Ann Thorac Surg 1999;67:1165-1167
© 1999 The Society of Thoracic Surgeons
Case Reports
Operative strategies for resection of pulmonary sarcomas extending into the left atrium
Robert J. Korst, MDa,
Todd K. Rosengart, MDb
a Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
b Division of Cardiothoracic Surgery, The New York Hospital-Cornell Medical Center, New York, New York, USA
Accepted for publication September 26, 1998.
Address reprint requests to Dr Korst, Thoracic Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021;
e-mail: korstr{at}mskcc.org
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Abstract
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Pulmonary sarcomas may extend into the left atrium through the pulmonary veins, requiring the use of cardiopulmonary bypass for resection. The operative strategy for these complicated resections must account for the laterality of the tumor, the extent of atrial involvement, the severity of local invasion within the hemithorax, and intrinsic surgical heart disease, if present. We discuss these issues using an illustrative case of a patient with a right pulmonary sarcoma extending from the lateral chest wall into the left atrium.
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Introduction
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Pulmonary sarcomas, whether primary or metastatic, have been reported to extend into the left atrium [1, 2], complicating attempts at resection due to the higher likelihood of tumor embolism and incomplete resection [3]. Multiple reports have described the use of cardiopulmonary bypass for the resection of these tumors; however, no consensus exists regarding the best operative strategy [1, 2, 4]. Our purpose is to summarize the important issues involved when resecting these lesions, using a specific case to illustrate these issues.
A 43-year-old woman was taken to the operating room with a primary leiomyosarcoma of the right lung extending to both the lateral chest wall and left atrium (Fig 1). She was positioned with her left chest down, but with her hips semisupine, and a posterolateral thoracotomy was performed through the fifth interspace. The tumor was densely adhered to the lateral chest wall, but could be separated away from it in the extrapleural plane with negative margins. The bronchus and intrapericardial pulmonary artery were stapled and divided. The right femoral vessels were cannulated with the venous cannula extending up to the infradiaphragmatic level. The superior vena cava was also cannulated. The operative setup is depicted in Figure 2.
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Fig 1. Magnetic resonance image of the chest confirming the lung mass (white arrow) with extension from the chest wall into the left atrium (black arrow).
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Fig 2. Right anterolateral view of the operative layout for the resection of a large, right pulmonary sarcoma extending from the lateral chest wall into the left atrium. The patient’s head lies at the top of the diagram. The cardiac portion of the resected specimen is depicted in the boxed area. The pulmonary portion of the specimen, as well as the pericardium and azygous arch, have been omitted for the sake of simplicity.
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The patient was then placed on cardiopulmonary bypass and cooled systemically to 28°C. The heart fibrillated and arrested at this temperature. The left atrium was opened and it became obvious that the tumor extended well into the atrium and seemed to be invading the interatrial septum as well. An en bloc resection of the tumor, entire lung, left atrial free wall, and interatrial septum was performed as depicted in Figure 2. Care was taken to allow maintenance of a blood reservoir at the base of the atrial cavities to simplify removal of air at the end of the procedure. The right atrial free wall was then brought down and approximated primarily to the edge of the interatrial septum, and a bovine pericardial patch was used to close the defect in the left atrial free wall. Air was removed from the atria by loosening the caval snares before completion of the patch closure and the patient was warmed to 37°C. The heart was defibrillated and cardiopulmonary bypass was discontinued. The patient remains alive and disease-free 14 months after resection.
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Comment
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Sarcomas involving the lung are best treated by complete, en bloc resection [5]. When they extend into the left atrium, cardiopulmonary bypass is required to achieve negative margins and to prevent tumor embolism [3]. Preoperative cardiac catheterization is not mandatory unless additional intrinsic surgical heart disease is suspected, or if the patient is elderly. Each patient needs a tailored approach based on several factors, including the laterality of the tumor, the extent of atrial involvement, the severity of local invasion within the hemithorax (ie, chest wall invasion, extensive hilar involvement), and the presence or absence of intrinsic surgical heart disease. Figure 3 summarizes these factors in the form of an algorithm.
