VATS Right Middle Lobe Lobectomy in the Setting of Oligometastatic Lung Cancer

Background

A 31-year-old woman who was a former ice hockey player, was in the military, and is a lifetime never-smoker presented with a medical history of asthma, migraine headaches, endometriosis, and recurrent sinus infections. She had a maternal grandfather with lung cancer and a paternal grandmother with colon cancer. During an initial evaluation for a breast abnormality, magnetic resonance imaging (MRI) of the breast was performed and revealed an incidental lung nodule. She then had a computed tomography (CT) scan of the chest, which showed a 3 cm spiculated lesion in the minor fissure on the right, without thoracic adenopathy (shown in video). The lesion was primarily located in the right middle lobe (RML) but extended focally into the right upper lobe (RUL) through the fissure. A 3.4 cm arterial-enhancing liver lesion was noted, but extended imaging determined that this lesion was benign focal nodular hyperplasia.

Methods

A positron emission tomography (PET)-CT scan showed flurodeoxyglucose (FDG) uptake in the right lung mass along with an FDG-avid subcentimeter right paratracheal lymph node. A video bronchoscopy-guided biopsy diagnosed adenocarcinoma, and further genetic testing revealed an exon 19 mutation. A brain MRI revealed two metastases, one in the left occipital lobe of the brain and one in the right parietal lobe (shown in video). She underwent an endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA), which revealed a station 4R lymph node (LN) positive for malignancy.

She underwent stereotactic body radiation (SBRT) to the two brain metastases. Her care was discussed in the multidisciplinary lung ablation tumor board (MDTB). The decision was made to treat her with erlotinib, an inhibitor of the epidermal growth factor receptor. After several months of treatment and SBRT to the brain, reimaging by PET scan showed only residual disease in the RML of the lung. There was no residual uptake in the mediastinum.

The decision was then made to remove the right mediastinal lymph nodes and the RML of the lung, extending the resection to the portions of the RUL that were contiguous with the tumor for a complete resection.

Preference Card (shown in video)

• 5 – 10 mm 30° camera and scope
• 3 long double-action ringed forceps
• (1 sponge stick to stay on the back table at all times)
• 14″ Metzenbaum scissors
• Yankour suction tip and VATS suction tip
• 2 Weitlaner retractors or port protector
• long protected bovie tip, bent at tip
• long-handle double-action curved glover
• large right angle double-action (larger more blunt tip)
• VATS suture scissors
• long-handled double-action right angle clamp
• large EndoCatch™ bag
• Mayo Clinic Scanlan™ VATS Pan (shown in video)
• gray, tan, and purple endoscopic staplers
• Hem-o-lok™ clips
• optional energy device
• Peanut and Tonsil sponges
• 30° operating thoracoscope and video system

Operative Steps

Step One

• Bronchoscopy
• Position and break table
• Confirm DLETT
• Prepare, drape, local anesthetic, incisions
• Hilar LN dissection
• Posterior dissection

Step Two

• Posterolateral retraction of lobe  
• Remove LN between RUL and RML veins
• Right angle clamp RML vein, then divide
• Stapler to complete fissure between RUL and RML

Step Three

• Retract RML superiorly
• Remove lobar LN from artery in fissure
• Divide RML bronchus

Step Four

• Staple RML artery branches

Step Five

• Staple fissure (RML and RUL)
• Complete LN dissection
• Bronchoscopy at end of case

Results

The patient stayed in the hospital for five days after surgery. Her follow-up scans have shown no residual disease. She continues on erlotinib and has a rash from the therapy, but otherwise continues with daily activity and has no complications from her resection.

Conclusions

Patients with oligometastatic disease can be candidates for resection, but they require extensive preoperative evaluation, staging, and multidisciplinary discussion. Such complex patients may have even better survival in the face of novel therapies and minimally invasive surgery.

Tips and Pitfalls

• For RML video-assisted thoracoscopic surgery (VATS) lobectomy, watch for a third branch of the pulmonary artery that can exist.
• When a tumor is in the fissure, take the adjacent lobe to complete the en bloc resection.
• In patients with oligometastatic disease, the brain metastases should be controlled first and then fit patients with controllable disease should demonstrate response to targeted therapy if their disease is an unusual case (such as cases of N2 disease).
• Extraordinary measures should be taken only after MDTB discussion in experienced centers.
• Lung resection in patients with oligometastatic disease should only be considered for patients with good performance status and adequate lung function.
• In the face of a negative CT and PET scan, invasive mediastinal staging (EBUS or video mediastinoscopy) is recommended in patients being considered for curative resection.
• Intrathoracic lymph node disease (N1, N2, or N3) is associated with worse outcome in oligometastatic non-small cell lung cancer.
• Primary lung cancer with synchronous solitary cranial or adrenal metastases should be evaluated for curative aggressive local therapy.
• Curative intent for oligometastatic disease to organs other than lung, brain, or adrenal glands should be considered on a case-by-case basis.

Video References

1. Postmus PE, Brambilla E, Chansky K, et al. The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol. 2007;2(8):686-693.
2. Seo JS, Ju YS, Lee WC, et al. The transcriptional landscape and mutational profile of lung adenocarcinoma. Genome Res. 2012;22(11):2109-2119.
3. Hellman S, Weichselbaum RR. Oligometastases. J Clin Oncol. 1995;13(1):8-10.
4. Mehta N, Mauer AM, Hellman S, et al. Analysis of further disease progression in metastatic non-small cell lung cancer: implications for locoregional treatment. Int J Oncol. 2004;25(6):1677-1683.
5. Ashworth AB, Senan S, Palma DA, et al. An individual patient data metaanalysis of outcomes and prognostic factors after treatment of oligometastatic non-small-cell lung cancer. Clin Lung Cancer. 2014;15(5):346-355.
6. Parikh RB, Cronin AM, Kozono DE, et al. Definitive primary therapy in patients presenting with oligometastatic non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2014;89(4):880-887.
7. Gomez DR, Blumenschein GR, Lee JJ, et al. Local consolidative therapy versus maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer without progression after first-line systemic therapy: a multicentre, randomised, controlled, phase 2 study. Lancet Oncol. 2016;17(12):1672-1682.
8. Lanuti M. Surgical management of oligometastatic non-small cell lung cancer. Thorac Surg Clin. 2016;26(3):287-294.