Case Report :108
Carcinoid Tumor Invading the Thoracic Aorta: En-Bloc Resection 1.. /1. Lampl
Summa ry One or th e rare cas es in whic h metastases of a ca rcino id tumor infiltrat e th e a ort ic wall is reponed. Cross -cla mping th e desc endi ng aorta a nd en-bloc rese ction of the tumor and th e descend ing aorta were possib le. The post oper at ive course was
uneventful. Infiltration der Aor te nwand durch Lymphknctenmet ast asen cines llron chu skarzinoids. En-bloc-Rese ktion des Tu mors und der Aorta descenden s Die 68jahri ge Paticnti n wa r 7 Ja hre vor de r Vorst ellung in unserer Klinik alia loco wegen cines Bronchuskarzinoids im
Iinken Lungenoberlappen mit Befall der Nj-Lymphknoten lobcktomi crt wor den . Jetzt wur de d ie Patientin wege n ein er Masse im linken hinteren Med iastinum vorges tellt. 1m CT-Sca n fan d sich ein ca . faustgroBer Tumor, der die Aorta descend ens hufciscnfOrm ig umgrifT. Intr aoper ativ fand sich folgende r Befund: Der Tumor wa r oberflachlich mit dem verb lieb en en Unt erlappen a dharent . der Lungen hilus wa r tumo rfrei , unt er dem Aortenbogen fanden
sich keine tu morbefa llene n Lymphknoten. Der Tu mor selbst umgrilThufeisen fOrmigca. 2/ 3 der Aort en zir kumferenz in ei ne r Lange nausdehn ung von ca. Scm. Die Abtrennung von der Lunge erfo lgte rnittels Stapler, d ie Abpraparation von Oso pha gus und wt rbelkdrpem gestaltete sich pro blemlos. von der Aorta kon nte der Tum or weder stumpf noch scha rf in der Schicht abprapart ert we rde n. Nach einfa che rn Cross-clamping der Aorta des cendens (Clamping -Zeit 15 min) erfolgte d ie en -bloc-Hesektion de r Tum ormasse zusa mmen mit ca . 12 cm der Aorta descen den s und die Interposition eine r gewebte n 24-mm -Dacron -Dopp elvelourproth es e. Zwi schen Proth ese und Osophagus wurde ein ges tielte r Pertkard lappe n Inte rponiert, der Perikardd efekt wu rd e mi t Dura mater ver schlossen. Der postop erative Heilverlauf ges taltete sich v61lig glatt. 18 Monate nach dieser Oper at ion wu rde cine Knoche nmet as tas e im Becken nachgewiesen . Key words Carcinoid tumor - Lymph- node metastases - Invasion of th e aorti c wa ll - En-bloc resection
Introduclion Ca rcino id tumors - except the atypical form - are described as low-grad e malignan cies (7). Lymph -node metastases a re report ed in 0 % (5) to 5.4 % (4) up to 26 % (9) of the cases . Some reports deal with resections ofl ymph-node recurrencies (5). a nd we have had to resect su ch a carina l lymphnod e recurrency. Metastases elsewhe re are rar e. Ca se Rep ort A 68 -years- old wom an was a dmitte d with a mass in the left posterior med ia stinum. In her previo us histo ry a left uppe r lobe resectio n had been perfo rm ed for bro nchial carcinoid (sp indle-cell type) seven yea rs before . At that operation there wer e found lymphnodes involved in the l'1· level. l'OW the CT-sca n revealed a hor sesh oe-shaped mass su rrou ndi ng two thirds of th e descend ing ao rta and 7 to 8 em long (Fig. 1I. No furt he r lymph node or bon e metasta sis could be detected . Th roug h a left posterolateral ap proach in th e fourth intercost al space (the fifth intercost al space was obliterated after the pr evious proced ure ) th e tho rax was entere d. The left lowe r lobe was free d fro m the tum or using a sta pling device. Separation of the tum or
Thorae. cardiovasc. Surgeon 39 (99 1) 308-309 © Georg Thieme Verlag Stuttgart· New York
Fig. 1 CScan. Tumor surrounding theposteriorand lateralaspect of theaorta
lIeceived for Publi cation: May 10. 199 I
Downloaded by: University of British Columbia. Copyrighted material.
