metastasis also has involvement of other sites such as brain, liver, bone, or adrenal gland and is unlikely to live six months. It is not surprising that undifferentiated carcinomas predominate in this population; even the squamous cell neoplasms were described as poorly differentiated. One cannot rely on the histologic appearance, however, to distinguish between primary and secondary lesion in the skin (eg, squamous cell) or to determine organ of origin if secondary (eg, adenocarcinoma). An interesting finding heretofore unreported (to our knowledge) is the near-universal location of the primary lung cancer in the upper lobes in our patients. Cancer cells destined for the skin likely travel via the bloodstream; perhaps the particular milieu in the upper lobes, the result of anatomic and gravitational differences affecting blood and lymphatic Bow, favors such hematogenous metastasis. Related evidence can be found in the literature on lung cancer with brain metastasis; in the series of Torre et al, 5 20 of 21 such patients had upper lobe cancers. Biopsy specimens must be taken from all new skin lesions, particularly in individuals who smoke or who already have a history of lung cancer. REFERENCES
1 Rosen T. Cutaneous metastases. Med Clio North Am 1980; 64:885-900
2 Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatoll972; 105:862-68 3 Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer 1972; 29:1298-1307 4 Thiers BH. Dermatologic manifestations of internal cancer. CA 1986; 36:130-47
5 Torre M, Quaini E, Chiesa G, et al. Synchronous brain metastasis from lung cancer. J Thorac Cardiovasc Surg 1988; 95:994-97
Tension Pneumothorax Complicating Small-caliber lUbe Insertion*
Chest
Stevhen E. Malnini, M.D.;t and Frank E. johnson, M.D.:j:
We report two patients who developed tension pneumothorax as a result of improper attachment of a Heimlich valve to a chest tube. (Cheat 1990; 91:159-60)
S
mall-caliber chest tubes are generally safe and effective in the treatment of pneumothoraces.'" Complications such as malposition, kinking, occlusion, and inadvertent visceral injury are well known. We now report two cases of tension pneumothorax which occurred in patients with properly placed small-caliber chest tubes. In each case, this was due to improper use of the one-way Butter valve which accompanies the thoracostomy kit. • *From the Departments of Internal Medicine and Surgery, St. Louis University Medical Center, St. Louis. tPulmonary Fellow and Clinical Instructor. :!:Associate Professor of Surgery. Reprint requests: Dr. Mainini, Division of Eblmonology, 3635 VISta Avenue at Grand Blvd, St. Louis 63110-0250
CASE REPORTS
CASE I A 33-yeaN>Id man was admitted for multiple trauma sustained in a motor vehicle accident. He developed a left pneumothorax, which was successfully treated using a small-caliber chest tube and controlled-pressure suction. Twenty-four hours later, a Heimlich valve was substituted for the suction apparatus. This valve was accidentally dislodged, inverted, and replaced. The patient promptly became short of breath. Chest roentgenogram at that time revealed a large tension pneumothorax, which was treated by removal of the small-caliber chest tube and placement of a standard chest-tube. The patient had an uncomplicated course thereafter. CASE2 A 61-YeaN>Id man developed a left pneumothorax during computed tomography-guided drainage of a subdiaphragmatic abscess. A small-caliber chest tube was placed and the lung remained expanded while the catheter was maintained on controlled suction. The suction was discontinued one day later, and a Heimlich valve was attached. The lung remained expanded until the valve was inadvertently disconnected and inverted by the patient, who quickly developed respiratory distress. Chest roentgenogram revealed a tension pneumothorax. At this time, the incorrect valve configuration was noted and corrected, with rapid evacuation of the pneumothorax and recovery of the patient. DISCUSSION
Pneumothorax is a common problem which is usually easily treated. Because of safety, patient acceptance, and ease of placement, the small-caliber chest tube provides a good alternative to the standard chest tube. At our institution, both cost the same. The one-way valve described by Heimlich5 is an effective substitute for suction when correctly used. However, our cases reveal that this valve as currently designed is vulnerable to error at the connection with the chest tube. The Heimlich apparatus is a rubber, Buttering valve enclosed by a hard transparent plastic case which has tapered, ridged ends. These ends are identical except for color. On the transparent casing is an arrow (Fig 1A) indicating the desired direction of air Bow. Simple but easily overlooked instructions are also supplied on the device. Incorrect assembly (Fig 1B) renders this apparatus hazardous, as indicated in these cases in which tension pneumothoraces developed after the valve was inadvertently attached backwards to the chest tube. This allowed air to move into the chest during inspiration. The one-way valve prevented its out8ow during expiration resulting in the rapid development of a tension pneumothorax. Thus, the pneumothorax is due not only from the possible continued leakage of air from the lung, but more importantly from air entering through the chest tube. The actual incidence of accidental inversion is unknown. One can predict that the incidence may rise since small-caliber chest tubes are becoming more popular (at our institution 65 were used in 1987 to 1988, compared to 19 the year before). Precautions can be taken to avoid this dangerous problem. Secure taping of the valve to the catheter is important. The patient and hospital personnel should also be aware of the possible danger of improper placement of the valve. We have found in-service nursing and housestaff instruction valuable here. The valve also suffers from a vulnerable configuration, which could be CHEST I 97 I 3 I MARCH. 1990
759
FrcuHE 1A (top). Heimlich Hutter valve properly attached to a chest tube . 1B (bottom). ln('()rrect attachment.
