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Ann Thorac Surg 1998;66:981-982
© 1998 The Society of Thoracic Surgeons

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Correspondence

Severe postoperative hemorrhage after neoadjuvant chemotherapy for invasive thymoma

^a Cattedra di Chirurgia Toracica, Policlinico Umberto I, Universita’ di Roma "La Sapienza", V. le del Policlinico, 00100 Rome, Italy

e-mail: Fevenuta{at}tin.it

To the Editor

We would like to make an addendum to the discussion of our article, "Multimodality Treatment of Thymoma: A Prospective Study" [1]. Doctor Dieter raised several interesting questions; one of these was related to the possible development of postoperative coagulopathies after neoadjuvant chemotherapy in patients with malignant thymoma invading the myocardium and great vessels. At the time when we presented the paper before The Society of Thoracic Surgeons in January 1997 we had not yet faced this complication, either in the group of patients reported in the study or in our previous experience [2]. In the last year we have operated on 4 patients with malignant thymoma previously treated with neoadjuvant chemotherapy; all these patients had a stage III cortical thymoma with extensive invasion of the pericardium, lung, phrenic nerve, superior vena cava, and left brachiocephalic vein. They underwent an extended resection after three cycles of neoadjuvant chemotherapy. Two patients presented a severe postoperative bleeding 24 hours after the operation; in both cases the veins had to be reconstructed with a tube of autologous pericardium and a polytetrafluoroethylene prosthesis after systemic heparinization. Preoperative blood count and coagulation parameters were normal, even though profound leukopenia and thrombocytopenia had developed in both patients during chemotherapy. At reexploration a diffuse bleeding from the bed of the resected tumor was present. Hemostasis was improved with cautery and fibrin glue; fresh frozen plasma, albumin, and blood were infused. The second postoperative course was uneventful with the exception of wound infection in 1 patient. Both patients are alive 4 and 12 months after the operation, and both received adjuvant chemotherapy and radiotherapy.

As far as we know, the rationale for postoperative severe bleeding with normal coagulation parameters in this subset of patients is not known. Bleeding is reported as a minor complication after neoadjuvant chemotherapy for lung cancer [3]; however, chemotherapy-induced coagulopathies are reported in the literature [4, 5] when treating other cancers. Myelodepression may result in a possible malfunction of the coagulation system, potentially causing dysfunction only during or after the stress of the operation. Prevention is difficult because the standard preoperative workup is generally normal and fails to show minor problems.

In conclusion, postoperative bleeding is a possible complication after neoadjuvant chemotherapy for malignant thymoma. We thank once more Dr Dieter for raising such an interesting question, and we are glad to share with him our recent experience.

References

1. Venuta F., Rendina E.A., Pescarmona E.O., et al. Multimodality treatment of thymoma: a prospective study. Ann Thorac Surg 1997;64:1585-1592.[Abstract/Free Full Text]
2. Pescarmona E., Rendina E.A., Venuta F., et al. Analysis of prognostic factors and clinicopathological staging of thymoma. Ann Thorac Surg 1990;50:534-538.[Abstract/Free Full Text]
3. Rusch V.W., Albain K.S., Crowley J.J., et al. Surgical resection of stage IIIA and stage IIIB non–small-cell lung cancer after concurrent induction chemoradiotherapy. J Thorac Cardiovasc Surg 1993;105:97-106.[Abstract]
4. Gabazza E.C., Taguchi O., Yamakami T., et al. Alteration of coagulation and fibrinolysis systems after multidrag anticancer therapy for lung cancer. Eur J Cancer 1994;30A:1276-1281.
5. Kumar A., Chaturvedi P., Gupta Y.N. Combination chemotherapy for breast carcinoma using a combination of cyclophosphamide, methotrexate and 5-fluorouracil (CMF) causes a platelet aggregation defect. Int J Cancer 1996;66:159-161.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Federico Venuta Erino A. Rendina Tiziano De Giacomo Anna Maria Ciccone Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Venuta, F. Articles by Coloni, G. F. Search for Related Content PubMed PubMed Citation Articles by Venuta, F. Articles by Coloni, G. F.