Introduction

Compared with a lobectomy, wedge resection carries a three to five times greater risk of local recurrence and has a lower survival rate.¹ The standard of practice for the surgical treatment of lung cancer is a lobectomy, but because some patients cannot physiologically tolerate a lobectomy, an alternative is needed. Traditional external beam radiation can have the same negative impact on pulmonary function as a lobectomy. Wedge resection with localized radiation (i.e., brachytherapy) has been developed as better alternatives. Because preliminary series have shown very good results, an intergroup, randomized trial (ACOSOG Z4032) has been undertaken to evaluate the long-term benefits of brachytherapy for reducing the risk of local recurrence.

Santos and colleagues described one approach to brachytherapy. They embedded iodine 125 sutures in a Vicryl mesh that was subsequently secured to the surface of the lung at the margin of the resection.² This provided a radiation dose of 100 Gy to a depth of 5 mm. The brachytherapy group had a lower local recurrence rate (19% versus 2%, P = .0001).² There were no adverse effects related to the placement of the brachytherapy mesh, including no radiation pneumonitis, no implant migration or implant-related morbidity, and no compromise of pulmonary function when comparing preoperative and postoperative values. A concern regarding that approach is the radiation exposure for intraoperative personnel and for the patient’s visitors. An alternative approach with afterload catheters appears to have similar results.³ Both approaches are described in this chapter.

Key Points

Criteria

Approach to Wedge Resection and Brachytherapy

Step 2. Wedge Resection

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed toward the apex of the chest.

♦ The goal of resection is a 2-cm gross margin around the tumor.

♦ Ring forceps hold the lung 1 to 2 cm inferior to the tumor and in a line between the mass and the thoracoscope. Hold the parenchyma so that the stapler easily slides across the lung tissue. You can compress the lung parenchyma below the tumor, in the anticipated path of the stapler, to facilitate passage of the stapler across the lung.

♦ Introduce the stapler through incision 1 for the wedge resection (Figure 5-1).

♦ After firing the stapler enough times to transect lung tissue beyond the tumor, perform a final firing of the stapler through incision 3 to perpendicularly transect and separate the specimen from the remainder of the lung (Figure 5-2).

Figure 5-1 A wedge resection is achieved with the stapler through incision 1.

Figure 5-2 The stapler is inserted through incision 3 and crosses the lung to be resected.

Step 3. Afterload Catheters

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.

♦ Place three 3-0 polydioxanone sutures (PDS) on the staple line (Figure 5-3).

♦ Pass the afterload catheter through the sutures.

♦ Tie the sutures in place. This usually can be accomplished with extracorporeal knot tying. A finger through incision 3 secures the knots (Figure 5-4).

♦ A large clip is placed on the staple line closest to where the tumor was resected. This helps with the subsequent planning by the radiation therapist.

Figure 5-3 Sutures are placed to hold the brachytherapy afterload catheters.

Figure 5-4 The first brachytherapy catheter is sewn in place with the 3-0 PDS suture.

Step 4. Additional Afterload Catheters

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.

♦ Secure additional catheters parallel to and 1 cm away from the staple line (Figure 5-5).

Figure 5-5 All three catheters are sewn in place.

Step 6. Postoperative Care

♦ Brachytherapy is high-dose radiation (HDR); a robot passes the seeds into the afterload catheters to avoid radiation exposure by health care personnel.

♦ Treatment schedule

Monday: operation

Tuesday: computed tomography (CT) scan for planning

Tuesday through Friday: twice-daily radiation treatments

Friday: brachytherapy catheters and chest tube removed in anticipation of patient discharge

Alternative Approach to Wedge Resection and Brachytherapy

Radiation Safety After Iodine 125 Seed Implantation