Less Invasive Approach to Pancoast Tumor in a Partitioned Incision

Abstract

We describe our approach to resect a Pancoast tumor with thoracoscopic assistance in a partitioned incision. We used the LigaSure vessel-sealing system under thoracoscopy in chest wall resection for Pancoast tumor. This approach is of great utility: easy-to use and less invasive for Pancoast tumor resection.

Introduction

Resection of Pancoast tumors has two aspects: the surgical incision in the chest wall at the thoracic inlet and upper lobe lobectomy with hilar and mediastinal lymph node dissection. Pancoast tumors are difficult to resect because of the location of the apex, a small and rigid area, and the need to approach the hilar lymph nodes. Although several surgical approaches have been described to improve the access and usefulness of a thoracoscope to minimize invasiveness,^1–3) surgery for Pancoast tumors remains a challenge. We discuss a novel technique using a combination approach for Pancoast tumor resection using thoracoscopy and the LigaSure vessel-sealing system (Valleylab, Boulder, CO, USA) for chest wall resection, with a partitioned incision.

Technique

A 46-year-old man presented with pain in his right arm, which was diagnosed as a right Pancoast tumor (squamous cell carcinoma). Computed tomography showed a main tumor 3 cm in diameter invading the apical chest wall in a posterior direction from the first rib to the third rib (cT3N0M0). He was treated with concurrent paclitaxel plus carboplatin, and received 40 Gy of radiation (ycT3N0M0), and surgical resection was proposed (Fig. 1A).

Fig. 1. (A) Computed tomographic image showing a Pancoast tumor in the right upper lung lobe invading the thoracic inlet. (B) Postoperative 1 month chest radiograph.

The operation was performed under single-lung anesthesia. The patient was placed in the supine position, and a 30-degree thoracoscope was placed through a 15-mm port at the 7th intercostal space to observe the lesion (Fig. 2E). First, a 6-cm skin incision was made in the infraclavicular region (Fig. 2A), and the anterior edge of the first to third ribs were divided under direct vision in the supine position. Then, the patient was moved to the lateral position, and a 10-cm incision was made posteriorly over the first to third ribs (Fig. 2B). The posterior rib resection was performed under direct vision and followed by chest wall dissection through this incision. Position to separate the posterior rib resection was paravertebral body (adjacent to costotransverse joint). We confirmed the surgical margin while checking with visual monitoring using a thoracoscope. The intercostal muscles and vessels were divided using the LigaSure via thoracoscope (Fig. 3).

Fig. 2. The skin incision in this case. A utility port was placed just over the anterior and dorsal edge of the targeted chest wall (A and B) in addition to the usual three ports for video-assisted thoracic surgery-lobectomy C, D, and E.

Fig. 3. Thoracoscopic appearance of the chest wall resection (dotted-line: chest wall’s cutting line).

Next, video-assisted thoracoscopic upper lobe lobectomy was performed with hilar and mediastinal lymph node dissection by making another utility incision (6-cm incision at the fifth intercostal space on the axillary line, with another port at the sixth intercostal space on the anterior axillary line) (Figs. 2C and 2D) without rib spread, which is our usual procedure for video-assisted thoracoscopic lobectomy. Upper lobe lobectomy, including apical tumor resection and hilar and mediastinal lymph node (stations 4 and 10) dissection, was performed successfully (ypT3N0M0). The operation time was 352 min and the blood loss was 100 mL.

Oral narcotics and rehabilitation were started on the first postoperative day, and the patient’s postoperative recovery was uneventful, and without complications.

Discussion

Pancoast tumor without invasion of the thoracic inlet can be resected through the posterior Shaw–Paulson approach, alone. However, if the posterior incision is made small, the visual field and operation technique will be compromised. Although other minimally invasive methods have been reported, these techniques require experiences to become familiarized. In addition, it is difficult to convert to the posterior approach from these reported methods when necessary during operation. Therefore, we modified the posterior approach using a partitioned incision with thoracoscopy. During chest wall resection, by making adjunct ventral incisions (in this case, we made a 6-cm infraclavicular incision), dissecting the rib edges under direct vision, and dissecting the intercostal muscles using the LigaSure under thoracoscopic vision, we were able to perform the chest wall resection from a limited posterior incision without special techniques to retract the specimen. Dividing the approach facilitates the chest wall treatment,⁴⁾ and the LigaSure facilitates the operation; both permit maximum preservation of the thoracic muscle.⁵⁾ The LigaSure can easily hold the layer of muscle to be dissected, and the hemostatic effect was reliable without damaging the surrounding tissues. Following chest wall resection at the thoracic inlet, the video-assisted thoracoscopic lobectomy was performed using usual method. This combined approach to resect Pancoast tumors is easy by modified the usual procedure and affords good access to both the apical and hilar sites in a less invasive manner.

Disclosure Statement

None declared.