<b>RFA, VATS, Thoracotomy:

Summary of risks, benefits, and indications.</b>



1. <b>Thoracotomy </b>is the surgical opening up of the thorax, the chest cavity.  If done for mets, it will allow for palpation of the entire lung, and mets that haven't shown on imaging can be removed as well.  There is no size limitation to the removal.  Surgeons have more mobility and access.  It can be done as a bilateral procedure...i.e. clamshell. It is very invasive and has a long convalescence, and there can be complications.  Seeding of tracks can occur, but isn't a usual occurrence.


2. <b>VATS</b> is Video Assisted Thoracoscopic Surgery.  It is like laparoscopic or keyhole surgery.  VATS is less invasive than thoracotomy, but has a limit to the size of the tissue that can be removed [tumors under 3cm, usually].  It is possible also to seed tumor cells in the surgical tracts, but this is not a usual occurrence.  You cannot manually feel for other lung tumors with this.  But you can result in getting live tumor for biopsy or chemoresistance or other testing.  


3. <b>RFA</b> is radio frequency ablation, essentially heat ablation.  It is also done through the skin, also a less invasive process.   The tumor must be completely ablated, with some margin, otherwise it will return.  There is an optimal size tumor for this technique as well.   This cannot be used near major blood vessels or vital structures because of the danger of heat injury.  It doesn't seed its tracks as heat is applied to the exit channel.  Because the tumor is ablated, it is not possibly to get tissue from it to examine.


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Since stage IV LMS has no cures, NONE of these operations would actually be considered curative, really. 
BUT surgical removal or ablation of lung tumors does give a good benefit for survival time, and generally longer than chemotherapy treatment for lung mets.
There are a limited number of chemotherapy agents that might work on LMS.  And chemo works better on high-grade cancers, too.

So if there is a chance to buy some time off chemo, with a fairly noninvasive technique, it would make sense.   Even if other metastases are present, lung mets are potentially lethal and require attention.  If chemo is going to be done anyway, OK, might as well see if the lung mets shrink.  But there is a place for VATS, RFA and thoracotomy, all of them, in the treatment of metastatic disease of the lung.

Furthermore, the lesser invasiveness of VATS and RFA lends them to managing lung mets in a frailer individual who might not be a candidate for a thoracotomy.

We have had 3 people with LMS lung mets treated by RFA on the LMS list.  They all bought time.    One of them had a recurrence from a bleed during preop embolization, requiring a thoracotomy.    One of them had a recurrence of one part of a huge tumor as well as two new mets, requiring another op.  One of them developed multiple small new lung mets 10 months later and went onto chemo.  All of them had time off chemo with an excellent quality of life after the RFA.

One of the ladies who had VATS twice, just presented with a wraparound lung tumor invading the chest wall in the area, presumably from seeding in the area.

All techniques have their advantages and disadvantages.  

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Decisions about which technique to use depend upon number and location of mets, and whether they are adjacent to blood vessels or vital organs.  It depends upon whether tissue is needed for diagnosis.   It may also depend upon the status of the disease in the rest of the patient's body, and how physically healthy the patient is.

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The best way to decide is to seek out practitioners of all techniques and ask them about feasibility and probable outcome, sometimes scans can be sent by courier to the doctor, alone, to cut down on traveling costs and time if the answer is NO.

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Then, there is this attitude:

European Journal of Cardio-Thoracic Surgery.  Vol. 21, issue 6, June 2002,
pg 1111-1114
PULMONARY METASTASES: CAN ACCURATE RADIOLOGICAL EVALUATION AVOID THE
THORACOTOMIC APPROACH?
Margarita, S., Porziella, V., D'Andrilli, A., Cesario, A., Galetta, D.,
Macis, G., Granone, P.

Interesting article.  The aim of the study (Italian) was to evaluate the
effectiveness of radiological assessment of lung mets and to verify if a
comlete manual exploration by thoracotomy is necessary.  They used
high-resolution CT and helical CT for imaging.  All patients (166) underwent
axillary thoracotomy (staged if bilateral lesions were present); accurate
palpation of the lung parenchyma was always performed to identify any
radiologically undetected lesions.  Non-metastatic lesions were excluded
from analysis.

High-resolution CT  (group A) correctly identified 142/188 lesions.  Helical
CT (group B) identified 142/173 lesions.  There was relatively poor
sensitivity of CT to identify lesions smaller than 6mm.

Conclusions: Preoperative assessment by conventional CT is unsatisfactory
even with high-resolution approach.  CT scan missed 24% of the lesions in
this study. In other studies CT missed 30-49% of mets found at thoracotomy.
This means that a significant number of smaller lesions would have been
missed with VATS approach to metastectomy.  CT sensitivity was 100% for
lesions larger than 1 cm but decreased as size of mets decreased.

These authors do not agree that VATS is a viable treatment option for
patients even with a solitary nodule.  They believe a muscle-sparing
thoracotomy is mandatory in  the surgical approach of pulmonary metastases.

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The rebuttal to this argument is that VATS or RFA can be repeated when the undetectable lung mets grow to a size that makes them amenable to RFA or VATS.  Since removal of lung mets in LMS is a palliative operation,  one aimed at increasing survival, VATS or RFA. can be repeated at such time that growth of the new mets makes it warranted.  


Last updated march 2003
doctordee

