Ann Thorac Surg 2015;99:1425–8
CASE REPORT SUGIMOTO ET AL PNEUMOCEPHALUS WITH CHYLOTHORAX
1425
Fig 6. A postoperative photograph of the patient. (A) Right side of the patient (operative scar this time). (B) Front side of the patient. (C) Left side of the patient (previous operative scar).
We thank Dr Junichi Shindoh for his contribution in the critical revision of our manuscript.
3. Spaggiari L, Grunenwald D, Girard P, Baldeyrou P. Completion right lower lobectomy for recurrence after left pneumonectomy for metastases. Eur J Cardiothorac Surg 1997;12: 798–800. 4. Barker JA, Yahr WZ, Krieger BP. Right upper lobectomy twenty years after left pneumonectomy. Chest 1990;97:248–50. 5. Falcoz PE, Assouad J, Pimpec-Barthes FL, et al. Lobectomy for metachronous lung cancer after pneumonectomy. Eur J Cardiothorac Surg 2009;35:373–4. 6. Quiroga J, Prim JMG, Moldes M, Ledo R. Middle lobectomy after pneumonectomy. Asian Cardiovasc Thorac Ann 2009;17: 300–1. 7. Liu Y, Cui P, Yang Z, Zhang P, Guo R, Shao G. Right lower lobectomy eight years after left pneumonectomy for a second primary lung cancer. J Cardiothorac Surg 2013;8:46. 8. Nakanishi R, Hirai A, Murakami K, et al. Successful videoassisted thoracic surgery lobectomy in a single-ling patient. Surg Laparosc Endosc Percutan Tech 2007;17:562–4.
Pneumocephalus and Chylothorax Complicating Vertebrectomy for Lung Cancer Seiichiro Sugimoto, MD, Masato Tanaka, MD, Ken Suzawa, MD, Hitoshi Nishikawa, MD, Shinichi Toyooka, MD, Takahiro Oto, MD, Toshifumi Ozaki, MD, and Shinichiro Miyoshi, MD Departments of General Thoracic Surgery and Orthopedic Surgery, Okayama University Hospital, Okayama, Japan
Pneumocephalus is a rare, but potentially fatal complication of thoracic surgery. We describe a case of successful management of pneumocephalus complicated by persistent chylothorax developing after en bloc partial vertebrectomy performed after induction chemoradiotherapy for lung cancer invading the spine. Surgical treatment should be considered for pneumocephalus
References 1. Spaggiari L, Grunenwald D, Girard P, et al. Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma. Ann Thorac Surg 1996;62:1598–602. 2. Donington JS, Miller DL, Rowland CC, et al. Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy. Ann Thorac Surg 2002;74:154–9. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication May 27, 2014. Address correspondence to Dr Sugimoto, Department of General Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.098
FEATURE ARTICLES
providing a good field of view under double lobe ventilation because of its magnifying effect. Second, less damage to the inspiration muscles contributes to preservation of postoperative respiratory function. Third, TS is less invasive, and the short recovery avoids postoperative complications such as pneumonia and delirium. Therefore, we aggressively perform TS with 3 ports as long as the patient does not have poor cardiopulmonary function and can tolerate general anesthesia. Our indication criteria for TS are the following: (1) a predictive postoperative FEV1 of 1.00 L or greater; and (2) normal right heart function on echocardiography. The present patient had a normal pulmonary arterial system and we decided after careful evaluation that the patient could tolerate a lobectomy. In addition, collaboration with the anesthesiologist is essential for such an operation. Before the operation, we consulted with the anesthesiologist, who considered selective blocking of the middle lobe branch to be possible, while keeping the patient oxygenized under ventilation of the residual lobes. Selective lobar ventilation during lung resection is also feasible in a TS approach with sufficient surgical view. Although we have never experienced this technique for a patient with impaired lung function who cannot tolerate single lung ventilation during surgery, it would be theoretically applicable for such a patient. In conclusion, TS could be a feasible surgical option in selected patients after contralateral pneumonectomy, with careful preoperative assessment and selective lobar ventilation in good collaboration with anesthesiologists.
