One Stage Thoracoscopic Segmentectomy and Transphrenic Adrenalectomy for Non-Small Cell Lung Cancer With Unique Metastasis
Metastasis from non-small cell lung cancer (NSCLC) is traditionally considered as a contraindication to surgery. Favourable long-term survival following staged lung resection and resection of synchronous isolated adrenal metastasis has been reported in N0 patients. Considering the retroperitoneal location of the adrenal gland, the transdiaphragmatic approach offers an attractive alternative to standard approaches to adrenal tumors. We describe a technique of simultaneously completing a lung resection and adrenalectomy safely through the thoracic approach.
Case video Summary:
We present the case of a 71 year old male with a personal history of Right Upper Lobectomy for T1aN0M0 NSCLC, Chronic obstructive pulmonary disease and malnutrition. During the follow up, a nodule in the left upper lobe was detected 24 month after lobectomy. The nodule was associated with synchronous isolated tumor of the left adrenal gland on PET CT scan. The adrenal gland biopsy confirmed the diagnosis of NSCLC metastasis. The multidisciplinary meeting decision was to operate both tumors after a pulmonary rehabilitation program.
A Video Assisted Thoracic Surgery (VATS) approach was performed through four thoracoports for optic (10 mm in diameter) and for endoscopic instruments (3 , 5 and 10 mm in diameter) placed in the sixth intercostal space on the anterior axillary line, on the seventh intercostal space on the mid-axillary line and posteriorly to the scapula in the auscultatory triangle in the sixth intercostal space .
The transdiaphragmatic approach was first performed through the four ports with a low pressure capnothorax . The phrenotomy was started from the mediastinum and then extended posteriorly with the ultracision device. The peritoneum and retroperitoneal fat were exposed with 3 mm instrument. Meticulous division of the venous and arterial drainage ligation was performed with clip and articulated bipolar device was used for inferior gland dissection . The adrenal gland was extracted en-bloc through the 10 mm incision. Hemostasis was completed with insertion of hemostatic sealant in the adrenalectomy bed and the diaphragm was closed using interrupted stiches. A VATS segmentectomy (left S1,2,3) was then performed with hilar and mediastinal lymphadenectomy.
The pain control is obtained with a paravertebral catheter inserted in the seventh intercosto-vertebral space. The post operative course was uneventful and the patient was discharged on the third post operative day . After a 18 months follow up, the patient is still alive without cancer recurrence.
Adrenalectomy should be considered as a therapeutic option for patients with synchronous metastases from NSCLC. Adrenalectomy can be carried out during the same operation. The minimal invasive technique should be the preferred approach in this small subset of patients with resectable primary lung cancer.
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