remedied with improved product
desi~n.
REFERENCES
Conces DJ. T:trver RD. Gray WC, Pearl'y EA. Treatment of pneumothoral'cs utilizin~ smalll'aliber l'hest tubes. Chest 1988; 94:55-57
2 Cannon \VB, Mark JBD. Jamplis RW Pneumothorax: a therapeutic update . Am J Sur~ 1981; 142:26-29 3 Sar~ent EN , Turner AF. Emer~enl'y treatmt>nt of pneumothorax. Am J Roent~enolo~y 1970; 109:531-35 e nt of sponta4 Bernstt>in A, Waqamddin M, Shah l\1 . Mana~em neous pneumothorax usin~ a Heimlich Hutter valve. Thorax 1973; 28:386-89 of tht> pleural cavity. Chest 1968; 5 lleimlich HJ. Valve draina~e 53:282-H/
Cardiac Pheochromocytoma Originating in the Interatrial Septum Hongpyo H. Lee. M.D. ;* William/. Brnmer. /II.D.;t lndubala 'krdhan. M.D.j: Joel Hytltt, M .D.;§ and Marta Terlecki, M.D.II *Chief. Cardiolo!,'Y Section, Kaiser Permanente Harbor City Medical Center, Harbor Citv, CA. tCardiac Sur~ical Depa'rtment. Kaiser Permanente Los An~eles Medical Center, Los An~eles. CA; Assistant Clinical Professor, Thoracic Surgery, UCLA. Medical Cenj:Cardiolo!,•y Fellow, Kaiser Permanente Los An~eles ter, L1s An~eles, CA. §Family Practice Department. Kaist>r Permanente Harbor City Medical Center, Harbor Citv, CA. IIEndocrinology Section, Kaiser Permanente Harbor City Medical Center, Harbor Citv, CA. Reprint requests: Dr_ Lee. c/o Ms. lbtricia l.LlWl' , Education and Research , Harbor City Kaiser Medical Center. Harbor City, CA 90710
760
A 36-year-old woman with classic clinical and biochemical features of pheochromocytoma was found to have a cardiac pheochromocytoma originating in the interatrial septum and a significant obstructive lesion in the left anterior descending coronary artery. Complete resection of the pheochromocytoma and an aortosaphenous vein graft were performed. This is the first reported case of successful resection of an interatrial pheochromocytoma. (Chest 1990; 97:760-62) MRI =magnetic resonance imaging; 131 1-MffiG = 13 1 1meta iodobenzylguanidine; VMA = vanillylmandelic acid
C
ardiac pheochromocytoma is extremely rare . Only 14 cases have been reported .'.., The patient reported here was found to have a cardiac pheochromocytoma involving the interatrial septum. She underwent surgical resection with a successful outcome. CASE REPORT
A 31-year-old married hlack woman was seen at the Harhor City Kaiser medical clinic for the first time in May of 1982 li1r treatment of chronic hypertension. She had a history of hypertension since 1973. She descrihed frequent palpitations, excessive diaphoresis and light-headedness. Blood pressure with the patient in the supine position was 220/140 and it dropped to oono rnm H~ when the patient stood up. The patient was admitted to the hospital with a strong suspicion of pheochromocytoma. lhtal 24-h urinary VMA was e levated at 26 mg (normal. 0-7 mg). An adrenal angiogram and selective venous samplings were suggestive of a possihle tumor in the left adrenal gland. She underwent an exploratory laparotomy. The left adrenal gland was resected, hut no pheochromocytoma was found. She was discharged on a regimen of phenoxyhenzamine and atenolol with controlled blood pressure. Several months later she developed overt diahetes mellitus and was treated with an oral hypoglycemic agent. In March of 1985, a routine chest x-ray film revealed an unusually prominent right atrial border but the patient declined further Cardiac Pheochromocytoma
(Lee et a/)
1 Rosen T. Cutaneous metastases. Med Clio North Am 1980; 64:885-900
2 Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatoll972; 105:862-68 3 Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer 1972; 29:1298-1307 4 Thiers BH. Dermatologic manifestations of internal cancer. CA 1986; 36:130-47
5 Torre M, Quaini E, Chiesa G, et al. Synchronous brain metastasis from lung cancer. J Thorac Cardiovasc Surg 1988; 95:994-97
Tension Pneumothorax Complicating Small-caliber lUbe Insertion*
Chest
Stevhen E. Malnini, M.D.;t and Frank E. johnson, M.D.:j:
We report two patients who developed tension pneumothorax as a result of improper attachment of a Heimlich valve to a chest tube. (Cheat 1990; 91:159-60)
S
