Asian Cardiovasc Thorac Ann 2004;12:171-172
© 2004 Asia Publishing EXchange Ltd
Thoracoscopic Transillumination in Chest Wall Resection
Francis J Podbielski, MD,
Roger A Issa, MD,
Jacques-Pierre Fontaine, MD,
Heron E Rodriguez, MD
Division of Thoracic Surgery, University of Massachusetts Medical School, Worcester, Massachusetts, USA
For reprint information contact: Francis J Podbielski, MD Tel: 1 508 334 8996 Fax: 1 508 334 6296 Email: Podbielf{at}ummhc.org Division of Thoracic Surgery, University of Massachusetts Medical School, 67 Belmont Street, Worcester, Massachusetts 01605-2657, USA.
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ABSTRACT
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Determining the extent of chest wall resection during en bloc lung cancer operations is often difficult secondary to the location of these tumors. We describe a hybrid technique that employs video-thoracoscopy and chest wall transillumination to determine the appropriate margin of resection.
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INTRODUCTION
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Less than ten percent of patients with non-small cell lung cancers treated with surgical resection are found to have tumor invasion into the chest wall1–2 (ribs and intercostal muscles) (Figure 1
). Multiple investigators have demonstrated both improvements in survival and a decrease in local tumor recurrence in patients treated with en bloc chest wall resection versus extrapleural dissection.3–5 Determining not only the resectability of these tumors, but the margin of disease-free tissue needed, can often be difficult given their location within the thorax. We report our experience with two patients in whom a hybrid video-assisted thoracoscopic and chest wall transillumination approach was used to perform an optimal resection.
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CASE REPORTS
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A twenty four year-old extremely muscular man presented with complaints of left scapular musculoskeletal pain after lifting heavy boxes at work. A chest radiograph and computed tomograms of the chest showed a lytic lesion in the lateral portion of his left third rib. Thoracoscopic evaluation of the pleura and lung nodules was performed and a lung biopsy showed multiple eosinophilic granulomata. Given the patient’s muscular body habitus and the inability of mechanical ventilation to adequately expand his contralateral lung, the diseased portion of rib measuring 2 cm was readily delineated using a video-thoracoscopy. With the rib lesion identified thoracoscopically, simple transillumination through the chest wall enabled us to map out the required area of resection without sacrifice of excess normal adjacent bone.
A sixty year-old man with an apical, non-small cell lung cancer was found on magnetic resonance imaging to have chest wall invasion without neurovascular involvement. The patient received 40 Gy of local radiation and was noted to have a significant reduction in tumor size, but persistent changes in the chest wall. An exploratory thoracoscopy was performed in conjunction with a standard posterolateral thoracotomy. Thoracoscopic lysis of filamentous adhesions between the lung and parietal pleura was performed. A 3 cm area of tumor invasion into the chest wall was clearly shown. The required line of resection through the ribs was thoracoscopically demonstrated by transillumination through the uninvolved adjacent intercostal musculature. The final en bloc specimen included an 8 x 10.5 cm portion of chest wall containing 3 rib segments as well as the right upper lobe with an attached adherent tumor.
We began our procedures with a thoracoscopic exploration of the chest via a small incision in the mid-axillary line at the eighth interspace. A standard posterolateral thoracotomy incision was made, and the ribs slowly spread. Lysis of pleural adhesions were performed either thoracoscopically or via the thoracotomy incision with improved lighting and visualization. After determining that the tumor was resectable, retractors were placed to expose the area of chest wall in question. The room lights were dimmed and the overhead spotlights extinguished. Using transillumination, the light of either a 0° or 30deg; telescope was used to delineate the exact margin of resection needed to perform an adequate but not excessive chest wall resection (Figures 2 & 3). The margin was inked with a marking pen and a standard rib and intercostal muscle resection performed.
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DISCUSSION
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Concurrent obstructive pneumonia or pleural scarring from adjuvant radiation therapy often obscures the plane for resection and makes differentiation of fibrous scar from tumor invasion difficult. Given the relative inaccessibility of the thoracic apex to direct visualization with the naked eye and to better delineate the extent of chest wall resection in these tumors, we have employed thoracic transillumination and video-thoracoscopy from within the thorax to guide our dissection margin. Digital dissection and blind separation of adhesions can frequently result in violation of the tumor capsule with spillage into the thorax. The benefits of this approach include more precise dissection, accurate margins, and a diminished need for repeated traction on and manipulation of the tumor during dissection.
The goal of en bloc chest wall resection is a negative surgical margin. Given the uncertainty in blind dissection, there exists a tendency for overcompensation to achieve this end. This hybrid open / thoracoscopic approach is advantageous as it limits the amount of normal chest wall sacrificed due to uncertainty while ensuring a sound oncologic surgical procedure.
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REFERENCES
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ABSTRACT
INTRODUCTION
