Spread of malignant cells in the surgical margin with stapled excision of lung cancer: comparison of aggressive clump and less traumatic jaw closure type staplers

A no-touch technique for pulmonary wedge resection of lung cancer

OBJECTIVE

Many of the surgical patients with lung cancer die by metastasis originated from circulating tumor cells (CTCs) which are seeds of metastases. A ring-shaped catching forceps, which generates the great pressure by compression, may reduce the risk of tumor cell spreading. Here, we investigated the efficacy of such forceps based on CTC occurrence.

METHODS

Twenty-three patients with clinical stage IA lung cancer who underwent a pulmonary wedge resection were investigated in a clinical-pathological manner. They were divided into those treated using ring forceps catching without tumor release (R group) (n = 16) and non-complete use of ring forceps (N group) (n = 7), then were determined circulating tumor cells (CTCs).

RESULTS

Radiographic findings, tumor location, pathological diagnosis, and stapling method were not significantly different between the groups. The risk of detection of CTCs after surgery was significantly lower in group R (12.5 vs. 85.7%, p = 0.02), whereas there were no significant differences found in risk of negative-stapled margin cytology, pre-OP CTC detection, V (+), Ly (+), and Pl (+).

CONCLUSIONS

Patients who underwent pulmonary wedge resection of lung cancer had low chance of CTC detection after surgery when they were treated with ring forceps without tumor release, which might become a no-touch isolation technique.

Potential errors in staging primary pulmonary adenocarcinomas by sublobar resection

INTRODUCTION

There is increasing interest in treating patients with stage I pulmonary adenocarcinoma with sublobar resection and staging lymphadenectomy (StLN), but there is no information on the potential impact of this approach on staging.

METHODS

A total of 241 consecutive wedge resections followed by immediate completion lobectomy (n = 225), bilobectomy (n = 3), or trisegmentectomy (n = 13) ("second specimens") and StLN were retrieved from our database. Tumor location, size, pT, and distance to closest margin (D) in the wedge specimens were compared with the presence of residual and/or additional tumor nodules in the lung and metastatic tumor in N1 lymph nodes of the "second specimens."

RESULTS

Residual tumor (n = 14), additional tumor nodules (n = 9), and both (n = 1) were present in the lung parenchyma of 24 "second specimens." Problems orienting residual tumor to tumor in the wedge made it difficult to accurately determine overall tumor size and final pT in some cases. In 10 of the 241 cases, metastatic tumor was present only in N1 lymph nodes in the "second specimen."

CONCLUSIONS

Sublobar resections with StLN would have potentially understaged 19 (7.9%) of 241 patients (9 as pT1 or pT2 instead of pT3, 9 as pN0 instead of pN1, and 1 as pT1N0 instead of pT3N1). Preoperative positron emission tomography/computed tomography suggested the presence of more than 1 parenchymal tumor nodule and/or metastatic tumor in N1 lymph nodes of the "second specimen" in only 5 of these cases. Sublobar resections may miss additional tumor nodules and positive lymph nodes and understage a small proportion of pulmonary adenocarcinoma patients.

Cytologically malignant margin without continuous pulmonary tumor lesion: cases of wedge resection, segmentectomy and lobectomy

The surgical margin is usually investigated during the operation using a pathological method, though cytological methods are also used to identify remaining malignant cells. We reviewed cases of pulmonary resection for a malignant tumor. At our institution, an on-site surgical margin examination using a cytological method is mandated for cases of wedge resection and segmentectomy, and an option in lobectomy cases. We examined 21 wedge resection (3 primary lung cancer, 18 metastasis), 17 segmentectomy (13 primary lung cancer, 4 metastasis), and 4 lobectomy (all primarily lung cancer) cases. Six cases showed malignant cells in the surgical margin, of which one had a microscopic skip lesion pattern and five an 'occult' pattern (positive cytology, negative pathology). Cytological malignancy occurred even in cases of wedge resection of a tiny (4 mm in diameter) lesion metastasized from colon cancer, as well as segmentectomy with a sufficient gross margin containing microscopic skip lesions and right middle lobectomy with an additional right upper lobectomy due to two previous cytological malignancies in a residual lobe. Surgical margin cytology revealed remaining malignancy in the residual lobe, which provided important information for deciding additional procedures during surgery.

A novel needle-type sampling device for flexible ultrathin bronchoscopy

Diagnosis of suspected cancer in the periphery of the lung is difficult. A flexible ultrathin bronchoscope has been developed for the diagnosis of peripherally located pulmonary lesions that cannot be reached with the sampling devices for standard flexible bronchoscopes. The diagnostic yield with forceps and a brush for ultrathin bronchoscopes, however, is not adequate, especially when a lesion is not exposed to the bronchial lumen. We have thus developed a novel needle-type sampling device and tested its yield in transbronchial cytology. The device consists of an elongated dental H-file (0.4 mm in diameter and 110 cm in length), a housing sheath (1.0 mm in outer diameter), and a novel handle, which enables rapid out-and-in motion of the needle. Ten consecutive patients with a peripheral pulmonary lesion who had an indication for diagnostic procedure with a flexible ultrathin bronchoscope were enrolled. The optimal bronchial route to the lesion was analyzed with virtual bronchoscopy in a data set obtained with high-resolution computed tomography, and a novel bronchial route labeling system (prior-ridge-based relative orientation nomenclature) was employed to guide insertion of the bronchoscope. Sampling with the novel needle was performed prior to use of the forceps and brush under conventional fluoroscopy. In all the cases, sampling with the needle was successful and the amount of the specimen was sufficient for cytology. Our novel sampling system with flexible ultrathin bronchoscopes may contribute to accurate and minimally invasive diagnosis of peripheral pulmonary lesions.