Kim, Anthony W. MD*; Kull, David R. MPH*; Zieliński, Marcin MD, PhD†; Boffa, Daniel J. MD*; Detterbeck, Frank C. MD*
From the *Section of Thoracic Surgery, Yale School of Medicine, Yale University, New Haven, CT USA; and †Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
Accepted for publication December 19, 2013.
A video clip is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.innovjournal.com). Please use Firefox when accessing this file.
Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 12–15, 2013, Prague, Czech Republic.
Disclosure: The authors declare no conflicts of interest.
Address correspondence and reprint requests to Frank C. Detterbeck, MD, Section of Thoracic Surgery, Yale School of Medicine, Yale University, 330 Cedar St, BB 205, New Haven, CT 06520 USA. E-mail: Frank.Detterbeck@yale.edu.
Abstract: Transcervical extended mediastinal lymphadenectomy (TEMLA) has been shown to be feasible and safe. This approach may be underrecognized for providing excellent access to the pleural space. We present a 60-year-old woman who had a clinical stage T2b N0 M0 adenocarcinoma of her right lower lobe and several ground glass opacities throughout her upper lobes bilaterally. She underwent a TEMLA to confirm absence of lymph node involvement in her mediastinum. During the same anesthetic setting, a transpleural right upper lobe wedge resection via the cervical approach was performed as an extension of her TEMLA. The pathology from this wedge resection demonstrated atypical adenomatous hyperplasia. Ultimately, she underwent a thoracoscopic right lower lobectomy that confirmed that she had a pathologic T2b N0 M0 (5.0 × 4.0 × 3.0 cm) adenocarcinoma. There were no perioperative adverse events with either operation. Transcervical extended mediastinal lymphadenectomy and transcervical lung resections may be performed safely during the same anesthetic setting.
Video mediastinoscopic transcervical mediastinal lymphadenectomy demonstrates that extensive extirpative procedures can be performed via the neck.1,2 In the process of performing the lymphadenectomy, the space that is created is relatively large and can provide easy access to the chest. This principle has been extended by Zieliński and associates,3 who described the performance of right upper lobectomies through the transcervical approach. We present the case of a 60-year-old woman who underwent a video-assisted transcervical extended mediastinal lymphadenectomy (TEMLA) for staging of her known non-small cell lung cancer. We added a transcervical right upper lobe wedge resection to complete her staging given the presence of innumerable, bilateral, upper lobe–predominant, pure ground glass opacities (GGOs) of unclear etiology.
A 60-year-old woman was found to have a right lower lobe mass on a chest radiograph. A chest computed tomographic scan demonstrated a large (5 cm) central mass in the right lower lobe concerning for a primary lung malignancy. In addition, she was found to have innumerable pure GGOs predominantly in the upper lobes, bilaterally (Fig. 1).
She underwent flexible bronchoscopy and endobronchial ultrasound–guided biopsies; the right lower lobe lesion was positive for a moderately differentiated adenocarcinoma, but right and left station 4 and station 7 lymph node biopsies were negative. Concern remained that the other GGOs could represent other foci of malignancy or possibly multifocal disease. Furthermore, our policy is to perform mediastinoscopy to confirm the absence of mediastinal lymph node involvement after a negative endobronchial ultrasound–guided biopsy result. Therefore, TEMLA and a transcervical right upper lobe wedge resection were planned to rule out the presence of additional malignancies in the right upper lobe (RUL) (and presumably also on the left) that would have precluded curative-intent resection. A priori, the TEMLA approach was thought to be the ideal approach for a transcervical wedge resection because of the fact that the resection of the mediastinal lymph nodes would result in a remaining thin veil of mediastinal pleura that could be traversed with relative ease. As per institutional protocol, the Rultract (Rultract Inc, Cleveland, OH USA) was placed across the chest of the patient and used to retract the sternum anteriorly. Once the pleurotomy was created and widened, gentle multidirectional retraction was used to provide sustained access to the right pleural cavity. Using a combination of laparoscopic and thoracoscopic instruments, the apex of the right upper lobe was grasped and retracted. A standard linear cutting endoGIA stapler (Covidien, North Haven, CT USA) was then introduced through the same incision alongside the retracting instruments. Through a series of firings of the endostapler, a generous wedge resection of the right upper lobe was accomplished (Video 1, http://links.lww.com/INNOV/A44). At the completion of the procedure, the neck incision was closed in a manner identical to that which is used with a routine cervical mediastinoscopy. A 14F pigtail catheter was placed in the second intercostal space in the midclavicular line in the right side of the chest. The patient tolerated the operation, which was performed without any complications. The chest tube was removed the next day, and the patient was discharged home less than 24 hours after admission.
