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VATS lobectomy combined with limited Shaw-Paulson thoracotomy for posterolateral Pancoast tumor

Abstract

Purpose

Several techniques have been proposed for the challenging surgical resection of Pancoast tumors. We describe a hybrid approach that combines video-assisted thoracic surgery (VATS) lobectomy and limited Shaw-Paulson thoracotomy.

Methods

We report a case of Pancoast tumor in a 57-year-old man, staged as cT3N0M0, that was treated with induction chemoradiotherapy prior to the hybrid surgical approach. After thoracoscopic pleural cavity inspection, an upper right VATS lobectomy by a 3-port standard approach was performed. The chest wall was resected through a limited paravertebral incision, allowing the extraction of the lobe together with the rib segments. The posterior chest wall defect was repaired with a synthetic patch.

Results

The postoperative period was uneventful and the pain never exceed a score of 3 on a visual analogue scale. Pathological examination revealed nonvital tumor cells in the specimen (ypT0N0M0). The patient is disease free at 6 months’ follow-up.

Conclusions

With this approach we experienced excellent access to both the apical and hilar structures. Further experiences are needed to validate the role of VATS lobectomy in the multidisciplinary management of posterior Pancoast tumor.

Tumori 2016; 102(Suppl. 2): e43 - e45

Article Type: CASE REPORT

DOI:10.5301/tj.5000430

Authors

Lorenzo Rosso, Mario Nosotti, Alessandro Palleschi, Davide Tosi

Article History

Disclosures

Financial support: No funding provided.
Conflict of interest: No conflict of interests to declare.

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Introduction

Pulmonary sulcus tumor is a complex and challenging disease that requires a multidisciplinary team approach. This tumor is a rather uncommon type of non-small cell lung cancer, amounting to less than 5% of all lung malignancies. It is also known as Pancoast tumor and is defined as a malignancy invading the parietal pleura at the level of the first rib and above. The SWOG 9416 Intergroup 0160 study has led to the current treatment of Pancoast tumors with a tri-modality combination of chemotherapy, radiotherapy and surgical resection (1). This combination allows a high pathological response rate, a good radical resection level, a reduced local recurrence rate, and an acceptable survival.

The surgical approaches to Pancoast tumors require careful preoperative assessment, and different surgical procedures have been described for improving access to the apical area depending on which structures are involved. We describe a hybrid approach that combines video-assisted thoracic surgery (VATS) lobectomy and limited Shaw-Paulson thoracotomy.

Case report

A 57-year-old man was referred to a peripheral hospital for management of a Pancoast tumor in the right lung. The patient presented with severe right shoulder pain and paresthesia in the right T2 region. Chest x-ray showed a right apical mass; computed tomography (CT) demonstrated a 99 × 92 mm tumor partially invading the lateral aspect of the first, second and third ribs but no mediastinal or hilar lymph node involvement (Fig. 1). Positron emission tomography (PET) showed consistent tumor uptake (standard uptake value: 13.8) and confirmed the absence of mediastinal and distant metastases. Core biopsy resulted in a diagnosis of lung adenocarcinoma, staged as cT3N0M0. The patient was treated with 3 cycles of cisplatin and gemcitabine followed by 30 Gy radiation; the induction therapy ended with an additional 3 cycles of cisplatin and gemcitabine. Restaging with CT and PET revealed total regression of the tumor (ycT0N0M0; Fig. 2).

Computed tomography scan showing the superior sulcus tumor in the upper lobe of the right lung before chemoradiation therapy. The lesion was situated mainly in the lateral and posterior aspects of the thoracic inlet.

Computed tomography scan showing the outcome of induction therapy.

