Chapter 75

It has been established that lobectomy offers the best chance of cure for early-stage non-small cell lung cancer. According to the Cancer Study Group, sublobar or wedge resection is not as effective as lobectomy or pneumonectomy because it is associated with a high incidence of local recurrence.1 However, a large resection requires the patient to have a reasonable forced expiratory volume in 1 second (FEV1) of 0.8–1.2 L and a ventilation-perfusion scan corresponding to adequate breathing in other lung segments. Patients who have long histories of smoking commonly fail to have these advantageous characteristics. Emerging techniques that combine sublobar resection with radiotherapy delivered intraoperatively or through the implantation of radioactive 125I seeds at the lung resection margin have shown promising results. These new procedures have been reported to reduce local disease recurrence and improve palliation of symptoms. Additionally, they provide new treatment options for patients who are not physically capable of undergoing lobectomy or pneumonectomy or who are considered high-risk surgical candidates consequent to other comorbidities.

There are several reports of wedge resection procedures for stage I tumors that have been performed in conjunction with planar 125I seed implants. This new procedure has been reported to reduce local disease recurrence and improve palliative control.

After the wedge resection, the surgeon must measure the area at risk for length and width to determine the dimension of the implant. The implant is made of two components. The source material, called the Seed-in-Carrier, available through the Oncura Company (Plymouth Meeting, PA), consists of 125I seeds that are embedded in strands of absorbable Vicryl suture. There are 10 seeds in each strand, and each seed and strand is spaced 1 cm apart center to center. The individual seed measures 0.7 × 4 mm in dimension. The source material is attached to an absorbable mesh material made of either Dacron or Vicryl that is custom trimmed to fit the area at risk. Before trimming, 1 cm is added to the overall dimension to ensure an adequate margin for suturing. Parallel lines spaced 1 cm apart are drawn longitudinally on the mesh patch. The radioactive strands then are stitched to the mesh along these lines. The radioactive strands and suture should be handled with care using forceps only (Fig. 75-1). The source material is anchored on each side of the implant with a small staple, and any excess source material should be cut and disposed of properly in accordance with radiation disposal guidelines (Fig. 75-2). The custom mesh then is placed over the area of interest and sutured into place, using extreme care not to puncture the seeds (Fig. 75-3). After the operation is concluded and the patient is stable (or at some future date), a postoperative CT scan is obtained over the area of interest to verify and document the final dose.

###### Figure 75-1.

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