title: Minimally invasive rib-sparing video-assisted thoracoscopic surgery resections with high-dose-rate intraoperative brachytherapy for selected chest wall tumors.
abstract: BACKGROUND
  By avoiding chest wall resection, iridium-192 (Ir-192) high-dose-rate (HDR) intraoperative brachytherapy (IOBT) and video-assisted thoracoscopic surgery (VATS) might improve outcomes for high-risk patients requiring surgical resection for pulmonary malignancy with limited pleura and/or chest wall involvement.
  
  
  METHODS
  Seven patients with non-small cell lung cancer involving the pleura or chest wall underwent VATS pulmonary resections combined with HDR IOBT. After tumor extraction, an Ir-192 source was delivered via a Freiburg applicator to intrathoracic sites with potential for R1-positive surgical margins. The number of catheters, dwell position along each catheter, prescription depth, and dose were customized based on clinical needs.
  
  
  RESULTS
  Six patients had pT3N0M0 non-small cell lung cancers. A seventh case was a recurrent sarcomatoid carcinoma. One case required conversion to open thoracotomy for pneumonectomy with en bloc chest wall resection. There were no intraoperative complications and average operative time was 5.8 hours. Five of seven patients without transmural chest wall involvement underwent rib-sparing resection. Four of the 6 patients treated with VATS and IORT remain alive in follow-up without evidence of local recurrence (median follow-up, 25 months). Noted toxicities were recurrent postoperative pneumothorax, pleural effusion with persistent chest wall pain, avid fibrosis at 2 years of follow-up, and a late traumatic rib fracture.
  
  
  CONCLUSIONS
  HDR IOBT with Ir-192 via VATS is technically feasible and safe for intrathoracic disease with pleural and/or limited chest wall involvement. Short-term morbidity associated with chest wall resection may be reduced. Additional study is required to define long-term benefits.
authors.affiliation: Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, New York. Electronic address: daniel.j.bourgeois.iii@gmail.com.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Bourgeois
authors.affiliation: Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Sai
authors.initials: S
authors.lastname: Yendamuri
authors.affiliation: Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Mark
authors.initials: M
authors.lastname: Hennon
authors.affiliation: Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Jorge
authors.initials: J
authors.lastname: Gomez
authors.affiliation: Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Harish
authors.initials: H
authors.lastname: Malhotra
authors.affiliation: Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Lalith
authors.initials: L
authors.lastname: Kumaraswamy
authors.affiliation: Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Iris
authors.initials: I
authors.lastname: Wang
authors.affiliation: Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Todd
authors.initials: T
authors.lastname: Demmy
mesh_terms: D001918:Brachytherapy / Q000379:methods*; D002289:Carcinoma, Non-Small-Cell Lung / Q000628:therapy*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods*; D008175:Lung Neoplasms / Q000628:therapy*; D000072662:Margins of Excision; D019060:Minimally Invasive Surgical Procedures; D059351:Organ Sparing Treatments; D010997:Pleural Neoplasms / Q000628:therapy*; D011013:Pneumonectomy; D012272:Ribs; D012983:Soft Tissue Neoplasms / Q000628:therapy*; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D035441:Thoracic Wall / Q000601:surgery*