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OBJECTIVE: To show the benefit in the use of ROLL technique with the Robotic resection and bronchoplasty in the neuroendocrine tumor producing ectopic ACTH syndrome (EAS).
METHODS: Radio-guided Occult Lesion Localization (ROLL) with 99-Technetium marcation was used for thoracoscopic exploration with assistance of the surgical Davinci robotic system in a 41 years old male patient with ectopic ACTH syndrome (EAS). A lesion on the wall of the lingula's bronchus was detected as the source of radioactivity. Resection was done using the multi-wrist instruments of the robot. The wall defect in the bronchus was repaired suturing by bronchoplastic procedure.
RESULTS: After procedure the lung parenchyma was preserved. Lung reexpansion was totally achieved. In The post-operative period, admission to ICU was not required. The chest tube was removed the first postoperative day. Microscopic examination of the peribronchial tumor reported small fragments of neuroendocrine tumor, with vascular invasion, no mitotic activity or necrosis and two peribronchial lymph nodes negative for infiltration. The tumor stained positively for CAM5.2, synaptophysin, Chromogranine A, CD5 and ACTH, and negative for CD117, TTF-1 and CDX2; The Ki-67 was of 1%. These results supported a Typical Carcinoid tumor (WHO grade 1) of thymic origin due to CD5 expression. The patient recovered from Cushingoid phenotype, lost of weight, and his hypertension and diabetes were cured. After two years of follow up the patient persist with clinical and biochemical cure criteria.
CONCLUSIONS: Using robotic aid with high definition three-dimensional vision and the multiarticulated instruments with more intuitive movements and greater flexibility is possible to dissect, remove tumor lung and perform the reconstruction of the structures through a minimal invasive surgery, and more efficiently than open or conventional video assisted thoracic surgery. With the aid of localization of the abnormal tissue with nuclear medicine was possible find the lesion preserving lung tissue. This technological aid permitted no admission to Intensive care unit and only two days of hospital stay. Currently this is the first published case of a lung low grade neuroendocrine tumor treated by bronchial resection without lung resection and bronchoplasty with ROLL localization and totally robotic assistance.