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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Successful thoracoscopic removal of a giant teratoma following extraction of cystic conponents: A case report Yoshihiro Miyauchi, Hirochika Matsubara, Tsuyoshi Uchida, Hiroyasu Matsuoka, Tomofumi Ichihara & Masahiko Matsumoto Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
Keywords Mediastinal tumor; teratoma; thoracoscopic surgery Correspondence Yoshihiro Miyauchi, Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato Chuo, Yamanashi 409-3898, Japan. Tel: +81 55 273 9682 Fax: +81 55 273 6767 Email: [email protected]
Abstract Video-assisted thoracoscopic surgery is a type of minimal-access surgery. The nature of the surgery means that there are limitations on the size of a tumor that can be removed through an access incision. Herein, we report our experience removing a giant teratoma (16 × 14 × 13 cm in size) from the anterior mediastinum of a young girl. We employed video-assisted thoracoscopic surgery to remove the teratoma through a mini-thoracotomy following the extraction of the cystic components.
Received: 11 February 2013; revised 2 September 2013; accepted 5 September 2013 DOI:10.1111/ases.12067
Introduction Video-assisted thoracoscopic surgery is a type of minimalaccess surgery. The nature of the surgery means that there are limitations on the size of a tumor that can be removed through an access incision. Although VATS is widely applied in the treatment of various diseases, there have been only a few reports of successful VATS operations involving a giant mediastinal teratoma (1–3). Herein, we report our experience of employing VATS to extirpate a giant teratoma, 16 × 14 × 13 cm in size, from a patient’s anterior mediastinum.
Case Presentation A giant left thoracic mass was incidentally found in an asymptomatic 15-year-old girl during a routine chest film examination when entering high school (Figure 1). She was referred to our hospital for further treatment. Chest axial CT revealed an anterior mediastinal mass with softtissue elements, fat, a large amount of fluid, and foci of calcification, measuring 16 × 14 × 13 cm (Figure 2). The
serum markers of β-human chorionic gonadotropin and α-fetoprotein were within normal limits, but there was a high level of CA19-9 (120.9 U/mL). We diagnosed this tumor as a benign mature teratoma. The patient was a young girl and opted for a VATS approach for cosmetic reasons. VATS was performed with one-lung anesthesia. The patient was placed in the right lateral decubitus position with the left chest wall draped as for thoracotomy. A 50-mm mini-lateral thoracotomy was placed through the fifth intercostal space, and a 30° video telescope was carefully introduced to evaluate the possibility of performing VATS resection. To extract cystic components before dissection, we punctured the cystic part of the tumor, and the aspirated fluid was sent to cytology and biochemistry for analysis. When the cystic part was collapsed as much as possible, the puncture point was closed with a purse suture. Next, three other trocars were inserted: one 12-mm trocar through the seventh intercostal space in the mid-axillary line and two 5-mm trocars through the seventh and eighth intercostal spaces posterior to the scapular line to facilitate dissection (Figure 3a). The techniques of sharp and blunt dissection,
Asian J Endosc Surg 7 (2014) 79–81 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
79
Thoracoscopic removal of giant teratoma
Y Miyauchi et al.
Figure 1 Chest X-ray showing a giant mediastinal mass.
Figure 2 Chest CT scan showing an anterior mediastinal mass, 16 × 14 × 13 cm in size, with soft-tissue elements, fat, a large amount of fluid, and foci of calcification.
Figure 4 The mature cystic teratoma was composed cartilage, fat, intestine, hair and so on.
cystic components after dissection, the mass was opened outside the thoracic cavity. The fluid and atheromatous contents were removed with a conventional suction tube. Finally, we removed a solid part of the freed mass that had remained in the bag. A chest tube was inserted, and the tube was removed 7 days postoperatively. The operative time was 315 min and intraoperative blood loss was 315 mL, including some fluid and contents of the tumor. The patient recovered well and was discharged 9 days after her operation. Her levels of serum CA19-9 rapidly normalized. Histopathological examination confirmed a mature cystic teratoma with fat, intestine, hair and so on (Figure 4). The cytological examination of aspirated fluid showed no tumor cell, and biochemical testing showed an extremely high level of CA19-9 (340 000 U/mL). When last seen at her 36-monts follow-up, the patient was well and had no sign of recurrence.
Discussion
Figure 3 (a) A 50-mm lateral mini-thoracotomy and three trocars were placed. (b) The intraoperative view after the suction of tumor contents.
cautery incision with ultrasonic scalpel, and hemostasis were used to free the tumor from surrounding tissue. The whole procedure was performed with endoscopic instruments (Figure 3b). During the procedure, the phrenic nerve was kept intact. Because the mass was large, we collected it in a highstrength, disposable specimen bag made of polyurethane and pulled it through the mini-thoracotomy. To extract
80
VATS is a type of minimal-access surgery that is appropriate for pubescent girls, many of whom prefer this type of procedure for cosmetic reasons. When surgeons are confronted with a giant teratoma, conventional thoracotomy has usually been adapted to prevent tumor rupture and chemical pleural irritation from its spilled contents (4). However, according to recent reports VATS for extirpation of benign teraroma is feasible, regardless of tumor size (1–3). Despite this, removing a giant tumor through mini-incisions remains a challenge. One alternative is to use a piecemeal resection and the other is involves removing the tumor after an extraction of the cystic components. Though a piecemeal resection is commonly used in gastroenterological endoscopic resection, we believe a piecemeal resection is an inappropriate
Asian J Endosc Surg 7 (2014) 79–81 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Thoracoscopic removal of giant teratoma
Y Miyauchi et al.
