LASER METASTASECTOMY IN LUNG METS BREAST CANCER

(Case Report)

Author :

Linda Jana Sintaningtyas

Consultant:

dr. Darmawan Ismail Sp. BTKV

SURGERY DEPARTMENT

SEBELAS MARET UNIVERSITY / RSUD DR. MOEWARDI

SURAKARTA

2018
LASER METASTASECTOMY IN LUNG METS BREAST CANCER : Case

Report

Sintaningtyas, LJ 1, Ismail D 2

1
Medical Faculty of Sebelas Maret University, Surakarta, Indonesia
2
Sub Department Thoracic, Cardiac and Vascular Surgery, Department of

Surgery, Moewardi General Hospital, Surakarta, Indonesia

Abstract

Background :Indications and surgical techniques for pulmonary metastasectomy

are controversially discussed issues. Numerous retrospective studies have

demonstrated that resection of metastases limited to the lungs may be associated

with prolonged survival. Laser metastasectomy is a recent innovation that has

been advocated especially in patients with multiple pulmonary metastases. The

aim of the current study was to describe the first Laser Metastasectomy in patient

with lung metastasis breast cancer in Moewardi Hospital Solo.

Objective : A 45 years old woman with carcinoma mammae dextra post MRM

on chemotherapy come with lung metastasis. Previous examination reveal that

the patient had carcinoma mammae dextra BIRADS 5 with pneumonic type

pulmonal metastasis. Laser metastasectomy performed to this patient.

Result : The first time lung metastasectomy with laser have performed to Solo at

December 2017. It used laser 1318nm ND Yag. The operation last about 30

minutes, post operative patient was set WSD. Patient stayed for about 7days. No
complication found at preoperative, durante and post operative. Patient come to

control regularly 1times a month up to now.

Conclusion: Laser metastasectomy was well performed to this patient. This

palliative option was promising, safe and increasing life expectancy.

Keyword : carcinoma mammae, lung metastase, laser metastasectomy

INTRODUCTON prolong survival, has been

The lung is a frequent questioned. 3-4

metastatic site for recurrent breast Pulmonary metastasectomy

cancer but the role of pulmonary (PME) is the only therapeutic option

resection is still under debate, in with curative intent for selected

particular in the results of patients with pulmonary metastases

nonsurgical treatments, like hormon originating from various solid

or chemotherapy.1 Surgical resection tumors.5

is widely employed as a conventional PME can be performed

treatment option for patients with using a number of different surgical

lung metastases originating from a techniques, including conventional

wide range of primary tumors.2 excision with electrocautery and

From the fundamentals of laser-assisted surgery (LAS). Since

basic patient selection, to the chosen the implementation of LAS for PME,

surgical approach, there is no this resection technique quickly

prevailing evidence that guides became popular due to advantages

practice. The heterogeneity in the such as ontime coagulation, sparing

biologic behavior of the many of lung parenchyma and potentially

primary tumors adds to the difficulty higher safety regarding local

in drawing conclusions from mixed completeness of resection.5-7

series. The very essence of the CASE PRESETATION

practice, that is a belief that A 45-year-old female patient

pulmonary metastasectomy can was admitted to hospital with lung

metastasis from breast cancer. She

had breast cancer for about one year patient was planned for lung

and MRM had been commenced. metastasectomy with laser on

Patient admitted to our hospital December 14, 2017.

because of dyspnea. The patient have On admission at December

already undergone chemotherapy. 12, 2017, the patient was stable. She

From the result of anatomy was normotensive (TD 120/70), heart

pathology laboratory, patient had rate was 80 times perminutes,

infiltrating ductal carcinoma respiratory rate was normal, 20 times

mammae (NOS) grade I/II with per minutes and oxygen saturation

positive LVI. Hystochemistry was 100% on room air. She was

examination reveal that esterogen afebrile. On general examination she

reseptor negative, progesteron looked normal with height 160cm

receptor positive, HER2/Neu and weight 71kg. The head was

negative (score 1). Radiodiagnostic atraumatic and normocephalic;

examination reveal that retroaraeola pupils were bilaterally equal and

mammae tumour dextra highly reactive. There was no evidence of

suggestive malignant BIRADS 5, neck vein distension or pedal edema.

