Ann Thorac Surg 2007;84:1378-1379
© 2007 The Society of Thoracic Surgeons
Case Reports
Lymph Node Metastases in a Pedicled Pericardial Fat Pad Flap
Biruta Witte, MD*,
Martin Hürtgen, MD
Department of Thoracic Surgery, Katholisches Klinikum Koblenz, Koblenz, Germany
Accepted for publication May 14, 2007.
* Address correspondence to Dr Witte, Department of Thoracic Surgery, Katholisches Klinikum Koblenz, Kardinal-Krementz-Str. 1–5, Koblenz, 56073, Germany (Email: b.witte{at}kk-koblenz.de).
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Abstract
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Routine use of pedicled thymus or pericardial fat pad flap for prophylactic bronchial stump coverage in neoadjuvant treated non-small cell lung cancer (NSCLC) is challenged by the observation of synchronous lymph node metastases to the flap. As a consequence, we suggest local muscle flaps, and histological examination of the pericardial fat pad.
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Introduction
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The pedicled thymus or pericardial fat pad flap [1, 2] is considered to be an easy to use and effective coverage for prevention and repair of bronchial stump insufficiency (Fig 1). Successful prophylactic use has been reported in situations with an increased risk of bronchial stump insufficiency, as pneumonectomies [3], resections after neoadjuvant treatment of lung carcinoma [4, 5], and mesothelioma [6].
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Fig 1. Sketch of the anterior mediastinum and costomediastinal recessus seen from the right. The pericardial fat pad is supplied by a branch of the pericardiophrenic artery (4), descending from the internal mammary artery. Therefore, the flap should be pedicled cranially. First the mediastinal pleura is incised into a U-shaped manner (dotted line) following the sternum (1), diaphragm (2), and pericardium (3). Then the pericardial fat pad is dissected bluntly from the sternum, pericardium, and contralateral pleura mediastinalis in a cranial direction (arrow). (SVC = superior vena cava.)
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A 64-year-old man who is a smoker was diagnosed with a moderately differentiated squamous cell carcinoma of the right lower lobe. Clinical staging (ie, thoracic and cranial computed tomographic scans, abdominal sonography, bone scan) showed no signs of mediastinal or distant metastases. Video-mediastinoscopic lymphadenectomy showed microscopic disease at the 4R station in one of nine resected mediastinal lymph nodes. Re-staging by computed tomographic scan after two courses of carboplatin and pacitaxel showed partial response of the primary and a distinct pretracheal nodule in an otherwise unsuspicious mediastinum. At re-mediastinoscopy, exploration was impossible due to extensive scars. The patient underwent a right lower lobectomy and systematic nodal dissection. Interlobar, paraesophageal, and tracheobronchial lymph nodes were enlarged. A pericardial fat pedicle harvested for routine bronchial stump coverage turned out to be too short to reach the stump without tension. The useless flap, free of macroscopic signs of malignancy, was excised and routinely sent for pathologic examination. Histology showed lymphangiosis carcinomatosa, mediastinal disease at stations 4R and 8, and near the phrenic nerve with 4 of 13 lymph nodes involved, and surprisingly 12 lymph nodes in the randomly excised pericardial fat pad, among them were 5 with metastatic disease. The postoperative course was uneventful. The patient received adjuvant radiochemotherapy.
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Comment
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Routine prophylactic bronchial stump coverage after neoadjuvant treatment and resection of lung carcinoma is widely accepted, especially with right-sided pneumonectomies. The pericardial fat pad flap is quickly harvested without leaving problems at the harvesting site, and therefore it is increasingly popular. There are few oncologic objections, as bronchial lymphatics are known to drain mainly through the middle mediastinum [7]. For the same reason, the fat pad of the anterior mediastinum has never been part of routine systematic nodal dissection [7]. Thus the incidence of metastatic disease to anterior mediastinal nodes, its prognostic significance, and its TNM classification regarding non-small cell lung cancer are not defined. It should be considered that lymphatic drainage might be compromised and altered by mediastinal disease, invasive mediastinal staging, and neoadjuvant treatment, especially radiation therapy. Therefore patients who benefit most from prophylactic bronchial stump coverage could be more likely to have lymphatic spread to the anterior mediastinum. Unfortunately it is impossible to use the same flap for stump coverage and histologic examination. As a consequence, in locally advanced or neoadjuvant treated lung carcinoma we suggest local muscle flaps for bronchial stump coverage, and the pericardial fat pad for histologic examination.
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References
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- Infante MV, Alloisio M, Balzarini L, et al. Protection of right pneumonectomy bronchial sutures with a pedicled thymus flap Ann Thorac Surg 2004;77:351-353.[Abstract/Free Full Text]
- Klepetko W, Taghavi S, Perezlenyi A, et al. Impact of different coverage techniques on incidence of postpneumonectoy stump fistula Eur J Cardiovasc Surg 1999;15:758-763.
- Sonett JR, Krasna MJ, Suntharalingam M, et al. Safe pulmonary resection after chemotherapy and high dose thoracic radiation Ann Thorac Surg 1999;68:316-320.[Abstract/Free Full Text]
- Stamatis G, Djuric D, Eberhardt W, et al. Postoperative morbidity and mortality after induction chemoradiotherapy for locally advanced lung cancer: an analysis of 350 operated patients Eur J Cardiothorac Surg 2002;22:292-297.[Abstract/Free Full Text]
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- Hata E, Hayakawa K, Miyamoto H, Hayashida R. Rationale for extended lymphadenectomy for lung cancer Theor Surg 1990;5:19-25.
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Abstract
Introduction
