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.     

Mediastinoscopy and mediastinotomy after cardiac surgery: are safety and efficacy affected by prior sternotomy?

BACKGROUND: The diagnostic and staging value of cervical mediastinoscopy is well established. Left anterior mediastinotomy is of further value in assessing left upper lobe tumors. However the efficacy and safety of both these procedures after median sternotomy for cardiac surgery is unknown. METHODS: We undertook a retrospective review of our experience of mediastinal exploration by cervical mediastinoscopy with or without left anterior mediastinotomy in patients with prior sternotomy between 1980 and 2001. RESULTS: During this period 28 patients (25 male and 3 female; mean age, 63 +/- 10 years), all with prior sternotomy for cardiac surgery (14 had left internal mammary artery graft), underwent mediastinal exploration. The mean interval between sternotomy and mediastinal exploration was 7.2 +/- 5.1 years. Additionally, 3 patients also had superior vena cava obstruction. Cervical mediastinoscopy was performed in all 28 patients and additionally left anterior mediastinotomy was undertaken in 7 of 28 patients (4 with left internal mammary artery graft). Indications for exploration were staging of lung cancer in 22 patients (cervical mediastinoscopy, n = 22; left anterior mediastinotomy, n = 7) and diagnostic biopsy of mediastinal mass in 6 patients (cervical mediastinoscopy, n = 6). Thorough mediastinal assessment was possible in all 28 patients. In the 22 patients with lung cancer the median number of lymph node stations sampled during mediastinoscopy was 3 (range, 1 to 5). A specific diagnosis was obtained in 16 patients (metastatic lung cancer, n = 10; lymphoma, n = 3; sarcoidosis, sinus histiocytosis, and metastatic melanoma, n = 1 each). The other 12 patients with negative findings underwent pulmonary resection and only 1 of 12 (8%) patients had unexpected N2 disease, a similar proportion to our overall experience with lung cancer. There were no operative complications. CONCLUSIONS: Prior sternotomy for cardiac surgery does not compromise the efficacy and the safety of mediastinoscopy and mediastinotomy.     

Pulmonary pleomorphic carcinoma; report of a case

We report a case of a 64-year-old man with pleomorphic carcinoma of the lung and thymic cyst. He was admitted to our hospital because of an abnormal shadow observed on chest X-ray. Computed tomography (CT) showed a mass lesion located in the right upper lobe and a non-invasive anterior mediastinal tumor adjacent to the left brachiocepharic vein. On enhanced CT, the lung mass showed central low-attenuation areas with a substantial enhancement in the periphery. Preoperative transbronchial blushing cytology of the mass revealed adenocarcinoma. With a diagnosis of primary lung cancer (cT3N0M0) and mediastinal tumor, an operation was performed through a median sternotomy. The mediastinal tumor was excised and a right upper lobectomy and were also accomplished, because the lung tumor did not show adhesion or pleural invasion. Histopathologic examination of the resected specimen revealed that the lung tumor composed of a mixture of spindle and giant cell features and contained a component of adenocarcinoma and squamous cell carcinoma. This finding yielded a pathological diagnosis of pleomorphic carcinoma (pT2N0M0). The mediastinal tumor was diagnosed as thymic cyst. The postoperative course was uneventful, and he is currently well 6 months after surgery.     

Thymic basaloid carcinoma with aggressive invasion of the lung and pericardium: Report of a case

We report a case of basaloid carcinoma of the thymus, invading the lung and pericardium. The patient was a 72-year-old man who suffered thoracic trauma in a fall and was taken to his family physician. Computed tomography revealed a huge mediastinal tumor with cystic components, pressing into the lung. He was referred to our hospital, where magnetic resonance imaging showed suspicious invasion of the pericardium and mediastinum. We made an assumed diagnosis of a mediastinal malignancy and performed mediastinal tumor resection. The tumor was adherent to the lung, pericardium, and left innominate vein. The final pathological diagnosis was a basaloid carcinoma of the thymus. Basaloid carcinoma is often a component of a multiloculated thymic cyst (MTC) and should be considered when MTC is identified within an anterior mediastinal tumor.     

A case of lung cancer with mediastinal tumor

A 72-year-old female underwent surgical resection of lung cancer and mediastinal tumor. Abnormal shadows on the chest roentgenogram were incidentally detected by the regular health screening. The lung cancer existed in the left upper lobe, and the mediastinal tumor existed in the posterior mediastinum along left side of the spines. Serum CEA level was 299 ng/ml by enzyme immunoassay method. We judged the lung cancer as being in Stage I (T2 N0 M0), and the mediastinal tumor as benign neurogenic tumor unrelated to the lung cancer through detailed examination. Surgical resection of both tumors was performed through left thoracotomy, and the surgical procedure was curative operation. Pathological examination revealed the lung cancer was moderately differentiated adenocarcinoma and the mediastinal tumor was Schwannoma. Eight months after surgery, serum CEA level is 1.1 ng/ml without evidence of recurrence. This experience suggested us that a mediastinal tumor accompanied by lung cancer is not necessarily metastatic tumor, and that curative operation may be possible in these cases.     

