Robotic resection of a Pancoast tumor after induction chemoimmunotherapy: a case report

Introduction

The most common treatment for resectable superior sulcus tumors (Pancoast tumors) includes neoadjuvant chemoradiation followed by surgical removal of the affected upper lobe and chest wall, with a variety of available approaches to access the pleural cavity (1-3). Since 2018, a few case reports have described robot-assisted removal of these tumors (4-7).

This report describes a robotic-assisted en bloc excision of the right chest wall and right upper lobectomy with mediastinal lymph node dissection. This approach does not involve a thoracotomy like many other surgical approaches to Pancoast tumors do, which may reduce post-operative pain, morbidity, and length of hospital stay. We present this case in accordance with the CARE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-24-19/rc).

Case presentation

This patient is a 59-year-old male who presented with right-sided back pain. Computed tomography (CT) demonstrated a tumor in the right upper lobe of the lung involving the right T1, T2, and T3 ribs. Positron emission tomography (PET) was performed and reported no evidence of mediastinal lymphadenopathy or distant metastatic disease. Further evaluation included magnetic resonance imaging (MRI) of the brachial plexus which demonstrated partial encasement of the C8 and T1 roots and lower trunk of the brachial plexus and involvement of the middle scalene muscle. MRI of the brain displayed no cerebral metastasis. Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) was used to biopsy the tumor and mediastinal lymph nodes. Pathologic assessment of the biopsy samples revealed a squamous cell carcinoma with high expression of programmed death-ligand 1 (PD-L1), and no mediastinal lymphadenopathy. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

The case was discussed at a multidisciplinary tumor board, and the decision was made to proceed with neoadjuvant chemoimmunotherapy with carboplatin, paclitaxel, and nivolumab.

After completion of his neoadjuvant treatment regimen, restaging CT scans demonstrated a decrease in the size of the mass from 6.0 cm × 5.9 cm on original CT to 4.9 cm × 5.0 cm on restaging (Figure 1A), and PET showed necrosis of the tumor, no signs of metastatic disease, and no evidence of mediastinal, hilar, or axillary lymphadenopathy (Figure 1B). Repeat MRI of the brachial plexus found that there was no longer involvement of the middle scalene muscle or C8 nerve root, but still found involvement of the T1 and T2 nerve roots (Figure 1C). Overall, the patient responded favorably to the induction chemoimmunotherapy without progression of the disease.

Figure 1 Pre-induction and post-induction imaging. (A) Pre-induction (left) and post-induction (right) computed tomography imaging of the tumor. (B) Pre-induction (left) and post-induction (right) positron emission tomography/computed tomography imaging. (C) Pre-induction (top) and post-induction (bottom) T1 and T2 weighted magnetic resonance imaging of the brachial plexus displaying tumor involvement.

Pre-operative forced expiratory volume in 1 second (FEV₁) and diffusion capacity of lung for carbon monoxide (DLCO) were 73% and 55%, respectively. A mediastinoscopy was performed at the beginning of the operation to exclude N2/N3 disease. Biopsies obtained from stations 4L, 4R, and 7 were negative for nodal involvement. A bronchoscopy was then performed and noted normal endobronchial anatomy with no endobronchial lesions.

