Small Peripheral Tumors Research Articles

Videothoracoscopic staging and treatment of lung cancer

Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate.(ABSTRACT TRUNCATED AT 250 WORDS)

The correlation between tumor size and lymphatic vessel invasion in resected peripheral stage I non-small-cell lung cancer: A potential risk of limited resection

We attempted to clarify whether a correlation exists between tumor size and the incidence of lymphatic vessel invasion in peripheral non-small-cell lung cancer without regional lymph node metastasis. The study included 212 resected non-small-cell lung cancers classified as pathologic stage I disease and located on the periphery of the lung. The incidence of lymphatic vessel invasion was relatively correlated with the maximum diameter of the tumor as follows: 25% (1/4) for tumor size 1.0 cm or less, 40% (19/48) for size 1.1 to 2.0 cm, 49% (28/58) for size 2.1 to 3.0 cm, and 57% (58/102) for tumor size 3.1 cm or more. The incidence of lymphatic vessel invasion of tumors measuring 3 cm or less in greatest dimension was 44% (48/110). The degree of lymphatic vessel invasion of 20 resected tumor samples measuring 3 cm or less in greatest diameter with hilar lymph node metastasis was also examined for comparison. This figure was as high as 85%. These observations suggest that even small peripheral tumors without any regional lymph node metastasis have a relatively high rate of lymphatic vessel invasion and thus pose a potential risk of local recurrence after a limited resection, especially in a wedge resection of the tumor. (J THORAC CARDIOVASC SURG 1994;108:684-6)

4th World congress of endoscopic surgery Kyoto, Japan 16–19 June 1994 mini-video and oral presentations

Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate. This is sufficient to justify routine performing of videothoracoscopic operative staging as the first step of operation for lung cancer. Furthermore, videothoracoscopic operative staging permits confirmation of resectability of the lesion and, in selected patients, even direct video-excision. In our experience videothoracoscopic treatment proved a safe and concrete opportunity.

Needle Localization of Peripheral Lung Nodules for Video-assisted Thoracoscopic Surgery

Video-assisted thoracoscopic surgery provides an alternative to conventional thoracotomy for resection of peripheral lung nodules. To localize small peripheral lung nodules that may not be visible or palpable by the surgeon, we have placed a Kopans hook wire percutaneously into the lung as a guide. The indications for localization included previous nondiagnostic percutaneous needle aspiration biopsy (PNAB) (n = 4), nodules too small for PNAB (n = 2), nodules inaccessible to PNAB (n = 3), and planned resection of a known peripheral tumor less than 1 cm (n = 1). The localization procedure was performed with computed tomographic guidance in all patients. The nodules ranged in size from 2 to 15 mm and were located immediately subpleural to 2-cm deep the pleura. A 20-gauge Greene biopsy needle was used as an introducer for a 35-cm-long Kopans hook wire. Patients were sent directly to the operating room in a dependent position. All ten nodules were successfully resected, including hamartoma (n = 1), carcinoid tumors (n = 2), granulomas (n = 3), adenocarcinoma (n = 1), fibrosis (n = 1), benign metastasizing leiomyoma (n = 1), and lymphoma (n = 1). In two patients, the wire slipped out of the lung. Small focal pneumothoraces developed in five patients. There were no major complications. This procedure can safely and effectively localize nonvisible or nonpalpable pulmonary nodules for thoracoscopic surgery for diagnostic purposes or for resection of small peripheral tumors in patients who cannot tolerate a lobectomy or pneumonectomy.

Value of computed tomography and mediastinoscopy in preoperative evaluation of mediastinal nodes in non-small cell lung cancer. A study of 569 patients.