1426
CASE REPORT SUGIMOTO ET AL PNEUMOCEPHALUS WITH CHYLOTHORAX
Ann Thorac Surg 2015;99:1425–8
complicated by any condition requiring persistent chest drainage. (Ann Thorac Surg 2015;99:1425–8) Ó 2015 by The Society of Thoracic Surgeons
P
FEATURE ARTICLES
neumocephalus is commonly encountered in the field of neurosurgery, but is an extremely rare and potentially life-threatening complication of thoracic surgery that may lead to meningitis or brain herniation [1, 2]. In the context of thoracic surgery, pneumocephalus is generally caused by escape of air into the injured nerve root sleeves or a subarachnoid-pleural fistula from a pneumothorax or bronchopleural fistula, with persistent air leak [1]. However, even in the absence of a persistent air leak, the air accumulation in the pleural dead space after lung resection can also cause pneumocephalus along with the subarachnoid-pleural fistula. Moreover, chest drainage, which is routinely performed after lung surgery, can serve as an unfavorable factor for pneumocephalus by leading to persistent cerebrospinal fluid (CSF) leakage from the subarachnoid-pleural fistula and complicate the management of pneumocephalus. We describe a case of successful management of pneumocephalus, caused by a subarachnoid-pleural fistula, and chest drainage for chylothorax developing after en bloc partial vertebrectomy performed after induction chemoradiotherapy for lung cancer invading the spine. A 79-year-old man was referred to our hospital for the treatment of a lung adenocarcinoma, 2.3 cm in diameter, involving the right upper lobe with invasion of the Th2 and Th3 vertebrae and rib heads (clinical T4N0M0). The patient was treated with 3 cycles of S-1 chemotherapy and concurrent radiotherapy at a radiation dose of 46 Gy administered in 23 fractions, with partial response. After the induction chemoradiotherapy, resection was accomplished through a posterolateral thoracotomy, Th2 to Th3 rib resection, partial vertebrectomy of Th2 and Th3, and right upper lobectomy with mediastinal lymphadenectomy. Intraoperative neurosurgical assistance was obtained during the paraspinal dissection. There was no clear evidence of CSF or air leak after the resection and the patient was extubated in the operating room. The postoperative course was marked by the development of delirium and chylothorax requiring prolonged chest tube drainage. Because conservative therapy failed for chylothorax, a second surgery was performed for closure of the chyle leakage site in the lymphadenectomized area on postoperative day 13, with chest drainage. Although no air leak was found postoperatively, air accumulated in the right thorax after the second thoracotomy (Fig 1A). The patient developed a headache and sudden alteration of the mental status with decreased level of consciousness 2 days after the second surgery. Urgent brain computed tomography (CT) showed a pneumocephalus in the subarachnoid pericerebral space and the cerebral ventricles (Fig 1B). The patient was intubated and stabilized in the head-down position to allow the air to escape from the subarachnoid space. The
Fig 1. (A) Chest computed tomography (CT) showing accumulation of intrathoracic air after the second surgery. (B) Brain CT showing pneumocephalus in the subarachnoid pericerebral space and the cerebral ventricles. (C) Post-myelography chest CT showing the formation of a subarachnoid-pleural fistula at the Th2 level with collection of contrast material in the right thorax (yellow arrowheads).
chest tube was temporarily clamped to collect fluid in the pleural space and prevent exacerbation of the CSF leak. Depending on the respiratory status or status of fluid
Ann Thorac Surg 2015;99:1425–8
CASE REPORT SUGIMOTO ET AL PNEUMOCEPHALUS WITH CHYLOTHORAX
1427
Fig 2. Intraoperative findings at the third surgery. (A) A small dural tear on the Th1 nerve root (arrowheads). (B) Primary repair of the dural tear (arrowheads).
