two other patients required conversion to thoracotomy for optimal control of bleeding during attempted VATS excisions: 1 from extensive tumor vascularity in a paraganglioma and 1 from an intercostal vessel in a bronchogenic cyst. The other 3 conversions were to improve exposure during excision of a large anterior germ cell tumor, an esophageal leiomyoma, and a metastatic adenocarcinoma nodule adherent to the esophagus. The conversion group required a similar total operating time ( versus minutes; p 0.1)

4 190 DEMMY ET AL Ann Thorac Surg VATS AND MEDIASTINAL TUMORS 1998;66: and received no transfusions. One case of pneumonia and 1 postoperative chylothorax were treated in the converted group, and neither patient remained hospitalized for longer than 8 days. Nevertheless, postoperative stay was longer for the conversion group ( versus days; p 0.05), as was chest tube duration ( versus days; p 0.03). There were no operative or hospital deaths in this study and no patients had a major complication. For all patients, the mean chest tube duration was days and the mean postoperative stay was days and reflects the inclusion of time in which some patients remained in the hospital for chemotherapy. Seven minor complications occurred, including a 4-day pleural air leak, ileus, superficial wound infection, and severe perioperative pain (1 each). One pneumothorax and 1 pleural effusion responded to thoracentesis, and 1 case of Horner syndrome resolved by 3 months. By the first 2- to 6-week postoperative) clinic visit, all patients with benign disease and VATS alone had returned to work or their preoperative activity except for the patient who noted mild exercise limitation from a pleural effusion that later resolved. Postdismissal data were available for 92% of patients, with an average follow-up time of months (range, 1 to 52 months). The proportion of patients reporting return to full preoperative activity was 33% by 2 weeks, 50% by 3 weeks, and 80% by 4 weeks. Most of the remaining patients had been converted to thoracotomy or had their convalescence delayed by treatments such as chemotherapy. The average times of follow up were briefer for posterior compartment operations ( months) than anterior ( months, p not significant) or middle mediastinal tumors ( months, p 0.01) because 70% of the lesions in the last 30 months of the study were in the posterior compartment compared with 35% from the first 30 months (Fig 2). Two patients with histoplasmosis-related mediastinal cysts received itraconazole postoperatively to prevent progression of their fungal disease. To date this strategy appears to be successful. One bronchogenic cyst recurred on the basis of chest roentgenogram findings 4 years after VATS resection in a patient who remains asymptomatic. In this patient, one fourth of the cyst wall lining was cauterized and was allowed to remain because of its attachment to the descending thoracic aorta. An intrathoracic recurrence developed in 1 patient with liposarcoma after the primary tumor was resected transabdominally from the retrohepatic and periaortic region. There were multiple vital intrathoracic related organs, and 2 unexpected concomitant pulmonary metastasectomies were performed. This tumor recurred 3 years later, and the patient underwent open resection of the liposarcoma along with a portion of the vertebral body. The patient died 2 years later of metastatic disease. The remaining patients who underwent mediastinal tumor excision are alive and well; however, there are only 6 months of follow up data for the other patient with liposarcoma resection. Fig 2. Posterior mediastinal lesions. (A) Typical magnetic resonance image of a posterior mediastinal schwannoma. Arrows denote lesion. (B) Operative photograph of a posterior mediastinal cyst (bronchogenic). Comment This study shows that VATS may be applied with acceptable outcome for certain mediastinal masses. Biopsies of unresectable tumors and excisions of benign cysts by VATS are potentially less morbid than by open thoracotomy. Characteristics associated with the nonmalignant lesions are important. For instance, patient youth and lack of symptoms increased the likelihood that the masses were benign [4]. The benign tumors often were located in the middle or posterior mediastinum. Most importantly, the preoperative radiographic studies of

5 Ann Thorac Surg DEMMY ET AL 1998;66: VATS AND MEDIASTINAL TUMORS 191 these patients did not show invasive relationships that would make resection by minimally invasive techniques hazardous. However, the distribution of tumors in the middle and posterior compartments seen in this series is similar to that of other series of open resections, including the dominance of neurogenic tumors in the posterior mediastinum. In this study, which is comparable with other favorable reports detailing the use of thoracoscopy for mediastinal cysts, we found a ratio of cystic to solid tumors similar to that found in other series [1, 4 7]. There were no early complications using the technique of cyst drainage followed by complete or nearly complete excision. Other investigators found that a portion of the cyst wall can be left behind provided its lining is nonsecretory or is rendered inactive by cautery or other means [5]. In this study, however, one cyst recurred, suggesting this compromise may need future study. Two pericardial cysts were resected. One was large and