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Eur J Cardiothorac Surg 1999;16:S37-S39
© 1999 Elsevier Science NL

Staged axillary thoracotomy for bilateral lung metastases: an effective and minimally invasive approach

General Thoracic Surgery, Catholic University of Rome (Divisione di Chirurgia Toracica, Università Cattolica del Sacro Cuore), Largo Agostino Gemelli, 800168 Rome, Italy

^* Corresponding author. Tel.: +39-06-3015-4166; fax: +39-06-3051-162 (Email: stemargaritora{at}yahoo.com).

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objective: We describe our experience with the staged axillary thoracotomy (SAT), for the treatment of bilateral lung metastases. Materials and Methods: Between January 1995 and June 1998, 75 lung metastasectomies were carried out in our institution, 49 (65%) monolateral, and 26 (35%) bilateral. In the latter group of patients we adopted a staged axillary thoracotomy. Results: All wedge resections and two lobectomies (1 LUL and 1 RLL) were performed through this approach. Resection has been complete in all patients. Histology was epithelial in 15 (57%), sarcoma in nine (35%) and germ cell in two (8%). Two to three metastases have been resected in 10 patients (38%); four to 10 in 12 patients (46%) and over 10 in four patients (15%). The radiological pre-operative assessment was accurate in 15 patients (57%), underestimated in nine (35%) and overestimated in two (8%). The average interval between the two procedures has been 24±6 days. The average operation duration time was 50 min (range 36–67). We do not report any post-operative death or major complication. The average hospitalization was 3.2 days (range 2–6) for each single procedure and 6.2 days (range 4–10) for both procedures. Conclusion: This technique is adequate, fast and safe and did not affect the shoulder girdle motion at all providing an excellent cosmetic outcome. The operative trauma is limited and a minor post-operative pain is present. A shortening of the interval between the two operations is allowed.

Key Words: Lung metastases • Surgery • Axillary thoracotomy • Muscle sparing

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
The lung, in its filtering capacity for the entire circulation, is a common metastatic site for malignant disease. Since metastatic pulmonary tumors are often multiple and bilateral [1], surgery, within the framework of multidisciplinary treatment [2] is often needed.

With regard to the approaches for bilateral lung metastasectomy, several techniques have been used in the different institutions: the bilateral thoracotomy, the median sternotomy, the ‘clamshell' thoracotomy, and the video-assisted thorascopic surgery (VATS) bilateral approach. Each of these techniques presents its advantages and drawbacks. Since 1995 we have employed a staged axillary thoracotomy for the treatment of bilateral lung metastases. The results of our experience, in terms of feasibility and surgical outcome, are described herein.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
During the period between January 1995 and June 1998 75 patients underwent lung metastasectomy in our Institution, 49 monolateral (65%) and 26 (35%) bilateral. In this paper we refer to this group of 26 patients (18 males and eight females) with a mean age of 41 years (range 11–76 years). The patients were selected according to the following criteria: (a) complete control of the primary tumor; (b) ability to resect all the pre-operatively detected metastatic disease; (c) ability of the patients to withstand the extent of bilateral pulmonary resections; (d) absence of extra-thoracic disease; and (e) absence of better alternative treatment.

A radiological assessment of the extent of intra-thoracic disease has been performed by means of high resolution CT scan and the respiratory function was evaluated in all patients. The vital capacity (VC) ranged from 1.95 to 4.85 l (mean 3.37 l), the %VC ranged from 72% to 128% (mean 101%), the forced expiratory volume in 1 s (FEV₁) ranged from 1.45 to 4.15 l (mean 2.60 l) and FEV₁% ranged from 65.8% to 92.4% (mean 77.3%).

The primary tumor was epithelial in 15 cases (57%), sarcoma in nine (35%) and germ cell in two (8%). An interval in the range of 3 to 4 weeks between the two staged procedures has been planned. The number of metastases in each side (the higher first) was the only selection criteria to decide which side to operate upon first.

