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Original Research: Lung Cancer |

Thoracoscopic Versus Open Pulmonary MetastasectomySurgical Approach for Pulmonary Metastasectomy: A Prospective, Sequentially Controlled Study

Jens Eckardt, MD; Peter B. Licht, MD, PhD
Author and Funding Information

From the Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.

Correspondence to: Jens Eckardt MD, Department of Cardiothoracic Surgery, Odense University Hospital, 29 Sdr. Blvd, Odense, DK-5000 Denmark; e-mail: jens.eckardt@ouh.regionsyddanmark.dk


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1598-1602. doi:10.1378/chest.12-0249
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Background:  Patients with limited metastatic disease in the lung may benefit from metastasectomy. Thoracotomy is considered the gold standard, and video-assisted thoracoscopic surgery (VATS) is controversial because nonimaged nodules may be missed when bimanual palpation is restricted. Against guideline recommendations, metastasectomy with therapeutic intent is now performed by VATS by 40% of thoracic surgeons surveyed. The evidence base for optimal surgical approach is limited to case series and registries, and no comparative surgical studies were observer blinded.

Methods:  Patients considered eligible for pulmonary metastasectomy by VATS prospectively underwent high-definition VATS by one surgical team, followed by immediate thoracotomy with bimanual palpation and resection of all palpable nodules by a second surgical team during the same anesthesia. Both surgical teams were blinded during preoperative evaluation of CT scans and during surgery. Primary end points were number and histology of nodules detected.

Results:  During a 12-month period, 37 patients were included. Both surgical teams observed exactly 55 nodules suspicious of metastases on CT scans. Of these, 51 nodules were palpable during VATS (92%), and during subsequent thoracotomy 29 additional nodules were resected: Six (21%) were metastases, 19 (66%) were benign lesions, three (10%) were subpleural lymph nodes and one was a primary lung cancer.

Conclusions:  Modern VATS technology is increasingly used for pulmonary metastasectomy with therapeutic intent, but several nonimaged, and therefore unexpected, nodules are frequently found during subsequent observer-blinded thoracotomy. A substantial proportion of these nodules are malignant, and, despite modern imaging and surgical technology, they would have been missed if VATS was used exclusively for metastasectomy with therapeutic intent.

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