Hybrid Robotic Assisted Right Upper Lobectomy With En Bloc Chest Wall Resection for Pancoast Tumor

The treatment of superior sulcus tumors (Pancoast tumors) has evolved over the past seventy years. Initial treatment was resection followed by irradiation (1). Now, the established trimodal treatment popularized by Shaw and Paulson involves neoadjuvant chemoradiation followed by thoracotomy with right upper lobectomy and resection of the involved ribs (2). The five-year survival with node-negative disease is 30–50 percent, but it is a morbid operation with 5 percent mortality and up to 40 percent major morbidity (3,4,5,6).

Resection of Pancoast tumor is a two-step operation involving dissection of the tumor from the apical structures and upper lobectomy with lymphadenectomy. The open approach is needed for apical dissection and resection of the involved ribs. The lobectomy and lymphadenectomy may be enhanced by video-assisted thoracic surgery (VATS) or a robotic approach. A hybrid approach allows both apical dissection, lobectomy, and lymphadenectomy in a less invasive fashion (7).

Recent studies have demonstrated the safety of VATS for resection of Pancoast tumors (8,9). One study demonstrated similar survival but reduced opioid and analgesics consumption with better recovery of forced vital capacity with VATS (7). In addition, initial VATS allowed exploration of the pleural cavity and avoiding thoracotomy in cases of unexpected pleural involvement. Another study found a shorter length of stay and reduced incidence of chronic pain with hybrid VATS lobectomy followed by limited open resection compared to conventional thoracotomy (10).

A robotic hybrid approach for treatment of Pancoast tumors has only been described in a few case reports (11–13). The robotic approach was first described by Mariole for an anterior Pancoast tumor in an obese patient (11). The apical structures were first dissected followed by robotic lobectomy. Kostic reported a sequential surgical approach with apical dissection followed by robotic lobectomy two days later (12). Uchidu recently described a hybrid approach with robotic inspection of the pleura followed by dissection of the apical structures and chest wall resection, then followed by robotic lobectomy (13). It has been stated that the sequence of lobectomy first has the advantage of disconnecting all pulmonary blood vessels and lymphatics before dissecting the tumor, which may prevent intravenous migration of malignant cells during chest wall resection (10).

This video demonstrates hybrid robotic assisted right upper lobectomy with en bloc chest wall resection for a Pancoast tumor. Lobectomy with mediastinal and hilar lymph node dissection was performed first, followed by posterolateral thoracotomy and dissection of the apical structures with resection of the first three ribs. The patient was discharged home on the second postoperative day. The final pathology revealed adenocarcinoma with extensive treatment effect-pT3N0M0 (Stage IIB) with zero out of eighteen lymph nodes involved. All margins were negative and there was 25 percent viable tumor.

The robotic approach offered inspection of the thoracic pleura to rule out invasion, visualization of the subclavian vessels, and allowed the appropriate number of ribs to be resected. The superior vision and stable platform associated with the robot permitted the lobectomy and lymph node dissection to be performed in a minimally invasive fashion. This resulted in reduced pain and hospital length of stay with enhanced patient recovery.
 

References

1. Chardack WM, MacCallum JD. Pancost syndrome due to bronchogenic carcinoma (successful surgical removal and postoperative irradiation). J Thorac Surg 1953; 25:40 2-12.
2. Shaw RR, Paulson DL, Kee JL. Treatment of the superior sulcus tumor by irradiation followed by resection. Ann Surg 1961; 154:29-40.
3. Paulson DL. The survival rate in superior sulcus tumors treated by presurgical irradiation. JAMA 1966; 196:342.
4. Archiea VC, Thomas CR Jr. Superior sulcus tumors: A mini-review. Oncologist 2004; 9 (5):550-5.
5. Attar S, Kransa MJ, Sonett JR, et al. Superior sulcus (Pancoast) tumor: Experience with 105 patients. Ann Thorac Surg 1998; 66:193-8.
6. Martinod E, D’Avdiffret A, Thomas P, et al. Management of superior sulcus tumors: Experience with 139 cases treated by surgical resection. Ann Thorac Surg 2002; 73:1534-9.
7. Shikuma K, Miyahara R, Osako T. Transmanubrial approach combined with video-assisted approach for superior sulcus tumors. Ann Thorac Surg 2012; 94: e29-30.
8. Caronia FP, Ruffini E, Monte AIL. The use of video-assisted thoracic surgery in the management of Pancoast tumors. Interactive Cardiovascular and Thoracic Surgery 2010; 11:721-726.
9. Caronia FP, Fiorelli A, Ruffini E, et al. A comparative analysis of Pancoast tumor resection performed via video-assisted thoracic surgery versus standard open approaches. Interactive Cardiovascular and Thoracic Surgery 2014; 19:426-435
10. Nun AB, Simansky D, Rokah M, et al. Hybrid video-assisted and limited open (VAL0) resection of superior sulcus tumors. Surg Today 2016; 46:686-690.
11. Mariolo AV, Casiraghi M, Galetta D, et al. Robotic hybrid approach for an anterior Pancoast tumor in a severely obese patient. Ann Thorac Surg 2018; 106: e115-6.
12. Kostic M, Sarsam M, Bottet B, et al. Post-immunotherapy combined with operative technique with an anterior surgical approach and robotic-assisted lobectomy for an anterior superior sulcus tumor-case report. J Vis Surg 2022; 8: 1-5.
13. Uchida S, Suzuki K, Fukui M, et al. Hybrid robotic lobectomy with thoracic wall resection for superior sulcus tumor. Gen Thorac Cardiovasc Surg 2022; 70:756-758.

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G. Kimble Jett is a proctor and speaker for Intuitive Surgical.

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