Synchronous primary intrapulmonary and mediastinal thymoma-A case report

We report an extremely rare case of Synchronous primary intrapulmonary and mediastinal thymoma in a Chinese patient. We describe the histological and radiological findings, which support the possibility of multicentric thymoma. Resection of the mass in the left anterior superior mediastinum and upper lobectomy of right lung were performed, with lymph Nodes clearance, superior vena cava, left and right brachiocephalic veins resection, reconstruction of left brachiocephalic vein to right auricle and reconstruction of right brachiocephalic vein to superior vena cava.     

Invasive thymoma with extensive growth in the superior vena cava;report of a case

An anterior mediastinal tumor was incidentally found in a 58-year-old asymptomatic woman on a medical checkup. Computed tomography (CT) demonstrated a large tumor plugging the almost entire lumen of the superior vena cava (SVC), and 3 nodules in the bilateral lungs. The tumor seemed most likely an advanced thymoma or thymic carcinoma extending into the SVC and presenting with lung metastases. The patient underwent a combined resection of the invasive tumor and the SVC under cardiopulmonary bypass (CPB), and lung wedge resection for the nodules. The bilateral brachiocephalic veins were reconstructed with the separate grafts. The invasive tumor and the lung nodules were histologically confirmed as thymoma. Resection and reconstruction of the SVC was successfully performed under CPB for extirpation of an invasive thymoma with extensive intracaval growth. Combination chemotherapy for the relapsing lung metastases finally achieved complete response 41 months after surgery.     

Surgical treatment of the malignant mediastinal tumors--with special reference to prosthetic reconstruction of superior vena cava

Sixteen patients with the malignant mediastinal tumors compromising the superior vena cava (SVC) and brachiocephalic veins (BCV) were treated from April 1974 to March 1987. SVC reconstruction by prosthesis combined with or without tumor resection were performed in 6 cases and removal of the tumor with partial resection of SVC and right BCV in one case. Two patients died within one month and two patients survived over 5 years postoperatively. Tumor resection, removal of the right lung and SVC wall, and patch angioplasty were performed in one patient who died three and one half months postoperatively. Resection of the tumor and left BCV were performed in 4 patients. Segmentally resected left BCV was reconstructed with interposed graft in two, prosthesis was implanted between left BCV and right atrium in one and no venous reconstruction was attempted in one. Three patients are alive and one patient died six and one half years after operation. Exploratory mediastinotomy was carried out in 3 cases and radiation therapy alone in one case. All but one patients died within one year after diagnosis. Though the long term results of the surgical treatment for malignant mediastinal tumor was not satisfactory, extensive resection of the tumor was worth attempting, as the patency rate of the prosthetic venous reconstruction was improved.     

Long-term graft patency after replacement of the brachiocephalic veins combined with resection of mediastinal tumors

OBJECTIVE: We sought to investigate the correlation between type of vascular reconstruction and long-term graft patency after replacement of brachiocephalic veins combined with resection of mediastinal malignancies. METHODS: Eighteen patients underwent surgical resection of tumors and the superior vena cava with concomitant vascular reconstruction using ringed polytetrafluoroethylene grafts. Graft patency was verified by means of venography or contrast-enhanced computed tomography at time points ranging from 3 to 77 months (median, 33 months) postoperatively. RESULTS: Seven patients underwent sole reconstruction of the right brachiocephalic vein, with occlusion observed in only 1 patient. In 6 patients who underwent reconstruction of the bilateral brachiocephalic veins with 2 separate grafts, the grafts remained patent in 2, whereas 4 patients experienced occlusion of one of the two grafts yet remained asymptomatic. Both patients who underwent reconstruction with a Y graft experienced left brachiocephalic vein graft occlusion. In the 3 patients who underwent reconstruction of a left brachiocephalic vein, the graft became occluded, and superior vena cava syndrome developed in 2 of these patients. CONCLUSION: When replacing the superior vena cava, reconstruction of a left brachiocephalic vein alone results in a significant rate of occlusion and development of superior vena cava syndrome. Thus we advocate sole right brachiocephalic vein reconstruction or bilateral brachiocephalic vein reconstruction in this setting, and separate reconstruction of the veins is preferable to use of a Y graft.     

