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Update Course Rewind: Thoracotomy vs VATS for Lung Metastases

Video Published 2022-08-02 Updated 2024-02-10

Timestops (7)

Case Presentation: Osteosarcoma with Lung Metastases

Surgical Indications and Prognostic Factors

Thoracotomy vs VATS Detection Rates

VATS Technique and Requirements

Comparative Outcomes and Survival Data

Bilateral Disease and Staging Strategies

Future Technologies and Closing Remarks

Topic Overview

A panel discussion comparing thoracotomy versus video-assisted thoracoscopic surgery (VATS) for pulmonary metastasectomy in pediatric osteosarcoma patients. The discussion centers on a case of a 16-year-old with tibial osteosarcoma and lung metastases, examining the evidence that complete metastatic clearance can achieve 40% five-year survival, that even 1-millimeter nodules contain malignant disease in 60% of cases, and that a multi-institution study of 200 patients found no mortality difference between open and thoracoscopic approaches in oligometastatic disease (fewer than 4 nodules per side). The panel acknowledges significant practice variation and the need for prospective trials, with a Children's Oncology Group study planned to address this question.

Key Takeaways

Complete metastasectomy achieves 40% 5-year survival in osteosarcoma; even 1mm nodules contain tumor in 60% of cases. (2:08)
In oligometastatic disease (<4 nodules/side), VATS and thoracotomy show equivalent survival in largest study (n=200). (5:23)
Manual palpation detects 30-40% more nodules than CT, but survival benefit of removing submillimeter lesions is uncertain. (3:19)
VATS offers shorter stay and easier repeat procedures but is limited in nodule count and requires IR localization support. (4:41)
Children's Oncology Group trial launching to prospectively compare thoracotomy vs VATS for metastatic osteosarcoma. (8:56)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rob Gerardo — host
Ellen Ancisco — host
Roshni Dasgupta — guest
Todd Ponsky — guest
Steve Rothenberg — guest
Speaker 6

Chapters

0:00Case Presentation: Osteosarcoma with Lung Metastases — Introduction of a 16-year-old with tibial osteoblastic osteosarcoma and multiple small lung nodules (2-6mm) detected on staging CT, with epidemiology noting 20% of patients have lung metastases at diagnosis.
1:36Rationale for Metastasectomy and Role of Manual Palpation — Discussion of 40% five-year survival with complete metastatic clearance, evidence that 60% of 1mm nodules contain malignancy, and the historical standard of thoracotomy allowing detection of 30-40% more nodules by manual palpation than CT imaging.
3:30Thoracotomy versus VATS: Technical Considerations — Comparison of approaches including ICG use for deeper nodules in thoracotomy, VATS advantages of shorter stay and reduced adhesions on repeat procedures, and VATS limitations requiring localization and handling fewer nodules (versus 15-20 with thoracotomy).
5:16Outcomes Data and Practice Variation — Presentation of a 200-patient multi-institution study showing no mortality difference between thoracotomy and VATS in oligometastatic disease (fewer than 4 nodules per side), discussion of selection bias, and varied approaches to bilateral disease including staged procedures 4-6 weeks apart.
7:22Expert Perspectives and Future Directions — Expert opinions supporting VATS for 3-4 nodules per side to reduce morbidity, discussion of non-surgical methods like CyberKnife for future management, and announcement of an upcoming Children's Oncology Group prospective study.