Transesophageal endoscopic ultrasonography in lung cancer involving mediastinal organs in the assessment of resectability

The resectability of primary lung cancer depends on the extent of invasion to the mediastinum. To evaluate whether transesophageal endoscopic ultrasonography (E-EUS) could detect mediastinal invasion of lung cancer or not, this method was applied in 22 lung cancer cases in which mediastinal invasion was suspected on the basis of the chest roentgenogram and/or CT scan. An ultrasonic probe with a 5 MHz linear array transducer, 12 mm in diameter and 40 mm in length was attached to the tip of an esophagofiberscope for this study. Ultrasonographic findings were classified into four grades, grade 0; existence of a hyperechoic area between the tumor mass and the mediastinum, grade I; tumor mass in direct contact with mediastinum which appears to be normal in structure accompanied by movement of tumor mass on respiration, grade II; partial disappearance of laminar structures and changes in the mediastinal wall, with no movement of the tumor mass relative to the mediastinum, grade III; tumor invasion within the lumen of the mediastinum. Organs contained by the mediastinum include the pulmonary arteries, aorta, left atrium, pulmonary veins, superior vena cava (SVC) and the esophagus were clearly visualized in detail as real-time images, therefore more detailed information about changes in the laminar structures of walls could be obtained. The sensitivity, specificity and accuracy of E-EUS were 77.8%, 81.8% and 80.0%, respectively. E-EUS could detect mediastinal invasion more accurately than chest roentgenogram, CT or MRI. Particularly, in the SVC, descending aorta and esophagus, the longitudinal extent of tumor can be analyzed accurately. These results suggest that E-EUS can be useful to assess resectability and also to decide the surgical margin preoperatively in case of primary lung cancer in which mediastinal involvement is considered.     

Combined thoracoscopic and open chest approach of lobectomy with inferior chest wall resection for advanced lung cancer

Patients with advanced non-small cell lung cancer invading a chest wall are surgical candidates if complete resection is possible. When a primary tumor locating the lower lobe invades an inferior chest wall, either a wide skin incision or double skin incisions to secure surgical views both for dissection of hilum and mediastinum and for inferior chest wall resection is necessary. Wider incision causes higher rate of wound necrosis and infection. We describe a combined approach of thoracoscopic and open chest surgery for lobectomy and inferior chest wall resection, respectively. Patient was a 68-year-old man with an advanced non-small cell lung cancer. Video-assisted thoracoscopic middle and lower lobectomies and mediastinal nodal dissection was completed via 5 ports. Chest wall resection including the posterior portion of the 9th and 10th ribs and the transverse process followed inferior postero-lateral thoracotomy. Postoperative course was uneventful. The present surgical approach can avoid a wide thoracotomy for an advanced lung cancer invading an inferior chest wall.     

Thymoma which is detected with a cough derived from pulmonary invasion; report of a case

A 83-year-old female was referred to our hospital for investigation of a persistent cough. A chest X-ray showed enlargement of the mediastinum. Computed tomography of the chest showed an anterior mediastinal mass with a maximal diameter of 6.5 cm, which had invasion to the lung. The patient underwent thymothymectomy combined resections of the lung, pericardium, and left innominate vein through a median sternotomy. Histological examination of the resected tumor revealed a World Health Organization (WHO) classification type B3 thymoma with infiltration into the lung. There were no infiltrations of the tumor into the pericardium and the innominate vein. A persistent cough disappeared after surgery. No adjuvant chemotherapy was performed. She is still free from disease with a follow-up period of 4 months. We report a rare case of thymoma detected with a persistent cough derived from pulmonary invasion.     

Mid-mediastinal parathyroid lesions: preoperative localization and surgical approach in two cases

Although hyperfunctioning mediastinal parathyroid lesions that require median sternotomy or thoracotomy for removal are occasionally present, the majority are located in the anterior mediastinum closely associated with the thymus. Only eight cases of ectopic hyperfunctioning parathyroid tumors in the middle mediastinum have been reported. We experienced two cases of either persistent or recurrent hyperparathyroidism in which abnormal parathyroid tissue was located in the aorticopulmonary window. One of the patients had a parathyroid adenoma and the other had metastatic lesions of parathyroid carcinoma. In both cases, thallium scanning proved useful in identifying the lesions while computed tomography scan was effective for mediastinal three-dimensional localization. In one case, single photon emission computed tomography imaging with thallium proved beneficial for both identification and localization of the middle mediastinal lesion. The surgical approach used in both cases was different. In one case, left thoracotomy was performed, after which the ligamentum arteriosum was divided, and an adenoma anterior to the left main bronchus and posterior to the left pulmonary artery removed. In the other case, two metastatic tumors of parathyroid carcinoma anterior to the right main bronchus and posterior to the right pulmonary artery were resected through a median sternotomy and opening of the pericardium.     