Superior vena cava reconstruction combined with resection of mediastinal-pulmonary malignant tumors

From 1988 to 1997, we experienced 5 cases of the superior vena cava (SVC) replacement with expanded polytetrafluoroethylene (ePTFE) grafts combined with resection of mediastinal or pulmonary malignant tumors. Two patients had lung cancer and three had invasive thymoma. Resection and reconstruction of the superior vena cava (SVC) were performed by application of a bypass graft between the innominate vein and the right atrium in two cases and a temporary bypass using a heparin-coated tube in three cases. Except in one patient who died of acute respiratory failure, no complication or occlusive symptom were observed postoperatively. Two patients remain healthy for 5 years 4 months and 2 years 7 months after operation. Three died 9 years, 5 months, and 110 days after operation respectively. In conclusion, ePTFE graft replacement or patch angioplasty of the SVC should be part of planning and execution of radical excision with curative intent of mediastinal or pulmonary malignant tumors.     

Surgical strategy for invasive pulmonary and mediastinal tumors requiring superior vena cava reconstruction

During the past 16 years, 22 patients were operated on concomitantly with superior vena cava (SVC) reconstruction in our university hospital. Among them, 19 patients had anterior mediastinal tumor and 3 advanced lung cancer. They were 13 males and 9 females, ranging in age from 16 to 70 (mean, 51.4) years. Severe SVC syndrome was found in 10 cases of them. The anterior mediastinal tumors consisted of invasive thymoma in 10 cases, thymic Hodgkin's disease in 2, seminoma in 2, and thymic cancer, thymic carcinoid, thyroid cancer, metastasis of chondrosarcoma and yolk sac tumor in each one. Regarding SVC reconstruction, anatomical bypass was performed in 18 cases, in addition to a radical resection of the tumor. The left innominate vein was reconstructed in 5, the right innominate vein including SVC in 4 and bilateral veins in 9. Extra-anatomical bypass was performed in 4 cases with unresectable tumors because of severe SVC syndrome. Subclavian-femoral vein bypass was performed in one and internal jugular-femoral vein bypass in 3. In anatomical bypass, 7 cases have been alive now though 11 died, and graft patency rate was 82% in the right and 38% in the left. All 4 cases with extraanatomical bypass showed improvement of SVC syndrome, but died one to seven months postoperatively. In conclusions, radical operation with reconstruction of SVC was effective to long-term survival and improvement of SVC syndrome. Extraanatomical bypass improved postoperative quality of life remarkably.     

Reconstruction of the superior vena cava in patients with mediastinal malignancies.

We performed reconstruction of the superior vena cava (SVC) and left brachiocephalic vein following extensive resection of malignant thymic tumours in eight patients, five of whom had invasive thymoma. The other patients each had a thymic Hodgkin's lymphoma, thymic carcinoma and thymic germ cell tumour. Teflon grafts were used in the first two cases and expanded polytetrafluoroethylene (EPTFE) grafts in the subsequent six cases. Occlusion occurred only in one SVC graft and two left brachiocephalic vein grafts. The mean survival after this operation was 35 months, with the longest survivor showing no occlusive symptoms for 8 years. This operation not only alleviates the symptoms of the SVC syndrome but may also improve the prognosis of such patients.     

Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors

The contraindication to curative excision of mediastinal and pulmonary cancers because of invasion of the superior vena cava is now challenged by the existence of vascular prostheses that are suitable for venous replacement. Between 1979 and 1990 22 patients underwent resection of lung cancer (n = 6) or malignant mediastinal tumors (n = 16) involving the superior vena cava. Resection was done with concomitant venous reconstruction, and polytetrafluorethylene grafts were used. All bronchogenic carcinomas necessitated right pneumonectomy, whereas the excision of mediastinal tumors had to include pulmonary resections in nine patients (five lobectomies and four sublobar resections) and the right phrenic nerve in 12 patients. Venous reconstruction was performed by interposition of a large polytetrafluoroethylene graft between the proximal and cardiac ends of the superior vena cava (n = 8), or between one (n = 10) or both brachiocephalic veins (n = 4) and the right atrium. One patient died postoperatively (4.5%), and another had mediastinitis that was successfully treated by omentopexy. Chemotherapy was administered preoperatively to five patients and postoperatively to seven patients; radiotherapy was administered to two and 10 patients, respectively. The overall actuarial survival rate is 48% at 5 years, with 11 patients presently alive. The survival rate of patients with mediastinal tumors is 60% at 5 years. Among the patients with lung cancer, two with N1 disease are alive at 16 and 51 months, and one died at 38 months; the two patients with N2 disease died at 6 and 8 months. Only one graft occlusion occurred in the postoperative period; another occurred 14 months after operation and was precipitated by insertion of a central venous catheter. The patency of all remaining grafts was demonstrated after an average time of 23 (1 to 98) months. On the basis of these results, polytetrafluoroethylene graft replacement of the superior vena cava should be part of the planning and execution of radical excision with curative intent of mediastinal and right pulmonary malignant tumors that are not present with other contraindications, such as pleural or distant metastasis and severe systemic disease.     