The patient was sent to our unit and scheduled for surgical resection 8 weeks after completion of the induction therapy. He was positioned in lateral decubitus after thoracic epidural catheter placement. An upper right VATS lobectomy through a 3-port standard anterior approach was planned (incisions: 4-cm utility thoracotomy in the fourth intercostal space with soft tissue retractor; two 10.5-mm trocars in the eighth intercostal space). The pleural space and hilar structures were carefully examined with a thoracoscope. The apical adhesions remained untouched but we mapped their external projections with a needle under thoracoscopic guidance. The inferior pulmonary ligament, hilar pleura and lymph node stations 7, 8, and 9 were treated with Harmonic ACE®+7 shears (Ethicon, Somerville, NJ, USA). The upper pulmonary vein and the first arterial branch were individually resected with Tri-Staple EndoGIA® (Covidien, Mansfield, MA, USA). An additional 6-7 mm arterial branch was sectioned safely with the Harmonic. The right upper bronchus and the fissures were treated with staplers. A paravertebral limited chest wall incision, parallel to the edge of the right scapula, allowed resection of the posterolateral portions of the first, second, third and fourth ribs according to the previously drawn map. The right upper lobe was extracted together with the rib segments through the posterior incision. The upper mediastinal lymph node stations were resected under thoracoscopic guidance. Considering that the chest wall resection involved the fourth rib, reconstruction of the posterior chest wall was obtained with a DUALMESH® patch (GORE, Flagstaff, Arizona, USA) to avoid postoperative trapping of the scapula inside the thorax. The utility incision was sutured without the use of intercostal stitches and 2 chest tubes were inserted through the caudal ports (Supplementary Video 1. Available online at www.tumorijournal.com). The postoperative period was uneventful; the pain was surprisingly limited and never exceeded a score of 3 on a visual analogue scale. Definitive pathological examination revealed complete response without tumor cells in the specimen (pathological stage ypT0N0M0). The patient was alive with no recurrence at 6 months’ follow-up.

Discussion

It is well known that VATS offers several potential advantages compared with traditional thoracotomy, but thoracoscopic resections for locally advanced lung cancers must solve problems which are not faced when early-stage disease is managed (2). For patients who need en bloc chest wall resection, thoracoscopic procedures are rather uncommon; in such situations the advantages of VATS over traditional thoracotomy may appear less obvious. Nevertheless, some authors have put forward the hypothesis that postoperative pain may be correlated with “accessory” incisions rather than with the portion of thoracic wall resected, given that the innervation in that portion has been removed (3). In the context of Pancoast tumors, this hypothesis has been endorsed by Caronia and coworkers, who published a study that clearly documented the advantage of surgery supplemented with thoracoscopy over the standard open approach in terms of postoperative pain and morbidity (4).

Proper VATS lobectomy associated with en bloc thoracic wall resection for Pancoast tumor has been sporadically reported: since 2010 6 cases have been described where the anterior transmanubrial approach was combined with VATS lobectomy (5-6-7-8). An aggressive surgical approach to Pancoast tumor located posteriorly has been reported even less: Berry and coworkers mention 2 patients treated with VATS lobectomy plus posterior thoracotomy but provide only minimal technical details (9). In 2012 Cheung and Lim described a VATS lobectomy followed by posterior chest wall resection of the second, third and fourth ribs through a limited posterior thoracotomy (10).

With the described approach we obtained excellent access to both the apical and hilar sites. Of primary importance is a preliminary assessment with the thoracoscope to identify unexpected local conditions which would prevent radical surgical management. Pleural thoracoscopic inspection was imperative in our case because of the uncommon time interval between induction therapy and surgery (8 weeks). It was interesting to note that no cancer cells were found in the original mass despite the long interval. Although the present case included resection of the first, second, third and fourth ribs, the postoperative period was particularly well tolerated, as in all case reports mentioned.

Over the last decades, several techniques have been proposed for the challenging surgical resection of Pancoast tumors; the classical Shaw-Paulson approach is generally accepted as satisfactory in managing posteriorly located tumors. Our experience and review of the literature lead us to consider that specification of terminology will be necessary for a better analysis of future reports on the posterior surgical approach to Pancoast tumors in the era of minimally invasive surgery. Two surgical techniques in particular seem to deserve autonomous value: 1) limited open Shaw-Paulson access plus thoracoscopy aid; 2) proper VATS lobectomy plus minimal Shaw-Paulson thoracotomy. Further experiences are needed to validate the role of VATS lobectomy and to indentify its specific indications in the multidisciplinary management of posterior Pancoast tumors.

Disclosures

Financial support: No funding provided.
Conflict of interest: No conflict of interests to declare.
References
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Authors

Affiliations

  • Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan - Italy

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