limphonody axillaris anterior dextra A well-healed surgical scar of MRM

metastase, pneumonic type pulmonal was noted extending from his left

metastase at right lung, chemoport in axilla to his sternum. On percussion,

left venae subclavia to superior the right chest appeared to be dull

venae cava, cholelitiasis and and on auscultation breath sounds

cholesisititis. Primary cancer of the were decreased in the right base in

patient was well controlled. This comparison to the left. The abdomen
was soft, nontender, and type pulmonal metastase, and

nondistended with normoactive chemoport showed from left

bowel sounds. Tenderness was subclavian vein to superior cava

elicited on palpation of the upper vein.

thoracic spine and right scapular area Table 1. Laboratory Preoparative

and range of motion of both arms Result

was mildly restricted due to pain and EXAMI RES NORMAL METHODS
NATION UL
T
Hb 11,8 g/dl 12,0-15,6
discomfort. Cardiovascular and Hct 37 % 33-45
AL 4,4 x103 /uL 4,5-11,0
AT 178 x103 /uL 150-450
neurological examination was AE 4,46 x106 /uL 4,10-5,10
Eritrocyte Index
noncontributory. MCV 83,4 /um 80,0-96,0
MCH 26,5 Pg 28,0-33,0
MCHC 31,7 g/dl 33,0-36,0
On laboratory pre-operative RDW 11,8 % 11,6-14,6
MPV 8,4 Fl 7,2-11,1
PDW 16 % 25-65
examination at December,12,2017, Diff Count
Eosinofil 6,30 %
Basofil 0,40 %
the patient was found to have Neutrofil 57,1 %
0
Limfosit 27,2 %
normocytic normochromic anemia Monosit
0
9,00 %
Gol O AGLUTINATI
Darah ON
with hemoglobin of 11,8 gm/dL. The Homostasis
PT 11,6 Second Semi automatic

leukocyte count was normal. APTT 33,2 Second Semi automatic

INR 0,89 Semi automatic
0
Clinic Chemical
Metabolic panel and liver function GDS 86 mg/dl 60-140 Hexokinase

SGOT 27 u/L <31 IFCC tsnps

pyridoxal
test results were within normal
LPGT 21 u/L <34 IFCC tsnps
pyridoxal
Albumin 3,5 g/dl 3,5-5,2 BCG
limits. The coagulation panel was Creatinin 0,6 mg/dl 0,6-11 Enzimatic

normal. The MSCT thorax at Ureum 16 mg/dl <50 Enzimatic UV

Assay

Electrolyte

November 28, 2017 concluded the Natrium 139 mmol/L 136-145 DIREK ISE

Kalium 3,9 mmol/L 3,3-5,1 DIREK ISE

mass at retroareola and retronipple Chlorida 107 mmol/L 98-106 DIREK ISE

Patologic Hepatitis
HbsAg NR NR ICT
right mammae highly suggestive Rapid

malignant (BIRADS 5), pneumonic

Figure 1. MSCT Thorax
Figure 2. Durante Op At December 14, 2017 patient

undergone the operation. Here is the

operation report:

OPERATION REPORT

Pre operative diagnose: lung

metastase breast cancer

Post operative diagnose: lung

metastase

Operation: thoracotomy exploratory,

segmentectomy, chest tube

thoracostomy

Operator: Darmawan Ismail, dr,

SpBTKV

1. Patient on theatre in half decubitus

position in general anesthesia, toilet

operation field, hollow sterile doek

lid

2. Incised above costa 6 dextra along

10cm, layer by layer, split musc

latissimus dorsi (D) and anterior

muscle serratus (D), intercostalis

muscle of SIC 6  pulmo

visualized
3. Identification of metastasis of

mammary tumor to lung  visible 3 The operation was held in 30

mass size 2x1x1cm, 3x2x1cm, minutes. Post operation, patient

1x1x1cm (2mass in superior lobe, 1 stayed at Intensive Care Unit.

