title: Usefulness of videothoracoscopic intrapericardial examination of pulmonary vessels to identify resectable clinical T4 lung cancer.
abstract: BACKGROUND
  Discrepancies in predicting resectability by imaging techniques (computed tomography and magnetic resonance imaging) compared with actual intraoperative findings have persuaded us to perform systematic exploratory videothoracoscopy (EVT) as the first step in the surgical evaluation of patients with lung cancer. Resectability of centrally located primary tumors with intrapericardial extension (clinical T4), however, can be established only by direct examination of the pericardial sac contents. Therefore, in these instances, videopericardioscopy (VPC) has been added to our protocol.
  
  
  METHODS
  From April 1993 to December 2000, members of our department used EVT to assess 620 patients with lung cancer. Of them, 27 patients, 25 men and 2 women, were seen with pericardial tumor extension. The mean age of the group was 62 years (range, 41 to 77 years). To be properly evaluated, these patients underwent VPC. We used three and, occasionally, four incisions to perform EVT. The same incisions were used to enter the pericardial cavity during VPC.
  
  
  RESULTS
  In 15 of the 27 patients, hilar and vascular invasion was correctly predicted by imaging techniques. The other 12, however, were correctly staged only during EVT. The tumor was deemed unresectable by VPC in 6 patients (5 with invasion at the origin of the pulmonary artery and 1 with involvement of the left inferior pulmonary vein and left atrium), and exploratory thoracotomy was obviated. There was no morbidity or mortality in these 6 patients, and their mean length of hospital stay was 48 hours. The remaining 21 patients underwent thoracotomy and intrapericardial lung resection. Six of them had been considered to have unresectable disease on the basis of computed tomographic findings or magnetic resonance imaging studies. An average of 22 minutes (range, 16 to 33 minutes) was added to the operation when VPC was used.
  
  
  CONCLUSIONS
  This study suggests that EVT is superior to imaging techniques (computed tomography or magnetic resonance imaging) in detecting tumor extension into the pericardium. In addition, short of an exploratory thoracotomy, VPC seems to be the most definitive study to establish resectability of centrally located tumors with pericardial invasion. Unnecessary exploratory thoracotomies can thus be avoided.
authors.affiliation: Department of General and Thoracic Surgery, University Hospital Virgen Macarena, Seville, Spain. jloscert@us.es
authors.forename: Jesús
authors.initials: J
authors.lastname: Loscertales
authors.forename: Rafael
authors.initials: R
authors.lastname: Jiménez-Merchán
authors.forename: Miguel
authors.initials: M
authors.lastname: Congregado-Loscertales
authors.forename: Carlos
authors.initials: C
authors.lastname: Arenas-Linares
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Girón-Arjona
authors.forename: Andrés Arroyo
authors.initials: AA
authors.lastname: Tristan
authors.forename: Javier
authors.initials: J
authors.lastname: Ayarra
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006325:Heart Atria / Q000473:pathology; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating; D010496:Pericardium / Q000473:pathology* / Q000601:surgery; D011237:Predictive Value of Tests; D011651:Pulmonary Artery / Q000473:pathology* / Q000601:surgery; D011667:Pulmonary Veins / Q000473:pathology* / Q000601:surgery; D020775:Thoracic Surgery, Video-Assisted; D014057:Tomography, X-Ray Computed