method for removing a tumor from the thoracic cavity (5,6). In contrast, removing the tumor after an extraction of cystic components may be more suitable. This is a common method in ovarian dermoid cyst resection and intrathoracic cyst resection (7,8). In this case, extracting cystic components before and after dissection enabled us to thoracoscopically extirpate a giant teratoma that contained a large amount of fluid.
3.
4. 5. 6.
Acknowledgment The authors have no conflicts of interest to report. 7.
References 1. Dominique G, Ricard RR, Philippe G et al. Thoracoscopic resection of bulky intrathoracic benign lesions. Eur J Cardiothorac Surg 2007; 32: 848–851. 2. Nakano T, Endo S, Tsubochi H et al. Video-assisted thoracoscopic removal for mediastinal mature teratoma
8.
following extraction of cystic components. Kyobu Geka 2009; 62: 358–361. Cheng YJ, Huang MF, Tsai KB. Video-assisted thoracoscopic management of an anterior mediastinal teratoma: Report of a case. Surg Today 2000; 30: 1019–1021. Zisis C, Rontogianni D, Stratakos G et al. Teratoma occupying the left hemithorax. World J Surg Oncol 2005; 3: 76. Seewald S, Ang TL, Gotoda T et al. Total endoscopic resection of Barrett esophagus. Endoscopy 2008; 40: 1016–1020. Katsinelos P, Paroutoglou G, Beltsis A et al. Endoscopic mucosal resection of lateral spreading tumors of the colon using a novel solution. Surg Laparosc Endosc Percutan Tech 2006; 16: 73–77. Remorgida V, Magnasco A, Pizzorno V et al. Four year experience in laparoscopic dissection of intact ovarian dermoid cysts. J Am Coll Surg 1998; 187: 519–521. Samuels LE & Cassano A. Videoscopic resection of a giant symptomatic pericardial cyst: Case report. Heart Surg Forum 2005; 8: E83–E84.
Asian J Endosc Surg 7 (2014) 79–81 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
81
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Successful thoracoscopic removal of a giant teratoma following extraction of cystic conponents: A case report Yoshihiro Miyauchi, Hirochika Matsubara, Tsuyoshi Uchida, Hiroyasu Matsuoka, Tomofumi Ichihara & Masahiko Matsumoto Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
Keywords Mediastinal tumor; teratoma; thoracoscopic surgery Correspondence Yoshihiro Miyauchi, Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato Chuo, Yamanashi 409-3898, Japan. Tel: +81 55 273 9682 Fax: +81 55 273 6767 Email: [email protected]
Abstract Video-assisted thoracoscopic surgery is a type of minimal-access surgery. The nature of the surgery means that there are limitations on the size of a tumor that can be removed through an access incision. Herein, we report our experience removing a giant teratoma (16 × 14 × 13 cm in size) from the anterior mediastinum of a young girl. We employed video-assisted thoracoscopic surgery to remove the teratoma through a mini-thoracotomy following the extraction of the cystic components.
Received: 11 February 2013; revised 2 September 2013; accepted 5 September 2013 DOI:10.1111/ases.12067
Introduction Video-assisted thoracoscopic surgery is a type of minimalaccess surgery. The nature of the surgery means that there are limitations on the size of a tumor that can be removed through an access incision. Although VATS is widely applied in the treatment of various diseases, there have been only a few reports of successful VATS operations involving a giant mediastinal teratoma (1–3). Herein, we report our experience of employing VATS to extirpate a giant teratoma, 16 × 14 × 13 cm in size, from a patient’s anterior mediastinum.
Case Presentation A giant left thoracic mass was incidentally found in an asymptomatic 15-year-old girl during a routine chest film examination when entering high school (Figure 1). She was referred to our hospital for further treatment. Chest axial CT revealed an anterior mediastinal mass with softtissue elements, fat, a large amount of fluid, and foci of calcification, measuring 16 × 14 × 13 cm (Figure 2). The
serum markers of β-human chorionic gonadotropin and α-fetoprotein were within normal limits, but there was a high level of CA19-9 (120.9 U/mL). We diagnosed this tumor as a benign mature teratoma. The patient was a young girl and opted for a VATS approach for cosmetic reasons. VATS was performed with one-lung anesthesia. The patient was placed in the right lateral decubitus position with the left chest wall draped as for thoracotomy. A 50-mm mini-lateral thoracotomy was placed through the fifth intercostal space, and a 30° video telescope was carefully introduced to evaluate the possibility of performing VATS resection. To extract cystic components before dissection, we punctured the cystic part of the tumor, and the aspirated fluid was sent to cytology and biochemistry for analysis. When the cystic part was collapsed as much as possible, the puncture point was closed with a purse suture. Next, three other trocars were inserted: one 12-mm trocar through the seventh intercostal space in the mid-axillary line and two 5-mm trocars through the seventh and eighth intercostal spaces posterior to the scapular line to facilitate dissection (Figure 3a). The techniques of sharp and blunt dissection,
Asian J Endosc Surg 7 (2014) 79–81 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
79
Thoracoscopic removal of giant teratoma
Y Miyauchi et al.