symptomatic and another required operation for diagnosis because of its unusual radiographic appearance. The ratio of benign to malignant lesions in this series (4:1) is greater than that in reports of open resections of mediastinal tumors (3:2) [4, 7]. This finding is not surprising because lesions that appear malignant would be less likely to be treated using a VATS technique. Because the anterior compartment has the largest proportion of malignant tumors, there are few anterior mediastinal masses in this series (10%) although this mediastinal tumor location is the most common (50% to 60% in most series) [7 9]. Therefore, thoracoscopic resections of mediastinal neoplasms, particularly those in the anterior compartment, need to be evaluated cautiously [10]. Furthermore, the excellent exposure afforded by the relatively well tolerated median sternotomy has limited the growth of the VATS procedure for anterior mediastinal masses. The limitations of VATS technology may compromise the results of resectional treatment of mediastinal neoplasms. For instance, disruption of thymomas during VATS dissection could lead to pleural and chest wall implants, which have been reported in other techniques [11]. Reports of early local cancer recurrence after thoracoscopic resection of indeterminant pulmonary nodules have led to routine encasing of specimens before extraction [12]. We endorse this practice for mediastinal mass extractions as well, regardless of whether it is an incisional biopsy or a partial or complete resection. Despite the effort to maximize accuracy, this study is limited by lack of prospective data collection and a contemporary comparison group. Unfortunately, a controlled trial is probably not possible given the unusual and varied nature of mediastinal tumors. Compared with operations that require thoracotomy, the postoperative lengths of stay and times to return to work or full home activity were favorable. Although the operative times seem longer than expected for open resection of middle and anterior tumors, the overall cost of an uncomplicated minimally invasive mediastinal mass excision may be less than that of an open operation. Much of the expensive disposable instrumentation that reduced cost savings in other VATS procedures is not needed for these operations [13]. Although not measured directly in this study, the reduced disposable costs along with the observed reduction in postoperative hospital stay should offset longer operative times and make VATS excision a cost-effective option. On the basis of our experience, the decision to treat a mediastinal lesion by VATS is based on whether exposure and dissection can proceed in a fashion similar to an open operation. This decision requires careful assessment of lesion location, proper port placement, and prerequisite experience with VATS. The learning curve is improved by increasing operator experience as well as evolving imaging and instrument technology [14]. There should be a low threshold to improve exposure by use of a limited or standard thoracotomy, especially when risks increase for tumor dissemination or hemorrhage. It is appropriate to consider all thin-wall mediastinal cysts for VATS resection because they can be decompressed and delivered through a small port. The results have been uniformly good for this therapy [4, 5]. Occasionally, portions of the cyst wall intimately related to vital structures will be left behind and cauterized in both VATS and open procedures. Small solid masses are appropriate for minimally invasive resection, particularly those with low risk by virtue of known benign histologic characteristics, slow growth, encapsulation, posterior compartment location, and lack of invasion or neovascularity by imaging studies or thoracoscopic inspection. Neoplastic or potentially malignant masses are approached by VATS largely for assessment of staging, planning open resection, or incisional biopsy. The last procedure is reserved for patients whose prognoses are unaltered by possible contamination of the pleural space by tumor, such as those with solid malignancies of documented advanced stage or nonsurgical hematologic malignancies such as lymphoma. Because this criterion was used, no patient in this series who underwent incisional biopsy manifested local recurrence. Videoassisted thoracic surgery provides a larger tissue sample for accurate histologic classification of presumed lymphomas than do simpler techniques such as computed tomographic-directed core biopsies. The need to access multiple areas, tumors remote from mediastinoscopy or mediastinotomy approaches, and high-risk anatomic tumor relations (eg, aorta) may also favor the exposure afforded by thoracoscopy. Considerable dissection is required to resect areas of potential intrathoracic invasion, ie, chest wall, to obtain margins free of tumor. This makes minimally invasive techniques less relevant and accounts for our limited experience and few reports from others. For patients with mediastinal neoplasms treated best by resection and who can tolerate standard thoracotomy, we cannot yet support VATS other than for investigative purposes. More time is needed to determine whether resection of malignant tumors such as those in this study results in findings similar to those of open resection. The case of nonmetastatic liposarcoma in this series had excellent exposure and its posterior attachments were

