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Annals of Surgical Oncology 8:175-178 (2001)
© 2001 Society of Surgical Oncology

ORIGINAL ARTICLES

VATS Port Site Recurrence: A Technique Dependent Problem

K. Parekh, V. Rusch, M. Bains, R. Downey and R. Ginsberg

From the Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.

Correspondence: Address correspondence and reprint requests to: Dr. Valerie W. Rusch, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021; Fax: 212-717-3682; E-mail: ruschv{at}mskcc.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objectives Video-assisted thoracic surgery (VATS) has become an accepted approach for the diagnosis and treatment of thoracic malignancies. Port site tumor recurrence is a reported complication of VATS. However, the true incidence of this problem is unknown. To try to determine the incidence of port site recurrence, we analyzed our experience with patients undergoing VATS wedge resection for malignancy.

Methods Data were obtained from our prospective VATS database. The analysis was confined to patients undergoing VATS wedge resection for malignancy, excluding those having a pleural biopsy only. Parameters analyzed included demographic factors, surgical technique, and port site recurrences identified by physical examination, CT scan, or both.

Results From 1992 to 1996, 410 patients (182 men, 228 women; median age= 61 years) underwent a VATS wedge resection for malignancy. The procedure was performed for diagnosis or staging in 90% of cases. Access incisions plus port sites were used in 97 (24%) patients; port sites only were used in 313 (76%) patients. Conversion to thoracotomy was necessary in 102 patients (25%) either for definitive resection (58 patients) or because VATS was not technically adequate (44 patients). Specimens were retrieved via access incisions or port sites with or without a specimen bag. The operative mortality was 0.25%. With long-term follow-up (median= 25 months) available for 374 patients (91%), only one port site recurrence was identified (0.26%).

Conclusion Our experience confirms the safety of VATS wedge resection in cancer patients. The incidence of port site tumor recurrence is low when oncologic principles are respected. In our institution, these principles include performing VATS wedge resection only for lesions that can be widely removed; converting to thoracotomy for definitive or extensive cancer operation; and using meticulous technique for the extraction of specimens from the pleural space.

Key Words: Thoracoscopy • VATS wedge resection • Port site recurrence


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Thoracoscopy was first described by Hans Christian Jacobaeus in 1910, when he used a cystoscope to inspect the pleural space.1 From that time until 1991, thoracoscopy was used primarily for the diagnosis and treatment of pleural diseases, including pleural effusions, empyemas, traumatic hemothorax, spontaneous pneumothorax, and pneumolysis after collapse therapy for tuberculosis.2–6 During the past decade, the application of video technology and the development of endoscopic instruments has revolutionized thoracoscopy, making it possible to perform endosurgically operations that previously required a thoracotomy. Although video-assisted thoracic surgery (VATS) has now become an accepted approach to the surgical management of various thoracic diseases, it also occasionally may be associated with serious complications.7–9 Among these is tumor implantation in the chest wall at port sites. Table 1 summarizes the information available to date on this complication and shows that previous reports are largely anecdotal.


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  		TABLE 1. Previous reports describing port site or local pulmonary parenchymal recurrences
 
Tumor spillage is known to occur during oncologic surgery regardless of the surgical approach.10–12 The mechanisms implicated for port site recurrence following VATS include direct contact of the chest wall with tumor during extraction, disruption of the tumor at the time of extraction, direct manipulation of tumor and contamination of instruments, transtumoral dissection, and leaving pleural fluid inside the chest at the end of the procedure.13 This potentially serious complication has not been studied systematically. Published information consists primarily of case reports, which do not provide the denominator for the surgeons’ experience.14–20 Thus, the true incidence of VATS port site recurrence is unknown. To define this incidence, we reviewed our experience with VATS wedge resection in a large, relatively homogenous group of cancer patients.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients who underwent pulmonary wedge resection for malignancy were identified from our prospective VATS database, which was established in January 1992 when members of the Memorial Sloan-Kettering Cancer Center Thoracic Service started performing VATS procedures. Patients who had a pleural biopsy only were excluded from the analysis, because those individuals usually have a very limited life expectancy. Limiting the analysis to the period of January 1992 through December 1996 allowed for long-term follow-up in all patients.

