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Communications to the Editor |

Is Minimally Invasive Outpatient Pneumonectomy the Current Standard of Care for Lung Cancer?Is Minimally Invasive Outpatient Pneumonectomy the Current Standard of Care for Lung Cancer? FREE TO VIEW

Jemi Olak, MD, FCCP
Author and Funding Information

Affiliations: Lutheran General Hospital, Park Ridge, IL ,  University of California Orange, CA



Chest. 1999;115(6):1753-1755. doi:10.1378/chest.115.6.1753
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I read with some concern the article by Tovar in a recent issue of CHEST (November 1998).1 The author has demonstrated that a minimally invasive approach to pneumonectomy is feasible, but is it appropriate to advocate this approach for the definitive treatment of lung cancer? I submit that the answer is no—at least, not yet.

It would be important to know what percentage of all patients he treated for lung cancer required pneumonectomy and, of those patients, what proportion were candidates for this approach. In addition, what selection criteria did he use in determining who required a pneumonectomy and who was a candidate for the minimally invasive approach? Three tumors were staged as T2, but the basis for this designation (eg, size > 3 cm, or of smaller size but with visceral pleural invasion) was not elucidated.

How were the patients staged before pneumonectomy? If surgical staging occurred, did any patients receive induction therapy for N2 disease before pneumonectomy? Tovar states that each patient had a mediastinal lymphadenectomy at the same time as the pneumonectomy. How many lymph node stations were analyzed for each patient? What was the extent of disease in each of the lymph node stations? How does this compare with published results following traditional thoracotomy with lymphadenectomy?

Tovar states that the surgeon’s office communicated with the patient daily. How were patients followed for perioperative complications, such as atrial fibrillation and deep venous thrombosis? Were visiting nurses utilized? What analgesia was used and for how long was it required?

Tovar states that a 6- to 8-cm incision decreases the possibility of chest wall implantation of tumor, yet provides us with no long-term evidence to confirm this statement. I suspect that chest wall implantation with tumor would be likely (Tovar’s Fig 2) as long as the specimen is removed from the chest cavity without enclosing it in a protective plastic bag, as is now done when a video-assisted thoracic surgery approach is used.

I was disappointed that no mortality data (30 day, 1 or 2 year) were reported in his series of five patients, three of whom had stage IIIa non-small cell lung cancer.

This approach has not been proven in a randomized controlled trial to be a cancer operation equivalent to traditional thoracotomy. I would strongly caution the public and the medical profession against seeking out minimally invasive surgery for the definitive treatment of lung cancer at this time. A 4- to 5-day hospital stay with a curative resection should appeal more to an individual with lung cancer than a 1-day stay following an unproven minimally invasive procedure given the knowledge that recurrent or persistent disease is rarely cured by remedial surgery or adjuvant therapy. While thoracic surgeons everywhere continue to try to decrease the pain associated with thoracotomy and the length of stay following the procedure by utilizing smaller incisions, thoracic epidural analgesia, clinical pathways, and careful assessment of the impact that these changes have on the quality of the surgical procedure is mandatory.

Correspondence to: Jemi Olak, MD, FCCP, Lutheran General Hospital, 1700 Luther Lane, Park Ridge, IL 60068; e-mail: jemi.olak@advocatemedical.com

Figure Jump LinkFigure 1. This patient underwent a traditional posterolateral thoracotomy for diagnostic purposes in another institution. Aspiration of an abscess followed a 9-day hospital stay. Five months later, following failure of medical therapy, I performed right upper and middle lobectomies through the upper incision. The patient was discharged home the day after surgery.Grahic Jump Location
Tovar, EA (1998) Minimally invasive approach for pneumonectomy culminating in an outpatient procedure.Chest114,1454-1458. [PubMed] [CrossRef]
 

Is Minimally Invasive Outpatient Pneumonectomy the Current Standard of Care for Lung Cancer?

To the Editor:

“Surgery is not a province with fixed boundaries.”

O. H. Wagensteen

I thank Dr. Olak for her interest and comments regarding my recently published article (November 1998).1-1 Access to the chest cavity through the standard posterolateral thoracotomy consists of a large incision in which major thoracic muscles are divided, a rib resected, and one or two other ribs transected to improve visibility. The technique of opening the thorax and performing a pneumonectomy was a fairly straightforward exercise in applied anatomy, perfected by the end of the 19th century when less than 200 cases of lung cancer had been reported.1-2 This approach, by itself, has significant complications.1-3 In fact, patients who undergo exploration without parenchymal resection do not escape severe complications following an open-and-close procedure (Fig 1). Olak refers to the traditional thoracotomy as a “cancer operation” as though a paramedian incision to perform a radical gastrectomy is less of a cancer operation compared to one performed through a midline incision. There is no scientific evidence, to my knowledge, that a larger incision in itself produces more curative resections than a smaller one. The quality of the resection depends on the intracavitary technique used to resect the cancerous tissue and not the approach to access the chest cavity. It is therefore possible to perform an oncologically sound resection while minimizing collateral damage.

Like most surgeons trained before the advent of laparoscopic cholecystectomy, I was taught the standard posterolateral thoracotomy approach as the method of choice to access the chest cavity. The now anachronic adage, “big surgeons make big incisions,” was omnipresent in operating suites throughout the country. To decrease morbidity and discomfort to patients in my practice, I made a gradual transition to the oblique muscle-sparing minithoracotomy. Initially, I stopped removing and transecting ribs, then I spared a muscle, and then I adopted the muscle-sparing approach. Throughout this process, I developed new skills that allowed me to perform exactly the same operation that I would have with a wide open thorax.