mall-caliber chest tubes are generally safe and effective in the treatment of pneumothoraces.'" Complications such as malposition, kinking, occlusion, and inadvertent visceral injury are well known. We now report two cases of tension pneumothorax which occurred in patients with properly placed small-caliber chest tubes. In each case, this was due to improper use of the one-way Butter valve which accompanies the thoracostomy kit. • *From the Departments of Internal Medicine and Surgery, St. Louis University Medical Center, St. Louis. tPulmonary Fellow and Clinical Instructor. :!:Associate Professor of Surgery. Reprint requests: Dr. Mainini, Division of Eblmonology, 3635 VISta Avenue at Grand Blvd, St. Louis 63110-0250
CASE REPORTS
CASE I A 33-yeaN>Id man was admitted for multiple trauma sustained in a motor vehicle accident. He developed a left pneumothorax, which was successfully treated using a small-caliber chest tube and controlled-pressure suction. Twenty-four hours later, a Heimlich valve was substituted for the suction apparatus. This valve was accidentally dislodged, inverted, and replaced. The patient promptly became short of breath. Chest roentgenogram at that time revealed a large tension pneumothorax, which was treated by removal of the small-caliber chest tube and placement of a standard chest-tube. The patient had an uncomplicated course thereafter. CASE2 A 61-YeaN>Id man developed a left pneumothorax during computed tomography-guided drainage of a subdiaphragmatic abscess. A small-caliber chest tube was placed and the lung remained expanded while the catheter was maintained on controlled suction. The suction was discontinued one day later, and a Heimlich valve was attached. The lung remained expanded until the valve was inadvertently disconnected and inverted by the patient, who quickly developed respiratory distress. Chest roentgenogram revealed a tension pneumothorax. At this time, the incorrect valve configuration was noted and corrected, with rapid evacuation of the pneumothorax and recovery of the patient. DISCUSSION
Pneumothorax is a common problem which is usually easily treated. Because of safety, patient acceptance, and ease of placement, the small-caliber chest tube provides a good alternative to the standard chest tube. At our institution, both cost the same. The one-way valve described by Heimlich5 is an effective substitute for suction when correctly used. However, our cases reveal that this valve as currently designed is vulnerable to error at the connection with the chest tube. The Heimlich apparatus is a rubber, Buttering valve enclosed by a hard transparent plastic case which has tapered, ridged ends. These ends are identical except for color. On the transparent casing is an arrow (Fig 1A) indicating the desired direction of air Bow. Simple but easily overlooked instructions are also supplied on the device. Incorrect assembly (Fig 1B) renders this apparatus hazardous, as indicated in these cases in which tension pneumothoraces developed after the valve was inadvertently attached backwards to the chest tube. This allowed air to move into the chest during inspiration. The one-way valve prevented its out8ow during expiration resulting in the rapid development of a tension pneumothorax. Thus, the pneumothorax is due not only from the possible continued leakage of air from the lung, but more importantly from air entering through the chest tube. The actual incidence of accidental inversion is unknown. One can predict that the incidence may rise since small-caliber chest tubes are becoming more popular (at our institution 65 were used in 1987 to 1988, compared to 19 the year before). Precautions can be taken to avoid this dangerous problem. Secure taping of the valve to the catheter is important. The patient and hospital personnel should also be aware of the possible danger of improper placement of the valve. We have found in-service nursing and housestaff instruction valuable here. The valve also suffers from a vulnerable configuration, which could be CHEST I 97 I 3 I MARCH. 1990
759
FrcuHE 1A (top). Heimlich Hutter valve properly attached to a chest tube . 1B (bottom). ln('()rrect attachment.
remedied with improved product
desi~n.