Key claims

1:29About 20% of osteosarcoma patients already have lung metastases by the time of diagnosis — Ellen Ancisco
2:08About 40% of patients can get a durable cure response after 5 years if you have complete metastatic site clearance — Roshni Dasgupta
2:23Complete surgical resection of all metastatic tumor sites is an independent positive prognostic factor and affects overall survival, not just disease recurrence — Roshni Dasgupta
2:35Even at the size of 1 millimeter, you can get about 60% of 1 millimeter nodules contained malignant disease in patients with metastatic osteosarcoma — Roshni Dasgupta
2:47The bigger the nodule is, the more likely you're going to have malignancy, but all the way down to 1 millimeter, you will see tumor — Roshni Dasgupta
3:19You will find about 30 to 40% more lung nodules with your fingers and looking than you actually find on CAT scan, even with special MP scanning and thin cut CT scans — Roshni Dasgupta
3:54One of the issues with ICG is depth of penetration, so when you are open, it's a little bit easier to use ICG to find those deeper nodules — Roshni Dasgupta
4:10Thoracotomy is more invasive than other alternatives and there is longer hospital stay — Ellen Ancisco
4:15We're not really sure that removing those tiny little 1 millimeter nodules actually gives you a survival advantage — Roshni Dasgupta
4:41VATS is minimally invasive with shorter length of stay — Roshni Dasgupta
4:44When you go back in for a repeat thoracoscopy, you don't have the same adhesions, it's not as stuck — Roshni Dasgupta
4:58With VATS you often need to have some sort of localization process and need to have good interventional radiology — Roshni Dasgupta
5:07Often with thoracotomy, you can take out 15 to 20 nodules, but with thoracoscopy, it's a little more limited as to how many you can actually find and localize — Ellen Ancisco
5:23A multi-institution study including 200 patients with metastatic osteosarcoma is the largest study that has ever been done — Ellen Ancisco
5:34In oligometastatic disease (patients who have less than 4 nodules on each side), there was no difference in terms of mortality between open resection and thoracoscopy — Roshni Dasgupta
5:44The survival curves for thoracotomy versus VATS are pretty much exactly the same in oligometastatic disease — Roshni Dasgupta
5:52Maybe those small little nodules that you're feeling with a grain of sand don't actually make that much difference — Roshni Dasgupta
6:09There was definitely significant selection bias and institutional selection bias in the study comparing thoracotomy and VATS — Roshni Dasgupta
6:34Metastatic disease is addressed after 4 cycles of chemotherapy, and often if these nodules are still residual, you're not going to see any change — Roshni Dasgupta
7:13Most people do staged procedures, particularly for thoracotomy, between 4 and 6 weeks apart to allow a cycle of chemotherapy in between — Roshni Dasgupta
7:29Survival didn't change when you had only 3 to 4 nodules on the side — Steve Rothenberg
7:29The argument that you needed to put your hand in to feel all the granules means you automatically should do a bilateral thoracotomy because this is a systemic disease, not a unilateral disease — Steve Rothenberg
7:52We can only see 1 or 2 millimeter nodules now even with the best CTs, and you still miss some — Steve Rothenberg
8:02There's no question that tumor clearing improves survival — Steve Rothenberg
8:05There are ones that you can feel and not see, and there are ones that you can't feel — Steve Rothenberg
8:12If there's only 3 to 4 nodules on the side and they're applicable to thoracoscopy, that's how we go just to reduce the morbidity — Steve Rothenberg
8:56The Children's Oncology Group is starting a study to answer the question of thoracotomy versus VATS, with enrollment starting towards the end of this year or early next year — Todd Ponsky

Cases discussed

0:4716-year-old with tibial osteosarcoma and lung metastases

Points of disagreement

5:52Clinical significance of removing 1-millimeter nodules detected only by palpation
- Roshni Dasgupta: Uncertain whether small nodules that feel like grains of sand actually make a survival difference despite containing malignancy
- Steve Rothenberg: Acknowledges there are nodules you can feel but not see, and ones you can't feel, but advocates for VATS when only 3-4 nodules present to reduce morbidity

Open questions

Does removing 1-millimeter nodules detected only by palpation provide a survival advantage?
What is the optimal approach for bilateral lung metastases - median sternotomy, staged thoracotomies, or bilateral thoracoscopies?
Can non-surgical methods like CyberKnife with fiducial localization replace surgical metastasectomy for small pulmonary nodules?
Will the upcoming Children's Oncology Group prospective trial definitively answer whether thoracotomy or VATS is superior for oligometastatic osteosarcoma?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Thoracotomy vs VATS in Oligometastatic Osteosarcoma: The Palpable Nodule Problem

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Clinical Question

In pediatric osteosarcoma with oligometastatic lung disease — defined here as fewer than four nodules per hemithorax — does the ability to palpate additional submillimeter nodules during open thoracotomy translate to improved survival compared to video-assisted thoracoscopic surgery? The question matters because 20% of osteosarcoma patients present with lung metastases 1:29, and complete surgical clearance is an independent positive prognostic factor affecting overall survival 2:23. The stakes are high: 40% of patients achieve durable cure at five years with complete metastatic clearance 2:08.

The tension arises from two established facts that pull in opposite directions. First, even 1-millimeter nodules harbor malignancy in 60% of cases in metastatic osteosarcoma patients 2:35, and manual palpation during thoracotomy detects 30-40% more nodules than thin-cut CT imaging 3:19. Second, a 200-patient multi-institutional study — the largest ever conducted in this population — found no mortality difference between open resection and thoracoscopy in oligometastatic disease, with survival curves that are "pretty much exactly the same" [c15, c16].