The efficacy of computed tomography (CT) and mediastinoscopy as staging modalities to assess mediastinal lymph node status was evaluated in 569 patients with a presumed resectable non-small cell lung cancer (NSCLC). Computed tomography scan was performed in every patient and followed by mediastinoscopy in 331 and by thoracotomy in 477 patients. Mediastinal lymph nodes on CT larger than 1.5 cm were considered pathological. Overall, CT had a sensitivity of 69%, a specificity of 71% and an accuracy of 71% in identifying mediastinal lymph node metastases. For mediastinoscopy these figures were 72%, 100% and 89%, respectively. Computed tomography accuracy was distinctly lower in squamous cell carcinomas and in central tumors, as CT sensitivity was significantly lower in left-sided tumors. The positive predictive value (PPV) of CT in T1 lesions (29%) and PPV and negative predictive value (NPV) of CT in T2 squamous cell carcinomas (30% and 83%, respectively) were low, so questioning its use in those instances. We perform a mediastinoscopy in every situation except for squamous cell carcinomas or small (less than 3 cm) peripheral tumors in the absence of enlarged mediastinal lymph nodes. This selective attitude is rewarding since a) the number of pN2 in the straight thoracotomy group was only 16% versus 41% in the mediastinoscopy group, b) the exploratory thoracotomy rate in the straight thoracotomy group was low (4.6%).

Partial Nephrectomy for Renal Cell Carcinoma: Indications, Results and Implications

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.

Results of Conservative Surgery for Stage I Lung Cancer

This paper reports our results with sublobar resections for stage I non small cell lung cancer. Sixty-one cases of wedge or segmental resection were compared with 517 standard resections (411 lobectomies and 106 pneumonectomies), performed during the years 1971-88. Operative mortality was 0% in the limited resection group and 4% (19/517) in the standard resection group; cancer recurrence was detected in 36% of both groups; actuarial survival at 5 years was 55% versus 48% overall. In 28 patients with pre-existing cardiac or pulmonary co-morbidity, limited resection yielded a similar 5-year survival than standard resection (53% vs 49%) with no perioperative deaths (0 vs 6%). Our data support the experience of other authors on conservative management of stage I lung cancer. Particularly in patients with concomitant cardio-pulmonary disease, previous cancer or small peripheral tumors, limited resection combined with adequate nodal staging may be as effective as standard lobar resection with respect to long term survival.

Nipple preservation during mastectomy

In a retrospective study of 100 patients with operable breast cancer, microscopic involvement of the nipple-areola complex was found in 16 cases. Each of these 16 cases occurred in patients with centrally situated tumours. In contrast, nipple involvement did not occur with peripherally situated tumours lying greater than 2 cm outside the areolar margin (P less than 10(-6), Fisher's exact test). Nipple involvement was more likely in patients with greater than or equal to 4 positive axillary nodes (P less than 0.01, chi 2 test). From this study it appears that nipple preservation may be undertaken during mastectomy for small peripheral tumours, provided the nipple is clinically normal, and frozen section analysis of the sub-nipple area is shown to be free from tumour invasion. These criteria for nipple preservation were satisfied in 20 patients out of a prospective series of 60. In this group, nipple preservation on the skin flap improved the cosmetic result of breast reconstruction in 35 per cent, and facilitated skin closure in 20 per cent. After a mean follow-up period of 50.4 months, nipple preservation was not associated with any significant excess of local recurrences.

Surgical Approach to Lung Cancer with Solitary Cerebral Metastasis: Twenty-Five Years' Experience

From 1960 to 1985, 41 patients underwent resection of a lung cancer and one or more brain metastases. There were 24 men and 17 women ranging in age from 40 to 71 years (average, 56 years). Cell type was adenocarcinoma in 19 patients, squamous in 16, small cell in 4, and large cell in 2. Wedge resection was performed in 4 patients, lobectomy in 20, pneumonectomy in 14, and bilobectomy in 3. Brain irradiation was used for 25 patients (61%). To date, the longest survival is 18.3 years after craniotomy; mean survival is 2.3 years ± 3.8 (± standard deviation). Survival was 55 ± 7.9% (± standard error) at 1 year, 31 ± 7.4% at 2 years, 21 ± 6.5% at 5 years, and 15 ± 6.0% at 10 years. Using multivariate analysis, we evaluated possible significant predictors of improved survival. Only wedge resection was a significant predictor ( p < .01), which suggests better results with a small peripheral lung tumor. Results of our 25 years' experience using an aggressive approach to lung cancer with solitary cerebral metastasis indicate significantly improved patient survival that justifies its widespread use.

Aspiration of thoracic masses and fluid collections under guidance of ultrasonography.

