Ann Thorac Surg 1998;66:263-264
© 1998 The Society of Thoracic Surgeons
Case Reports
Reconstruction of the aortic arch in invasive thymoma under retrograde cerebral perfusion
Shozo Fujino, MDa,
Noriaki Tezuka, MDa,
Shoji Watarida, MDa,
Kazuhiko Katsuyama, MDa,
Shuhei Inoue, MDa,
Atsumi Mori, MDa
a Second Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
Accepted for publication February 6, 1998.
Address reprint requests to Dr Fujino, Second Department of Surgery, Shiga University of Medical Science, Seta, Otsu, Shiga 520-2192, Japan
e-mail: (shozo{at}belle.shiga-med.ac.jp)
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Abstract
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Extensive en-bloc resection of the aortic arch and anterior wall of the main pulmonary artery was performed in a 46-year-old man with invasive thymoma. The aortic arch was replaced with a Hemashield vascular graft under hypothermic circulatory arrest with retrograde cerebral perfusion. Patch plasty with Xenomedica was performed for the anterior wall of the main pulmonary artery under cardiopulmonary bypass. The patient was treated with postoperative radiotherapy and has remained asymptomatic for 15 months after the operation. An extensive operation is considered necessary to improve the prognosis of invasive thymoma.
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Introduction
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The surgical results of stage III thymomas are not satisfactory compared with those of stage I and II thymomas [1]. Many authors insist that complete resection of the tumor is necessary to prolong survival in patients with stage III thymomas. We report 1 patient with invasive thymoma that invaded the aortic arch and main pulmonary artery who was treated with en-bloc resection of the tumor, aortic arch, and anterior wall of main pulmonary artery under cardiopulmonary bypass and hypothermic circulatory arrest with retrograde cerebral perfusion (RCP).
A 46-year-old man was hospitalized for further evaluation of an abnormal shadow on chest x-ray film. Before admission, he had been diagnosed with nonresectable thymoma at another hospital and treated with 30 Gy of irradiation, which had shown no effect. Computed tomography of the chest revealed a mediastinal tumor with invasion into the aortic arch and main pulmonary artery (Fig 1).
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Fig 1. Computed tomography of the chest revealed a mediastinal tumor with invasion into the aortic arch and main pulmonary artery.
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At operation, the mediasinum was explored through a median sternotomy after ligation and incision of the bronchus and vessels of the left upper lobe through a left fourth intercostal thoracotomy. A hard tumor with irregular margins occupied the whole of the superior anterior mediastinum, invading the anterior segment of the left upper lung and pericardium. Furthermore, the tumor invaded the aortic arch and main pulmonary artery. After patch plasty of the anterior wall of the main pulmonary artery with Xenomedica (Baxter Healthcare Corp, Horw, Switzerland) under cardiopulmonary bypass, the aortic arch was replaced with a Hemashield (Meadox Medicals, Oakland, NJ) vascular graft (30 mm wide for the aorta and 8 and 10 mm wide for the three branches) under hypothermic circulatory arrest (hypothermic circulatory arrest time was 50 min) with RCP (RCP time was 42 minutes and perfusion pressure was 20 mm Hg) (Figs 2, 3).
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Fig 3. Replacement of the aortic arch with a Hemashield vascular graft and patch plasty of the anterior wall of the main pulmonary artery with Xenomedica were performed.
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Microscopic examination showed thymoma with invasion into the left upper lobe, the pericardium, the aortic wall, and main pulmonary arterial wall.
The postoperative course has been uneventful, and extubation was performed 10 hours after the operation. The patient was treated with 36 Gy additional radiotherapy to the mediastinum. He remains asymptomatic and free of disease 15 months after the operation.
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Comment
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Thymoma often infiltrates mediastinal structures such as the pericardium, lungs, and large vessels because of anatomic relations, and the surgical results are unfavorable when the adjacent organs have been invaded by thymoma that has broken through its capsule. The results of operation for invasive thymoma have been reported by many institutions, and most investigators have insisted that complete resection of the tumor is necessary to prolong survival [2–5].
Many authors have reported favorable results of reconstruction of large veins in invasive thymoma. However, invasive thymoma treated with vessel reconstruction under cardiopulmonary bypass is rare. We have already reported a patient with thymic carcinoma that invaded the main pulmonary artery and was resected under cardiopulmonary bypass [6]. She remains alive without disease 6 years after the operation. Angioplasty and vascular reconstruction should be recommended even in patients requiring some kind of circulatory assist because the success of treatment for invasive thymoma depends on complete resection of the tumor.
In this present case, we used hypothermic circulatory arrest with RCP during replacement of the aortic arch. Hypothermic circulatory arrest has been used for various cardiac procedures and, in recent years, RCP has been employed to protect the brain. In our previous study, we showed that hypothermia of the central nervous system, oxygen supply, metabolite excretion, aerobic metabolism, and cerebral adenosine triphosphate levels were well maintained by RCP [7]. We think that hypothermic circulatory arrest with RCP is a useful technique for this kind of operation.
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References
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- Verley J.M., Hollmann K.H. Thymoma: a comparative study of clinical stages, histologic features, and survival in 200 cases. Cancer 1985;55:1074-1086.[Medline]
- Cohen D.J., Ronnigen L.D., Graeber G.M., et al. Management of patients with malignant thymoma. J Thorac Cardiovasc Surg 1984;87:301-307.[Abstract]
- Shimizu N., Moriyama S., Aoe M., Nakata M., Ando A., Teramoto S. The surgical treatment of invasive thymoma. Resection with vascular reconstruction. J Thorac Cardiovasc Surg 1992;103:414-420.[Abstract]
- Ciernik I.F., Meier U., Lutolf U.M. Prognostic factors and outcome of incompletely resected invasive thymoma following radiation therapy. J Clin Oncol 1994;12:1484-1490.[Abstract]
- Yagi K., Hirata T., Fukuse T., et al. Surgical treatment for invasive thymoma, especially when the superior vena cava is invaded. Ann Thorac Surg 1996;61:521-524.[Abstract/Free Full Text]
- Fujino S., Nojima T., Asakura S., Onoe M., Watarida S., Mori A. Complete resection of thymic carcinoma supported by cardiopulmonary bypass. Jpn J Thorac Surg 1991;39:1188-1193.
- Nojima T., Mori A., Watarida S., Onoe M. Cerebral metabolism and effects of pulsatile flow during retrograde cerebral perfusion. J Cardiovasc Surg 1993;34:483-492.[Medline]
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Abstract
Introduction
