Video-Assisted Thoracic Surgery for Ambiguous Lung or Mediastinal Masses in Response Assessments for Hematological Malignancies
Thoracic lesions are a significant concern during the treatment of hematological malignancies. These lesions can arise from tumor recurrence, invasion, or infections, making their diagnosis and management particularly challenging. Conventional diagnostic methods, such as percutaneous lung biopsy or bronchoscopy, often pose risks of severe complications like hemoptysis, pneumothorax, or infection, especially in patients with low platelet counts and compromised immunity. Additionally, these methods may fail to provide a definitive diagnosis, leading to ineffective treatment. Even when fungal infections are suspected, antifungal therapy alone may not suffice to eliminate the lesions. Video-assisted thoracic surgery (VATS) has emerged as a minimally invasive surgical procedure that offers significant advantages in diagnosing and managing these ambiguous lung or mediastinal masses.
VATS is a surgical technique that allows for major and minor lung resections with adequate pain relief and sedation. It is performed in a minimally invasive setup, enabling thoracic procedures under spontaneous breathing. This approach has been increasingly utilized for lung biopsy or pulmonary resections in patients with hematological malignancies, providing a safer and more effective alternative to traditional methods. This article presents a series of cases to evaluate the feasibility and safety of VATS in diagnosing and managing lung or mediastinal masses in patients with hematological malignancies.
Between December 2017 and July 2019, 12 patients with hematological malignancies underwent uniportal VATS (U-VATS) for lung or mediastinal masses. The decision to use VATS was made after comparing it with other biopsy methods, such as interventional bronchoscopy and computerized-assisted transthoracic needle biopsy. The choice of VATS was based on the location of the lesions, the patients’ conditions, and the risk of misdiagnosis. The characteristics of the patients are detailed in Table 1. Among the 12 patients, 83.33% (10/12) had achieved complete remission after regular chemotherapy, one patient had partial remission, and one patient was diagnosed with hemophagocytic syndrome of unknown origin.
All patients received standard prophylactic treatment for pulmonary infection, which included triazole antifungal agents and cotrimoxazole when the neutrophil count was below 1 × 10^9/L. None of the patients were confirmed to have fungal or Pneumocystis carinii infection before the mass lesions were detected. For patients who underwent hematopoietic stem cell transplantation (HSCT), antimicrobial prophylaxis was administered during HSCT and continued for three months post-transplantation. Patients with lung or mediastinal masses confirmed by computed tomography (CT) scans or positron emission tomography/computed tomography (PET/CT) received broad-spectrum antibacterial and empiric antifungal therapy for one month, but no improvement was observed.
VATS was performed in all 12 patients, with VATS-mediated lung and mediastinal mass biopsy conducted in five patients, VATS wedge resection in six patients, and VATS radical resection in one patient. The average blood loss during the procedures was 103.25 ± 159.57 mL. The length of hospital stay from post-operation to discharge ranged from 2 to 10 days, with an average of 4.25 ± 2.16 days. The results of the pathological assessment following VATS are summarized in Table 1. Among the 12 patients, one was confirmed to have a relapse of lymphoma, one had newly diagnosed lymphoma, six were diagnosed with pulmonary fungal infections, one was confirmed to have secondary cancer, and three patients who were suspected of having a relapse before VATS were found to have fibrous connective tissue hyperplasia.
Patients were followed until death or the end of data collection on December 31, 2020, whichever came first. The 2-year cumulative survival rate was 66.7%. The diagnosis of lung or mediastinal masses in patients with hematological malignancies is particularly challenging due to low white blood cell counts, low platelet counts, coagulopathy, and immunodeficiency, which make conventional surgical resection impossible. Without a definitive diagnosis, patients may be overtreated or miss the optimal treatment window.
Contrast-enhanced CT or PET/CT has limitations in differentiating between infection and malignancy, as residual masses or new lesions after chemotherapy could indicate relapse, infection, or secondary tumors. For instance, the standard uptake value (SUV) in cryptococcal pneumonia fluctuates between 0.93 and 11.6, and the average SUVmax in tuberculosis (TB) is 4.2 ± 2.2, making it difficult to distinguish these conditions from tumor relapse. The 2021 revised National Comprehensive Cancer Network (NCCN) guidelines for many types of lymphoma emphasize the importance of rebiopsy for residual lung or mediastinal masses to confirm the pathological diagnosis and prevent overtreatment for malignancy.
Biopsy technologies, such as interventional bronchoscopy and computerized-assisted transthoracic needles, have limitations in obtaining sufficient samples. The NCCN guidelines indicate that excisional or incisional biopsy is preferred over core needle biopsy. VATS has become increasingly used to assist in pathological evaluation. In this report, 50% of the patients were pathologically confirmed to have infections, and only one patient was confirmed to have a relapse, suggesting that infection, rather than tumor relapse, was the main cause of the mass after regular treatment for hematological malignancy.
Among the six patients confirmed to have infections, two had cryptococcal infections, three had Aspergillus infections, and one had TB. VATS enabled a reliable diagnosis, allowing for the initiation of appropriate antifungal treatment. VATS is an effective and safe option for managing invasive pulmonary fungal infections in these patients and can also help remove lesions when necessary. Compared to traditional surgery, VATS is less invasive, involves fewer and smaller incisions, and results in a shorter hospital stay.
A study by Ma et al. reported that 51 patients with hematological diseases underwent VATS for invasive pulmonary fungal infections, with no life-threatening complications or infection recurrences observed during the 6- to 24-month follow-ups. In this series, three patients who underwent VATS radical or wedge resection had very short hospital stays, and one of them underwent allogeneic HSCT only 14 days after VATS. VATS is associated with fast recovery and fewer complications, providing an opportunity for transplantation.
The differential diagnosis of new pulmonary lesions or residual mediastinal masses shown by contrast-enhanced CT or PET/CT for remission assessment of hematological diseases is of great importance. VATS is a safe and important procedure for making diagnoses and guiding treatment. It offers a minimally invasive approach with significant advantages in terms of diagnostic accuracy, patient safety, and recovery time.
In conclusion, VATS is a valuable tool in the management of ambiguous lung or mediastinal masses in patients with hematological malignancies. It provides a definitive diagnosis, guides appropriate treatment, and minimizes the risks associated with traditional biopsy methods. The use of VATS in this patient population is supported by its feasibility, safety, and effectiveness, as demonstrated in this series of cases.
doi.org/10.1097/CM9.0000000000001910
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