Ann Thorac Surg 2005;79:e32-e33
© 2005 The Society of Thoracic Surgeons
Case reports
Trans-Arterial Infusion Chemotherapy for Recurrence of Pleural Dissemination After Thymectomy
Yasuji Terada, MDa,*,
Takatoyo Kambayashi, MDa,
Satomi Okahashi, MDa,
Tetsuo Noguchi, MDb,
Kunihiko Kamakari, MDb,
Soichi Kubo, MDc
a Department of Thoracic Surgery, Nagahama, Japan
b Department of Respiratory Medicine, Nagahama, Japan
c Department of Radiology, Nagahama City Hospital, Nagahama, Japan
Accepted for publication January 10, 2005.
* Address reprint requests to Dr Terada, Department of Thoracic Surgery, Nagahama City Hospital, 313 Oinui-cho, Nagahama, 526-8580 Japan (E-mail: yaterada{at}ex.biwa.ne.jp).
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Abstract
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We present a report of trans-arterial infusion chemotherapy through the intercostal arteries and subphrenic artery for pleural dissemination of recurrent thymoma after thymectomy. The disseminated tumor did not enlarge for more than a year after this treatment, and there were no side effects. Trans-arterial infusion chemotherapy appears to be a preferable procedure for pleural dissemination of thymoma.
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Introduction
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Treatment of recurrent thymoma after surgery still remains controversial, and several treatments for recurrent pleural dissemination have been reported, including surgery, chemotherapy, and radiotherapy. However, trans-arterial infusion chemotherapy has not been fully reported as a treatment option for this condition. We present 2 patients with pleural dissemination of recurrent thymoma after primary tumor resection who were treated successfully with trans-arterial infusion chemotherapy through the intercostal arteries and subphrenic artery.
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Patient 1
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A 64-year-old woman underwent total thymectomy and lobectomy of the right middle lobe of the lung for invasive thymoma in July 1999. Two years after the surgery, a solitary tumor recurrence in the right posterior costophrenic angle was detected, and therefore a second operation was performed. The main tumor was resected, but disseminated small nodules were recognized on the diaphragm and the inferior part of the parietal pleura but not on the visceral pleura. These nodules could not be completely resected. Two cycles of chemotherapy (cisplatin [CDDP] [50 mg/m2] and doxorubicin [ADM] [40 mg/m2] on day 1; vincristine [0.5 mg/m2] and cyclophosphamide [500 mg/m2] on day 3) were performed after the second operation. Regrowth of the disseminated tumor was recognized 12 months later (Fig 1A), and therefore we performed selective trans-arterial infusion of cisplatin and doxorubicin into the 8th to 11th intercostal arteries and subphrenic artery (Fig 1B) in November 2002. For this we injected a mixture of CDDP (50 mg), ADM (20 mg), and saline (50 mL) for a total of 150 mL at 10 mL/min for 3 minutes into each artery. The total dosage was 50 mg of CDDP and 20 mg of ADM. No regrowth of the disseminated tumor has been recognized for 24 months since this treatment.
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Fig 1. (A) Chest computed tomographic scan shows pleural dissemination (arrows) of the chest wall (right) and diaphragm (left). (B) At the time of trans-arterial infusion chemotherapy, angiographic scan of the subphrenic artery shows the tumor stain on the diaphragm (arrow).
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Patient 2
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A 70-year-old woman underwent total thymectomy and partial resection of the right upper lobe of the lung for invasive thymoma in January 1999. Three years later, local recurrence of the right pleural dissemination was found (Fig 2). In September 2002, one cycle of the same chemotherapy that was used in patient 1 was performed on patient 2. The disseminated tumor was found to have slightly enlarged 6 months later, and therefore we performed selective trans-arterial infusion of CDDP and ADM into the 7th to 11th intercostal arteries in April 2003. However, the subphrenic artery was not detected. The infused drug mixture was the same as that used in patient 1, and the total dosage was 50 mg of CDDP and 20 mg of ADM. The patient was uneventfully discharged and the size of the tumor did not change for 19 months.
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Comment
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Recurrence of invasive thymoma is often observed after total thymectomy, and the most frequent type of recurrence is pleural dissemination [1]. However, treatment for pleural dissemination of recurrent thymoma remains controversial, and reported methods have included partial resection, pleuro-pneumonectomy, systemic chemotherapy, intrathoracic chemotherapy, radiotherapy, and their combinations.
There have been some reports of successful surgical treatment for invasive thymoma with pleural dissemination, including 1 patient who underwent four operations [2]. However, Haniuda and colleagues [1] reported that the reoperation was not significantly effective for prolongation of postrecurrent survival and that the effect of subtotal resection for severe pleural recurrence was unsatisfactory. The reported doses of radiotherapy for thoracic dissemination of thymoma have ranged from 10 to 17 Gy to the entire hemithorax containing the site of dissemination and from 30 to 55 Gy to the primary tumor bed, performed postoperatively with chemotherapy using various protocols [3]. Also a complete response has been reported in a case of recurrence in the form of pleural tumors after five courses of radiotherapy [4]. However, the effects of low-dose radiotherapy are undetermined, and frequent radiotherapy carries a risk of radiation pneumonitis.
Thymoma is reported to be a chemotherapy-sensitive tumor, and Fornasiero and colleagues [5] reported that the overall clinical response rate (complete response plus partial response) was 91.8%, with 43% of patients achieving complete remission. Therefore, high-dose chemotherapy involving trans-arterial infusion into the feeding arteries of tumors could be effective for reducing the total dosage and systemic side effects. Preoperative trans-arterial infusion chemotherapy via the internal thoracic artery is reportedly effective for invasive thymoma [6]. However, trans-arterial infusion chemotherapy for pleural dissemination of recurrent invasive thymoma after thymectomy has not been previously reported. Pleural disseminated thymoma often occurs on the parietal pleura, which is fed by the intercostal arteries and subphrenic artery. In the present patients, good control was achieved by trans-arterial infusion chemotherapy without any side effects. Trans-arterial infusion chemotherapy through the intercostal arteries and subphrenic artery thus appears to be an effective treatment for pleural disseminated lesions of invasive thymoma.
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References
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- Haniuda M, Kondo R, Numanami H, et al. Recurrence of thymoma: clinicopathological features, re-operation, and outcome J Surg Oncol 2001;78:183-188.[Medline]
- Sakada T, Sugio K, Nishioka K, et al. Invasive thymoma with long-term survival by extensive reoperation Respiration 1999;66:167-169.[Medline]
- Yoshida H, Uematsu M, Itami J, et al. The role of low-dose hemithoracic radiotherapy for thoracic dissemination of thymoma Radiat Med 1997;15:399-403.[Medline]
- Ichinose Y, Ohta M, Yano T, et al. Treatment of invasive thymoma with pleural dissemination J Surg Oncol 1993;54:180-183.[Medline]
- Fornasiero A, Daniele O, Ghiotto C, et al. Chemotherapy for invasive thymoma: a 13-year experience Cancer 1991;68:30-33.[Medline]
- Otani Y, Yoshida I, Ishikawa S, et al. Preoperative intra-arterial infusion chemotherapy for invasive thymoma: a case report Jpn J Clin Oncol 1996;26:476-479.[Abstract/Free Full Text]
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Abstract
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