Comment Pneumocephalus is a potential complication of vertebrectomy for thoracic malignancy invading the spine. It
can be caused by a combination of subarachnoid-pleural fistula formation and presence of intrathoracic air. In the previously reported cases [1–5], pneumocephalus occurred due to a persistent air leak after removal of the chest tube, probably because the intrathoracic positive pressure caused by the persistent air leak forced the air into the subarachnoid space. In contrast, because there was no air leakage after the surgery in our case, the pneumocephalus was considered to have been caused by the accumulated air in the pleural space entering the subarachnoid space. We speculated about the mechanism of pneumocephalus in our case as follows: At first, the subarachnoid-pleural fistula was formed by excess traction on the Th1 nerve root during the first thoracotomy. Subsequently, the subarachnoid-pleural fistula was uncovered during the second surgery when the pleural cavity was cleaned, and finally, after the second surgery, the accumulated air was easily forced into the subarachnoid space by the positive intrathoracic pressure caused by coughing after the surgery. When there was no cough, the negative intrathoracic pressure sucked the CSF through the subarachnoid-pleural fistula leading to decreased CSF volume in the cerebral ventricles. In addition, a chest tube for the treatment of chylothorax drained not only chyle but also CSF, resulting in further decrease of the CSF volume in the cerebral ventricles. Thus, care has to be taken not only to prevent persistent air leakage, but also chyle leakage in cases of thoracic vertebrectomy, in addition to covering the exposed dura mater with a muscle flap to prevent the formation of a subarachnoid-pleural fistula. Prophylactic division of the intercostal nerve next to the excision site might be useful to prevent nerve root injury caused by excess traction. For the treatment of pneumocephalus after thoracic surgery, primarily conservative therapy is useful [3, 4], and in case of failure of conservative therapy, surgical repair would be required [2, 5]. In our case, the
FEATURE ARTICLES
collection, the chest tube was unclamped and maintained a water-seal status to drain excess pleural fluid. Intravenous meropenem was administered to prevent meningitis after the onset of pneumocephalus. Follow-up brain CT showed resolution of the pneumocephalus, but decreased CSF volume in the cerebral ventricles, indicating persistent CSF leak. Post-myelography chest CT revealed the formation of a subarachnoid-pleural fistula at the Th2 level (Fig 1C). The patient still had decreased level of consciousness and chylothorax, which prompted us to perform a third thoracotomy 17 days after the second surgery. The CSF was found to be seeping from a small dural tear on the Th1 nerve root (Fig 2A). Primary repair of the dural tear was performed with 6-0 Pronova (Ethicon Inc, Tokyo, Japan) (Fig 2B), and a right longissimus dorsi muscle flap was mobilized to establish onlay coverage of the dural repair site. Fibrin glue was also applied at the repair site. Absence of any residual CSF leak was confirmed by the Valsalva maneuver. Subsequently, the supradiaphragmatic thoracic duct was ligated for the treatment of chylothorax, and no evidence of chyle leak was found at the end of surgery. The patient’s consciousness level recovered postoperatively and brain CT showed no evidence of CSF leak 3 days after the third surgery. Even though the pleural fluid volume decreased markedly, persistent chylothorax required octreotide and factor XIII administration postoperatively. The chest tube was removed 68 days after the third surgery. The patient’s neurologic status recovered except for muscular weakness resulting from the prolonged bed rest. He was transferred to a local hospital for rehabilitation 137 days after the third surgery.
1428
CASE REPORT MAHOWALD ET AL PRIMARY PULMONARY MALIGNANT MELANOMA
pneumocephalus disappeared with the head-down position and collection of fluid in the pleural space. However, prolonged chest tube drainage was necessitated by the intractable chylothorax, which could exacerbate CSF leakage and prevent natural self-repair of the subarachnoid-pleural fistula. Because prolonged chest drainage can serve as an unfavorable factor for a subarachnoid-pleural fistula, we performed simultaneous surgery for pneumocephalus and chylothorax, which led to successful control of this complicated clinical situation. Thus, even in the absence of persistent air leakage, surgical treatment should be considered when the pneumocephalus is associated with any condition requiring persistent chest drainage, such as chylothorax.
