Elsevier

Surgical Oncology

Volume 12, Issue 3, November 2003, Pages 195-200
Surgical Oncology

The role of thoracoscopy in the management of lung cancer

https://doi.org/10.1016/S0960-7404(03)00029-XGet rights and content

Abstract

The use of video-assisted thoracic surgery (VATS) has allowed surgeons to perform complex procedures that previously required a thoracotomy. While VATS is well accepted in the management of benign thoracic disease, its role in the management of lung cancer continues to evolve. VATS is utilized in many aspects of the management of lung cancer including the evaluation of indeterminate pulmonary nodules and pleural effusions, staging of mediastinal lymph nodes, and the resection of primary and metastatic tumors. However, concerns regarding cost, training issues, and adherence to oncological principles have caused some surgeons to proceed more slowly. This review discusses the current role of thoracoscopy in the management of lung cancer.

Introduction

Lung cancer is the leading cause of cancer death in the United States. While pulmonary malignancies account for 13.2% of all cancers, 28% of cancer deaths are due to lung carcinomas [1]. The 5-year survival rate remains low at <10% [2]. Currently, complete surgical resection is the best hope for cure and has traditionally consisted of an anatomic resection through a thoracotomy. Over the past decade, however, the use of VATS has evolved, and although the indications are still being defined, thoracoscopy is now utilized in many aspects of the management of lung cancer.

Thoracoscopy was introduced in 1910 by Hans Christian Jacobaeus for the treatment of tuberculosis. Originally, a cystoscope was introduced through a small intercostal incision and allowed simple pleural procedures. Visibility was generally limited to the surgeon until the development of video-endoscopic equipment which allowed the entire operating team to view and assist in the operation.

Section snippets

Advantages of video-assisted thoracic surgery

When compared with a traditional thoracotomy, VATS has reduced the amount of chest wall trauma, deformity, and post-operative pain. While a thoracotomy generally requires a 30–40 cm incision, biopsies can be performed through three 1 cm ports (Fig. 1), and a VATS lobectomy is performed using a 5–8 cm incision. The forced expiratory volume at 1 s (FEV1), a measure of pulmonary function, decreases 29% after a thoracotomy versus 15% in those undergoing VATS [3]. There is also indirect evidence that

Diagnosis of pulmonary nodules

With the increasing use of helical CT scans, patients are presenting more frequently with incidental pulmonary nodules and other radiographic lesions (Fig. 2). The potential for malignancy depends on the patient's age, exposure to tobacco smoke, size of the nodule, and growth pattern. If accessible, lesions can be biopsied endobronchially. Percutaneous CT-guided needle biopsy is the least invasive alternative and can offer a specific diagnosis. However, there is a 24% incidence of pneumothorax

Malignant pleural effusion

VATS can be useful in the diagnosis of pleural effusions for which no cause has been found after thoracentesis. In malignant pleural effusions, 40% of cytology results are inconclusive by thoracentesis while VATS is successful in making a diagnosis in 90% of cases due to the ability to visualize suspicious areas for biopsy (Fig. 5) [8]. In addition, VATS allows other interventions to be performed at the time of exploration including talc pleurodesis (Fig. 6), lysis of adhesions, or

Staging of mediastinal lymph nodes

The prognosis and optimal treatment of non-small cell lung cancer is directly related to the pathologic stage at presentation which centers on the status of hilar and mediastinal lymph nodes. With the increasing use of neoadjuvant therapy, staging has become even more important. In a study of 1900 patients, Schirren found that radiographic exams were accurate for staging 33–65% of the time [11]. When these studies are inconclusive, cervical mediastinoscopy is the gold standard and permits

Video-assisted thoracoscopic lobectomy

While VATS lobectomy is technically demanding, it is performed safely in carefully selected patients with conversion to a standard thoracotomy when necessary. VATS should be considered in patients with peripheral stage I tumors with no evidence of hilar or mediastinal lymphadenopathy or fibrosis and complete or near-complete fissures. Lymph node staging and surgical resection margins are equivalent to those obtained by thoracotomy [13]. In addition, VATS has been reported by Kaseda et al. [3]

Resection of pulmonary metastases

The lungs are the second most frequent site of metastasis from a variety of primary cancers. The resection of pulmonary metastases can provide diagnostic and prognostic information in patients with a history of malignancy, and survival may be improved in favorable tumors including colon and renal cell carcinoma, sarcoma, and germ cell tumors. The first resection of a pulmonary metastasis was described by Weinlecher in 1882 [19]. However, the procedure was performed infrequently until Martini et

Conclusions

Over the past decade, the use of VATS has become widespread and has allowed surgeons to perform complex procedures that previously required a thoracotomy. The use of thoracoscopy in benign disease is well accepted, and indications for its use in the diagnosis and treatment of lung cancer are currently being defined. While the use of VATS lobectomy and resection of metastatic lesions continues to evolve, thoracoscopy is now commonly used to evaluate pulmonary nodules and pleural effusions, as an

Jules Lin completed his undergraduate education at Indiana University in 1995 and received his MD degree from Harvard Medical School in 1999. He is currently in his fourth year of general surgical residency training at the University of Michigan where he is a research fellow in the laboratory of Dr. David G. Beer. His research interests include the identification of novel genes in Barrett's dysplasia and esophageal adenocarcinoma as diagnostic and prognostic markers as well as potential targets

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    Jules Lin completed his undergraduate education at Indiana University in 1995 and received his MD degree from Harvard Medical School in 1999. He is currently in his fourth year of general surgical residency training at the University of Michigan where he is a research fellow in the laboratory of Dr. David G. Beer. His research interests include the identification of novel genes in Barrett's dysplasia and esophageal adenocarcinoma as diagnostic and prognostic markers as well as potential targets for future therapy.

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    Mark Iannettoni received his MD degree and a general surgery residency at the State University of New York Health Sciences Center Medical School. After completing both a thoracic surgery residency and a general thoracic surgery fellowship at the University of Michigan, Dr. Iannettoni joined the faculty in 1994. He is currently the Director of the Photodynamic Therapy Program and the Lung Transplant Program. Dr. Iannettoni's interests include thoracic oncology, chest wall reconstruction, minimally invasive surgery, and artificial lung development.

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