The Case for Prioritizing Complete Palpation

The traditional argument rests on tumor biology and detection limits. "The bigger the nodule is, the more likely you're going to have malignancy, but all the way down to 1 millimeter, you will see tumor" 2:47. If complete surgical resection affects overall survival 2:23, and if imaging misses a third of disease burden 3:19, then the surgeon's hand becomes a diagnostic instrument that no technology replicates. One discussant framed the uncertainty this way: "From a cancer surgeon perspective, you're like, I need to get all the tumor out all the time, but when you actually look at the data, maybe those small little nodules that you're feeling with a grain of sand don't actually make that much difference, and we don't know" 4:25.

The "we don't know" is critical. The absence of proven benefit does not establish the absence of benefit. Indocyanine green can identify deeper nodules during open surgery 3:54, and thoracotomy permits resection of 15-20 nodules where thoracoscopy is limited in number 5:07. The procedure accepts greater morbidity — longer hospital stay 4:10, more adhesions on re-operation — in exchange for maximal cytoreduction in a disease where incomplete resection predicts failure.

The Case for VATS in Oligometastatic Disease

The counterargument begins with the survival data and ends with the logic of systemic disease. One discussant noted being pleased to see recent studies emerge, as their own data from nearly two decades ago showed survival did not change with only a few nodules on one side 6:00. If palpating additional submillimeter nodules improved outcomes, the 200-patient study should have detected it. It did not 5:34.

The systemic disease argument cuts deeper. One discussant argued that the rationale for thoracotomy based on palpating all nodules logically requires bilateral thoracotomy, since this is a systemic disease rather than a unilateral one 7:29. If the rationale for thoracotomy is detecting occult nodules, then unilateral thoracotomy is internally inconsistent — imaging misses disease bilaterally, not just on the operated side. Yet bilateral simultaneous thoracotomy is rarely performed. The same discussant advocates VATS when there are only a few nodules on one side that are amenable to thoracoscopic resection, in order to reduce morbidity 8:12.

VATS offers shorter length of stay 4:41 and less adhesion formation on repeat procedures 4:44. In a disease requiring staged bilateral procedures 4-6 weeks apart to allow intervening chemotherapy 7:13, and where nodules unchanged after four cycles of chemotherapy are unlikely to respond further 6:34, minimizing surgical morbidity preserves the patient's ability to tolerate subsequent treatment.

Where They Agree

Both positions accept that tumor clearing improves survival 8:02 and that imaging has detection limits 7:52. Both acknowledge that "there are ones that you can feel and not see, and there are ones that you can't feel" 4:55. Neither disputes the 60% malignancy rate in 1-millimeter nodules 2:35. The disagreement is not about tumor biology but about whether the additional nodules detected by palpation in oligometastatic disease — nodules that imaging and VATS miss — change the outcome enough to justify the morbidity difference.

Both discussants also acknowledge significant selection bias in the existing comparative data 6:09. Institutions with thoracoscopic expertise selected patients differently than those performing primarily open surgery. The study compared practices, not randomized interventions.

What Would Resolve It

The Children's Oncology Group is launching a study comparing thoracotomy and VATS, with enrollment beginning late this year or early next 8:56. Until those results arrive, the choice in oligometastatic disease remains a judgment about which uncertainty to accept: the unmeasured benefit of removing palpable-but-invisible nodules, or the unmeasured cost of thoracotomy morbidity in patients whose survival may not depend on those nodules.

Takeaways from this story

In oligometastatic osteosarcoma (<4 nodules/side), survival curves for thoracotomy and VATS are identical despite thoracotomy detecting 30-40% more nodules by palpation.
Even 1mm lung nodules contain malignancy in 60% of metastatic osteosarcoma cases, but whether removing palpable-only submillimeter disease improves survival remains unknown.
The argument for thoracotomy based on palpating occult nodules logically requires bilateral simultaneous thoracotomy, since this is systemic disease—yet that's rarely done.
VATS allows repeat thoracoscopy without dense adhesions, critical when staged bilateral procedures 4-6 weeks apart are standard to permit intervening chemotherapy.