FEATURE ARTICLES
References 1. Malca SA, Roche PH, Touta A, Pellet W. Pneumocephalus after thoracotomy. Surg Neurol 1995;43:398–401. 2. Brown WM III, Symbas PN. Pneumocephalus complicating routine thoracotomy: symptoms, diagnosis, and management. Ann Thorac Surg 1995;59:234–6. 3. Singh RS, Pathak A. Tension pneumocephalus after excision of posterior mediastinal mass. Ann Thorac Surg 1999;68:566–8. 4. Lucchi M, Dini P, Givigliano F, Ribechini A, Mussi A. Massive pneumoencephalus of late onset after an en bloc resection for lung cancer. J Thorac Cardiovasc Surg 2004;127:1836–8. 5. Schuchert MJ, Myers TG, DeGraft-Johnson J, Bejjani GK, Luketich JD, Landreneau RJ. Pneumocephalus after resection of a lung cancer with posterior chest wall involvement. Ann Thorac Surg 2009;87:1609–11.
Long-Term Survival After Pneumonectomy for Primary Pulmonary Malignant Melanoma Madeline K. Mahowald, MD, Bassam I. Aswad, MD, Ikenna C. Okereke, MD, and Thomas Ng, MD Departments of Surgery and Pathology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
Ann Thorac Surg 2015;99:1428–30
occult primary has been missed. A study of almost 85,000 cases of melanoma published in 1998 [1] reported that the percentage of cases of melanoma not originating in the skin, mucous membranes, or eyes to be only 2.2%. Fewer than 30 cases of primary malignant melanoma of the lung (PMML) have been published, most of which describe a poor prognosis. Because of the rarity of the condition, there is little evidence available to guide treatment. A 55-year-old white male presented with 2 months history of unresolved cough. He had a 45 pack-year smoking history but had quit 15 years prior to presentation. He was an auto mechanic and had no major medical conditions. He denied a history of prior malignancies, including any skin lesions removed in the past. The family history was unremarkable, as was the physical examination. Chest radiograph revealed a large left-sided pulmonary mass. Computed tomographic (CT) scan confirmed the presence of a left upper lobe lung mass, 7.5 cm in size, with an endobronchial component and abutting the major fissure. This lung mass was the only site of activity seen on integrated positron emission tomography (PET) and CT scan (Fig 1). Brain magnetic resonance imaging examination was normal. The patient then underwent CT-guided fine needle aspiration biopsy of the lung mass that showed malignant large tumor cells, with abundant eosinophilic cytoplasm, that by immunohistochemistry were negative for keratin cocktail, and positive for S-100, Melan-A (focal), and HMB-45 (focal). The findings were considered consistent with malignant melanoma. With this diagnosis, the patient underwent thorough evaluation by dermatology and ophthalmology, finding no evidence of cutaneous, oral, perianal, or ocular lesions. Preoperative forced expiratory volume in the first second of expiration was 2.14 L, 66% predicted, and diffusing capacity of lung for carbon monoxide was 53% predicted. At the multidisciplinary thoracic oncology conference the patient’s case was reviewed and the diagnosis of PMML was agreed upon. Surgical therapy was recommended.
As few as 30 cases of primary malignant melanoma of the lung have been reported in the literature. Many patients die within months of diagnosis; few published cases describe patients who survive long-term after treatment. We report a case of primary pulmonary malignant melanoma in a patient who remains disease-free 60 months after pneumonectomy. (Ann Thorac Surg 2015;99:1428–30) Ó 2015 by The Society of Thoracic Surgeons
A
lthough primary malignant melanoma occurs in organs other than the skin, and less commonly the eye and mucous membranes, such cases are rare and often regarded with skepticism by those who suspect that an Accepted for publication June 11, 2014. Address correspondence to Dr Ng, 2 Dudley St, Ste 470, Providence, RI 02905; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Integrated positron emission and computed tomographic scan showing a left upper lobe lung mass with intense activity and an endobronchial component extending into the distal left main bronchus (arrow). 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.110
CASE REPORT SUGIMOTO ET AL PNEUMOCEPHALUS WITH CHYLOTHORAX
1425
Fig 6. A postoperative photograph of the patient. (A) Right side of the patient (operative scar this time). (B) Front side of the patient. (C) Left side of the patient (previous operative scar).
