One Stage Thoracoscopic Segmentectomy and Transphrenic Adrenalectomy for Non-Small Cell Lung Cancer With Unique Metastasis

Objective

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 a VATS 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 months after the 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 on both tumors after a pulmonary rehabilitation program.

Surgical Technique

A video-assisted thoracic surgery (VATS) approach was performed through four thoracoports for optics (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 an ultracision device. The peritoneum and retroperitoneal fat were exposed with a 3 mm instrument. Meticulous division of the venous and arterial drainage ligation was performed with a clip and an articulated bipolar device was used for the inferior gland dissection. The adrenal gland was extracted en-bloc through the 10 mm incision. Hemostasis was completed with the insertion of hemostatic sealant in the adrenalectomy bed and the diaphragm was closed using interrupted stitches. A VATS segmentectomy (left S1,2,3) was then performed with hilar and mediastinal lymphadenectomy.

The pain control was obtained via a paravertebral catheter inserted in the seventh intercosto-vertebral space. The postoperative course was uneventful and the patient was discharged on the third post operative day . After 18 months of follow up, the patient is still alive without cancer recurrence.

Conclusion

Adrenalectomy should be considered as a therapeutic option for patients with synchronous metastases from NSCLC. Adrenalectomy can be carried out during the same operation. A minimally invasive technique should be the preferred approach in this small subset of patients with resectable primary lung cancer.

References

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