The right upper lobe wedge resection demonstrated the presence of atypical adenomatous hyperplasia, and the TEMLA showed the absence of mediastinal lymph node involvement, resulting in a final clinical stage of T2b N0 M0. She underwent a video-assisted thoracoscopic right lower lobectomy (Video 2, http://links.lww.com/INNOV/A43). At the time of her planned lobectomy, another RUL wedge resection was performed to confirm that there was adequate sampling during the transcervical wedge resection. Her postoperative course was unremarkable. The final pathology demonstrated a 5.0 × 4.0 × 3.0-cm right lower lobe adenocarcinoma and atypical adenomatous hyperplasia in the additional RUL wedge resection. Therefore, the pathologic stage was pT2b N0 M0 (stage IIA). She remains disease-free at 21-month follow-up.
In the patient presented in this report, the transcervical approach to her wedge resection was performed to provide additional staging information. The patient had no prior chest computed tomographic scans; therefore, knowing whether the innumerable pure GGOs represented multifocal primary lung cancers or metastasis was not possible a priori. Resecting the apex of the right lung was presumed to provide sufficient information regarding the other GGOs. Had the final pathology from the right upper lobe wedge resection demonstrated an invasive adenocarcinoma, the patient would have been designated as having T4 or M1 disease. Ultimately, chemotherapy would have been administered rather than proceeding with a right lower lobectomy with or without focused resections of any other suspected disease because of the diffuse nature of her disease.
A review of the literature demonstrates that transcervical surgery currently is gaining acceptance and slowly moving from a novel approach to one that may have a greater number of indications, possibly including a greater number of lung resections.4,5 In the procedures performed to date, the transcervical approach has been found to be safe. Transcervical extended mediastinal lymphadenectomy represents the most thorough level of mediastinal staging6 and obviously relies on the transcervical approach, with excellent visualization of the mediastinum and the pleural spaces bilaterally.
A major benefit is that a transcervical approach is tolerated significantly better than even a minimally invasive thoracic approach. Cervical mediastinoscopy and other cervical operations are typically performed as outpatient procedures. We acknowledge that patients undergoing wedge resections can also be discharged on the same day (as the authors have done), but this practice is generally not performed as commonly as outpatient mediastinoscopy. Although thoracoscopic resection is less painful than open thoracotomy, it is still associated with more pain than a cervical incision.7 Furthermore, the possibility of longer-term pain associated with thoracoscopy exists.8 For these reasons, we believe that the transcervical approach should also garner additional consideration.
The technique described in this report represents an extension of an existing procedure rather than the development of an entirely new one. Unlike the development of natural orifice surgery, which represents an entire paradigm shift, the transcervical approach to a lung resection represents a natural and extended iteration of a preexisting approach. The history of thoracic surgery has been one in which innovations that have emerged as successful are often extensions of prior operations. A modern-day example is the acceptance of the thoracoscopic approach as an oncologically equivalent alternative approach to thoracotomy for pulmonary resections. Like the thoracoscopic approach, the authors would argue that the technique presented in this report is less of a radical change in approach but represents an alternative that potentially could benefit patients. Others have reported the transmediastinal approach via a thoracotomy or thoracoscopy for the resection and retrieval of the contralateral lung for different indications, malignant and nonmalignant.9–11 The rationale for proceeding with the right side was multifaceted. All of the GGOs were assumed to be similar, and, therefore, a sampling of any lesion was planned to be adequate. Given this assumption, accessing the right pleural cavity was considered to be the most straightforward route into the chest because of the fact that the aortic arch and its vessels did not have to be negotiated.
Given the limited experience associated with this approach, establishing the indications and contraindications for the transcervical approach to the pleura specifically has yet to be completely and definitively delineated. Nevertheless, it should not be considered presently in patients in whom there is a contraindication to cervical mediastinoscopy, TEMLA, or entering the pleura via thoracoscopy. Similarly, the full spectrum of complications that can potentially occur has yet to be understood completely. However, because this approach is an extension of the TEMLA approach and also uses the principles of thoracoscopy, it is imperative that measures be taken to avoid complications in a manner similar to if each approach was performed independently. The theoretical advantage of the approach described is its benefit in terms of pain and pain management. Owing to the novelty of this approach, the data supporting this theoretical advantage are presently lacking. Although there are data to support TEMLA being very well tolerated from a pain perspective,7 extrapolating these data to the transcervical approach to the pleural cavity may not be entirely valid. Furthermore, direct comparisons of the transcervical and thoracoscopic approaches for lung resections with respect to pain are nonexistent. Greater clinical experience with this approach specifically may help to elucidate this issue.
To our knowledge, this is the first report of the coupling of TEMLA and transcervical lung resection in the United States. This report demonstrates that the addition of the transcervical lung resection is feasible during the same anesthetic setting and represents a minor extension to the dissection that is already being performed as part of the TEMLA operation.
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This interesting experimental study examined the efficacy of a number of different resection tools for excising human calcified aortic valves in an ex vivo model. The laser scalpel, scissors, and a punching device were used, and the cutting surface area was examined with standard histology and electron microscopy. The laser scalpel had better results than either the punching device or the scissors. There were no significant differences between the scissors and the punching device. They concluded that the laser cutting device may have some advantages over the other tools. The readers should keep in mind that this was an ex vivo experiment and in vivo studies will need to be performed to better assess these different tools. However, the authors are to be congratulated on their work and their efforts to objectively evaluate these devices.