Analysis of surgical treatment of Masaoka stage III-IV thymic epithelial tumors

Objective

The purpose of this study is to elucidate the outcomes after surgical resection of Masaoka stage III-IV thymic epithelial tumors.

Methods

We retrospectively reviewed patients with Masaoka stage III-IV thymic epithelial tumor who underwent surgical resection from January 1995 to January 2017. The clinicopathological features, surgical procedures, and postoperative outcomes were investigated.

Results

Thirteen patients with thymoma and 18 patients with thymic carcinoma were assessed. The postoperative Masaoka stages were III/IVa/IVb?=?8/4/1 in thymoma and III/IVa/IVb?=?11/2/5 in thymic carcinoma. In patients with thymoma, the World Health Organization pathological subtypes were A/B1/B2/B3?=?2/1/4/6. We performed combined resection and reconstruction for brachiocephalic vein or superior vena cava in 3 patients with thymoma and 7 patients with thymic carcinoma. In all patients, the patency rate of the grafts was very low for the left brachiocephalic vein and well maintained for the right brachiocephalic vein. Macroscopically and pathologically complete resection was achieved in 11 and 6 patients with thymoma, respectively, and in 15 and 9 patients with thymic carcinoma, respectively. The 10-year survival rates were 85.7% in thymoma and 70.3% in thymic carcinoma. Postoperative recurrences were observed in 2 and 9 patients with thymoma and thymic carcinoma, respectively. Recurrences were observed within 5 and 10 years after surgery in 2 patients with thymoma and within 2 years in all patients with thymic carcinoma.

Conclusions

Patients with Masaoka stage III-IV thymic epithelial tumor showed relatively favorable long-term survival after surgical treatment. Therefore, aggressive surgical resection for complete resection may be a treatment option for these conditions.

     

累及气管下段右侧壁和上腔静脉的右上肺癌的外科治疗

目的：探讨累及气管下段右侧壁和上腔静脉的右上肺癌外科治疗策略及其疗效。方法累及气管下段右侧壁和上腔静脉的T4期肺癌外科治疗患者4例,采用“左主支气管延长”法气道重建,2例采用腔外分流法置换上腔静脉,2例行上腔静脉侧壁切除术。1例同时行肺动脉侧壁部分切除术。结果4例患者均顺利完成手术,无围手术期死亡。术后均给予低分子肝素抗凝治疗2周,之后改为阿司匹林抗凝治疗。术后声音嘶哑合并肺部感染1例,1例房颤。无其他严重并发症,术前上腔静脉阻塞综合征的2例患者术后无上腔静脉阻塞表现,胸部增强CT提示上腔静脉通畅。2例患者分别生存34个月和36个月,仍在随访中;另2例术后病理N2的患者分别生存30个月和31个月,已死亡。结论左主支气管根部延长术和腔外分流法上腔静脉置换或侧壁切除用于治疗累及气管下段右侧壁和上腔静脉的右上肺癌,安全有效。     

Extended resection of the great vessels for primary lung cancer and mediastinal tumor

From 1973 to 1998, we resected and reconstructed the great vessels in 44 patients with primary lung cancer or mediastinal tumor. Among them, 39 patients (28 with lung cancer and 11 with mediastinal tumor) and 5 patients (all with lung cancer) underwent reconstruction of the superior vena cava (SVC) and aorta, respectively. The SVC was repaired by expanded polytetrafluoroethylene (EPTFE) graft (n = 8), prosthetic patch (n = 5) or direct suture (n = 26). The aorta was repaired with temporary subclavian artery-descending aorta (n = 3), or left atrium-femoral artery bypass (n = 2). No complication or operative death occurred after surgery. The survival rate of the patients with lung cancer who underwent SVC reconstruction at 3 year and 5 year were 26.2% and 11.2%, respectively. Five of 11 (45.5%) patients with mediastinal tumor are alive at 5 years. We concluded that extended resection for primary lung cancer or mediastinal tumor invading the SVC is acceptable operation method for some patients.     