Mid-mediastinal parathyroid lesions: Preoperative localization and surgical approach in two cases

Although hyperfunctioning mediastinal parathyroid lesions that require median sternotomy or thoracotomy for removal are occasionally present, the majority are located in the anterior mediastinum closely associated with the thymus. Only eight cases of ectopic hyperfunctioning parathyroid tumors in the middle mediastinum have been reported. We experienced two cases of either persistent or recurrent hyperparathyroidism in which abnormal parathyroid tissue was located in the aorticopulmonary window. One of the patients had a parathyroid adenoma and the other had metastatic lesions of parathyroid carcinoma. In both cases, thallium scanning proved useful in identifying the lesions while computed tomography scan was effective for mediastinal three-dimensional localization. In one case, single photon emission computed tomography imaging with thallium proved beneficial for both identification and localization of the middle mediastinal lesion. The surgical approach used in both cases was different. In one case, left thoracotomy was performed, after which the ligamentum arteriosum was divided, and an adenoma anterior to the left main bronchus and posterior to the left pulmonary artery removed. In the other case, two metastatic tumors of parathyroid carcinoma anterior to the right main bronchus and posterior to the right pulmonary artery were resected through a median sternotomy and opening of the pericardium.     

Preoperative staging of lung cancer: accuracy of computed tomography versus mediastinoscopy.

Forty-four patients coming to surgery for carcinoma of the bronchus underwent preoperative staging of the mediastinum by computed tomography (CT scanning) and surgical exploration of the mediastinum by cervical mediastinoscopy or left anterior mediastinotomy or both. Where mediastinal nodes were affected the sensitivity and specificity of computed tomography was inferior to that of mediastinoscopy (57% and 85% versus 71% and 100%). The sensitivity of computed tomography in predicting mediastinal invasion was superior to that of mediastinoscopy (77% v 46%), especially in the case of lower-lobe tumours (67% v 17%). Mediastinoscopy had the considerable advantage of 100% specificity. In the assessment of hilar lymphadenopathy computed tomography had a sensitivity of 38% and a specificity of 64%. In cases where computed tomography showed a normal mediastinum or enlargement of the hilar glands only, mediastinal exploration conferred no additional information and could have been omitted. A computed tomography scan showing mediastinal abnormality is an indication for mediastinoscopy and not a contraindication to surgery. In 23 patients computed tomography showed some abnormality of the mediastinum, confirmed at mediastinoscopy in 12 cases. The remaining 11 patients underwent thoracotomy, resection being carried out in nine. Postsurgical staging showed that six of these tumours were N0 lesions without invasion; in two further N0 cases there was a minor degree of mediastinal invasion which did not prevent resection, and the remaining tumour was N1 without invasion.     

Experience with invasive thymoma presenting pleural dissemination

A 61-year-old man was admitted to Showa University Hospital because of a myasthenia gravis. Chest computed tomography revealed a mediastinal invasive tumor. During surgery, invasion to the pericardium and dissemination on the left visceral pleura and the left diaphragm were observed. Extended thymo-thymectomy and partial resection of the pericardium, left lung, and diaphragm were performed. Incomplete resection was achieved because of the dissemination on the diaphragm. Chemotherapy using ADOC and radiotherapy for mediastinum and left diaphragm were done. Four years after surgery, neither recurrence of the tumor nor myasthenia gravis was observed.     

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.     

Thoracoscopic right upper mediastinal dissection for left lung cancer

OBJECTIVE: In left lung cancer, left and right mediastinum lymphatic spread occur equally frequently. We evaluated the safety and effectiveness of thoracoscopic right upper mediastinal dissection, implemented prior to left lung resection for left lung cancer. METHODS: Between January 1999 and May 2000, 17 patients with left lung cancer underwent thoracoscopic right upper mediastinal dissection prior to resection of the left lung and left mediastinal dissection for left lung cancer. These patients had either enlarged left hilar or bilateral mediastinal nodes, or either a tumor at least 3 cm in diameter or tumor extension to the hilum, mediastinum, or chest wall. Tumor and lymph nodes were examined with hematoxylin and eosin and immunohistochemical staining of cytokeratin for micrometastasis. RESULTS: In 3 patients (17.6%), metastasis occurred in right paratracheal nodes. The 30-day mortality was 0% and morbidity 35.3% (6/17). Postoperative complications occurred in 3 of 4 patients (75%) undergoing induction chemotherapy, but none were lethal. CONCLUSION: Thoracoscopic right upper mediastinal dissection is safe and feasible in treating advanced left lung cancer.     