Surgery was performed via a staged axillary bilateral thoracotomy. With the patient secured in the lateral position, a vertical incision 10 cm long is made in the mid-axillary line just below the hairline between the sixth and seventh intercostal space. The sub-cutaneous layer is dissected and then, with a muscle sparing technique, the latissimus dorsi and the serratus anterior are exposed and elevated from the chest wall with a retractor. The appropriate interspace is opened and a small rib spreader is inserted. Ribs are spread to the extent of 7–10 cm, just to allow hand palpation of the entire lung and the resection of all detected metastases. Once haemostasis and aerostasis are verified a single chest drain is placed and the thoracotomy is closed in layers. An overall number of 52 surgical procedures have been carried out. In two cases we performed a lobectomy (one right lower lobectomy and one left upper lobectomy), in two different patients due to the proximity to the primary hylum of the lesions. All other patients underwent wedge resections.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
The resection was considered complete in all patients. Two to three metastases were resected in 10 patients (38%); four to 10 in 12 patients (46%) and more than 10 in four patients (15%). The average time of surgery, referred to the single procedure, was 50 min (range 36–67 min), while the average blood loss was 220 ml (50–650 ml). In all patients the endotracheal double-lumen tube was removed immediately after the operation and no intensive care unit recovery was needed.

The blood gases have been checked 24 h after the second operation and we obtained the average value of PaO₂ of 130.7 mmHg (range 102–170 mmHg with a FiO₂ of 40%. The average value of PaCO₂ was 42.3 mmHg (range 39.7–49.3 mmHg).

We did not have any post-operative death or major complication. The post-operative analgesia was obtained by means of continuous infusion for the first 24 h of Ketorolac 1.5 mg/kg per day. No one of the patients needed further i.v. pain medication. When necessary, oral NSAIDs were administered. The average value of hospital stay was 3.2 days (range 2–6) when referred to the single procedure and 6.2 days (range 4–10) when referred to both procedures.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
It has been clearly demonstrated that lung metastasectomy, since the primary cancer is under control, is a potentially curative treatment. In fact, a complete removal of all metastatic disease is associated with long term survival [1]. Furthermore, there is sufficient experience reported in literature to suggest that pulmonary metastasectomy can be undertaken with extremely low mortality and minimal morbidity [3].

In patients with bilateral pulmonary metastases, the best surgical approach should be radical, minimally traumatic and cosmetically acceptable.

A two stage postero-lateral thoracotomy has been performed in earlier treatments [4] when bilateral lung metastatic disease was detected. This procedure is radical and less traumatic than the single-stage one, which is accompanied by a very severe post-operative pain that can result in severe restrictive disorder, but it was revealed to have, however, several disadvantages. In fact, tumors continue to grow due to the long interval between the two operations and the reduction of immunological competence, moreover adjuvant therapy is impossible in between the two procedures [5,6].

Median sternotomy was then proposed as an alternative to the postero-lateral [7] for the treatment of bilateral lung metastases. This approach allows the resection of the bilateral disease in a single procedure and it is less painful [8]. Large lesions close to the hylum lesions in the lower lobes, particularly in the posterior segments, are accessible with great difficulty [2]. Moreover, where the consistency of lesions is anticipated to be similar to that of normal lung (i.e. in synovial sarcoma metastases), their detection through this approach can be also difficult [6]. The cosmetic outcome of the median sternotomy is poor.

The ‘clamshell' bilateral thoracotomy combines the benefits of a single procedure with the ability to access all locations of the disease [9]. For this procedure, the post-operative pain is intense and the cosmetic outcome is poor. Furthermore, even if technically easy, it has been reported that the average operation time, in a consecutive series of 14 patients, is 212 min, with an average post-operative hospitalization of 22 days [2].