Keywords

osteosarcoma osteoblastic osteosarcoma lung metastases pulmonary metastases oligometastatic disease thoracotomy VATS video-assisted thoracoscopic surgery metastasectomy pulmonary metastasectomy limb salvage procedure bone biopsy median sternotomy bilateral thoracoscopies CyberKnife

Hashtags

#pediatricsurgery #thoracotomy #VATS #lungmetastases #osteosarcoma #pediatriconcology #metastatectomy #PulmonaryMetastases #ThoracicSurgery

Transcript

If you missed our annual pediatric surgery update course, don't worry. We're gonna summarize our favorite sessions right here on this podcast. In today's episode, It's a battle between thoracotomy and VATs, or video-assisted thoracoscopic surgery, specifically for lung metastases. Most pediatric surgeons probably already have opinions about this, but we're here to discuss the two techniques with pros and cons, and hopefully we'll give you a little more insight into the surgical management of pulmonary metastases in osteosarcoma. I'm Rob Gerardo and I'm Ellen Ancisco. We are research residents at Cincinnati Children's Hospital. And this is the Stay Current in Pediatric Surgery podcast. So a 16 year old uh kid comes to the clinic. Um, he has a lot of pain from his left tibia. Um, you get an X-ray and you see this lesion. Everyone, that was Doctor Roshni Dasgupta. She is a pediatric surgeon at Cincinnati Children's Hospital Medical Center, and she's gonna be explaining this through a case. In the next step, they get a bone biopsy and it shows osteoblastic osteosarcoma, which is basically a type of bone cancer that usually develops in the osteoblast cells that form bone. It happens most often in children, adolescents, and young adults. The most common primary site is in the long bones in the leg, like in his case in the tibia. And the most common site of metastatic disease is in the lung. In fact, about 20% of patients already have lung metastases by the time of diagnosis, and they're usually picked up on staging chest CT. In this chest CT, we see three small nodules on the right side, um, measuring 2 to 6 millimeters, and then there's a sort of non-specific nodule on the left side. He then undergoes his 4 cycles of chemotherapy, he goes to orthopedics, has his limb salvage procedure, get another CAT scan, and um the CT scan is unchanged. So the same number of nodules on both the right and the left side. OK, then, what's the role for a metastectomy? I mean, does it make a difference? Should we even bother doing surgery on the lungs for this? About 40% of patients, you can get a. Durable cure response after 5 years. If you have complete metastatic site clearance, you can make these patients long-term survivors. Um, Obviously, the less mets you have, the better outcome you do. So patients with solitary nodules do better. But if you are able to surgically resect all metastatic tumor sites, independent positive prognostic factor, and it does affect overall survival, not just disease recurrence. Small nodules matter? Our data actually from one of our PSA studies shows that even at the size of 1 millimeter, you can get about 60% of 1 millimeter nodules contained malignant disease. This is in a group of patients with metastatic osteosarcoma. Obviously, the bigger the nodule is, the more likely you're going to have malignancy, but all the way down to 1 millimeter, you will see tumor. Even 1 millimeter? Wow. OK, that's important to consider. Let's move on, we got a lot to learn here. The next question is, if we think that removing these nodules will have some overall survival advantage, and we wanna do something about them. How do you approach the lung nodules? Historically, thoracotomy has really been standard of care. Why? Because we can use our fingers and hands and feel the tiny little grains of sand. You will find about 30 to 40% more lung nodules with your fingers and looking than you actually find on CAT scan, even with our special MP scanning and our like thin cut CT scans. All right. Seems like hands are very important to check for any nodules that may have been missed by radiology, but hands are not the only helpers. We also have indocyanin green or ICG to help us diagnose these nodules. ICG is a dye used in a variety of diagnostic and therapeutic procedures. Is there any role for ICG in these cases? We can use ICG with thoracotomy and you can sometimes find the deeper nodules. One of the issues with ICG is depth of penetration. So when you are open, it's a little bit easier to use ICG to throw those deeper nodules. So these are very good reasons to do a thoracotomy, Ellen. I mean, why isn't it our first choice or our best choice? Great question, Rod. It is Obviously more invasive than other alternatives, and there is longer like this day. Also, sometimes it's just technically more difficult and we're not really sure that removing those tiny little 1 milli nodules actually gives you a survival advantage. Of course, keep in mind that if we prefer not to do a thoracotomy or we literally can't do a thoracotomy. The other option, it's a video-assisted thoracoscopic surgery, also known as a VAT. So when do we choose vats and why do we prefer that over thoracotomy? Well, it's minimally invasive. It's a shorter length of stay. Often when you go back in for a repeat thoracoscopy, you don't have the same adhesions. It's not as