REFERENCES
Conces DJ. T:trver RD. Gray WC, Pearl'y EA. Treatment of pneumothoral'cs utilizin~ smalll'aliber l'hest tubes. Chest 1988; 94:55-57
2 Cannon \VB, Mark JBD. Jamplis RW Pneumothorax: a therapeutic update . Am J Sur~ 1981; 142:26-29 3 Sar~ent EN , Turner AF. Emer~enl'y treatmt>nt of pneumothorax. Am J Roent~enolo~y 1970; 109:531-35 e nt of sponta4 Bernstt>in A, Waqamddin M, Shah l\1 . Mana~em neous pneumothorax usin~ a Heimlich Hutter valve. Thorax 1973; 28:386-89 of tht> pleural cavity. Chest 1968; 5 lleimlich HJ. Valve draina~e 53:282-H/
Cardiac Pheochromocytoma Originating in the Interatrial Septum Hongpyo H. Lee. M.D. ;* William/. Brnmer. /II.D.;t lndubala 'krdhan. M.D.j: Joel Hytltt, M .D.;§ and Marta Terlecki, M.D.II *Chief. Cardiolo!,'Y Section, Kaiser Permanente Harbor City Medical Center, Harbor Citv, CA. tCardiac Sur~ical Depa'rtment. Kaiser Permanente Los An~eles Medical Center, Los An~eles. CA; Assistant Clinical Professor, Thoracic Surgery, UCLA. Medical Cenj:Cardiolo!,•y Fellow, Kaiser Permanente Los An~eles ter, L1s An~eles, CA. §Family Practice Department. Kaist>r Permanente Harbor City Medical Center, Harbor Citv, CA. IIEndocrinology Section, Kaiser Permanente Harbor City Medical Center, Harbor Citv, CA. Reprint requests: Dr_ Lee. c/o Ms. lbtricia l.LlWl' , Education and Research , Harbor City Kaiser Medical Center. Harbor City, CA 90710
760
A 36-year-old woman with classic clinical and biochemical features of pheochromocytoma was found to have a cardiac pheochromocytoma originating in the interatrial septum and a significant obstructive lesion in the left anterior descending coronary artery. Complete resection of the pheochromocytoma and an aortosaphenous vein graft were performed. This is the first reported case of successful resection of an interatrial pheochromocytoma. (Chest 1990; 97:760-62) MRI =magnetic resonance imaging; 131 1-MffiG = 13 1 1meta iodobenzylguanidine; VMA = vanillylmandelic acid
C
ardiac pheochromocytoma is extremely rare . Only 14 cases have been reported .'.., The patient reported here was found to have a cardiac pheochromocytoma involving the interatrial septum. She underwent surgical resection with a successful outcome. CASE REPORT
A 31-year-old married hlack woman was seen at the Harhor City Kaiser medical clinic for the first time in May of 1982 li1r treatment of chronic hypertension. She had a history of hypertension since 1973. She descrihed frequent palpitations, excessive diaphoresis and light-headedness. Blood pressure with the patient in the supine position was 220/140 and it dropped to oono rnm H~ when the patient stood up. The patient was admitted to the hospital with a strong suspicion of pheochromocytoma. lhtal 24-h urinary VMA was e levated at 26 mg (normal. 0-7 mg). An adrenal angiogram and selective venous samplings were suggestive of a possihle tumor in the left adrenal gland. She underwent an exploratory laparotomy. The left adrenal gland was resected, hut no pheochromocytoma was found. She was discharged on a regimen of phenoxyhenzamine and atenolol with controlled blood pressure. Several months later she developed overt diahetes mellitus and was treated with an oral hypoglycemic agent. In March of 1985, a routine chest x-ray film revealed an unusually prominent right atrial border but the patient declined further Cardiac Pheochromocytoma
(Lee et a/)