Olak would like to know what percentage of my patients were candidates for this approach and what criteria I used in determining who required pneumonectomy, as though the criteria should change. Since April 1993, without exception, every patient I have operated on for lung cancer has received an oblique muscle-sparing minithoracotomy.1-4 The criterion for lobectomy, bilobectomy, and pneumonectomy has never changed and the type of access has nothing to do with it. The criterion is universal and consists of the removal of the least amount of lung parenchyma necessary to completely clear all malignant tissue and lymphatic spread. There is no justification to jeopardize the quality of the resection in the name of a small incision. If the appropriate skill has not yet been developed, a more redundant approach should be used. As stated by Morgenstern,1-5 competence is at the heart of professional ethics and it is always challenged by new technology.

There are two kinds of intracavitary techniques for major lung resections: mass ligation vs individual ligation of hilar structures. The former was virtually abandoned in the early 1940s in favor of the latter. A stapling technique has emerged as a modern version of mass ligation in thoracoscopic procedures. The value of mediastinal lymphadenectomy vs nodal sampling remains controversial. I practice the isolation-ligation of the three hilar elements and find mass ligation to be an aberration. I also believe that systematic mediastinal lymphadenectomy is a sounder cancer operation.

Through a minithoracotomy, the specimen can be removed as easily as with a larger thoracotomy; that is shown in Figure 2 of the article.1-1 A nonrib-spreading thoracoscopic resection may lead to deposition of viable clumps of malignant cells during the extraction of the specimen1-6 and, therefore, a plastic bag in these cases seems appropriate.

The clinical pathway given in the article is implemented to prevent complications. If patients are active immediately after surgery, the possibility of deep vein thrombosis and many other common complications is nonexistent. Some of our patients did not require any analgesia, despite early activity, and others required only oral pain medication.

There were no deaths at 30 days, one death at 8 months due to distant recurrence, and one patient with metastatic disease from the appendix, who presented with brain metastasis 13 months after surgery and died 3 months later. The other three patients remain alive and cancer-free at 21, 23, and 24 months of follow-up, despite the advanced disease stage. None of the five patients has had local recurrence.

Olak would like me to present numbers, sizes, and percentages as though I could statistically prove that the access should be used. She forgets that the paper is about “can do,” not “should do,” as I clearly stated in the article.1-1

Finally, I would like to close with the words of A. J. Walt1-7: “If the objective of surgery is to achieve cure or palliation with as little discomfort to the patient as possible, conceptual transformations are inevitable. Genuine recognition of the tyranny of mind-sets that have inflexible and nonporous walls is essential to productive change. Paradigm-lepsis is dangerous but not rare.”

Correspondence to: Eduardo A. Tovar, MD, FCCP, 100 E. Valencia Mesa Dr., Suite 301, Fullerton, CA 92835; e-mail: etovarmd@aol.com

References
Tovar, EA Minimally invasive approach for pneumonectomy culminating in an outpatient procedure.Chest1998;114,1454-1458. [PubMed] [CrossRef]
 
Adler L. Primary malignant growths of the lungs and bronchi. New York, NY: Longsmans, Green & Co, 1912.
 
Goodman, P, Balachandran, S, Guinto, FC, Jr Postoperative atrophy of posterolateral chest wall musculature: CT demonstration.J Comput Assist Tomogr1993;17,63-66. [PubMed]
 
Tovar, EA, Roethe, RA, Weissig, MD, et al Muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia: an improved method for major lung resections.Am Surg1998;64,1109-1115. [PubMed]
 
Morgenstern, L The ethics of applying new technologies.Surg Rounds1998;21,477-482
 
Downey, RJ, McCormack, P, LoCicero, J, III, Video Assisted Thoracic Surgery Study Group. Dissemination of malignant tumors after video-assisted thoracic surgery: a report of twenty-one cases.J Thorac Cardiovasc Surg1996;111,954-960. [PubMed]
 
Walt, AJ New technology: temptations, challenges, and educational implications.Surg Endosc1994;8,1375-1379. [PubMed]
 

Figures

Figure Jump LinkFigure 1. This patient underwent a traditional posterolateral thoracotomy for diagnostic purposes in another institution. Aspiration of an abscess followed a 9-day hospital stay. Five months later, following failure of medical therapy, I performed right upper and middle lobectomies through the upper incision. The patient was discharged home the day after surgery.Grahic Jump Location

Tables

References

Tovar, EA (1998) Minimally invasive approach for pneumonectomy culminating in an outpatient procedure.Chest114,1454-1458. [PubMed] [CrossRef]
 
Tovar, EA Minimally invasive approach for pneumonectomy culminating in an outpatient procedure.Chest1998;114,1454-1458. [PubMed] [CrossRef]
 
Adler L. Primary malignant growths of the lungs and bronchi. New York, NY: Longsmans, Green & Co, 1912.
 
Goodman, P, Balachandran, S, Guinto, FC, Jr Postoperative atrophy of posterolateral chest wall musculature: CT demonstration.J Comput Assist Tomogr1993;17,63-66. [PubMed]
 
Tovar, EA, Roethe, RA, Weissig, MD, et al Muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia: an improved method for major lung resections.Am Surg1998;64,1109-1115. [PubMed]
 
Morgenstern, L The ethics of applying new technologies.Surg Rounds1998;21,477-482
 
Downey, RJ, McCormack, P, LoCicero, J, III, Video Assisted Thoracic Surgery Study Group. Dissemination of malignant tumors after video-assisted thoracic surgery: a report of twenty-one cases.J Thorac Cardiovasc Surg1996;111,954-960. [PubMed]
 
Walt, AJ New technology: temptations, challenges, and educational implications.Surg Endosc1994;8,1375-1379. [PubMed]
 
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