mass in posterior lobe) Followup day 1 patient condition

4. Performed excision of tumor with was stable, composmentis, and feel

laser  control of bleeding pain in scar post operative. Physical

5. Metastatic tumor is stored in examination and the patient

formalin 10%  specimen send to condition was normal. Followup day

PA 2, patient was transferred to

6. Lung leak test  (-) Pavilliun, WSD was removed, but

7. Sew layer by layer still complain about scar post

8. Operation is complete operative and sometime feel pain

Table 2. Laboratory Result Post during breathing. Followup day 3,

Operative (December 14, 2017) the complaining about pain was

RESU NORMAL METHO reduced, patient started to mobilized

LT DS
Hb 11,0 g/dl 12,0-15,6
Hct 34 % 33-45
AL 5,6 x103 /uL 4,5-11,0
tilted to right and left, but still used
AT 159 x103 /uL 150-450
AE 4,07 x106 /uL 4,10-5,10
Clinical Chemical oxyggen 3liters per minutes by nasal
Albu 3,2 g/dl 3,5-5,2 BCG
min
Electrolyte canul. Followup day 4, no complain
Natri 135 mmol/L 136-145 DIREK
um ISE
Kaliu 3,5 mmol/L 3,3-5,1 DIREK about scar, patient mobilized to
m ISE
Chlor 111 mmol/L 98-106 DIREK
ida ISE
BLOOD GAS ANALYZED
sitting and standing. The
pH 7,496 7,350-7,450
BE 4,2 mmol/L -2 - +3
PCO2 35,5 mmHg 27,0- 41,0 complaining about pain during
PO2 279,4 mmHg 83,0- 108,0
Hct 35 % 37-50
HCO 27,7 mmol/L 21,0-28,0 breathing was decreased, iv line and
3
Total 28,8 mmol/L 19,0-24,0
CO2
O2 99,4 % 94,0-98,0
douwer catheter was removed.
satura
tion
Lactat 1,80 mmol/L 0,36-0,75
Arter
y
Followup day 5, the condition patient disease-free interval (DFI), the

was stable and allowed to go home number and location of lung

with analgetics. The patient was metastases, the diameter in mm of

treated with oxygen, antibiotics and metastases and the extent of

analgetics when hospitalized. pulmonary resection.8

Patient come to control after That was the first time Laser

hospitalized 3days later. The Assisted Pulmonary Metastasectomy

physical examination and general (LAPM) held in Moewardi Hospital

condition was normal. Patient control in Surakarta. It used laser 1318nm

1times per week until 1month. The ND Yag. The operation last about

condition was stable. Then the 30minutes, post operative patient

patient control 1times per month up was set WSD. Patient stayed for

to now. Patient also came to about 7days. No complication found

policlinic oncologic and was at preoperative, durante and post

prescribed tamofen. operative.

DISCUSSION There was some preparation

One of the main before undergo LAPM. At first,

characteristics of breast cancer is its control of primary cancer must be

capability to disseminate. Solitary ascertained. Next, routine blood

pulmonary metastases from breast tests, chest X-ray, pulmonary

cancer occur rarely (0.4%). Potential function tests, EKG, blood gas

prognostic factors affecting survival, analysis, tumour marker studies,

namely survival after lung stress testing, abdominal ultrasound,

metastasectomy, assessed were CT-scan, MRI, PET-CT, GI

endoscopy etc. are usually pulmonary metastasectomy which

considered.9, 18 does not permit digital exploration

Limitations of CT-scan in by surgeon is not a proper way of

diagnosing lung metastasis must be handling the disease. A clear

clearly understood. Firstly, all example of this is Video Assisted

nodules seen on CT-scan are not Thoracic Surgery (VATS) for this

metastatic in nature. Many of them, operation. It can leave disease behind

9,16
especially in case of breast cancer, which LAPM can easily remove.

could either be non-cancerous or At this case, patient have prepared

second primary lung cancer. It is for for LAPS. Primary cancer was

this reason, too, LAPM should be controlled and routine examination

considered as a diagnostic aid paving have been done.

way for correct treatment. 9,17 For preoperative

Secondly, a most preparation, the patients undergo

sophisticated CT-scan also misses a thorough medical and anaesthetic

metastatic nodule smaller than 3 to 4 evaluation. They work on incentive

mm in size. On the other hand, spirometry during every waking

careful inspection of lung through hour. Aggressive chest

open chest and exploration by physiotherapy helps in early

surgeon’s experienced fingers can recovery. Bronchospasm, diabetes

detect 25% more nodules , as small mellitus and hypertension must be

as 1 mm in diameter, which are controlled well. Smoking must be

missed by CT-scan. It is for this avoided at least a week prior to

reason that any technique of surgery. Inhalers, nebulisation and

steam inhalation improve lung can be vaporised instead removed.

