Ann Thorac Surg 2000;69:937-939
© 2000 The Society of Thoracic Surgeons
Case Reports
Preoperative embolization in surgical treatment of mediastinal hemangiopericytoma
Uliano Morandi, MDa,
Alessandro Stefani, MDa,
Mario De Santis, MDb,
Massimiliano Paci, MDa,
Renzo Lodi, MDa
a Department of Cardio-thoracic Surgery, University of Modena and Reggio Emilia, Modena, Italy
b Department of Radiology, University of Modena and Reggio Emilia, Modena, Italy
Address reprint requests to Dr Lodi, Department of Cardio-thoracic Surgery, University Hospital, Via del Pozzo 71, 41100 Modena, Italy
e-mail: rlodi{at}unimo.it
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Abstract
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The case of a 47-year-old man with a tumor of the posterosuperior mediastinum is reported. Surgical biopsy sample revealed a hemangiopericytoma, but radical excision was impossible because of massive bleeding. Percutaneous embolization of mediastinal tumor was performed to reduce peroperative blood loss. It allowed uneventful complete removal of the lesion. We recommend preoperative embolization in cases of hypervascular mediastinal tumors.
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Introduction
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Hemangiopericytoma is rarely encountered in the mediastinum. This tumor arises from pericytes, cells wrapping around the pericapillary arteries. There are benign and malign forms and various degrees of malignancy. Areas of hemorrhage, necrosis, and cystic degeneration are suggestive of malignant lesion, as well as the microscopic findings of high mitotic activity, cellular pleomorphism, and increased cellularity. However, in cases in which there are no metastases and involvement of vital mediastinal structures, surgery is the treatment of choice. The clinical course depends on the findings mentioned.
Hemangiopericytoma is often a hypervascular neoplasm, thus the risk of intraoperative uncontrollable bleeding is high. Simonton and colleagues [1] reported a case of mediastinal hemangiopericytoma in a child with fatal outcome for massive peroperative bleeding.
We report the case of a resectable hemangiopericytoma treated with preoperative embolization to reduce intraoperative blood loss.
A 47-year-old man was admitted because a chest roentgenogram accidentally disclosed a tumor mass located in the posterosuperior mediastinum, on the right side. The patient was asymptomatic. He underwent thoracic magnetic resonance imaging, which showed a bulky mass arising in the paravertebral sulcus (Fig 1). The radiologist thought that the tumor might be a sarcoma.
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Fig 1. Magnetic resonance image (Spin-Echo (SE): Repetition time (TR) 400; Echo-time (TE) 10) showing a large hypointense mass in the right paravertebral sulcus, with hyperintense hemorrhagic area on T1-weighted Spin-Echo (SE) magnetic resonance scan. The tumor was inhomogeneously hyperintense on T2-weighted image.
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Because the mass seemed to be resectable, the patient underwent right thoracotomy. At operation, the mass appeared highly vascularized and massive bleeding from the tumor tissue occurred when attempting to dissect the mass. We therefore performed only a biopsy. The overall peroperative blood loss was 2.1 liters (intraoperative bleeding and blood loss on drain bottles). One liter of blood was administered postoperatively. Pathologic examination showed a hemangiopericytoma. The low mitotic activity and the absence of clear nuclear pleomorphism were suggestive of a low-grade malignancy tumor.
Two months after operation the patient underwent arterial embolization of the tumor. A thoracic aortogram revealed four feeding arteries, arising from the intercostal vessels (Fig 2); the spinal artery was not seen on selective intercostal angiogram. Three of these contributory arteries were selectively catheterized and embolized with 150 to 250 µm polyvinyl alcohol particles; it was impossible to catheterize the fourth one because it rose from the aortic kink. The blood supply through these arteries was thereby occluded to obtain complete stasis. The patient remained asymptomatic throughout the procedure and no neurologic or other complications occurred. Ten days later a right rethoracotomy was performed. No intimal relation of the mass with any mediastinal structure was found; the thrombotic vessels were identified and ligated and complete removal of the tumor was achieved (Fig 3). During surgical excision bleeding was minimal and easy to control.
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Fig 3. The resected lesion, capsulated, with focal hemorrhages. It weighed 530 g, was 14 x 10 x 5 cm in size, and was of firm consistency.
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The postoperative period was uneventful and the patient was discharged on postoperative day 8. Three years after the operation the patient is alive and well, without evidence of recurrence of the disease.
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Comment
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Malignant hemangiopericytoma often presents with a small number of nondistinctive symptoms, which has a negative influence on the prognosis of the disease because the diagnosis is delayed. In our case the patient was asymptomatic, despite the large size of the tumor. The disease was detected accidentally but early enough to allow a complete resection. If possible, radical surgery is the elective treatment for these neoplasms.