6 192 DEMMY ET AL Ann Thorac Surg VATS AND MEDIASTINAL TUMORS 1998;66: dissected in a manner comparable with open thoracotomy. The follow-up of this case is still very short. Several unusual patients were included in this multicenter experience. One patient had a venous hemangioma of the superior vena cava, which is rare [4]. The conversion to thoracotomy in this patient may have been avoided if subsequent technical innovations had been available at that time. For instance a longitudinally applied endoscopic vascular stapler would have better controlled the tumor s stalk. The intercostal bleeder related to a bronchogenic cyst could have been controlled easily by cautery technology now available. The case of recurrent laryngeal nerve compromise by histoplasmosis is also quite rare [15]. Our patient s hoarseness resolved after cyst excision, unlike the patient described by Gilbert and associates [15], in whom the hoarseness was permanent. Video-assisted thoracic surgery appears to be a safe technique for the diagnosis and treatment of benign mediastinal tumors, particularly those in the middle and posterior mediastinum in carefully selected patients. The application of this technology for potentially resectable malignant mediastinal masses should be limited to an investigative setting until its safety and oncologic validity can be verified. References 1. DeCamp MM Jr, Jaklitsch MT, Mentzer SJ, Harpole DH Jr, Sugarbaker DJ. The safety and versatility of videothoracoscopy: a prospective analysis of 895 consecutive cases. J Am Coll Surg 1995;181: Landreneau RJ, Hazelrigg SR, Ferson PF, et al. Thoracoscopic resection of 85 pulmonary lesions. Ann Thorac Surg 1992;54: Page RD, Jeffrey RR, Donnelly RJ. Thoracoscopy: a review of 121 consecutive surgical procedures. Ann Thorac Surg 1989; 48: Rice TW. Benign neoplasms and cysts of the mediastinum. Semin Thorac Cardiovasc Surg 1992;4: Hazelrigg SR, Landreneau RJ, Mack MJ, Acuff TE. Thoracoscopic resection of mediastinal cysts. Ann Thorac Surg 1993; 56: Lewis RJ, Caccavale RJ, Sisler GE. Imaged thoracoscopic surgery: a new thoracic technique for resection of mediastinal cysts. Ann Thorac Surg 1992;53: DeCamp MM Jr, Swanson SJ, Sugarbaker DJ. The mediastinum. In: Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS, eds. Glenn s thoracic and cardiovascular surgery, 6th ed. Stamford: Appleton and Lange, 1996: Landreneau RJ, Dowling RD, Castillo WM, Ferson PF. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg 1992;54: Sugarbaker DJ. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56: Mack MJ. Thoracoscopy and its role in mediastinal disease and sympathectomy. Semin Thorac Cardiovasc Surg 1993;5: Nagasaka T, Nakashima N, Nunome H. Needle tract implantation of thymoma after transthoracic needle biopsy. J Clin Pathol 1993;46: Fry WA, Siddiqui A, Pensler JM, Mostafavi H. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;59: Hazelrigg SR, Nunchuck SK, Landreneau RJ, et al. Cost analysis for thoracoscopy: thoracoscopic wedge resection. Ann Thorac Surg 1993;56: Demmy TL, Curtis JJ, Boley TM, Walls JT, Nawarawong W, Schmaltz RA. Diagnostic and therapeutic thoracoscopy: lessons from the learning curve. Am J Surg 1993;166: Gilbert EH, Murray KD, Lucas J, et al. Left recurrent laryngeal nerve paralysis: an unusual presentation of histoplasmosis. Ann Thorac Surg 1990;50: DISCUSSION DR FREDERICK L. GROVER (Denver, CO): Do you advocate draining mediastinal cysts or do you try to excise them? If you excise them, how difficult is it to do using a thoracoscopic technique? DR DEMMY: I think that in all but two of the cysts, controlled drainage facilitated the process of their dissection and removal through the ports. Benign cysts are usually thin walled and rupture easily. Generally one is careful to drain them without spilling too much of the cyst s contents. Two were excised without opening them. DR DANIEL L. MILLER (Rochester, MN): In regard to the bronchogenic cysts, I think it is very important to remove the entire cyst. We are currently reviewing our cases of recurrent bronchogenic cysts at the Mayo Clinic. There are a moderate number of cysts that had been opened previously and drained only with recurrence developing years later. We had 1 patient who was 35 years out from her first operation in whom a recurrent bronchogenic cyst developed because at the first operation the cyst was not removed completely. I think before we dive into thoracoscopic removal of these bronchogenic cysts, it is very important that we remember the principles of surgical resection to remove the entire cyst, because if you do not remove the entire lining of the cyst, it has the potential to come back at a later date. DR DEMMY: I agree. I think the principle behind all these video-assisted techniques is that you should be able to accomplish what you were doing in an open procedure. The patient whose cyst recurred in this series had one fourth of the cyst left attached to the descending thoracic aorta, and its lining was cauterized. I am not sure whether the cyst would have been dissected free with an open procedure. It was the opinion of the surgeon that it may have been approached the same way in an open procedure. For the patient with a bronchogenic cyst wall containing a coronary bypass graft, I was reluctant to cauterize the cyst lining there. In general, however, one should try to ablate the epithelial lining as best one can.