The following data were recorded: patient age and gender; the indication for VATS wedge resection (diagnosis, staging, or therapy); whether access incisions or only port sites were used; whether and why conversion to thoracotomy occurred; the method of specimen retrieval; the disease status at last follow-up; and the date and sites of relapse. Some follow-up information was not fully recorded in the database and therefore was obtained from chart review and through direct communication with the patient or the referring physician.

Port site recurrence was defined as incisional tumor recurrence at the sites of port entry. Ipsilateral parenchymal recurrences were considered as locoregional recurrence. Port site recurrences were identified on follow-up by CT scan or physical examination.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
From January 1992 through December 1996, 410 patients underwent a VATS wedge resection for malignancy. There were 182 men and 228 women, with a median age of 61 years (range, 23–85 years). The indications for the VATS wedge resection are shown in Table 2. The number of indications listed exceeds the total number of patients because some patients had more than one indication for the procedure. Ninety percent of patients underwent VATS wedge resections for diagnosis and staging. The final tumor histology was primary lung cancer in 162 (40%) patients and metastatic disease in 248 (60%) patients. The primary tumor sites in patients with metastatic lesions were breast (n= 50), gastrointestinal tract (n= 50), esophagus (n= 5) genitourinary tract (n= 28), kidney (n= 25), skin and soft tissue (n= 44), head and neck (n= 13), esophagus (n= 5), testicle (n= 6), and various less common sites and histologies (n= 27).


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  		TABLE 2. Indications for VATS wedge resection
 
The procedure was completed using port sites only in 313 (76%) patients. Ninety-seven patients (24%) had an access incision in addition to the port sites. One hundred and two patients (25%) had conversion to a formal thoracotomy for definitive resection (58 patients) or because VATS technically was not adequate (44 patients). The reasons for conversion to thoracotomy and their frequency are shown in Table 3. The standard techniques used for specimen extraction included direct removal via the thoracoports when the specimen was very small—usually when three or fewer applications of the endosurgical stapler were used. Larger specimens were placed in a specimen retrieval bag and brought out via slightly enlarged port site incisions. These two techniques were specifically recorded in the operative notes on 182 cases (44%). In cases where an access incision was used and was long enough to allow atraumatic extraction, the specimen was removed directly.


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  		TABLE 3. Indications for conversion to thoracotomy (n= 410)
 
Only one patient died within 30 days of the operation, for an operative mortality of 0.25%. That patient experienced a massive pulmonary embolus. Immediate postoperative complications, including bleeding and pulmonary or wound infection, were infrequent, occurring in only 25 patients (6%).

Long-term follow-up was available on 374 (91%) patients. The median length of follow-up was 25 months from the date of surgery. Follow-up was by radiology in 243 (65%) patients, by physical examination in 91 (24%) patients, and by direct communication with the patient or the referring physician in 40 (11%) cases. The sites of relapse in patients who were alive with disease or who died of disease were distant (n= 110); locoregional without port site recurrence (n= 14); locoregional with port site recurrence (n= 1); and distant with locoregional but without port site recurrence (n= 138). The single patient who developed both a pulmonary parenchymal recurrence and a potential port site recurrence was a 38-year-old woman who had a VATS performed to diagnose small pulmonary nodules. At surgery, she was also found to have extensive pleural metastases from a spindle cell sarcoma. Two months later, while receiving treatment at another hospital, she presented with progression of the pulmonary parenchymal disease, including the previous staple line and tumor invading the chest wall. Although the patient underwent formal resection of the area of chest wall involvement, it was unclear whether this represented growth of the pleural metastases or a port site recurrence.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The development of VATS a decade ago created an exciting prospect for thoracic surgeons, because it raised the possibility of performing via less invasive means operations that previously had required a thoracotomy. It rapidly became clear that VATS wedge resection usually could replace open lung biopsy.21,22 Other operations, ranging from thoracoscopic sympathectomy to esophageal myotomy, gradually have gained acceptance as standard VATS procedures.23–26 However, the role of VATS as an approach for the treatment of most thoracic malignancies is more controversial. Initial enthusiasm about thoracoscopic lobectomy, pneumonectomy, and esophagectomy27–30 waned once it became clear that these more technically complex operations were not easily performed by VATS and that such an approach potentially compromised oncologic principles without decreasing operative morbidity or hospital stay.31–34 Port site tumor recurrence emerged as a potential risk, but its frequency was not well defined.13–20,35,36

