Ann Thorac Surg 2000;69:1579-1580
© 2000 The Society of Thoracic Surgeons
Case reports
Chest wall implantation of a mediastinal liposarcoma after thoracoscopy
Axel Aubert, MDa,
Philippe Chaffanjon, MDa,
Michel Peoc’h, MDb,
Pierre Y. Brichon, MDa
a Service de Chirurgie Générale et ThoraciqueCHU de Grenoble, Grenoble, France
b and Service d’Anatomo-pathologie, CHU de Grenoble, Grenoble, France
Address reprint requests to Dr Brichon, Service de Chirurgie Générale et Thoracique, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 9, France
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Abstract
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We report a case of mediastinal liposarcoma resected by thoracoscopy. Despite the precautionary measures, chest wall implantations occured rapidly at the port’s sites in the chest wall and led to death within 24 months. We conclude that thoracoscopy is not a good approach for resection of anterior mediastinal masses in view of their possible malignant character.
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Introduction
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For the past 10 years or so, videothoracoscopy has gained wide acceptance for treatment of some intrathoracic disease. Although this minimally invasive procedure may be valid for removal of benign tumors, it remains questionable for treatment of malignant lesions, especially in terms of quality of resection and then possibly of cure. This case report demonstrates that a classic approach (thoracotomy or sternotomy) is still the better method for removal of potentially malignant mediastinal tumors.
A 25-year-old woman, previously healthy, showed signs of left thoracic pain for 2 months. Chest roentgenogram showed a left medium arch enlargment. The computed tomography (CT) scan (Fig 1) showed a 4.8 ± 3.3 cm homogeneous tumor in the thymic area, of 10-Hounsfield unit (HU) density without enhancing by contrast. The tumor was suspected to be benign because of its limitation well away from mediastinal vessels. Electromyogram was normal. Because of this benign aspect, and because of the possibility of resection, we choose not to perform thin needle aspiration or Chamberlain mediastinotomy, to have a definitive diagnosis preoperatively. Resection was planned by video-assisted thoracic surgery (VATS) because of the small size and cystic aspect. Three trocar sites were created for introduction of the instruments and the thoracoscope (Thoracoport Autosuture, US Surgical Corp, Norwalk, CT): two on the medium axillary line (5 mm in the sixth and 10 mm in the third intercostal space) and one 10 mm on the anterior axillary line in the fifth space. The tumor had no contact with the pulmonary parenchyma and was dissected easily and enucleated out from the thymic area. It was placed into a protection bag (Endobag, MEL600 mL S8C600, Laboratoires Peters, Bobigny, France). During this maneuver, the tumor escaped from the forceps and fell down into the costovertebral sulcus. It was removed, in the bag, across the upper axillary orifice enlarged to 20 mm. Resection seemed to be macroscopically complete. Postoperative course was uneventfull. The tumor, weighing 50 g, had a gelatinous aspect and broke up in the bag during the crossing of the chest wall.
Pathology revealed a low grade myxoid liposarcoma [1]. An extension of resection was planned 1 month later because of this result: by total median sternotomy an extended thymectomy was performed, with a mediastinal lymphadenectomy, the resection of a pericardic fragment (posterior limit of the initial tumoral site), and wedge resection of the ventral segment of the left upper lobe (fixed on the site of the initial resection by postoperative adherences). Postoperative course was uneventful. Pathology revealed residual tumor at the initial site of resection and absence of tumoral cells in lymph nodes and in the rest of the thymus. A 55-Gy mediastinal radiation was performed.
Four months after the first operation, chest roentgenogram showed two axillary parietal masses. CT scan confirmed the occurrence of many parietal and pleural tissue density tumors: at the level of the anterior axillary line in the fifth space, the median axillary line in the third (Fig 2) and sixth space, and the left costovertebral sulcus. A left lateral thoracotomy was performed that revealed multiple intrathoracic tumoral locations: mediastinal, diaphragmatic, pleural (axillary median and anterior) and costovertebral sulcal. Complete resection was judged unsuitable. The patient was then treated by chemotherapy without effect and died 24 months after the first operation with a near total ipsilateral thoracic involvement and without any sign of metastasis.