We did not perform percutaneous needle biopsy because the mass appeared to be radiologically resectable, thus even in the presence of a malignant form, surgical resection was indicated. The massive intraoperative bleeding led us to perform only a biopsy. Because at operation too the mass appeared to be resectable, without involvement of mediastinal structures, we subsequently performed the embolization of the feeding vessels. This may have contributed to the significant reduction of the bleeding and made complete resection feasible.
In recent years arterial embolization in the chest has become popular as a preoperative treatment in hemoptysis, vertebral hemangiomas, and other vascularized tumors. In every case of well-vascularized tumor tissue, with high risk of massive blood loss, preoperative embolization is indicated. Olerud and colleagues [2] recommend this procedure for spinal metastases of renal cell carcinoma. Cases of tumor resection with minimal bleeding due to embolization are increasingly reported, such as leiomyoma [3], mesothelioma [4], and dumbbell schwannoma [5]. Preoperative embolization was also carried out on neoplasms secreting catecholamines to reduce bleeding and the secretion of catecholamines during the operation [6]. The main risks of embolization are ischemic myelitis resulting in paralysis, other nontarget organ ischemia, or thrombotic complications during catheter placement. These are less likely than the risk of exsanguination from the tumor if a meticulous angiographic technique, with extreme care to avoid reflux of embolic agents into the spinal artery distribution, is performed and if appropriate-sized polyvinyl alcohol particles are used [2, 7].
Hemangiopericytomas are often highly vascularized and cases of massive bleeding are described [1, 8]. If preoperative diagnosis of hemangiopericytoma is available, we recommend an angiographic study to detect the feeding vessels and subsequently embolization if high vascularization is shown. This may decrease the risk of uncontrollable bleeding and massive blood loss. Delay of the surgical procedure is not a problem, because the operation can be regularly performed less than 24 hours after the embolization [2].
A special consideration concerns the preoperative diagnosis. When a mediastinal mass appears to be radiologically resectable, many authors perform a thoracotomy d’emblée, without histologic diagnosis. On the basis of our experience and previous reports [1, 3, 5, 6], an attempt to obtain a preoperative diagnosis is recommended even in tumors that are clearly resectable if high vascularization is suspected on imaging techniques. Enhanced spiral computed tomography or dynamic enhanced magnetic resonance imaging can predict vascularization of thoracic tumors without using an invasive angiographic technique. The possibility to carry out an angiographic study on the radiologic evidence of hypervascular tumor should be considered, even without preoperative diagnosis, in order to perform preoperative emolization.
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References
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Simonton S.C., Swanson P.E., Watterson J., Priest J.R. Primary mediastinal hemangiopericytoma with fatal outcome in a child. Arch Pathol Lab Med 1995;119:839-841.[Medline]
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Olerud C., Jonsson H., Jr, Lofberg A.M., Lorelius L.E., Sjostrom L. Embolization of spinal metastases reduces peroperative blood loss. 21 patients operated on for renal cell carcinoma. Acta Orthop Scand 1993;64:9-12.[Medline]
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Baldò X., Sureda C., Gimferrer J.M., Belda J. Primary mediastinal leiomyoma. Eur J Cardiothorac Surg 1997;11:574-576.[Abstract/Free Full Text]
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Kawashima K., Yokoi K., Matsuguma H., Kamiya N., Miyazawa N. Huge localized mesothelioma of the diaphragm in a 17-year-old female—a case report with calculated tumor volume doubling time. Nippo Kyobu Geka Gekkai Zasshi 1998;46:225-230.
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Fiumara E., D’Angelo V., Florio F.P., Nardella M., Bisceglia M. Preoperative embolization in surgical treatment of spinal thoracic dumbbell schwannoma. J Neurosurg Sci 1996;40:153-156.[Medline]
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Montana E., Montana X., Morera R., et al. Functioning paraganglioma (pheochromocytoma) of the thorax. J Thorac Cardiovasc Surg 1990;100:626-627.[Medline]
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Cohen A.M., Doershuk C.F., Stern R.C. Bronchial artery embolization to control hemoptysis in cystic fibrosis. Radiology 1990;175:401-405.[Abstract/Free Full Text]
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Mori M., Nakanishi N., Furuya K. Hemangiopericytoma of the mediastinum causing spontaneous hemothorax. Ann Thorac Surg 1994;58:1525-1527.[Abstract/Free Full Text]
Accepted for publication July 12, 1999.
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Abstract
Introduction
