Is Palpation in the Operating Room the Best Method for Surgical Planning? Palpation in the Operating Room

Bold RJ. — Sat, 01 Sep 2012 00:00:00 GMT

Surgical resection of isolated pulmonary metastatic melanoma improves overall survival in a highly select group of patients. However, the devil is in the details. By that, I mean that a critical examination of how these “selected” patients are identified needs to be made to ensure a benefit from the surgical intervention while sparing those patients with poor outcomes the complications of a thoracic operation. Peterson et al reported a series of more than 1700 patients with pulmonary metastasis from cutaneous melanoma; less than 20% underwent resection of the metastatic disease to the lung. From this and other studies, those patients most likely to benefit harbor solitary lesions; furthermore, incomplete resection offers minimal improvement in survival. Chua et al recently reported a single-institution series of 292 consecutive patients; the median survival for patients undergoing resection of a solitary melanoma metastasis was 35 months, decreasing to 21 months for 2 or 3 melanoma metastases and 10 months for more than 3 distinct lesions, which is not different from the median survival of 8 months for those patients who did not undergo resection of pulmonary metastatic melanoma. Therefore, the preoperative selection of patients is essential to identify those patients most likely to benefit from thoracic surgery and to spare an unnecessary and potentially morbid operation for those who will not benefit.

Preoperative Imaging of Pulmonary Metastases in Patients With Melanoma Implications for Minimally Invasive Techniques Preoperative Imaging of Pulmonary Metastases

Kidner TB, Yoon J, Faries MB, et al. — Sat, 01 Sep 2012 00:00:00 GMT

Hypothesis

Preoperative imaging underestimates the number of pulmonary melanoma metastases. Although thoracoscopic resection is less invasive than resection via thoracotomy, it does not allow manual palpation of the lung to identify any metastases not visible on the preoperative scan or at the time of resection.

Design

Retrospective review of a prospectively maintained database.

Setting

Tertiary referral center.

Patients

A total of 170 patients who underwent preoperative computed tomography of the chest, followed within 30 days by thoracotomy for resection of pulmonary metastatic melanoma.

Main Outcome Measures

Number of pathology-confirmed pulmonary metastases detected by preoperative chest computed tomography vs intraoperative manual palpation.

Results

The mean age of the patients was 49.5 years at initial diagnosis of melanoma and 57.1 years at diagnosis of pulmonary metastases; 69% of patients were male. A total of 334 pulmonary metastases were resected; the mean lesion size was 2.0 cm (range, 0.1-14.0 cm). In 49 of 190 pulmonary resections (26%), manual palpation of the subpleural parenchyma revealed lesions not identified during preoperative imaging. The rate of 5-year overall survival was 33%.

Conclusions

Preoperative imaging underestimates the number of pulmonary lesions in patients with metastatic melanoma. Because incomplete resection of metastatic disease is associated with worse outcomes, we recommend caution when considering a minimally invasive approach for the resection of pulmonary metastatic melanoma.

JAMA Surgery: Lung Cancer Topic Collection

Is Palpation in the Operating Room the Best Method for Surgical Planning? Palpation in the Operating Room

Preoperative Imaging of Pulmonary Metastases in Patients With Melanoma Implications for Minimally Invasive Techniques Preoperative Imaging of Pulmonary Metastases