At Memorial Sloan-Kettering Cancer Center, the Thoracic Service adopted a conservative approach toward the use of VATS in cancer patients, starting in 1992 when we introduced this procedure into our practice. We were already performing thoracoscopy frequently for the diagnosis and management of pleural disease. VATS wedge resection for the diagnosis and staging of intrathoracic malignancies was, therefore, a natural and useful extension of our established practice. However, because of the concern that VATS might compromise formal curative resections of thoracic malignancies, we decided not to use it as a primary therapeutic approach. The small proportion of patients in this study who had a VATS wedge resection performed with therapeutic intent usually had medical comorbidities that precluded a more standard cancer operation.

Our concern about the role of VATS for the resection of thoracic malignancies was heightened by case reports of port site recurrence, and by three lung cancer patients who were referred to us for management after a limited pulmonary resection by VATS led to extensive parenchymal and chest wall tumor recurrence.

Although intraoperative pleural washings after pulmonary resection are sometimes cytologically positive, and suggest that spillage of tumor cells does occur, tumor implantation in thoracotomy incisions is extremely rare. Incomplete resection because of inability to palpate the tumor bimanually, disruption of the tumor at the time of resection or specimen extraction, or extensive direct contact with the chest wall during extraction are thought to make VATS resection of a malignancy more susceptible to incisional or port site recurrence.14,35,37 Based on these presumed risk factors, we have routinely exercised a very careful approach to specimen extraction, as described in Materials and Methods.

Despite several case reports of port site recurrences, the incidence of this complication has not been well defined. The largest series, by Downey et al., described 21 cases of chest wall or port site recurrence that were identified through a written survey of members of the VATS Study Group, a group of surgeons who collaborated in an early assessment of VATS.14 Of these 21 cases, 6 patients developed port site recurrence after VATS for malignant mesothelioma, a tumor known for its propensity to implant in needle tracks and incisions. Of the remaining 15 cases, only 11 had true port site recurrences. However, due to the nature of that survey, the authors could not state the true incidence of this potentially disastrous complication.

Our experience describes the risk of port site recurrence in a large and more homogenous group of cancer patients. It confirms that VATS wedge resection is a safe operation with low morbidity, even among patients with metastatic disease. The frequency of port site recurrence appears to be low when (1) VATS wedge resection is performed for selected indications and (2) oncologic principles are carefully respected. These principles include performing wedge resection only for lesions that are peripheral and can be widely removed; converting to thoracotomy for definitive or extensive resections; removing small specimens directly through thoracoports; and removing larger specimens in specimen bags or atraumatically via access incisions, if necessary.


   Acknowledgments
 
The authors acknowledge that some of the patients in this series had surgery performed by the late Dr. Michael Burt. The authors thank Melody Owens for her expert assistance in manuscript preparation.


   Footnotes
 
Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16-19, 2000.

Dr. Parekh is a resident in General Surgery at the Lenox Hill Hospital, New York, NY, and was supported by a research fellowship from that institution.

Received for publication April 25, 2000. Accepted for publication September 21, 2000.


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 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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