Dept. of'Surg ery. Centra l Hosp ita l. Augsb urg. Ger ma ny
Carcino id Tu mo r IlIl'ading the Thora cic Aorta: Ell-Bloc Res ection
Thora c. cardioua sc. S urg eon 39 (1991)
309
dissections , heparin-induced bleeding prob lems can be avoided. On the other hand there is a remarkable risk of neuro logical deficiencies, up to 28% for ( ' .\ (I ·Jl dl 'u tho racoabdom inal replacement. The crucial factor is the localisation ofthe lesion (esp. diaphragmati c region) and the extent of the resection rather than the clamping time. For the resection of the upper part of the descending aort a, clampin g times up to 70 minute s have been reported without neuro logical deficiencies (8). According to recent reports spina l cord protection by way of administratio n of pros taglandines (3) and, if possible, reinsertion of the (lower) intercostal arteries can reduce that severe complication. Reports of aortic wall infiltration cau sed by carcinoid tumor could not be found in the literature. Only Okike's series from the Mayo Clinic (203 cases of carcinoid tumo r) included one of them with distant metastasis into the femoral artery (4). Therefore this unus ual case of aortic wall invasion by a carci noid tumor and its successful immediate treatment by en-bloc resection of the tumor and the descend ing aorta is worth y of publication. Referen ces 1
Fig.2 Microscopic view. Tumor infiltration ofthe aorticadventitia 2
fro m eso phag us a nd the verteb ra l bodi es was easily done in th e appro priate plan e . Diss ection of the tumor from the aortic wa ll wa s, however . not possible, neither by blunt nor by sha rp dissection. Therefore after ligatio n of fou r pairs of inte rcostal arte ries the descendi ng ao rta was cross-clamped (clamping-tim e 15 min ) and th e en-bloc resection of the tumor a nd a 12 -cm pie ce of the descen d ing ao rta was perform ed . After interpos ition of a 24 mm woven double-velour Dacron pros thesis a ped icled pericardiu m flap was pos itioned betwee n the eso phagus an d th e pro sth esis as a pr otection agai nst arrosion. Th e pericard ial ga p was closed with dura ma ter. There were no neur ological deficiencies and the postoper ative cou rse wa s utte rly uneventful. As sus pe cted in the gross sp ecimen the micro scop ic view re veals clea rly the inva sion of the carcinoid tumo r (spindle-cell type) into the aorti c wall (Fig. 2). 18 months a fter that operation bone metastasis ha s bee n det ected in the pelvic region .
Discu ssion Infiltration of the aortic wa ll caused by bronchogenic carcinoma is not frequentl y report ed, and when cases are reported, they ar e considere d to be irr esect able with or without the use of extracorporeal circulation (I). There are only few cases of resectiona l procedures (6) successfully perform ed with extracorporea l circulation. Using the simple cross -clamping-technique as recommended by Craw-
Burt. M. E.. A. H. Pomeranz. M. S. Bains. P. M. McCormack, L. R. Kaiser, B. 51. Hilaris. and N. Martini: Results of su rgical treatment of stage III lung cancer invading the mediastinum. Surg. Clin. N. America 67 (987) 987-1 000 Crawford. E. 51. . L. G. Suen nso n, J. 51. Coselli. H. 1. Safi, and K. R. Hess: Aortic dissection and dissecting aortic aneurysms . Ann. Surg.
208 (1988)2 54-2 73 3
4
5
It
7 R
9
Grobitz, K.. K. Stuhmeier. und W.Sandmann: Erste klinische Erfah rungen zur Prostaglandin-Protektion des Rtickenma rks beim thorako-abdominellen Gefal3ersatz. Angio Archiv Ilm Druck) Okike. N.. P. E. Bemtuz, and L. B. Woolner: Carcinoid tumors of the lung. Ann . Thorac. Surg. 22 (19761270-2 75 Rea. F.. R. Binda. G. Sp reafico. F. Calabro. L. Bonauina, A. Cipriani. G. Di Vittorio, A. Passino, and F. Sa rtori: Bronchial carcin cids: A review of60 patients. Ann . Thorac. Surg. 47 (1989) 412-414 Semik, M.. I/. Toomes. A. Lind er. and K. Hellberg: Extended Resection of Central Bronchial Carcinomas Using the Heart-Lung Machine. Thorac. carciovasc. Surgeon 39 (991) Suppl. I 33/86 S tu rmberg, J. P.: Bronchuskarzinold - Tumor von niedrigem Malignitatsgrad. Munch. Med. Wsch r. 130 (1988)85-88 Weimann . S. und G. Flora: Zur chirurgischen Therapie des posttraumatischen thora kalen Aortenaneurysmas . Angio Archiv Om Druck) Wex, P. und D. Dragojevic: Die prognostische Bedeutung tumorpositiver Lymphknotenbefunde beim Bronchuskarzinoid. Herz-, Thorax- u. Gefabchir. im Druck
Dr. Ludwig Lamp l I. Chir. Klinik ZKAugshurg
Stenglinstral3e2 D-8900 Augsburg Germany
Downloaded by: University of British Columbia. Copyrighted material.