See Video 1 for visualization of the procedure described here. The patient was placed in the left lateral decubitus position. All robotic ports were placed in the seventh intercostal space. The camera port was inserted, and CO₂ insufflation was initiated. A 15-mm port was placed in the intercostal space just superior to the diaphragm, and the da Vinci Xi robotic platform was docked. The bipolar dissector was used to divide the inferior pulmonary ligament followed by dissection of the posterior mediastinal pleura for access to mediastinal lymph nodes. Lymph nodes at stations 8R, 9R, 7, and 11R were excised. The posterior oblique fissure was divided with a 45-mm green load robotic stapler; the right upper lobe bronchus was dissected free circumferentially and divided with a green load robotic stapler. At this point, a green load stapler was also used to partially divide the transverse fissure. The right upper lobe division of the superior pulmonary vein was dissected free circumferentially and divided with a 45-mm white load stapler, the truncus anterior branch of the right pulmonary artery was dissected and divided in similar fashion. The division of the transverse fissure was then completed with a green load stapler. The vessel sealer was used to excise lymph nodes at stations 2R and 4R. The monopolar spatula was used to divide the soft tissues on the chest wall margin. A Midas Rex pneumatic drill (Medtronic, Minneapolis, Minnesota, USA) was used to cut ribs 2–4 at the insertion to the vertebral bodies, and 2 cm anterior to where the right upper lobe was attached to the ribs. The first rib was also cut anteriorly, but a posterior separation was not performed because of poor visualization of the articulation with the vertebral body. The vessel sealer was used to divide the intercostal neurovascular bundles and separate the serratus anterior and scalene muscles, and the bipolar dissector was used near the brachial plexus and subclavian vessels. A 10-cm longitudinal paraspinal incision was made and the ribs were disarticulated from the vertebrae with the Alexander periosteal elevator. The remaining soft tissue attachments were divided using a combination of robotic and open posterior approach with video assistance. The specimen was removed with an anchor bag. The right middle lobe was fixed to the right lower lobe using a blue-load robotic stapler to avoid right middle lobe torsion. The lung was reinflated, and all incisions were closed (Figure 2).

Figure 2 Surgical incision scars.

His postoperative course was complicated with atelectasis requiring a single bronchoscopy on post-operative day 3, secretions were suctioned, and empiric antibiotics were prescribed. His chest tube was removed on post-operative day 4, and he was discharged home on post-operative day 5. At his 2-week follow-up in clinic, the patient was experiencing mild right ptosis and right-hand weakness, for which he was referred for rehabilitation. The patient recovered well otherwise. Pathology reported a complete pathologic response ypT0N0. His case was discussed at tumor board, and the recommendation was to proceed with immunotherapy. His ptosis required blepharoplasty several months later, his right-hand weakness completely resolved. He completed 1 year of adjuvant immunotherapy with atezolizumab. At his most recent visit, almost two and a half years after removal of his tumor, CT imaging was reviewed, and no definitive evidence of recurrence was noted.

Discussion

Superior sulcus tumors are lung carcinomas of the apex of the lung that can invade the anatomical structures of the thoracic inlet and surrounding chest wall. Neoadjuvant chemoradiation followed by surgical resection is currently the standard of care for treatment of these tumors (3). The implementation of induction chemoimmunotherapy in patients with resectable non-small cell cancer clinical stage II and III had resulted in a complete pathologic response of around 30% in our patient population. In addition, we have seen dramatic radiologic responses with over 50% reduction in tumor size after induction chemoimmunotherapy. Despite Pancoast tumors not specifically being described in published trials of neoadjuvant chemoimmunotherapy, we were hoping to obtain a good radiologic and pathologic response in this patient with high PD-L1 expression. A smaller tumor in the superior sulcus would make this minimally invasive operation less challenging. Our previous experience with induction chemoradiation has not been associated with a significant decrease in tumor size. We were hoping for a better response with induction chemoimmunotherapy. There is an ongoing open-label, phase II, single arm, multi-center clinical trial (DUMAS) with the primary objective to evaluate the complete resection (R0) rate of Pancoast tumors after induction chemoimmunotherapy and secondary objectives to evaluated the overall survival rate at 24 months and disease-free survival rate at 24 months (8).

Achieving adequate R0 oncologic resection of Pancoast tumors while limiting postoperative morbidity represents a technical challenge to the surgeon. Multiple approaches for resection have been described. The anterior transcervical approach was first described in 1993 (9). While providing excellent exposure to the subclavian vessels and brachial plexus, this approach involves resection of the medial clavicle which can lead to functional shoulder and cosmetic ramifications. Moreover, the anterior transcervical approach often requires a thoracotomy for tumors located posteriorly in the thoracic inlet.

The anterior transmanubrial approach was first introduced in 1997 (10). This approach employs an L-shaped incision of the manubrium along with resection of the 1st costal cartilage, allowing for the creation of an osteo-muscular flap that spares clavicular resection along with its muscular attachments. This approach avoids the consequence of functional shoulder impairment while maintaining adequate surgical exposure for tumor resection. However, this approach frequently necessitates an additional thoracotomy to achieve adequate exposure and lymph node harvest, increasing post-operative pain and morbidity.

