Source: European Journal of Cardio-Thoracic Surgery
(Chamberlain MH, et al., Video-assisted cervical thoracoscopy: a novel approach for diagnosis, staging and pleurodesis of malignant pleural mesothelioma, Eur J Cardiothorac Surg (2008), doi:10.1016/j.ejcts.2008.03.034)

Mesothelioma is one of the most difficult of all cancers to treat effectively. A patient is often diagnosed only after the disease has progressed to a more advanced stage and the malignancy has invaded a large tissue area, as well as the lymph nodes. In these situations especially, the standard treatments for pleural mesothelioma or peritoneal mesothelioma, such as surgery and chemotherapy, have not proven effective in managing the disease and median survival time generally averages under a year. Studies have shown that to achieve the best prognosis it is imperative that patients receive a diagnosis and begin mesothelioma treatments as early within the course of the disease as possible. Historically, however, this has proven difficult to realize because the multiple phases involved with imaging, biopsy, histological analysis and lymph node staging are often completed in serial, with one coming after another until weeks or months have passed before the series is completed and treatments begin. In light of this, a number of doctors and researchers are currently exploring the development of more effective and efficient techniques for the determination of disease diagnosis and stage in the hopes of reducing this crucial time-to-treatment factor. Doctors from the United Kingdom have recently published an article in the European Journal of Cardio-Thoracic Surgery where they describe their use of a new technique they’ve developed called Video-assisted Cervical Thoracoscopy (VACT), which, they claim, allows histological diagnosis and staging, as well as an intraoperative talc pleurodesis, during the same procedure.

Overview of the Study

The authors describe the VACT procedure in the following manner:

“Patients are intubated with a double lumen tube to allow collapse of the lung on the diseased side. They were placed supine on the operating table with a sandbag between the shoulder blades and the head supported on a head ring. They were prepared and draped in standard fashion with the diseased side exposed to allow thoracoscopy should access to the pleura from the neck be unfeasible. A conventional cervical video-assisted mediastinoscopy was performed. Biopsies were taken from left and right paratracheal lymph nodes (stations 2 and 4) and subcarinal lymph node station 7. Following this, the video mediastinoscope was partially withdrawn and directed owards the diseased side. Aspiration of the pleural space was performed (above the superior vena cava [SVC] on the right) and if successful, a mediastinal pleurotomy was fashioned. A 5 mm thoracoscope was inserted through the mediastinoscope and mediastinal pleurotomy into the pleural cavity and visualised on a second video-assisted thoracoscopic (VATS) system. Pleural biopsies were then taken under direct vision, the pleural effusion aspirated and pleurodesis performed using 8 g of medical talc. A 28 Fr chest drain was inserted into the pleural space via the mediastinoscope and tunnelled caudal to the collar incision through the pre-sternal tissues . The mediastinoscopy wound was closed and the drain placed on 5 kPa suction. When unable to enter the diseased hemithorax through the neck, a conventional single port VATS biopsy was performed with the patient supine, the effusion was drained and talc pleurodesis performed. A 28 Fr intercostal drain was inserted through the VATS port site.”

The authors attempted VACT on 15 patients who presented with pleural mesothelioma, or a high suspicion of the disease. There were 13 males and 2 females, with an average age of 57 years-old. 13 patients had right-side disease and 2 presented with left-side disease. This study group was compared to a cohort of 26 patients who underwent the standard preoperative workups.

Results

The authors state that VACT was successfully performed on 10 of the 15 patients it was attempted on. For those patients, average time of surgery was 71 minutes and the average hospital stay was 4 days. 6 patients went on to receive an extrapleural pneumonectomy, while four received a pleurectomy/decortication.

There were a total of five failures in the VACT group: three in patients with right-side disease and both of the patients with left-side disease. Regarding the former group, one failure was due to a large amount mediastinal fat which obscured the pleura, while the other two were due to disease-thickened pleura, which prevented the hemithorax from being safely entered. In the left-side patients, the reason for procedure failure was the same: disease-thickened pleura surrounding the aortic arch. After VACT failure, these patients underwent a conventional VATS biopsy with staging completed during a subsequent mediastinoscopy.

When comparing the results of the VACT group vs. the VATS/mediastinoscopy group, the most impressive result was found in the median time-to-surgery figure for each group: just 28 days for VACT patients, compared to 87 days for the latter group. These figures represent an almost two month improvement upon time-to-treatment for the VACT group, indicating that for those who are eligible for it, VACT is definitely a great advance upon conventional diagnostic and staging procedures.

Conclusion

The authors conclude their paper by recommending the use of VACT for mesothelioma patients with right-side disease. They do not, however, recommend the procedure for those patients who present with left-sided disease, due to the particular anatomy of this area of the body. Certain patients with right-side disease, such as those with extensive pleural thickening, may not be candidates for the procedure, but for those who are, the authors state that VACT can have a positive effect on survival time because it greatly reduces the time-to-treatment over conventional diagnostic procedures. With a disease as aggressive as pleural mesothelioma can be, the results as presented here definitely represent an advancement upon our current procedures. While more research is of course necessary to confirm these results, VACT remains a promising new technique in the fight against mesothelioma.

Labels: mesothelioma