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Lung Cancer

The Role of Video-assisted Thoracic Surgery in the Management of Lung Cancer 
  Submitted By: Mark  Iannettoni, M.D.

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The Role of Video-assisted Thoracic Surgery in the Management of Lung Cancer

Article by
Jules Lin, MD and Mark D. Iannettoni, MD

Section of General Thoracic Surgery, Department of Surgery
University of Michigan Medical Center


Thoracoscopy, the introduction of an illuminated tube through a small incision made between the ribs, was first used in 1910 by Hans Christian Jacobaeus for the treatment of tuberculosis. This allowed the surgeon to visualize structures inside the chest and to perform simple procedures. Visibility was generally limited to the surgeon until the development of video-endoscopic equipment which allowed the entire operating team to view and assist in the operation.

Advantages of Video-assisted Thoracic Surgery

When compared with a traditional open chest procedure, VATS has reduced the amount of chest wall trauma, deformity, and post-operative pain. While an open procedure generally requires a 30-40 cm incision, video-assisted biopsies can be performed through three 1 cm ports (Figure 1), and a VATS lobectomy, a resection of one lobe of the lung, is performed using a 5-8 cm incision.

Figure 1. Video-assisted excisional biopsy. (From Landreneau RJ, Mack MJ, Dowling RD, Luketich JD, Keenan RJ, Ferson PF, Hazelrigg SR. The role of thoracoscopy in lung cancer management. Chest 1998; 113: 6S-12S, reprinted here with permission)

The forced expiratory volume at one second (FEV1), a measure of pulmonary function, decreases 29% after an open procedure versus 15% in those undergoing VATS. (reference 1) In addition, the diagnostic accuracy of a VATS biopsy is equivalent to one performed by an open procedure. There is also indirect evidence that VATS may improve post-operative immune function by reducing the bodyís inflammatory response. (reference 2)
VATS was recently evaluated as a same-day outpatient procedure in 62 patients at the University of Michigan. 6 Using strict criteria for chest tube removal and discharge, to insure patient safety and comfort, 75% of patients were able to be discharged on the same day of their operation, and only 5% were admitted for longer than 3 days.

Diagnosis of Pulmonary Nodules

With the increasing use of helical computed tomography (CT) scans, patients are presenting more frequently with incidental pulmonary nodules (Figure 2). The potential for malignancy depends on the patientís age, exposure to tobacco smoke, size of the nodule, and growth pattern. A CT-guided needle biopsy is the least invasive and can offer a specific diagnosis. However, there is a 20% admission rate after percutaneous biopsy, and a 5% incidence of pneumothorax, or air leak from the lung, requiring a chest tube.

Figure 2. Pulmonary nodule on chest CT scan.

The evaluation of nodules less than 3 cm is controversial, and according to Landreneau, there is a 60% false-negative rate with CT-guided needle biopsy. (reference 3) Since many of these patients have resectable tumors, he concludes that good-risk patients should undergo video-assisted excisional biopsy if there is no evidence of airway invasion. If the biopsy is positive, the patient is able to undergo an immediate resection by a muscle-sparing open procedure or a VATS lobectomy. If the biopsy is negative or there are obvious signs of widespread cancer, the patient is spared an open procedure. CT-guided needle biopsies are recommended for larger lesions (> 3 cm), multiple nodules, or those that are deep within the lung tissue. In addition, patients with poor cardio-pulmonary reserve who would not tolerate an operation or those requiring a tissue diagnosis prior to chemo- or radiation therapy should undergo a CT-guided biopsy.
New techniques have been developed for small, deep lesions that have previously been difficult to biopsy by VATS. Various markers have been used to guide excision including the injection of methylene blue (Figure 3 and 4), placement of wires or coils, and the use of ultrasound and tactile sensors.

Figure 3. Localization of a pulmonary nodule after pre-operative injection with methylene blue.

Figure 4. Excision of a pulmonary nodule using an endoscopic GIA stapler.

Malignant Pleural Effusion

VATS can be useful in the diagnosis of pleural effusions, fluid that has collected between the lung and chest wall, for which no cause has been found. In malignant pleural effusions, the microscopic results are inconclusive 40% of the time after thoracentesis, where the fluid is drained using a needle, while VATS is successful in making a diagnosis in 90% of cases due to the ability to visualize suspicious areas for biopsy (Figure 5).(reference 3) In addition, VATS allows other interventions to be performed at the time of exploration including pleurodesis, using talcum powder to encourage the formation of scar tissue sealing the surface of the lung to the chest wall and preventing the recurrence of effusions (Figure 6).

