Role of Diagnostic

Thoracoscopy in Lung
Cancer management
DR L.M.Darlong
MS (AIIMS)
Fellow Thoracic Surg (Seoul )
 Lung Cancer –Diagnostic Tool
 Sputum & Blood Analysis
 Bronchoscopy & Biopsy
 Bronchoscopic Brushing
 Bronchial Lavage
 Tracheobronchial Needle
Aspiration/Biopsy
 Bronchoscopic /Transesophageal USG
 Imaging Techniques

 CXR
 CECT Chest
 MRI
 PET Scan
 Monoclonal Antibody Scan
 Antisense Oligonucleotides and the
Imagene Concept
 Accuracy of Radiological Assesment for SPN –
Misclassified as benign in 25% - 40% Malignant
nodules ( Gurney JW etal , Radiology 1993 )
 Invasive Techniques

 FNAC ( CT / USG guided )

 CT guided FNAC ( False – ve < 22% ,
inadequate 18% )
 Mediastinoscopy & Mediastinotomy
 Scalene & Supraclavicular node Biopsy
 Thoracentesis

 Thoracoscopy
 History - Thoracoscopy
 1920s,- Developed to facilitate
-Drainage of Pleural
Empyema
-Lysis of Tubercular adhesion
 Recent Popularity
-Improved Video-optics
-Improved instrumentation
-Limits incisional pain
Diagnostic Thoracoscopy – Lung
Cancer
 Tissue Diagnosis – under direct vision
 Cancer Staging
 Assesment of Ressectibility
Tissue Diagnosis – Lung Cancer
 Thoracoscopy has prompted earlier referral
to establish a diagnosis
 Indeterminate Pulmonary Lesion
- Failure of Bronchoscopy / FNAB
 Undefined Peripherally located lesions
 Centrally located nodules of lower lobe -
interlobar fissure extend to the stem of
pulmonary artery
 Limitation – Central upper lobe lesion
 Thoracoscopic intraoperative USG – Preop
imaging shows lesion to be to small / too
deep from pleural surface
 Thoracoscopic localization of pulmonary
nodule USG guided – 100% Radio guided –
80% Finger Palpation – 73% (Davide
Sortini etal 2003, A Sortini etal 2002 , S
Motsumota etal 2004 )
 Thoracoscopic FNAC
- Ideal for suspected small Peripheral
nodules
- Avoids Diagnostic Wedge Excision
- Lobectomy for cancer in same sitting
- Alternative to preop percutaneous
FNA
 Thoracoscopic Staging – Lung
Cancer
 Usually performed at the time Definitive
treatment planned
 Evaluation of Pleural spaces , Pulmonary
Hilum , nodes not accessible by Mediastinoscopy
 Confirm contra lateral lung metastasis
 T2 Lesion which could be staged as T3 on CT
 Confirm T status – Clinical T3 or doubtful cases
 Clinical N2 stage – Inaccessible by
Mediastinoscopy
 Carcinomas of the Lower Lobe due to
possible invasion of nodes 8 , 9
( Robert etal 1999 )
 N0 , N1 – High False Negative rates
 Undiagnosed Pleural effusion
 Suspected pleural metastasis
 Micro metastasis in Adenocarcinoma with
normal size lymph nodes
 Complimentary to Mediastinoscopy for N
staging Level 5 , 6 ( AP Window ) Level 7
( Posterior subcarinal ) Level 8 (Para
esophageal ) Level 9 ( Inferior Pulmonary
Ligament )
 Surgical staging has 100 % specificity , high
sensitivity and minimal morbidity
(Passlick B etal , Lung Cancer 2003 )
 Currently Surgical Staging recommended
by Majority of scientific societies for
patients with apparently ressectable
NSCLC
 CT Scan sensitivity for staging < 60 % ,
specificity 81 %
( Izbicki etal 1992 )
 Thoracoscopic Assesment of
Resectibility – Lung Cancer
 Criteria for Irresectibility
Massive extranodal N2 disease
Bilateral lymph node involvement
Extensive Pericardial invasion
Superior Vena Cava involvement
Esophageal invasion
Extensive chest wall involvement ( > 3 ribs )
Tumor invasion of artery
Pleural Dissemination
 Centrally located primary tumor with
intrapericardial extension ( Clinical T4 )
 Direct examination of Pericardial sac
content
 Avoids exploratory thoracotomy
4.7% Wain etal , 8.3% Rovario etal , 5% H
Asamura etal. (Not significant but still a
benefit of Thoracoscopy)
 Thoracoscopy - Limitations
 Single lung Ventilation
 Pleural Adhesions
 Contra lateral hemithorax not accessible
 Negative Thoracoscopy does not rule out a
Thoracotomy till a Histologic diagnosis
established
 Considered to be Final in -
Nodule Biopsy
Staging
Ressectability Evaluation
 Conclusion

 Combined with mediastinoscopy may

accurately determine
- Presence or absence of N2,N3 Disease
-Identify T3,T4 & Thoracic M1
 Assures the indicated therapeutic treatment
 Valid alternative to Cervical
mediastinoscopy
 Avoids exploratory thoracotomy