We thank Dr Junichi Shindoh for his contribution in the critical revision of our manuscript.
3. Spaggiari L, Grunenwald D, Girard P, Baldeyrou P. Completion right lower lobectomy for recurrence after left pneumonectomy for metastases. Eur J Cardiothorac Surg 1997;12: 798–800. 4. Barker JA, Yahr WZ, Krieger BP. Right upper lobectomy twenty years after left pneumonectomy. Chest 1990;97:248–50. 5. Falcoz PE, Assouad J, Pimpec-Barthes FL, et al. Lobectomy for metachronous lung cancer after pneumonectomy. Eur J Cardiothorac Surg 2009;35:373–4. 6. Quiroga J, Prim JMG, Moldes M, Ledo R. Middle lobectomy after pneumonectomy. Asian Cardiovasc Thorac Ann 2009;17: 300–1. 7. Liu Y, Cui P, Yang Z, Zhang P, Guo R, Shao G. Right lower lobectomy eight years after left pneumonectomy for a second primary lung cancer. J Cardiothorac Surg 2013;8:46. 8. Nakanishi R, Hirai A, Murakami K, et al. Successful videoassisted thoracic surgery lobectomy in a single-ling patient. Surg Laparosc Endosc Percutan Tech 2007;17:562–4.
Pneumocephalus and Chylothorax Complicating Vertebrectomy for Lung Cancer Seiichiro Sugimoto, MD, Masato Tanaka, MD, Ken Suzawa, MD, Hitoshi Nishikawa, MD, Shinichi Toyooka, MD, Takahiro Oto, MD, Toshifumi Ozaki, MD, and Shinichiro Miyoshi, MD Departments of General Thoracic Surgery and Orthopedic Surgery, Okayama University Hospital, Okayama, Japan
Pneumocephalus is a rare, but potentially fatal complication of thoracic surgery. We describe a case of successful management of pneumocephalus complicated by persistent chylothorax developing after en bloc partial vertebrectomy performed after induction chemoradiotherapy for lung cancer invading the spine. Surgical treatment should be considered for pneumocephalus
References 1. Spaggiari L, Grunenwald D, Girard P, et al. Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma. Ann Thorac Surg 1996;62:1598–602. 2. Donington JS, Miller DL, Rowland CC, et al. Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy. Ann Thorac Surg 2002;74:154–9. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication May 27, 2014. Address correspondence to Dr Sugimoto, Department of General Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.098
FEATURE ARTICLES
providing a good field of view under double lobe ventilation because of its magnifying effect. Second, less damage to the inspiration muscles contributes to preservation of postoperative respiratory function. Third, TS is less invasive, and the short recovery avoids postoperative complications such as pneumonia and delirium. Therefore, we aggressively perform TS with 3 ports as long as the patient does not have poor cardiopulmonary function and can tolerate general anesthesia. Our indication criteria for TS are the following: (1) a predictive postoperative FEV1 of 1.00 L or greater; and (2) normal right heart function on echocardiography. The present patient had a normal pulmonary arterial system and we decided after careful evaluation that the patient could tolerate a lobectomy. In addition, collaboration with the anesthesiologist is essential for such an operation. Before the operation, we consulted with the anesthesiologist, who considered selective blocking of the middle lobe branch to be possible, while keeping the patient oxygenized under ventilation of the residual lobes. Selective lobar ventilation during lung resection is also feasible in a TS approach with sufficient surgical view. Although we have never experienced this technique for a patient with impaired lung function who cannot tolerate single lung ventilation during surgery, it would be theoretically applicable for such a patient. In conclusion, TS could be a feasible surgical option in selected patients after contralateral pneumonectomy, with careful preoperative assessment and selective lobar ventilation in good collaboration with anesthesiologists.