Figure 5. Pleural nodule discovered during video-assisted thoracic surgery.

Figure 6. Thoracoscopic pleurodesis. Talcum powder may be applied during VATS to encourage the formation of scar tissue sealing the space between the lung and chest wall and preventing the recurrence of malignant pleural effusions.

Lymph Nodes Staging

The prognosis and optimal treatment of non-small cell lung cancer is directly related to the pathologic stage at presentation, which centers on the status of the surrounding lymph nodes. In a study of 1900 patients, Schirren found that radiographic exams were accurate for staging 33-65% of the time. (reference 4) When these studies are inconclusive, cervical mediastinoscopy, inserting a scope at the base of the neck to evaluate lymph nodes within the upper chest, is the gold standard. However, when necessary, access to lymph nodes in the anterior or lower chest, is best approached by other methods such as VATS. A combination of mediastinoscopy and VATS may increase the sensitivity for detection of positive lymph nodes.
In addition, sentinel lymph node biopsy has been proposed. In sentinel biopsy, radiolabelled technetium is injected into the tumor or surrounding lung, and a gamma camera is used to detect the nodes that the cancer is most likely to spread to first. A full lymph node dissection is then performed; however, the pathologist is able to focus on the sentinel nodes by examining multiple sections or staining with specific antibodies.

Video-assisted Lobectomy

A lobectomy, the resection of one lobe of a lung, is generally performed for the excision of lung tumors. While VATS lobectomy is technically demanding, it is performed safely in carefully selected patients with conversion to an open procedure when necessary. VATS should be considered in patients with a peripheral early stage tumor with no evidence of enlarged lymph nodes or fibrosis.
Lymph node staging and surgical resection margins are equal to those obtained during an open procedure. (reference 3)In fact, VATS has been proposed to increase survival after resection of stage I non-small cell lung cancers with a 5-year survival of 97% versus 78.5%. This is felt to be secondary to the decreased amount of inflammation and growth factors, which would encourage the growth of metastases, when VATS is compared to an open procedure. (reference 5) Post-operative complications and length of stay are also reduced.


Over the past decade, the use of VATS has become widespread and has allowed surgeons to perform complex procedures that previously required a thoracotomy, or open chest procedure. Although the use of VATS in the management of lung cancer continues to evolve, the procedure is now being used from diagnosis and staging to treatment and palliation with comparable results as well as decreased pain and complications when performed by experienced thoracic surgeons.

Corresponding author: Mark D. Iannettoni, MD
e-mail: mdi@umich.edu

Section of General Thoracic Surgery, Department of Surgery
University of Michigan Medical Center
2120 Taubman Health Care Center, 1500 E. Medical Center Drive
Box 0344, Ann Arbor, Michigan 48109


Additional Authors:  

Works Cited:  
  1. Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg 2000; 70: 1644-6.
2. Waller DA. Surgery for non-small cell lung cancer-new trends. Lung Cancer 2001; 34: S133-S136.
3. Landreneau RJ, Mack MJ, Dowling RD, Luketich JD, Keenan RJ, Ferson, PF, Hazelrigg SR. The role of thoracoscopy in lung cancer management. Chest 1998; 113: 6S-12S.
4. Hoffmann H. Invasive staging of lung cancer by mediastinoscopy and video-assisted thoracoscopy. Lung Cancer 2001; 34: S3-S5.
5. Lizza N, Eucher P, Haxhe JP, De Wispelaere JF, Johnson PM, Delaunois L. Thoracoscopic resection of pulmonary nodules after computed tomographic-guided coil labeling. Ann Thorac Surg 2001; 71: 986-8
6. Chang AC, Yee J, Orringer MB, Iannettoni MD. Diagnostic thoracoscopic lung biopsy: An outpatient experience. Ann Thorac Surg 2002; 74 (6) (Accepted for publication).

Article Links:  
  • Lung Cancer Book Section
  • Lung Cancer Surgery: An Emerging Role for PET Scanning in Lung Cancer
  • Lung Cancer Treatment Options Tool
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