A case of thymoma protruding into the superior vena cava through the thymic vein

We describe an unusual case of an invasive thymoma protruding into the superior vena cava and left brachiocephalic vein through the thymic veins in a 64-year-old patient. The tumor was resected with a bypass of the right brachiocephalic vein and right atrium. Although this type of growth form is rare for an invasive thymoma, this case suggests that in surgical procedures for thymomas, meticulous examination of the thymic veins is necessary to avoid leaving residual tumor.     

Thymic carcinoma successfully resected with superior vena cava after chemoradiotherapy

A 57-year-old woman hospitalized for thymic cancer invading the superior vena cava and left brachiocephalic vein evidenced both pleural and pericardial effusion. After chemotherapy with cisplatin and docetaxel and concurrent radiotherapy, the entire tumor was successfully resected along with the pericardium, superior vena cava, and left brachiocephalic vein, followed by vascular reconstruction. Pathologically, viable tumor cells were identified only in the center of the tumor as anaplastic cell carcinoma. Induction chemoradiotherapy thus appears useful in enabling complete resection of advanced thymic carcinoma.     

Superior vena cava reconstruction via a posterolateral thoracotomy without venous occlusion for locally advanced lung cancer: Report of a case

We performed a right upper lobectomy with prosthetic replacement of the superior vena cava (SVC) through a posterolateral thoracotomy in a 65-year-old man undergoing complete resection of a locally advanced non-small-cell lung cancer with invasion of the SVC. Instead of using a vascular shunt, the right atrium and a right brachiocephalic vein (BCV) were anastomosed using a ringed polytetrafluoroethylene (PTFE) graft. During the anastomosis, vascular flow was maintained through the left BCV. By using this technique, SVC resection and reconstruction during lung cancer surgery can be safely performed through a posterolateral thoracotomy without blood flow interruption.     

A long term survival case of thymic squamous cell carcinoma, performed complete extirpation with vascular reconstruction of the superior vena cava

A 59-year-old woman who complained of anterior chest pain exhibited an abnormal shadow on chest X ray and was admitted to our hospital. The chest X ray showed a demarcated tumor at the anterosuperior mediastinum and she was diagnosed as having a mediastinal tumor. After the midsternotomy was performed, the mediastinal tumor derived from the thymic tissues was discovered to have invaded the right upper lung, pericardium and superior vena cava. After excising the tumor, anastomosis between the right brachiocephalic vein and superior vena cava, followed by that between the left brachiocephalic vein and right cardiac auricle was performed using expanded polytetrafluoroethylene-ringed vascular grafts (? 10 mm) for reconstruction. The tumor was diagnosed as a thymic carcinoma (squamous cell carcinoma) pathologically. After surgery, she was treated by cobalt irradiation. One month and again 3 months after the operation, venography showed patency. The patient has not demonstrated recurrence for 9 years and 6 months.     

A long-term survival case of thymic squamous cell carcinoma, performed complete extirpation with vascular reconstruction of the superior vena cava.

A 59-year-old woman who complained of anterior chest pain exhibited an abnormal shadow on chest X ray and was admitted to our hospital. The chest X ray showed a demarcated tumor at the anterosuperior mediastinum and she was diagnosed as having a mediastinal tumor. After the midsternotomy was performed, the mediastinal tumor derived from the thymic tissues was discovered to have invaded the right upper lung, pericardium and superior vena cava. After excising the tumor, anastomosis between the right brachiocephalic vein and superior vena cava, followed by that between the left brachiocephalic vein and right cardiac auricle was performed using expanded polytetrafluoroethylene-ringed vascular grafts (phi 10 mm) for reconstruction. The tumor was diagnosed as a thymic carcinoma (squamous cell carcinoma) pathologically. After surgery, she was treated by cobalt irradiation. One month and again 3 months after the operation, venography showed patency. The patient has not demonstrated recurrence for 9 years and 6 months.     