1426
CASE REPORT SUGIMOTO ET AL PNEUMOCEPHALUS WITH CHYLOTHORAX
Ann Thorac Surg 2015;99:1425–8
complicated by any condition requiring persistent chest drainage. (Ann Thorac Surg 2015;99:1425–8) Ó 2015 by The Society of Thoracic Surgeons
P
FEATURE ARTICLES
neumocephalus is commonly encountered in the field of neurosurgery, but is an extremely rare and potentially life-threatening complication of thoracic surgery that may lead to meningitis or brain herniation [1, 2]. In the context of thoracic surgery, pneumocephalus is generally caused by escape of air into the injured nerve root sleeves or a subarachnoid-pleural fistula from a pneumothorax or bronchopleural fistula, with persistent air leak [1]. However, even in the absence of a persistent air leak, the air accumulation in the pleural dead space after lung resection can also cause pneumocephalus along with the subarachnoid-pleural fistula. Moreover, chest drainage, which is routinely performed after lung surgery, can serve as an unfavorable factor for pneumocephalus by leading to persistent cerebrospinal fluid (CSF) leakage from the subarachnoid-pleural fistula and complicate the management of pneumocephalus. We describe a case of successful management of pneumocephalus, caused by a subarachnoid-pleural fistula, and chest drainage for chylothorax developing after en bloc partial vertebrectomy performed after induction chemoradiotherapy for lung cancer invading the spine. A 79-year-old man was referred to our hospital for the treatment of a lung adenocarcinoma, 2.3 cm in diameter, involving the right upper lobe with invasion of the Th2 and Th3 vertebrae and rib heads (clinical T4N0M0). The patient was treated with 3 cycles of S-1 chemotherapy and concurrent radiotherapy at a radiation dose of 46 Gy administered in 23 fractions, with partial response. After the induction chemoradiotherapy, resection was accomplished through a posterolateral thoracotomy, Th2 to Th3 rib resection, partial vertebrectomy of Th2 and Th3, and right upper lobectomy with mediastinal lymphadenectomy. Intraoperative neurosurgical assistance was obtained during the paraspinal dissection. There was no clear evidence of CSF or air leak after the resection and the patient was extubated in the operating room. The postoperative course was marked by the development of delirium and chylothorax requiring prolonged chest tube drainage. Because conservative therapy failed for chylothorax, a second surgery was performed for closure of the chyle leakage site in the lymphadenectomized area on postoperative day 13, with chest drainage. Although no air leak was found postoperatively, air accumulated in the right thorax after the second thoracotomy (Fig 1A). The patient developed a headache and sudden alteration of the mental status with decreased level of consciousness 2 days after the second surgery. Urgent brain computed tomography (CT) showed a pneumocephalus in the subarachnoid pericerebral space and the cerebral ventricles (Fig 1B). The patient was intubated and stabilized in the head-down position to allow the air to escape from the subarachnoid space. The
Fig 1. (A) Chest computed tomography (CT) showing accumulation of intrathoracic air after the second surgery. (B) Brain CT showing pneumocephalus in the subarachnoid pericerebral space and the cerebral ventricles. (C) Post-myelography chest CT showing the formation of a subarachnoid-pleural fistula at the Th2 level with collection of contrast material in the right thorax (yellow arrowheads).
chest tube was temporarily clamped to collect fluid in the pleural space and prevent exacerbation of the CSF leak. Depending on the respiratory status or status of fluid
Ann Thorac Surg 2015;99:1425–8
CASE REPORT SUGIMOTO ET AL PNEUMOCEPHALUS WITH CHYLOTHORAX
1427
Fig 2. Intraoperative findings at the third surgery. (A) A small dural tear on the Th1 nerve root (arrowheads). (B) Primary repair of the dural tear (arrowheads).
