Optimizing the surgical management of lung nodules in children with osteosarcoma: Thoracoscopy for biopsies, thoracotomy for resections

The goal of this study was to assess the role of thoracoscopy (TS) and thoracotomy (TT) in the management of lung nodules in children with osteosarcoma. Charts of 16 osteosarcoma patients undergoing surgery for lung nodules were retrospectively analyzed for a correlation between nodule localization at CT scan, findings at surgery, and pathology. Fourteen TSs were performed in 10 children, eight of which were converted: two for technical problems, and six for inconsistency between CT scan and intraoperative findings. In three converted cases, TT allowed detection of more nodules than CT scan and/or TS. Eight TTs were performed as primary intention in seven children, in one as secondary surgery after a previous TS. In three cases, TT detected more nodules than CT scan. Overall, TT detected more nodules than CT scan in seven of 16 cases (sensitivity, 56.2%), six of whom had a predicted bilateral involvement. Neoplastic tissue was present in lung samples of all but three patients (86.4%). Lung nodules in osteosarcoma patients are usually metastases. CT scan is unreliable in detecting all the nodules, especially in the case of predicted bilateral involvement. If excision of all metastases is considered the goal of surgery, a TT approach should be chosen in patients with more than one thoracic nodule.