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Comment
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In the 1990s, technical improvement allowed a large use for VATS. After treatment of benign pleuropulmonary pathologies, many researchers used VATS for exeresis of some bronchogenic cancers or for wedge resection of pulmonary metastasis. Many mediastinal tumors suspected as benign (appearing small and noninvasive at CT scan) were treated by VATS: fibrous tumors, bronchogenic cysts, pleuropericardial cysts, lipomas, and neurogenic tumors. Researchers also used VATS for malignant tumor biopsy, but never for their exeresis. Exeresis of tumors with benign aspect has been also performed in the thymic area: thymic cysts, thymolipomas, thymomas, or normal thymus in myasthenia gravis [2].
Primary liposarcoma of the mediastinum is rare: about 0.25% from mediastinal tumors [3]. Usually CT scan shows a massive, compressive or invasive tumor with a density between fat and water (-80 to 0 HU). Reference treatment is extended surgical resection. Adjuvant treatment never proved efficient. The evolution is principally local, with operating site recurrence, but metastasis may be observed. Prognosis depends on three factors: histologic type (myxoid is the most favorable), histopronostic grade (lower is of best prognosis), and quality of surgical resection (better if complete and extended). Mean survival is usually short, 14 to 24 months, but longer survivals were reported: 17 years for a good prognosis tumor with complete exeresis, 14 years for a good prognosis tumor with local reccurencies and multiple exeresis.
Parietal tumor spreading in surgery has been known since 1955 [4]. It was described in the thorax after mediastinoscopy, thoracotomy, and especially after thin-needle aspiration biopsy. Chest wall tumoral implantation was reported more recently after VATS for parenchymal malignancies: on trocars sites or on removal site of the tumor, with [5] or without protection bag [6]. In 1996, Downey and the Video-Assisted Thoracic Surgery Group had reported 21 cases of dissemination of malignant tumors after VATS, including 15 of parietal spreading [7].
In our case, despite an exeresis that seemed to be easy and complete, a tumoral residue persisted on the operating site. We think that this complication would have had less opportunity to occur if either thoracotomy or sternotomy had been performed because the estimation of the real limits of the tumor, particularly by palpation, is not sufficient by VATS. Despite the use of a protection bag, the chest wall seems to have been contaminated during the tumor extraction. In addition, pleural recurrence appeared in the costovertebral sulcus, where the tumor fell down. We postulate that there were chest wall and pleural contamination by two ways: direct, by contact between parietal pleura and the tumor, and indirect, by the bag’s contamination during the placement of the tumor or by the trocar’s extremities contamination when instruments were successively introduced and removed. VATS may be directly involved in the poor and local evolution of this case. We postulate that survival of this patient could have been better if the first exeresis had been complete and extended. By another way, if thin-needle aspiration or Chamberlain mediastinotomy had been performed to determine the preoperative diagnosis, we think that the risk of parietal spreading could have been the same.
In conclusion, despite the rarity of this locally aggressive tumor that is associated with a poor prognosis, we think that resection of mediastinal tumors—particularly in the thymic area—should not be performed by VATS, even in cases of benign radiologic aspect. Sternotomy or thoracotomy should be preferable, especially in cases of thymomas or for thymus associated with myasthenia gravis, in which prognosis depends on the completeness of resection.
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References
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Enzinger F.M., Winslow S. Liposarcoma. In: Enziger F.M., Weiss S.H., eds. Soft tissue turmors. St. Louis: CV Mosby, 1995:431-466.
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Sugarbaker D.J. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653-656.[Abstract]
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Burt M., Ihde J.K., Hadju S.I., et al. Primary sarcomas of the mediastinum. J Thorac Cardiovasc Surg 1998;115:671-680.[Abstract/Free Full Text]
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Ackerman L.V., Myron W.W. The implantation of cancer—an avoidable surgical risk. Surgery 1955;37:341-355.[Medline]
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Thurer R. Video-assisted thoracic surgery. Ann Thorac Surg 1993;56:199-200.[Medline]
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Fry W.A., Siddiqui A., Pensler J.M., Mostafavi H. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;59:42-45.[Abstract/Free Full Text]
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Downey R.J., McCormack P., LoCicero J., III Dissemination of malignant tumors after video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1996;111:954-960.[Abstract/Free Full Text]
Accepted for publication October 4, 1999.
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Abstract
Introduction