Comment Pneumocephalus is a potential complication of vertebrectomy for thoracic malignancy invading the spine. It
can be caused by a combination of subarachnoid-pleural fistula formation and presence of intrathoracic air. In the previously reported cases [1–5], pneumocephalus occurred due to a persistent air leak after removal of the chest tube, probably because the intrathoracic positive pressure caused by the persistent air leak forced the air into the subarachnoid space. In contrast, because there was no air leakage after the surgery in our case, the pneumocephalus was considered to have been caused by the accumulated air in the pleural space entering the subarachnoid space. We speculated about the mechanism of pneumocephalus in our case as follows: At first, the subarachnoid-pleural fistula was formed by excess traction on the Th1 nerve root during the first thoracotomy. Subsequently, the subarachnoid-pleural fistula was uncovered during the second surgery when the pleural cavity was cleaned, and finally, after the second surgery, the accumulated air was easily forced into the subarachnoid space by the positive intrathoracic pressure caused by coughing after the surgery. When there was no cough, the negative intrathoracic pressure sucked the CSF through the subarachnoid-pleural fistula leading to decreased CSF volume in the cerebral ventricles. In addition, a chest tube for the treatment of chylothorax drained not only chyle but also CSF, resulting in further decrease of the CSF volume in the cerebral ventricles. Thus, care has to be taken not only to prevent persistent air leakage, but also chyle leakage in cases of thoracic vertebrectomy, in addition to covering the exposed dura mater with a muscle flap to prevent the formation of a subarachnoid-pleural fistula. Prophylactic division of the intercostal nerve next to the excision site might be useful to prevent nerve root injury caused by excess traction. For the treatment of pneumocephalus after thoracic surgery, primarily conservative therapy is useful [3, 4], and in case of failure of conservative therapy, surgical repair would be required [2, 5]. In our case, the
FEATURE ARTICLES
collection, the chest tube was unclamped and maintained a water-seal status to drain excess pleural fluid. Intravenous meropenem was administered to prevent meningitis after the onset of pneumocephalus. Follow-up brain CT showed resolution of the pneumocephalus, but decreased CSF volume in the cerebral ventricles, indicating persistent CSF leak. Post-myelography chest CT revealed the formation of a subarachnoid-pleural fistula at the Th2 level (Fig 1C). The patient still had decreased level of consciousness and chylothorax, which prompted us to perform a third thoracotomy 17 days after the second surgery. The CSF was found to be seeping from a small dural tear on the Th1 nerve root (Fig 2A). Primary repair of the dural tear was performed with 6-0 Pronova (Ethicon Inc, Tokyo, Japan) (Fig 2B), and a right longissimus dorsi muscle flap was mobilized to establish onlay coverage of the dural repair site. Fibrin glue was also applied at the repair site. Absence of any residual CSF leak was confirmed by the Valsalva maneuver. Subsequently, the supradiaphragmatic thoracic duct was ligated for the treatment of chylothorax, and no evidence of chyle leak was found at the end of surgery. The patient’s consciousness level recovered postoperatively and brain CT showed no evidence of CSF leak 3 days after the third surgery. Even though the pleural fluid volume decreased markedly, persistent chylothorax required octreotide and factor XIII administration postoperatively. The chest tube was removed 68 days after the third surgery. The patient’s neurologic status recovered except for muscular weakness resulting from the prolonged bed rest. He was transferred to a local hospital for rehabilitation 137 days after the third surgery.
1428
CASE REPORT MAHOWALD ET AL PRIMARY PULMONARY MALIGNANT MELANOMA
pneumocephalus disappeared with the head-down position and collection of fluid in the pleural space. However, prolonged chest tube drainage was necessitated by the intractable chylothorax, which could exacerbate CSF leakage and prevent natural self-repair of the subarachnoid-pleural fistula. Because prolonged chest drainage can serve as an unfavorable factor for a subarachnoid-pleural fistula, we performed simultaneous surgery for pneumocephalus and chylothorax, which led to successful control of this complicated clinical situation. Thus, even in the absence of persistent air leakage, surgical treatment should be considered when the pneumocephalus is associated with any condition requiring persistent chest drainage, such as chylothorax.