ford (2) for tho racoabdom inal repair of aortic aneurysms or
Carcinoid Tumor Invading the Thoracic Aorta: En-Bloc Resection 1.. /1. Lampl
Summa ry One or th e rare cas es in whic h metastases of a ca rcino id tumor infiltrat e th e a ort ic wall is reponed. Cross -cla mping th e desc endi ng aorta a nd en-bloc rese ction of the tumor and th e descend ing aorta were possib le. The post oper at ive course was
uneventful. Infiltration der Aor te nwand durch Lymphknctenmet ast asen cines llron chu skarzinoids. En-bloc-Rese ktion des Tu mors und der Aorta descenden s Die 68jahri ge Paticnti n wa r 7 Ja hre vor de r Vorst ellung in unserer Klinik alia loco wegen cines Bronchuskarzinoids im
Iinken Lungenoberlappen mit Befall der Nj-Lymphknoten lobcktomi crt wor den . Jetzt wur de d ie Patientin wege n ein er Masse im linken hinteren Med iastinum vorges tellt. 1m CT-Sca n fan d sich ein ca . faustgroBer Tumor, der die Aorta descend ens hufciscnfOrm ig umgrifT. Intr aoper ativ fand sich folgende r Befund: Der Tumor wa r oberflachlich mit dem verb lieb en en Unt erlappen a dharent . der Lungen hilus wa r tumo rfrei , unt er dem Aortenbogen fanden
sich keine tu morbefa llene n Lymphknoten. Der Tu mor selbst umgrilThufeisen fOrmigca. 2/ 3 der Aort en zir kumferenz in ei ne r Lange nausdehn ung von ca. Scm. Die Abtrennung von der Lunge erfo lgte rnittels Stapler, d ie Abpraparation von Oso pha gus und wt rbelkdrpem gestaltete sich pro blemlos. von der Aorta kon nte der Tum or weder stumpf noch scha rf in der Schicht abprapart ert we rde n. Nach einfa che rn Cross-clamping der Aorta des cendens (Clamping -Zeit 15 min) erfolgte d ie en -bloc-Hesektion de r Tum ormasse zusa mmen mit ca . 12 cm der Aorta descen den s und die Interposition eine r gewebte n 24-mm -Dacron -Dopp elvelourproth es e. Zwi schen Proth ese und Osophagus wurde ein ges tielte r Pertkard lappe n Inte rponiert, der Perikardd efekt wu rd e mi t Dura mater ver schlossen. Der postop erative Heilverlauf ges taltete sich v61lig glatt. 18 Monate nach dieser Oper at ion wu rde cine Knoche nmet as tas e im Becken nachgewiesen . Key words Carcinoid tumor - Lymph- node metastases - Invasion of th e aorti c wa ll - En-bloc resection
Introduclion Ca rcino id tumors - except the atypical form - are described as low-grad e malignan cies (7). Lymph -node metastases a re report ed in 0 % (5) to 5.4 % (4) up to 26 % (9) of the cases . Some reports deal with resections ofl ymph-node recurrencies (5). a nd we have had to resect su ch a carina l lymphnod e recurrency. Metastases elsewhe re are rar e. Ca se Rep ort A 68 -years- old wom an was a dmitte d with a mass in the left posterior med ia stinum. In her previo us histo ry a left uppe r lobe resectio n had been perfo rm ed for bro nchial carcinoid (sp indle-cell type) seven yea rs before . At that operation there wer e found lymphnodes involved in the l'1· level. l'OW the CT-sca n revealed a hor sesh oe-shaped mass su rrou ndi ng two thirds of th e descend ing ao rta and 7 to 8 em long (Fig. 1I. No furt he r lymph node or bon e metasta sis could be detected . Th roug h a left posterolateral ap proach in th e fourth intercost al space (the fifth intercost al space was obliterated after the pr evious proced ure ) th e tho rax was entere d. The left lowe r lobe was free d fro m the tum or using a sta pling device. Separation of the tum or
Thorae. cardiovasc. Surgeon 39 (99 1) 308-309 © Georg Thieme Verlag Stuttgart· New York
Fig. 1 CScan. Tumor surrounding theposteriorand lateralaspect of theaorta
lIeceived for Publi cation: May 10. 199 I
Downloaded by: University of British Columbia. Copyrighted material.