stuck. You can actually get in there pretty well. OK, so that seems so much more beneficial for patients and for surgeons. So why don't we just do VATs for everyone all the time? We often need to have some sort of localization process. You need to Have good interventional radiology. Also, there is some limitation on how many nodules you might be able to take out. Often with thoracotomy, you can take out 15 to 20 nodules, but with thoracoscopy, it's a little more limited as to how many you can actually find and localize. What about disease-free recurrence for patients who underwent a thoracotomy versus a thoracoscopy? There is a multi-institution study including 200 patients with metastatic osteosarcoma, which is the largest study that has ever been done. In that study, they looked at the outcomes between open resection and thoracoscopy. Um, which really tells you that an oligometastatic disease, meaning that patients who have less than 4 nodules on each side, there was no difference in terms of mortality. So if you look at these survival curves, they're pretty much exactly the same, which means we don't know the answer between which is the right operation. You know, sort of from a cancer surgeon perspective, you're like, I need to get all the tumor out all the time, but when you actually look at the data, maybe those small little nodules that you're feeling with a grain of sand don't actually make that much difference, and we don't know. This, our, our conclusion from the study was that um they have comparable outcomes and we really don't know what the right answer is. There was definitely significant selection bias, um, institutional selection bias, and, you know, patients were not gonna get a thoracoscopy for if they had a bunch of, you know, a lot of nodules. So, Um, that just tells us that we need to learn more. I still have some questions. Please help me, Dr. Dasgupta. What about chemotherapy? I mean, would that help for a 1 to 2 millimeter nodule? Can that help them shrink or regress? Basically, when we think about at which point do you address metastatic disease, it's after 4 cycles of chemotherapy, and often if these nodules are still residual, you're not going to see any change. I know we can't know right now which is superior to the other, but is it possible to at least use thoracoscopy for bilateral lung mets? I mean, Is that a thing, or is it just me putting a lot of hope into some less invasive way to get these nodules out? There's so many ways to do this, right? You could do a median sternotomy. You could do stage thoracotomies. You could do bilateral thoracoscopies, and I think the practice is so varied, and we don't know what the right answer is. Most people, I'd say the practice is, is that they do stage, staged procedures, particularly if the thoracotomy. Um, Between 4 and 6 weeks apart to allow a cycle of chemotherapy in between. OK, so here's Dr. Steve Rosenberg from Rocky Mountain Hospital for Children. He's going to talk about some different scenarios and how to approach them. I'm very happy to see these, these studies have finally come out because we actually did report it on our data almost 20 years ago, but survival didn't change when you had only 3 to 4 nodules on the side and The argument about that you needed to put your hand in to feel all the granules, then you automatically should do a bilateral thoracotomy because this is a systemic disease. It's not a unilateral disease, so it's, it's unreasonable to presume, and we can only see 1 or 2 millimeter nodules now even with the best CTs, and you still miss some. So there's no question that tumor clearing is, is. Improve survival, but there are ones that you can feel and not see, and there are ones that you can't feel. And so we do sequential monitoring and surveillance, but if, if there's only 3 to 4 nodules on the side and they're applicable to thoracoscopy, that's how we go just to reduce the morbidity. And if it's bilateral, we'll do it bilateral. Well said, Dr. Rothenberg. We still got a lot to figure out. Now, here's our boss, Doctor Todd Ponsky. He's a pediatric surgeon at Cincinnati Children's Hospital Medical Center. He's gonna share some of his thoughts, some of his expectations on the future of techniques to remove these lung nodules. We may have to find non-surgical methods. I think CyberKnife, that's happening in every other solid organ, things like that. That are going to be a future for, for, for localizing using fiducials and just zapping these lesions without surgery. Doctor Dasgupta shared with us that the Children's Oncology Group is actually starting a study to answer this very question, and they should be starting enrollment towards the end of this year or early next year. So, if you're not already involved and are interested, contact Doctor Dasgupta. So there you have it, our 2021 update course session on thoracotomy. Versus vats for lung metastases. If you love this content, be sure to like and subscribe to our YouTube channel. If you're listening to the audio version of this podcast, please leave us a rating and a review. And be sure to download the Sacred in pediatric surgery app. It's in the Apple App Store and in the Google Play Store. But until next time, I'm Rod and I'm Ellen, and remember, knowledge should be free.

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