Patient 1
A 53-year-old non-smoker female with a family history of colon cancer was diagnosed with a stage III sigmoid cancer in 2017. The patient complained of abdominal pain associated with constipation leading to a colonoscopy that revealed a sigmoid adenocarcinoma with a staging whole body Computed Tomography (CT) scan revealing no distant metastasis. She underwent surgical resection followed by adjuvant chemotherapy regimen (Avastin, Oxaliplatin, and Xeloda) of 8 cycles completed on July 2018. Follow-up Positron Emission Tomography (PET)/ (CT) scan showed new left lung lesions for which she underwent left Video-Assisted Thoracoscopic (VATS) metastasectomy, which was converted to thoracotomy on October of the same year.
On February of 2019, the patient was referred to King Hussein Cancer Center (KHCC) following disease progression with new bilateral pulmonary and liver lesions revealed by a PET/CT scan (the highest SUV max = 4.16 and 15.98 respectively), suggestive of metastatic disease (Fig. 1). A multidisciplinary clinic (MDC) decision after consulting the patient and her family was to go for surgical resection but the patient requested to start a new line of chemotherapy. From July 2019 to November 2019, the patient was started on Irinotecan, and Capecitabine (a total of 6 cycles), and Bevacizumab (a total of 5 cycles). Upon re-evaluation, the metastatic lung and liver lesions remained constant despite adjuvant chemotherapy. On February 2020, the patient was scheduled for surgical resection. Under general anesthesia with the utilization of double-lumen endotracheal tube, midline laparotomy was done followed by right liver wedge metastasectomy; the hepatobiliary surgery team mobilized the right hepatic lobe by opening the right triangular ligament. As the right lung deflated, a 3-cm opening was made in the right diaphragm peripherally to avoid phrenic nerve injury, followed by an installation of dual ring wound protector in the diaphragm opening. With assistance of 30-degree camera and VATS instruments, we mobilized the lung lobe, pushed the diaphragm upward for adequate exposure and palpated the lesions, then we did a wedge resection from upper, middle and lower lobes after we applied a clamp distal to each nodule and cut below the clamp to ensure resection with safety margin using endostapler (Fig. 2). Chest tube was inserted through the 7th intercostal space (ICS) at the anterior axillary line. The lung was inflated, and the diaphragm closed by a continuous-double layer using size 2 Ethibond Excel suture (Ethicon, Inc., Somerville, NJ).
After the procedure, the patient was transferred to the Intermediate Care Unit (IMU) for 24-h under continuous observation. Following that, she was transferred to the surgical ward. The chest tube was removed with a total output of 190 ml of serosanguinous fluid on post-operative day one (POD1). She was followed up during her stay with daily chest x-ray to ensure full lung expansion. The patient was discharged on post-operative day four and histopathological specimen analysis confirmed complete surgical resection (R0) of all excised lesions. The patient was followed up in clinic with no complications.
Patient 2
A 48-year-old male with morbid obesity (Body Mass Index (BMI) of 37.32 kg/m2), hypertension (medicated by bisoprolol 5 mg daily) and a strong family history of colon cancer on the paternal side (including his father, brother and aunt) was diagnosed with a stage IV rectal cancer. In January 2019, the patient started to complain of a change in bowel habits associated with bloody stool and a one-month significant weight loss (133 kg to 122 kg). Colonoscopy revealed an ulcerative mass 10 cm from the anal verge and a biopsy confirmed a diagnosis of moderately differentiated adenocarcinoma. The patient was referred to KHCC in April 2019, and a whole-body PET/CT scan showed hypermetabolic circumferential rectal wall thickening with SUVmax = 11.3, few hypermetabolic focal liver lesions in right liver lobe, the most prominent one in segment VIII measuring about 2.6 × 1.7 cm in its active component with SUVmax = 8.12 and hypermetabolic left upper lobe lung nodule measuring about 1.3 cm in its active component with SUVmax = 3.96 (Fig. 3). MDC decision after consulting the patient and his family was to go for 5 cycles of neoadjuvant chemotherapy (irinotecan, leucovorin, 5-fluorouacil) with the last cycle on December 2019. The patient underwent open low anterior resection of the rectal mass with multiple liver wedge resections from segments V, VI, and VIII. Through the midline laparotomy incision, the left triangular ligament was opened to retract the left liver lobe inferiorly. After ensuring left lung deflation via the double-lumen endotracheal tube, a 3-cm opening was made in the left diaphragm through the antero-lateral muscular part (left costal portion of diaphragm) to avoid phrenic nerve injury (Fig. 4) with application of a small-size dual ring wound protector (Fig. 5). Through this single opening, we introduced the 30-degree camera scope and the usual thoracoscopic instruments to perform a pleural adhesiolysis. A 13 mm nodule was identified in the anterior segment of the left upper lobe by pushing the diaphragm caudally while retracting the lung simultaneously. We Applied clamp distal to the nodule and cut below the clamp to ensure resection with safety margin using endostapler (Fig. 2). Chest tube (size 28 F) was inserted through the chest wall at the level of 7th ICS anterior axillary line. Lung inflation was insured, and the diaphragm was closed by a continuous-double layer using size 2 Ethibond Excel suture (Ethicon, Inc., Somerville, NJ) (Video).