FEATURE ARTICLES
References 1. Malca SA, Roche PH, Touta A, Pellet W. Pneumocephalus after thoracotomy. Surg Neurol 1995;43:398–401. 2. Brown WM III, Symbas PN. Pneumocephalus complicating routine thoracotomy: symptoms, diagnosis, and management. Ann Thorac Surg 1995;59:234–6. 3. Singh RS, Pathak A. Tension pneumocephalus after excision of posterior mediastinal mass. Ann Thorac Surg 1999;68:566–8. 4. Lucchi M, Dini P, Givigliano F, Ribechini A, Mussi A. Massive pneumoencephalus of late onset after an en bloc resection for lung cancer. J Thorac Cardiovasc Surg 2004;127:1836–8. 5. Schuchert MJ, Myers TG, DeGraft-Johnson J, Bejjani GK, Luketich JD, Landreneau RJ. Pneumocephalus after resection of a lung cancer with posterior chest wall involvement. Ann Thorac Surg 2009;87:1609–11.
Long-Term Survival After Pneumonectomy for Primary Pulmonary Malignant Melanoma Madeline K. Mahowald, MD, Bassam I. Aswad, MD, Ikenna C. Okereke, MD, and Thomas Ng, MD Departments of Surgery and Pathology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
Ann Thorac Surg 2015;99:1428–30
occult primary has been missed. A study of almost 85,000 cases of melanoma published in 1998 [1] reported that the percentage of cases of melanoma not originating in the skin, mucous membranes, or eyes to be only 2.2%. Fewer than 30 cases of primary malignant melanoma of the lung (PMML) have been published, most of which describe a poor prognosis. Because of the rarity of the condition, there is little evidence available to guide treatment. A 55-year-old white male presented with 2 months history of unresolved cough. He had a 45 pack-year smoking history but had quit 15 years prior to presentation. He was an auto mechanic and had no major medical conditions. He denied a history of prior malignancies, including any skin lesions removed in the past. The family history was unremarkable, as was the physical examination. Chest radiograph revealed a large left-sided pulmonary mass. Computed tomographic (CT) scan confirmed the presence of a left upper lobe lung mass, 7.5 cm in size, with an endobronchial component and abutting the major fissure. This lung mass was the only site of activity seen on integrated positron emission tomography (PET) and CT scan (Fig 1). Brain magnetic resonance imaging examination was normal. The patient then underwent CT-guided fine needle aspiration biopsy of the lung mass that showed malignant large tumor cells, with abundant eosinophilic cytoplasm, that by immunohistochemistry were negative for keratin cocktail, and positive for S-100, Melan-A (focal), and HMB-45 (focal). The findings were considered consistent with malignant melanoma. With this diagnosis, the patient underwent thorough evaluation by dermatology and ophthalmology, finding no evidence of cutaneous, oral, perianal, or ocular lesions. Preoperative forced expiratory volume in the first second of expiration was 2.14 L, 66% predicted, and diffusing capacity of lung for carbon monoxide was 53% predicted. At the multidisciplinary thoracic oncology conference the patient’s case was reviewed and the diagnosis of PMML was agreed upon. Surgical therapy was recommended.
As few as 30 cases of primary malignant melanoma of the lung have been reported in the literature. Many patients die within months of diagnosis; few published cases describe patients who survive long-term after treatment. We report a case of primary pulmonary malignant melanoma in a patient who remains disease-free 60 months after pneumonectomy. (Ann Thorac Surg 2015;99:1428–30) Ó 2015 by The Society of Thoracic Surgeons
A
lthough primary malignant melanoma occurs in organs other than the skin, and less commonly the eye and mucous membranes, such cases are rare and often regarded with skepticism by those who suspect that an Accepted for publication June 11, 2014. Address correspondence to Dr Ng, 2 Dudley St, Ste 470, Providence, RI 02905; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Integrated positron emission and computed tomographic scan showing a left upper lobe lung mass with intense activity and an endobronchial component extending into the distal left main bronchus (arrow). 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.110