Surgical therapy of HCG-producing mediastinal tumor accompanied with intrapulmonary metastasis]

The patient is a 31-year-old man who was suffering from hyperthyroidism and left hemothorax. His serum HCG level was extremely elevated and chest X-ray showed a mass shadow of anterior mediastinum and bilateral multiple intrapulmonary metastasis. Our clinical diagnosis was primary HCG-producing germ cell carcinoma of mediastinum and immediately administered CDDP and VP-16. Chemotherapy was effective and tumor extirpation was carried out for mediastinum and lungs by median sternotomy. All of the resected specimen showed no cancer cells and 4 years have passed with no evidence of recurrence. Aggressive surgical approach is indicated for mediastinal germ cell carcinoma accompanied with intrapulmonary metastasis when chemotherapy is effective.     

Thymic small cell carcinoma associated with pulmonary squamous cell carcinoma

A 63-year-old man presented with dyspnea on effort. Chest computed tomography showed an anterior mediastinal mass and a lung mass in the right lower lobe. Thallium scintigraphy revealed accumulation in the mediastinal mass. Therefore, under diagnosis of invasive thymoma or thymic carcinoma associated with suspected lung cancer, exploratory right thoracotomy was undertaken through a median sternotomy with video-assisted thoracoscopic support. The lung mass was intraoperatively diagnosed as squamous cell carcinoma. Right lower lobectomy and total thymectomy were then carried out without additional incision. Thymic small cell carcinoma was diagnosed; therefore the patient received 50 Gy of irradiation to the mediastinum. Ten months after surgery the patient is alive without recurrence.     

Cervical and mediastinal node dissection four and a half years after operation for pulmonary adenocarcinoma

Metastasis to bilateral mediastinal and cervical lymphnodes was noted in a 58 year old male four and a half years after left lower lobectomy of the lung with lymphnode dissection (R2a, P-T1N2M0) by posterolateral incision. This case was treated by dissection of the left cervical and bilateral mediastinal lymphnodes from left cervical and median sternal incisions. Metastasis to the right supraclavicular lymphnodes was noted 11 days after discharge, and additional right cervical dissection was performed with satisfactory results. These possible routes include the tracheobronchial lymphnodes and the carinal nodes, via the upper or anterior portion of the left main bronchus. The routes continue via the nodes surrounding the trachea and the right paratrachea to the cervical nodes. This case suggests the necessity of bilateral mediastinal dissection and the significance of cervical dissection in left lung cancer.     

Thymic carcinoma with combined resection of the hemisternum

We report a case of partial resection of the hemisternum of a thymic carcinoma invading the right anterior chest wall. A computed tomographic scan of the chest and positron emission tomography showed a mass invading the right anterior chest wall in the anterior mediastinum with high 18F-fluorodeoxyglucose accumulation. An operation was performed to obtain a definitive diagnosis and achieve complete resection. First, we assessed the boundaries of gross disease using left-sided video-assisted thoracoscopy. After delineating the margins of the lesion invading the anterior chest wall, a median sternotomy was added and the tumor was resected with the right half of the sternum, parts of the right third and fourth costal cartilages, part of the right upper lung lobe, and pericardium. Histopathological evaluation revealed a squamous cell carcinoma of the thymus with direct invasion to the right lung, pericardium, and the right third costal cartilages.     

A case of mediastinal seminoma which penetrated pericardium and invaded left upper lobe]

A 35-year-old man admitted at our hospital, with a complaint of anterior chest pain. Chest x-ray film and CT showed an anterior mediastinal tumor. An invasive thymoma was suspected by the biopsy specimen, invading left upper lobe of the lung. Resections of the tumor, thymus, invasion to the part of the left upper lobe and the pericardium were performed. The pathology showed pure seminoma penetrating the pericardium. As testis and the retroperitoneum were normal, the tumor was diagnosed as mediastinal origin. Adjuvant chemotherapy (CDDP, BLM and etoposide) and irradiation were performed. The patient is alive and well for 7 months postoperatively.     

Mediastinal lymph-node carcinoma with no apparent primary lesion; report of a case

A 57-year-old woman was admitted to our department because of a chest X-ray showing a mass shadow about 40 mm in diameter in the right side of the middle of the mediastinum. A chest computed tomography(CT) scan demonstrated a large tumor, adherent to the superior vena cava and right pulmonary artery. No other metastases and no primary tumor were found. The tumor was resected through median sternotomy. Intraoperative frozen section analysis showed that the mediastinal tumor was a metastatic lymph-node carcinoma. Postoperative examination, too, did not detect the primary lesion. Radiotherapy was given after the operation. This case was thought to be a very rare case of T0N2M0 lung cancer or primary mediastinal lymph-node carcinoma (yolk sac tumor).