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J Thorac Cardiovasc Surg 2008;135:261-268
© 2008 The American Association for Thoracic Surgery

General Thoracic Surgery

Is palpation of the nonresected pulmonary lobe(s) required for patients with non–small cell lung cancer? A prospective study

Robert James Cerfolio, MD, FACS, FCCP^_*,_*, Ayesha S. Bryant, MSPH, MD

Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Ala

Received for publication May 3, 2007; revisions received August 6, 2007; accepted for publication August 16, 2007.

^_* Address for reprints: Robert J. Cerfolio, MD, Professor of Surgery, Chief of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 703 19th St S, ZRB 739, Birmingham, AL 35294. (Email: Robert.cerfolio{at}ccc.uab.edu).

Objective: Video-assisted lobectomy is an increasingly used technique to treat patients with non–small cell lung cancer but it does not usually afford lung palpation.

Methods: A prospective study was conducted on patients with tumors amenable to video-assisted lobectomy (noncentral lesion and <5 cm) who underwent open lobectomy via thoracotomy. All patients underwent 64-slice helical computed tomographic scan with intravenous contrast at 5-mm intervals and had integrated 2-deoxy-2-18F-fluoro-D-glucose positron emission tomography computed tomography 30 days or less before thoracotomy. Unsuspected malignant pulmonary nodules that were palpated and removed (from a different lobe than the one resected) and that were not imaged preoperatively were defined as cancer that would have been missed by video-assisted lobectomy.

Results: From January 2006 to February 2007, 166 patients had non–small cell lesions that were resected via thoracotomy, despite being amenable to video-assisted surgery, by one surgeon. Thirty-seven (22%) patients had pulmonary nodules that probably would have been missed by video-assisted lobectomy; 14 (8.4%) of these nodules were malignant. These were unsuspected M1 pulmonary lesions in 9 patients and unsuspected different types of primary non–small cell lung cancers in 5 patients. All missed lesions were less than 6 mm and in different lobes from the one resected. Nine (64%) of these 14 patients' primary known lesions were pathologic T1 lesions. Nine patients received adjuvant chemotherapy because of these unsuspected M1 nodules.

Conclusions: Open lobectomy that affords palpation of the rest of the lung may discover nonimaged malignant pulmonary nodules in different lobes in 8% to 9% of patients with non–small cell lung cancer despite preoperative fine-cut chest computed tomographic scan with contrast and integrated integrated 2-deoxy-2-18F-fluoro-D-glucose positron emission tomography computed tomographic scanning. The clinical impact of these findings is unknown.