health. 10,17 Excised tumours can be subjected to

At the theatre room, chest is pathological studies. Raw areas can

entered through a small cut be sutured back leaving lung nearly

underneath the armpit. No muscle or normal. Loss of lung tissue is hardly

rib is cut or removed. A spreader is 10%. There is very little blood loss

inserted between the two ribs and and hence, no blood transfusion is

ribs are spread apart. Operator required. Total operating time varies

carefully inspects and explores the between 1 and 2 hours. Complication

entire lung with fingers. Thus he rate is hardly 1 to 2 %. Mortality is

detects and notes the site and number rare. 10, 16

of cancerous nodules. For post operative course,

All nodules are removed most of the patients either do not

along with a margin of 2-3 mm of need any ICU care or need it only for

healthy lung around them. Operator 2 to 24 hours. Most of the pre-

follows the contour of the nodule and operative measures are continued

goes all around in the healthy lung. post-operatively. Nasal oxygen

One nodule usually takes 1-2 cannula stays for 3 to 6 hours. Need

minutes. Though laser generates for ventilator is very rare.

temperature of 700 degree Celsius, Analgesics-epidural, IV and oral- are

healthy lung is not damaged. Usually given liberally. IV fluids are needed

7-8 nodules are removed from each for the first day. Oral liquids are

lung but even 100 can be removed in started from the evening of the day

the same fashion. Very tiny nodules of operation and normal diet is
started from the next day. Removal surgical resection. Some studies

of the chest tube and ambulation report no benefit in overall survival

begin on 2nd or 3rd day. Most often, for patients undergoing complete

patient stays in hospital for 3 to 5 metastasectomy for breast cancer

days depending on their tolerance to compared to systemic chemotherapy

pain. Pre-discharge chest X-ray is or to patients undergoing an

taken. At this cases, patient stayed at incomplete resection, whereas others

ICU for 24hours post operative and do find a survival benefit. 13-16

removal of chest tube on 2nd day. In selected cases, with a

Patient stayed for 5days after DFI of more than 36 months and
10-18
operation. complete resection, a long disease-

Currently, surgical resection free and overall survival period may

remains the gold standard for be obtained. However, not all lung

resectable lung metastases. nodules are metastatic lesions. Rena

Prognostic factors are histology, et al. showed that, in 50% of the

complete resection, number of patients with a history of breast

metastases and disease-free interval.9 cancer and a newly diagnosed lung

In breast cancer, chemotherapy is the nodule, primary lung cancer was

primary treatment option for patients found. Complete surgical resection

with lung metastases.10-12 Metastatic needs to be performed in this patient

disease of breast cancer responds group in order to have histological

very well to systemic chemotherapy confirmation and a real chance of

and/or antihormonal therapy, cure when a primary lung cancer is

resulting in an unclear role for found. Another study showed that

there is a reasonable chance that the few and small metastases,

hormonal receptor status of the irrespective of poor-prognosis

primary tumour is different from the aspects.20 Similarly Planchard et al.

lung metastases, warranting demonstrated that pulmonary

histological evidence to plan further metastasectomy from breast

treatment. Although most studies do carcinoma was associated with a

not find a survival benefit, surgical significant 5-year survival rate of

resection of lung metastases from 45%, but were not able to

breast cancer is warranted in selected discriminate whether this result was

cases if complete resection can be due to the surgical procedure itself or

achieved, if there is suspicion of to the selection of patients, the

primary lung cancer and to plan authors emphasized that when

further treatment depending on the resection is evaluated this cohort of

hormonal receptor status of the patients, both the size of the largest

metastases. 7,8,10 metastasis and the disease free

Yhim et al. analyzed clinical interval should be carefully

outcomes of patients suffering from considered. 21

recurrent breast-cancer with less than In this case report, from the

four pulmonary metastases, treated examination to the patient after lung

with systemic treatment alone or metastasectomy at December 2017

lung resection and then systemic up to now at July 2018, stiff

treatment, disclosing that pulmonary complain in patient continuously

metastasectomy can be an effective decreased. Although still can not be

therapeutic option for patients with concluded about post operative

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