Figure 1 Chest X-ray showing a giant mediastinal mass.
Figure 2 Chest CT scan showing an anterior mediastinal mass, 16 × 14 × 13 cm in size, with soft-tissue elements, fat, a large amount of fluid, and foci of calcification.
Figure 4 The mature cystic teratoma was composed cartilage, fat, intestine, hair and so on.
cystic components after dissection, the mass was opened outside the thoracic cavity. The fluid and atheromatous contents were removed with a conventional suction tube. Finally, we removed a solid part of the freed mass that had remained in the bag. A chest tube was inserted, and the tube was removed 7 days postoperatively. The operative time was 315 min and intraoperative blood loss was 315 mL, including some fluid and contents of the tumor. The patient recovered well and was discharged 9 days after her operation. Her levels of serum CA19-9 rapidly normalized. Histopathological examination confirmed a mature cystic teratoma with fat, intestine, hair and so on (Figure 4). The cytological examination of aspirated fluid showed no tumor cell, and biochemical testing showed an extremely high level of CA19-9 (340 000 U/mL). When last seen at her 36-monts follow-up, the patient was well and had no sign of recurrence.
Discussion
Figure 3 (a) A 50-mm lateral mini-thoracotomy and three trocars were placed. (b) The intraoperative view after the suction of tumor contents.
cautery incision with ultrasonic scalpel, and hemostasis were used to free the tumor from surrounding tissue. The whole procedure was performed with endoscopic instruments (Figure 3b). During the procedure, the phrenic nerve was kept intact. Because the mass was large, we collected it in a highstrength, disposable specimen bag made of polyurethane and pulled it through the mini-thoracotomy. To extract
80
VATS is a type of minimal-access surgery that is appropriate for pubescent girls, many of whom prefer this type of procedure for cosmetic reasons. When surgeons are confronted with a giant teratoma, conventional thoracotomy has usually been adapted to prevent tumor rupture and chemical pleural irritation from its spilled contents (4). However, according to recent reports VATS for extirpation of benign teraroma is feasible, regardless of tumor size (1–3). Despite this, removing a giant tumor through mini-incisions remains a challenge. One alternative is to use a piecemeal resection and the other is involves removing the tumor after an extraction of the cystic components. Though a piecemeal resection is commonly used in gastroenterological endoscopic resection, we believe a piecemeal resection is an inappropriate
Asian J Endosc Surg 7 (2014) 79–81 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Thoracoscopic removal of giant teratoma
Y Miyauchi et al.
method for removing a tumor from the thoracic cavity (5,6). In contrast, removing the tumor after an extraction of cystic components may be more suitable. This is a common method in ovarian dermoid cyst resection and intrathoracic cyst resection (7,8). In this case, extracting cystic components before and after dissection enabled us to thoracoscopically extirpate a giant teratoma that contained a large amount of fluid.
3.
4. 5. 6.
Acknowledgment The authors have no conflicts of interest to report. 7.
References 1. Dominique G, Ricard RR, Philippe G et al. Thoracoscopic resection of bulky intrathoracic benign lesions. Eur J Cardiothorac Surg 2007; 32: 848–851. 2. Nakano T, Endo S, Tsubochi H et al. Video-assisted thoracoscopic removal for mediastinal mature teratoma
8.
following extraction of cystic components. Kyobu Geka 2009; 62: 358–361. Cheng YJ, Huang MF, Tsai KB. Video-assisted thoracoscopic management of an anterior mediastinal teratoma: Report of a case. Surg Today 2000; 30: 1019–1021. Zisis C, Rontogianni D, Stratakos G et al. Teratoma occupying the left hemithorax. World J Surg Oncol 2005; 3: 76. Seewald S, Ang TL, Gotoda T et al. Total endoscopic resection of Barrett esophagus. Endoscopy 2008; 40: 1016–1020. Katsinelos P, Paroutoglou G, Beltsis A et al. Endoscopic mucosal resection of lateral spreading tumors of the colon using a novel solution. Surg Laparosc Endosc Percutan Tech 2006; 16: 73–77. Remorgida V, Magnasco A, Pizzorno V et al. Four year experience in laparoscopic dissection of intact ovarian dermoid cysts. J Am Coll Surg 1998; 187: 519–521. Samuels LE & Cassano A. Videoscopic resection of a giant symptomatic pericardial cyst: Case report. Heart Surg Forum 2005; 8: E83–E84.
Asian J Endosc Surg 7 (2014) 79–81 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
81