Dept. of'Surg ery. Centra l Hosp ita l. Augsb urg. Ger ma ny
Carcino id Tu mo r IlIl'ading the Thora cic Aorta: Ell-Bloc Res ection
Thora c. cardioua sc. S urg eon 39 (1991)
309
dissections , heparin-induced bleeding prob lems can be avoided. On the other hand there is a remarkable risk of neuro logical deficiencies, up to 28% for ( ' .\ (I ·Jl dl 'u tho racoabdom inal replacement. The crucial factor is the localisation ofthe lesion (esp. diaphragmati c region) and the extent of the resection rather than the clamping time. For the resection of the upper part of the descending aort a, clampin g times up to 70 minute s have been reported without neuro logical deficiencies (8). According to recent reports spina l cord protection by way of administratio n of pros taglandines (3) and, if possible, reinsertion of the (lower) intercostal arteries can reduce that severe complication. Reports of aortic wall infiltration cau sed by carcinoid tumor could not be found in the literature. Only Okike's series from the Mayo Clinic (203 cases of carcinoid tumo r) included one of them with distant metastasis into the femoral artery (4). Therefore this unus ual case of aortic wall invasion by a carci noid tumor and its successful immediate treatment by en-bloc resection of the tumor and the descend ing aorta is worth y of publication. Referen ces 1
Fig.2 Microscopic view. Tumor infiltration ofthe aorticadventitia 2
fro m eso phag us a nd the verteb ra l bodi es was easily done in th e appro priate plan e . Diss ection of the tumor from the aortic wa ll wa s, however . not possible, neither by blunt nor by sha rp dissection. Therefore after ligatio n of fou r pairs of inte rcostal arte ries the descendi ng ao rta was cross-clamped (clamping-tim e 15 min ) and th e en-bloc resection of the tumor a nd a 12 -cm pie ce of the descen d ing ao rta was perform ed . After interpos ition of a 24 mm woven double-velour Dacron pros thesis a ped icled pericardiu m flap was pos itioned betwee n the eso phagus an d th e pro sth esis as a pr otection agai nst arrosion. Th e pericard ial ga p was closed with dura ma ter. There were no neur ological deficiencies and the postoper ative cou rse wa s utte rly uneventful. As sus pe cted in the gross sp ecimen the micro scop ic view re veals clea rly the inva sion of the carcinoid tumo r (spindle-cell type) into the aorti c wall (Fig. 2). 18 months a fter that operation bone metastasis ha s bee n det ected in the pelvic region .
Discu ssion Infiltration of the aortic wa ll caused by bronchogenic carcinoma is not frequentl y report ed, and when cases are reported, they ar e considere d to be irr esect able with or without the use of extracorporeal circulation (I). There are only few cases of resectiona l procedures (6) successfully perform ed with extracorporea l circulation. Using the simple cross -clamping-technique as recommended by Craw-
Burt. M. E.. A. H. Pomeranz. M. S. Bains. P. M. McCormack, L. R. Kaiser, B. 51. Hilaris. and N. Martini: Results of su rgical treatment of stage III lung cancer invading the mediastinum. Surg. Clin. N. America 67 (987) 987-1 000 Crawford. E. 51. . L. G. Suen nso n, J. 51. Coselli. H. 1. Safi, and K. R. Hess: Aortic dissection and dissecting aortic aneurysms . Ann. Surg.
208 (1988)2 54-2 73 3
4
5
It
7 R
9
Grobitz, K.. K. Stuhmeier. und W.Sandmann: Erste klinische Erfah rungen zur Prostaglandin-Protektion des Rtickenma rks beim thorako-abdominellen Gefal3ersatz. Angio Archiv Ilm Druck) Okike. N.. P. E. Bemtuz, and L. B. Woolner: Carcinoid tumors of the lung. Ann . Thorac. Surg. 22 (19761270-2 75 Rea. F.. R. Binda. G. Sp reafico. F. Calabro. L. Bonauina, A. Cipriani. G. Di Vittorio, A. Passino, and F. Sa rtori: Bronchial carcin cids: A review of60 patients. Ann . Thorac. Surg. 47 (1989) 412-414 Semik, M.. I/. Toomes. A. Lind er. and K. Hellberg: Extended Resection of Central Bronchial Carcinomas Using the Heart-Lung Machine. Thorac. carciovasc. Surgeon 39 (991) Suppl. I 33/86 S tu rmberg, J. P.: Bronchuskarzinold - Tumor von niedrigem Malignitatsgrad. Munch. Med. Wsch r. 130 (1988)85-88 Weimann . S. und G. Flora: Zur chirurgischen Therapie des posttraumatischen thora kalen Aortenaneurysmas . Angio Archiv Om Druck) Wex, P. und D. Dragojevic: Die prognostische Bedeutung tumorpositiver Lymphknotenbefunde beim Bronchuskarzinoid. Herz-, Thorax- u. Gefabchir. im Druck
Dr. Ludwig Lamp l I. Chir. Klinik ZKAugshurg
Stenglinstral3e2 D-8900 Augsburg Germany
Downloaded by: University of British Columbia. Copyrighted material.
ford (2) for tho racoabdom inal repair of aortic aneurysms or