The anterior trap door approach requires a large incision consisting of a proximal median sternotomy extending to the base of the neck and down to the fourth intercostal space (11). While providing adequate surgical exposure, this approach carries the risk for wound complications. Posterior thoracotomies and hemiclamshell approaches have also been described which are highly invasive surgical exposures that often lead to significant post-operative pain and morbidity (1,12).

The primary consideration for resection of any Pancoast tumor is the ability to achieve R0 resection. In our case report, we describe a hybrid approach utilizing our standard incisions for robotic right upper lobectomy and a longitudinal paraspinal incision to achieve en bloc resection of the 1st–4th ribs. Our approach successfully achieved a R0 resection with complete lymphadenectomy. The indications for chest wall reconstruction commonly include defects of more than 5 cm in diameter when four or more ribs are absent with the risk of lung herniation and paradoxical motion of the chest wall. However, larger defects in the upper posterior chest wall can usually be tolerated without structural support due to the stability provided by the scapula (13). Our minimally invasive technique allowed for better preservation of the muscles stabilizing the scapula, so chest wall reconstruction did not appear to be needed. Surveillance physical examination and chest CT scan demonstrated no evidence of lung herniation and the patient never experienced paradoxical motion of the chest wall.

Despite this minimally invasive approach, his postoperative course was complicated by atelectasis requiring bronchoscopy. However, he was able to be discharged home on postoperative day 5. We predict that had he received a Shaw-Paulson incision, his pulmonary toilet would have been even more compromised, and a longer hospital stay would have been required. He also developed ptosis and hand weakness likely associated with injury to the stellate ganglion and the lower trunk of the brachial plexus. We do not think that those complications are directly attributed to our hybrid technique and are instead more likely related to difficult planes of dissection as a result of severe inflammation associated with induction chemoimmunotherapy. In our experience, the inflammation and fibrosis associated with induction chemoimmunotherapy can be similar to the reaction caused by neoadjuvant chemoradiation therapy in some patients. His hand weakness resolved with physical therapy and his ptosis was surgically corrected a few months later. He otherwise did not experience long-term functional deficits or cosmetically undesirable outcomes.

The advantages of robotic-assisted thoracoscopic lobectomy in comparison with open lobectomy are well established (14-16). However, only a few case reports exist in the literature describing robotic approaches to Pancoast tumors (4-7). Mariolo et al. utilized a robotic hybrid approach for an Anterior Pancoast tumor (4). In contrast to our case, the chest wall resection and reconstruction was performed first followed by the robotic lobectomy. Uchida et al. presented a similar case to ours with involvement of the posterior 1st to 4th ribs (5). They used a 15-cm posterior thoracotomy in contrast to our 10 cm paraspinal incision. Their paper does not describe which instrument they utilized to cut the ribs. Mandishona et al. also described a case involving the posterior 1st to 4th ribs which required involvement of a spine surgeon towards the end of the case (6). Kocher et al. reported a case of a Pancoast tumor involving the 1st and 2nd rib which did not require a posterior thoracotomy (7). A common observation by thoracic surgeons who have reported a robotic approach to Pancoast tumor is the faster patient recovery.

Implementation of a robotic approach to Pancoast tumors resulted as an extension to our experience with robotic 1st rib resection for thoracic outlet syndrome. In our opinion, the Midas Rex pneumatic drill is an excellent tool to cut the ribs in these challenging cases. The addition of the paraspinal incision and hand-assistance to push the chest wall into the pleural cavity is another important step when tumors involve 4 or more apical posterior ribs.

In our experience, this patient experienced less pain and recovered significantly faster than patients who have required a combination of Dartevelle and Shaw-Paulson incisions for tumors in a similar location. The range of motion of his right upper extremity was significantly better during the early postoperative period, in contrast to previous patients who have required several months of postoperative physical therapy to recover their range of motion.

Conclusions

In summary, this case report describes a novel approach to Pancoast tumors with involvement of the posterior ribs. Avoiding a posterolateral thoracotomy may be associated with less pain and faster recovery in these challenging cases.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-19/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-19/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-19/coif). N.V. reports that Ziosoft paid for AATS meeting in Los Angeles May 2023 registration, flight ticket and hotel. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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