A Different Perspective on Minimally Invasive Thoracic Surgery for a Strange Case of a Clinical Stage IA Lung Neuroendocrine Tumor

This video shows a novel minimally invasive thoracic (MIT) caudal approach used in the authors’ institution since 2014. The video illustrates a procedure for a patient affected by a biopsy-proven neuroendocrine tumor of the middle lobe of the lung (cT1aN0Mx). The tumor was incidentally discovered during a clinical workup for her HCV-related liver cirrhosis.

In April 2015, a 72-year-old woman with severe comorbidities (Charlson Comorbidities Index=8) and a 68Ga-DOTA-NOC PET/CT mildly positive for the suspected lung lesion (SUV max=2), underwent a right middle lobectomy via the MIT caudal approach. A systematic lymphadenectomy of the mediastinal, hilar, and intraparechymal stations (separately on specimen) was performed. A wedge resection of the lower lobe was also done intraoperatively for a sub-centimeter lung nodule discovered with finger palpation of the remaining lung parenchyma.

The overall surgical time was 215 minutes and the intraoperative blood loss was 250 ml. The postoperative course was uneventful. The daily chest tube output averaged 190 ml (range of 150-450), with no air leak or signs of subcutaneous emphysema. The patient had the chest tube removed on the fifth postoperative day, and was sent home the day after without supplemental oxygen. The pathological diagnosis was a rare association of multiple typical lung carcinoid lesions (pT3N1Mx, Stage IIA), idiopathic diffuse hyperplasia of pulmonary neuroendocrine cells (DIPNECH), and mucosa-associated lymphoid tissue (MALT). The micro-nodule of the lower lobe was a 0.4 cm tumorlet. The patient was alive in the eight month after surgery and her radiologic workup showed no evidence of local recurrence.

By adopting the caudal approach, the authors were able to successfully diagnose a unique case of an aggressive combination of multifocal carcinoid tumors and MALT, as well as treating a frail, elderly patient without any complications in a minimally invasive way.