胸腺癌的外科治疗与预后

目的探讨和评价对胸腺癌的临床表现、诊断、手术方法和术后辅助治疗的认识,以提高治疗效果。方法回顾性分析北京协和医院胸外科1961年6月~2004年6月手术治疗43例胸腺癌患者的临床结果;43例患者中完全切除15例,部分或大部分切除23例,开胸探查肿瘤活检5例。结果所有肿瘤均无完整包膜并侵犯周围器官,依次为心包、上腔静脉、左右无名静脉、胸膜、膈神经和肺。全组患者无手术死亡。经6个月至18年的随诊,随访率83.72%(36/43),术后1年内死亡8例,2年内死亡4例,术后5年和8年分别死亡2例和1例。按寿命表法计算1、3、5和8年存活率分别为68.29%、56.67%、41.56%和27.71%。结论胸腺癌与恶性胸腺瘤在临床表现、影像学特点、病理类型和预后诸方面均有明显不同,胸外科医师应予以区别;CT检查是重要的诊断方法。彻底切除肿瘤以及受侵的组织和器官,甚至切除上腔静脉人工血管置换可以明显提高患者的长期存活率。胸腺癌术后除放疗外,还需要进行全身化疗,以铂类为基础的第3代化疗药可有效地改善治疗效果。     

Extended operation for lung cancer invading the aortic arch and superior vena cava

Extended operation for lung cancer and mediastinal carcinoma involving the aortic arch or superior vena cava was performed in six patients. In three patients with lung cancer invading the right side of the mediastinum, sleeve pneumonectomy (two patients) or sleeve lobectomy was followed by resection and reconstruction of the superior vena cava with ringed polytetrafluoroethylene grafts. One patient with squamous cell carcinoma and T4 N1 M0 disease was alive and free of disease more than 34 months after the operation. The other patients with adenocarcinoma (T4 N1 M0) and adenosquamous cell carcinoma (T4 N2 M0) died 18 and 5 months after the operation of systemic metastases. In two patients with invasion of lung cancer into the left side of the mediastinum, resection and reconstruction of the aortic arch and left common carotid artery were performed by a femoro-femoral bypass. These patients had adenocarcinoma (T4 N2 M0) and large cell carcinoma (T4 N1 M0) and died of systemic metastases and bleeding during reoperation 12 and 4 months after the initial operation. In one patient with mediastinal squamous cell carcinoma, resection and reconstruction of the aortic arch and left subclavian artery were performed by application of a temporary bypass graft between the ascending and descending aorta. This patient was alive and free of disease more than 17 months after the operation.     

Radical excision of thymic adenocarcinoma with selective cerebral perfusion

Most cases of thymic carcinoma have some invasion to neighboring organs when diagnosed, and it is generally difficult to completely remove. We adopted selective cerebral perfusion as a cerebral protection and successfully performed resection of a thymic adenocarcinoma that involved the superior vena cava, left brachiocephalic vein, right brachiocephalic artery and vein, and left common carotid artery in a 47-year-old woman. Even if multiple great vessels were involved by mediastinal malignant tumor, complete resection with selective cerebral perfusion could be safely performed.     

Technical points of venous reconstruction for disorders of the superior vena cava

In recent years, the number of patients with disorders of the superior vena cava due to mediastinal tumors such as malignant thymoma, teratoma and hilus type of lung cancer is now increasing in Japan. For those patients, we have tried to do venous reconstruction for the disorders of the superior vena cava (SVC) due to malignant mediastinal tumors. By these combined surgical procedures such as resection of malignant tumor and SVC reconstruction, curability and longevity of the life were apparently recognized. However, it is very important to select patients of which resection of tumor and venous reconstruction can be carried out by several kinds of examinations such as computed tomography (CT), magnetic resonance angiography (MRA) and venography. There are 3 kinds of reconstruction such as direct suture and patch grafting, as well as bypass grafting with ringed e-PTFE (expanded-polytetrafluoloethylene) prosthetic graft except for endovascular interventions of which number of patients is still few. On the other hand, bypass grafting is also effective for high intracranial pressure with syncope for the patients whose tumors could not be resected, because of huge tumor and diffuse invasion.