The VATS procedure has spread in recent years, it is now also used in the treatment of bilateral lung metastases [10,11]. This approach is surely less traumatic and cosmetically acceptable, but it cannot provide optimal intra-operative identification and palpation of pulmonary lesions [2]. This is really important given the fact that it has been demonstrated how, when dealing with pulmonary metastases, pre-operative radiological assessment is still inadequate. In the consecutive series of 1134 patients with bilateral lung metastases observed by the members of the International Registry of Lung Metastases (IRLM) the radiological pre-operative assessment of the disease was accurate in only 37% of patients, underestimated in 38% and overestimated in 25% [1]. Furthermore there were a few reports of chest wall incisional metastasis arising after a VATS procedure for cancer [12,13].

We have employed the two stage axillary thoracotomy since 1995. This approach, as a muscle sparing technique, was described by Ginsberg in 1993 [14].

A very favorable operative field is provided by this approach that is adequate for all pulmonary resections. It has been demonstrated to be fast and safe and did not affect the shoulder girdle motion at all. The operative trauma is limited so that a minor post-operative pain is present and a shortening of the interval between the two operations is allowed. Furthermore it provides an excellent cosmesis.

The approach we described in this paper allowed us to obtain a complete resection, so we expect from our series, survival and disease free intervals values in line with those reported in literature.

When dealing with patients with bilateral lung metastases we think that the two stage axillary bilateral thoracotomy is a valuable approach and well accepted by patients. We cannot forget, however, that, in these patients, strict selection criteria must be observed, and, among these, the biological behavior of the disease has to be cautiously evaluated no matter which surgical approach is intended to be used.

	Footnotes

 
Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

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3. Todd TR. The surgical treatment of pulmonary metastases. Chest 1997;112:287S-290S.[Abstract/Free Full Text]
4. Takita H, Merin C, Didolkar MS, Douglas HO, Edgerton F. The surgical management of multiple metasases. Ann Thorac Surg 1977;24:359-364.[Abstract]
5. Stewart JR, Carey JA, Merrile WH, Frist WH, Hammon JW, Bender HW. Twenty years' experience with pulmonary metastasectomy. Am Surg. 1992;58(2):100-103.[Medline]
6. Robert JH, Ambrogi V, Mermillod B, Dehabreh D, Goldstraw P. Factors influencing long term survival after lung metastasectomy. Ann Thorac Surg 1997;63:777-784.[Abstract/Free Full Text]
7. Regal AM, Reese P, Antkowiak J, Hart T, Takita H. Median sternotomy for metastatic lung lesions in 131 patients. Cancer 1985;55:1334-1339.[Medline]
8. Johnston MR. Median sternotomy for resection of pulmonary metastase. J Thorac Cardiovasc Surg 1983;85:516-522.[Abstract]
9. Bains MS, Ginsberg RJ, Jones II WG, McCormack PM, Rusch VW, Burt ME. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumours. Ann Thorac Surg 1994;58:30-33.[Abstract]
10. Dowling RJ, Ferson PF, Landreneau RJ. Thoracoscopic resection of pulmonary metastases. Chest 1992;102:1450-1454.[Abstract/Free Full Text]
11. Miller DL, Allen MS, Trastek VF, Deschamps C, Pairolero PC. Video thoracoscopic wedge excision of the lung. Ann Thorac Surg 1992;54:410-414.[Abstract]
12. Fry WA, Siddiqui A, Pensler JM, Mostafavi H. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;58:42-45.
13. Walsh GL, Nesbitt JC. Tumor implants after thoracoscopic resection of a metastatic sarcoma. Ann Thorac Surg 1995;59:215-216.[Abstract/Free Full Text]
14. Ginsberg RJ. Alternative (muscle sparing) incisions in thoracic surgery. Proceedings from the First International Symposium of Thoracoscopic Surgery. San Antonio, TX, January 1993:22-23.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stefano Margaritora Alfredo Cesario Domenico Galetta Pierluigi Granone Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Margaritora, S. Articles by Granone, P. Search for Related Content PubMed PubMed Citation Articles by Margaritora, S. Articles by Granone, P.