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Fig 3. Algorithm for the resection of pulmonary sarcomas invading the left atrium. (PL = posterolateral; IVC = inferior vena cava.) (a) Concomitant surgical heart disease is present; (b) inferior vena cava readily accessible; (c) inferior vena cava not readily accessible; (d) no complicated disease in hemithorax; (e) complicated disease in hemithorax (chest wall or extensive hilar involvement); (f) ascending aorta readily accessible; (g) ascending aorta not readily accessible.
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Lesions originating in either hemithorax technically can be approached through either median sternotomy or lateral thoracotomy; however, the optimal approach for left-sided tumors is a left thoracotomy, as the left pulmonary hilum is not well visualized and easily dissected through a sternotomy without the heart being elevated out of the chest. As a result, if a sternotomy is used, the entire dissection and reconstruction may need to be performed with the patient heparinized and on cardiopulmonary bypass.
Bicaval venous cannulation should be practiced routinely when resecting right-sided lesions as these tumors may involve the interatrial septum. The inferior cannula may be placed either transthoracically or through the femoral vein. On the left, however, involvement of the septum is unlikely and placement of a single right atrial cannula should suffice for venous cannulation. This cannula can be placed into the right atrium through the femoral vein or through the left chest via the intrathoracic inferior vena cava. Although another potential site of venous return is the left pulmonary artery, we avoid this and view a groin dissection as much safer. Regardless of tumor laterality, the arterial cannula may be placed in the ascending aorta, but as Figure 2 demonstrates, wide exposure of the ascending aorta may not always be possible from the right hemithorax. Therefore, when a right thoracotomy is used, femoral cannulation may be advantageous. On the whole, we prefer femoral placement of cannulas for bulky lesions as exposure in the chest may be limited.
When locally advanced disease exists within the hemithorax, as in our patient, a posterolateral thoracotomy is preferable to a median sternotomy. Boland and colleagues [5] performed a sternotomy for the resection of a right lower lobe sarcoma invading the left atrium but could not safely perform the pulmonary resection, mandating a separate posterolateral thoracotomy. When additional valvular or coronary disease exists, median sternotomy is the safest, most versatile approach. If the pulmonary resection cannot be accomplished through the sternotomy, a separate lateral thoracotomy needs to be performed.
In most reports, the heart is arrested by clamping the ascending aorta and infusing the aortic root with cardioplegia solution [1, 2]. Cold fibrillatory arrest, as described herein, is an alternative approach that eliminates the requirement for aortic cross-clamping and cardioplegia delivery. The drawback of this approach is a longer period of warming after reconstruction. As a result, we advocate aortic root injection of cardioplegia when the ascending aorta can be exposed sufficiently to cross-clamp and deliver cardioplegia. Endoaortic balloon occlusion and cardioplegia delivery may represent another acceptable technique.
In summary, pulmonary sarcomas extending into the left atrium require careful planning before resection. An operative strategy that is tailored to the individual patient is needed to provide the best exposure for these complicated resections.
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References
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Gardner M.A.H., Bett J.H.N., Stafford E.G., Matar K. Pulmonary metastatic chondrosarcoma with intracardiac extension. Ann Thorac Surg 1979;27:238-241.[Abstract/Free Full Text]
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Shimono T., Yuasa H., Yuasa U., et al. Pulmonary leiomysarcoma extending into left atrium or pulmonary trunk: complete resection with cardiopulmonary bypass. J Thorac Cardiovasc Surg 1998;115:460-461.[Free Full Text]
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Mansour K.A., Malone C.E., Craver J.M. Left atrial tumor embolization during pulmonary resection: review of literature and report of two cases. Ann Thorac Surg 1988;46:455-456.[Abstract/Free Full Text]
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Janssen J.P., Mulder J.J.S., Wagenaar S.S., Elbers H.R.J., van den Bosch J.M.M. Primary sarcoma of the lung: a clinical study with long-term follow-up. Ann Thorac Surg 1994;58:1151-1155.[Abstract/Free Full Text]
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Boland T.W., Winga E.R., Kalfayan B. Chondrosarcoma: a case report with left atrial involvement and systemic embolization. J Thorac Cardiovasc Surg 1977;74:268-272.[Abstract]
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Abstract
Introduction
