Collection
Thoracic Oncology & Pulmonary Metastases
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
Because osteosarcoma is a systemic disease, the argument that manual palpation is necessary would logically require bilateral thoracotomy, not unilateral. — Steven Rothenberg, Update Course Rewind: Thoracotomy vs VATS for Lung Metastases · 7:52
Osteosarcoma Metastases3 items
Thoracoscopy vs thoracotomy for the management of metastatic osteosarcoma: A Pediatric Surgical Oncology Research Collaborative Study
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Complete surgical resection of pulmonary metastatic disease in patients with osteosarcoma is crucial to long-term survival. Open thoracotomy allows palpation of nodules not identified on imaging but the impact on survival is unknown. The ob
article · Oct 2026
Survival outcomes in pediatric patients with metastatic Ewing sarcoma who achieve a rapid complete response of pulmonary metastases
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Purpose: Our objectives were to compare overall survival (OS) and pulmonary relapse between patients with metastatic Ewing sarcoma (EWS) at diagnosis who achieve rapid complete response (RCR) and those with residual pulmonary nodules after
article · Oct 2026
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
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There are recent updates about the management of lung metastases in osteosarcoma and deciding thoracotomy vs VATS is our topic for today. At the recent 2021 Pediatric Surgery Update Course, Dr. Anusua "Roshni" Dasgupta reviewed the latest l
video9:40 · Aug 2022
Nodule Localization3 items
Interhospital variability in localization techniques for small pulmonary nodules in children: A pediatric surgical oncology research collaborative study
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Background: Pulmonary nodules that are deep within lung parenchyma and/or small in size can be challenging to localize for biopsy. This study describes current trends in performance of image-guided localization techniques for pulmonary nodu
article · Oct 2026
Thoracoscopic lung nodule resection techniques with wire localization and ICG imaging
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Weâre back with the second episode of our image guided surgery video series! In the second part of this episode we
podcast10:15 · Oct 2026
Hybrid OR workflow for pediatric lung nodule localization and resection
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Weâre back with the second episode of our image guided surgery video series! In the first part of this episode we
podcast17:19 · Oct 2026
Pneumonectomy for Pediatric Tumors-a Pediatric Surgical Oncology Research Collaborative Study
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Objective: To describe utilization and long-term outcomes of pneumonectomy in children and adolescents with cancer. Summary Background Data: Pneumonectomy in adults is associated with significant morbidity and mortality. Little is known abo
article · Oct 2026
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Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
About 20% of osteosarcoma patients already have lung metastases by the time of diagnosis, usually picked up on staging chest CT.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position1:29 ↗
About 40% of patients can achieve a durable cure response after 5 years with complete metastatic site clearance.
clinicalRoshni Dasgupta2:08 ↗
Complete surgical resection of all metastatic tumor sites is an independent positive prognostic factor and affects overall survival, not just disease recurrence.
clinicalRoshni Dasgupta2:23 ↗
In patients with metastatic osteosarcoma, even 1-millimeter nodules can contain malignant disease in about 60% of cases.
clinicalRoshni Dasgupta2:35 ↗
The bigger the nodule is, the more likely it contains malignancy, but all the way down to 1 millimeter, tumor can be found.
clinicalRoshni Dasgupta2:47 ↗
Thoracotomy has historically been standard of care because surgeons can use fingers and hands to feel tiny nodules.
clinicalRoshni Dasgupta3:13 ↗
Manual palpation during thoracotomy finds about 30 to 40% more lung nodules than are detected on CT scan, even with thin-cut CT scans.
clinicalRoshni Dasgupta3:19 ↗
ICG can be used with thoracotomy to find deeper nodules, though depth of penetration is a limitation.
clinicalRoshni Dasgupta3:50 ↗
It is uncertain whether removing tiny 1-millimeter nodules actually provides a survival advantage.
opinionRoshni Dasgupta4:15 ↗
VATS is minimally invasive with shorter length of stay, and repeat thoracoscopy typically encounters fewer adhesions compared to repeat thoracotomy.
clinicalRoshni Dasgupta4:41 ↗
VATS often requires some sort of localization process and good interventional radiology support.
clinicalRoshni Dasgupta4:58 ↗
With thoracotomy, surgeons can typically remove 15 to 20 nodules, but with thoracoscopy the number is more limited.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position5:03 ↗
A multi-institution study of 200 patients with metastatic osteosarcoma—the largest study ever done—compared outcomes between open resection and thoracoscopy.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position5:23 ↗
In oligometastatic disease (patients with fewer than 4 nodules on each side), there was no difference in mortality between open resection and thoracoscopy.
clinicalRoshni Dasgupta5:34 ↗
The survival curves for thoracotomy and thoracoscopy in oligometastatic disease are essentially identical, meaning the optimal operation is unknown.
clinicalRoshni Dasgupta5:44 ↗
The multi-institution study had significant selection bias and institutional selection bias, with patients unlikely to receive thoracoscopy if they had many nodules.
epidemiologicalRoshni Dasgupta6:03 ↗
Metastatic disease is typically addressed after 4 cycles of chemotherapy, and residual nodules at that point are unlikely to change with additional chemotherapy.
clinicalRoshni Dasgupta6:34 ↗
Practice for bilateral lung metastases is highly varied, with options including median sternotomy, staged thoracotomies, or bilateral thoracoscopies.
clinicalRoshni Dasgupta7:02 ↗
Most practitioners perform staged procedures for bilateral disease, particularly with thoracotomy, typically 4 to 6 weeks apart to allow a cycle of chemotherapy in between.
clinicalRoshni Dasgupta7:13 ↗
Dr. Rothenberg's institution reported almost 20 years ago that survival didn't change when there were only 3 to 4 nodules per side.
clinicalSteven Rothenberg7:29 ↗
Because osteosarcoma is a systemic disease, the argument that manual palpation is necessary would logically require bilateral thoracotomy, not unilateral.
opinionSteven Rothenberg7:52 ↗
Even with the best CTs, only 1 to 2 millimeter nodules can be visualized, and some are still missed.
clinicalSteven Rothenberg8:02 ↗
There are nodules that can be felt but not seen, and nodules that cannot be felt at all.
clinicalSteven Rothenberg8:05 ↗
Dr. Rothenberg's practice is to use thoracoscopy when there are only 3 to 4 nodules per side that are amenable to thoracoscopic resection, in order to reduce morbidity.
clinicalSteven Rothenberg8:12 ↗
For bilateral oligometastatic disease, Dr. Rothenberg performs bilateral thoracoscopy.
clinicalSteven Rothenberg8:23 ↗
Non-surgical methods such as CyberKnife using fiducials to localize and ablate lesions may be a future approach for lung metastases.
opinionTodd Ponsky8:43 ↗
The Children's Oncology Group is starting a study to answer the question of thoracotomy versus VATS, with enrollment expected to begin late 2021 or early 2022.
guidelineTodd Ponsky8:56 ↗
Thoracoscopic lung nodule resection techniques with wire localization and ICG imaging
The localization procedure from patient entry to surgical readiness takes approximately 45 minutes total.
clinicalDenise Liu1:03 ↗
The surgeon places the first port without initially collapsing the lung, finding and securing the wire while the lung remains inflated to prevent wire displacement through chest wall musculature during lung collapse.
clinical1:31 ↗
After CT confirmation of wire position, the wire is cut at the skin level rather than left at full length.
clinical2:35 ↗
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