Successful ultrasonic detection and fine needle aspiration of pleural effusions, loculated fluid, and peripheral lung masses were done in 115 patients. No complications, eg, pneumothorax or hematoma, were caused by the fine needle aspirations. There was no false-negative or false-positive cytology because of excellent localization by ultrasound and adequate tissue samples. This series shows ultrasonography to be a valid method of evaluating chest lesions seen to be peripheral on chest roentgenograms. The cystic or solid nature of these lesions was determined; however, we experienced difficulty in differentiating small amounts of loculated fluid from pleural thickening in a few cases. Difficulties were also noted with a few small peripheral tumors that appeared to be cystic on ultrasonography but were proven to be solid by fine needle aspiration. These problems can be resolved by an experienced sonographer using equipment with higher resolution, but we did not hesitate to do fine needle aspiration in such circumstances.

Correlation between the function and structure of the lung in smokers.

To study the relationship between morphologic changes and alteration of lung function, the excised lobes of 21 smokers and one nonsmoker who required lobectomy for small peripheral tumors were inflated and fixed in formalin, and measurements of bronchiolar narrowing and degree of emphysema were made. All patients had comprehensive pulmonary function tests (including diffusing characteristics, the single-breath N2 test, measurements of elastic recoil, and flow-volume measurements with air and helium) performed before lobectomy. Eight of the lobes excised from the smokers had emphysema of grade 15 or more, the greatest being grade 50. Lobes from 11 patients had evidence of airway narrowing. There were 6 lobes with both emphysema and airway narrowing. Pulmonary function was abnormal in some aspect in all lobes except that from the nonsmoker. Whereas the tests of diffusing capacity, particularly the fractional uptake of CO, correlated with the degree of emphysema, the tests of elastic recoil were not predictive of this early degree of emphysema. The degree of small-airway narrowing correlated with maximal mid-expiratory flow rate and the single-breath N2 test. The maximal flow/static recoil pressure curves were the most sensitive indicators of airway abnormality in the patients with emphysema.

Indications for surgery for intrathoracic metastases in testicular carcinoma.

S URGICAL TREATMENT of pulmonary metastases is considered if other means of therapy are not effective or not available. It is only offered when the primary tumor is under control, no metastases are present in other organs, and the patient is a good surgical risk. Metastases may be solitary or multiple, but must be located in areas of the lung where excision is possible without sacrifice of too much lung tissue. Small peripheral tumors may be wedged out with very little loss of lung tissue, whereas centrally placed tumors within the lung may necessitate a lobectomy or even a pneumonectomy. Before surgery, a careful search for extrathoracic metastases is carried out. The presence of major medical problems, such as cardiac disease, uncontrolled diabetes, or poor hepatic or renal function, increases the risks of safe surgical management and may preclude surgical treatment. Pulmonary evaluation is required to assess tolerance to anesthesia and surgery, as well as to loss of lung tissue by resection. Bleomycin, a frequently-used agent in the treatment of testicular carcinoma, impairs lung function by causing interstitial pneumonitis and fibrosis (see article by Go/diner this issue). This is often not appreciated on routine chest x-ray evaluation and is best assessed by pulmonary function tests. The aim of surgical treatment is to prolong survival without severe limitation of pulmonary reserve.

Newly recognized findings on bone scanning in patients with renal cell adenocarcinoma

Two new findings are described: a “cold,” photon deficient spinal metastasis and an absent polyphosphate uptake in a kidney with a small peripheral tumor.

Proceedings: Minimal pulmonary resection in treatment of carcinoma of the lung.

In over 3,000 resections for bronchial carcinoma done by the members of the Veterans Administration Surgical Adjuvant Group, 40 minimal pulmonary resections have been done. Eleven were palliative (identifiable tumor left in the hemithorax) and 29 were considered to be potentially curative. Fifteen of these latter procedures were segmental resections and 14 were wedge resections. Twenty-one were done as compromise procedures and 11 were done on an elective basis. In the 29 patients, there were two postoperative deaths, 18 patients have died prior to five years (nine due to active tumor and nine without clinical evidence of recurrent disease), one patient is alive four months postoperative, and eight patients have survived five years or longer. It is suggested that minimal resections may be selectively used in the treatment of bronchial carcinoma in patients with small peripheral tumors without lymph node involvement.