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Non-imaged pulmonary nodules discovered during thoracotomy for metastasectomy by lung palpation

^a University of Alabama at Birmingham (UAB), Division of Cardio-Thoracic Surgery, Department of Surgery, United States
^b University of Alabama School of Medicine, United States
^c Division of Cardio-thoracic Surgery, Department of Surgery, United States

Received 5 September 2008; received in revised form 2 January 2009; accepted 8 January 2009.

^_* Corresponding author. Address: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 703 19th St S, ZRB 739, Birmingham, AL 35294, United States. Tel.: +1 205 934 5937; fax: +1 205 975 2815. (Email: rcerfolio{at}uab.edu).

Background: Video-assisted thoracoscopic surgery (VATS) is an increasingly used technique to treat patients with pulmonary metastases, but it does not usually afford lung palpation. Methods: A retrospective study on patients with lesions defined as ‘VATA-able’ who underwent open metastasectomy via thoracotomy. All patients underwent 64-slice helical CT scan with intravenous contrast using 5 mm cuts and integrated FDG-PET/CT. Unsuspected malignant pulmonary nodules that were palpitated and removed, and were not imaged pre operatively were defined as ‘malignant nodules’ and would have been missed by VATS metastasectomy. Results: From January 2004 to December 2005, 57 patients had ‘VAT-able’ metastatic pulmonary lesions that were resected via thoracotomy by one thoracic surgeon. Twenty-one (37%) patients had non-imaged pulmonary nodules that were discovered only by bi-manual palpation and would have been missed by VATS metastasectomy, but these nodules were only malignant in 10 (18%) patients. The median size of the non-imaged pulmonary nodule was 0.7 cm (range, 0.4–0.8 cm). Colorectal carcinoma was the most common tumor requiring metastasectomy. Non-imaged malignant pulmonary nodules were most frequently found in patients with leiyomyosarcoma and osteosarcoma (three of eight patients in both). Conclusion: Metastasectomy via open thoracotomy, which affords bi-manual lung palpation of the entire ipsilateral lung, may discover non-imaged malignant pulmonary metastases in 18% of patients who have had a previously treated solid organ cancer and have at least one imaged metastatic lesion in the lung. The clinical impact of these findings is unknown. A prospective study to further examine this issue is underway.

Abbreviations: NSCLC = non-small cell lung cancer • VATS = video-assisted thoracoscopic surgery • CT = computed tomography • PET = positron emission tomography • maxSUV = maximum standardized uptake value • integrated FDG-PET/CT = integrated 2-dexoy-2-18F-flouro-D-glucose positron emission tomography computed tomography • UAB = University of Alabama at Birmingham • RUL = right upper lobe • RLL = right lower lobe • RML = right middle lobe • LUL = left upper lobe • LLL = left lower lobe • BAC = bronchoalveolar carcinoma

Key Words: Metastasectomy • Thoracotomy • VATS • FDG-PET • Pulmonary nodules