Additional file 1: Video. Intraoperative video showing the staged approach for lung metastasectomy starting with entering the thoracic cavity, identifying of the lung lesion, isolation and cutting, inserting chest tube, and closure.
The patient was kept under close observation in the IMU for 24 h, followed by transfer to the surgical ward and removal of the chest tube on POD1, which yielded only 10 ml of serosanguinous fluid. He had daily chest x-rays to ensure complete lung inflation and he was discharged on the sixth postoperative day. Definitive histopathologic examination showed completely resected (R0 resection) moderately differentiated adenocarcinoma in the primary tumor site as well as the liver and lung metastasis. The definitive pathological stage was pT3N1 due to involvement of one out of the 13 resected lymph nodes, the patient was placed on adjuvant chemotherapy regimen (irinotecan, leucovorin, and 5-fluorouracil), and had no postoperative complications.
Patient 3
A 27-year-old male who smokes 30 pack-years and otherwise medically free, started to complain of left progressive testicular swelling in January 2019. Despite being treated surgically as a case of simple hydrocele on July 2019, the swelling persisted necessitating a whole-body CT scan that showed left spermatic cord thickening with abnormal enhancement, enlarged para-aortic lymph nodes, and suspicious pulmonary nodule. Laboratory investigations showed alpha feto-protein (AFP) level of 4.5 ng/mL, beta human chorionic gonadotropin (βHCG) of 135 mIU/ml, and lactate dehydrogenase (LDH) of 248 U/L. He underwent left radical orchiectomy at an outside facility, with a histopathological diagnosis of non-seminomatous germ cell tumor, embryonal type. The patient was referred to KHCC with surgical wound dehiscence, scrotal swelling, pus discharge and necrosis. A new staging CT scan showed multiple bilateral rounded pulmonary nodules suggestive of metastasis with the largest seen at the medial aspect of the left lower lobe measuring about 2.8 cm (Fig. 6), and an irregular left inguinal soft tissue thickening with enhancement and few prominent lymph nodes that may represent postsurgical change. Multiple enlarged metastatic left external iliac, left common iliac and left para-aortic lymph nodes were seen with the largest at left para-aortic region at the level of the left renal hilum measuring about 3.7 cm in short axis with a stage of cT3N2M1aS2. MDC decision after meeting the patient and his family was to start BEP (Bleomycin, Etoposide and Cisplatinum) chemotherapy protocol. He completed four cycles on December 2019, tumor markers normalized, and follow-up imaging studies showed significant regression in the size of the previously noted pulmonary metastasis in the left lung lower lobe to 1.2 cm and decreased size of the previously noted enlarged retroperitoneal and left pelvic lymph nodes. The scan however showed an inferior vena cava (IVC) thrombus of 8 cm in length and the patient underwent thrombectomy using AngioJet Zelante catheter (Boston Scientific, Marlborough, MA) and IVC OptionELITE filter (ARGON Medical Devices, Frisco, TX) insertion. In April 2020, under general anesthesia, the patient underwent retroperitoneal mass excision, bilateral nerve sparing with retroperitoneal lymph node dissection, inguinal scar excision, left spermatic cord excision, left uretrouretorostomy, left double-J insertion, and transdiaphragmatic left single-port VATS lower lobe pulmonary metastasectomy.
Through the midline laparotomy incision, we cut the left triangular ligament to retract the left liver lobe downward. Left lung deflation was successful. It was followed by a 3-cm incision in the left diaphragm through the anterio-lateral muscular part (left costal portion of diaphragm) to avoid phrenic nerve injury and installation of dual ring wound protector. We introduced the 30-degree camera scope and the VATS instruments. We then identified the lower lobe nodule at the posteriobasal segment. We Applied clamp distal to the nodule and cut below the clamp to ensure resection with safety margin using endostapler. Chest tube size 28F was placed and attached to a negative pressure device through the chest wall at the level of 7th ICS anterior axillary line. Lung was inflated and the diaphragm was closed by a continuous-double layer using size 2 Ethibond Excel suture (Ethicon, Inc., Somerville, NJ).
The patient was kept under continuous monitoring for 24 h in the IMU followed by a transfer on POD1 to the surgical ward and removal of the chest tube with an output of zero milliliters. The patient was discharged on post-operative day 6 and was followed up in outpatient clinic without postoperative complications related to lung metastasectomy.