Pleuropneumonectomy for a large thymoma with multiple pleural dissemination using median sternotomy followed by posterolateral thoracotomy
© Shintani et al. 2015
Received: 1 March 2015
Accepted: 14 August 2015
Published: 2 September 2015
We present 2 cases of a large thymoma with invasion to the hilum of the lung and pleural dissemination. Case 1: a 47-year-old woman was diagnosed with a type B3 thymoma with abundant left pleural effusion and multiple pleural masses, Masaoka stage IVa. A radical resection was planned after chemical pleurodesis and systemic chemotherapy. The left main pulmonary artery and left upper and inferior veins were dissected and resected in the pericardium, while the left main bronchus was cut behind the pericardium through a median sternotomy. Next, the median incision was closed and a left posterolateral thoracotomy was made, thus allowing the pleuropneumonectomy to be safely performed. Case 2: a 47-year-old woman was diagnosed with a type B3 thymoma with lymph node swelling and multiple pleural masses, indicating Masaoka stage IVb. Following induction chemotherapy, a thymothymectomy combined with a right pleuropneumonectomy was performed under a median sternotomy followed by a right posterolateral thoracotomy. The left brachiocephalic vein (BCV) was reconstructed with a ringed polytetrafluoroethylene (PTFE) graft, followed by resection of the right BCV. Next, the right main pulmonary artery and right upper and inferior veins were resected in the pericardium, and the right main bronchus was cut behind the pericardium, followed by reconstruction of the right BCV. Finally, the median incision was closed and a right posterolateral thoracotomy was made, thus allowing performance of a safe pleuropneumonectomy. The median sternotomy allowed safe dissection of pulmonary vessels surrounding the hilum of the lung and, in combination with a posterolateral thoracotomy, was required for performing a pleuropneumonectomy in patients with a huge thymoma with pleural dissemination.
A Masaoka stage IV thymoma is defined as a tumor with pleura or pericardial dissemination, while standard treatment for affected patients has not been established . Here, we report two patients with a stage IV thymoma successfully treated with chemotherapy followed by a radical resection with a pleuropneumonectomy through anterior approach combined with posterolateral thoracotomy.
Optimal treatment for a Masaoka stage IVa thymoma with pleural dissemination has not been established. Even in patients with a locally advanced and initially unresectable thymoma, treatments with induction chemotherapy followed by resection have resulted in good overall survival rates [2, 3]. Kondo et al. also reported that thymomas have a moderate response rate to chemotherapy or radiotherapy; thus, multimodality therapy involving surgery, chemotherapy, and radiotherapy appears to increase the rate of complete resection and survival in the advanced thymomas . Some have reported that surgical debulking is acceptable for an invasive thymoma, because of the potential for a favorable outcome . We agree with that concept and prefer conservative treatment with resection of visible disseminated nodules by a partial pleurectomy for patients with a stage IVa thymoma. Whereas macroscopic total resection of tumors appears to be a promising prognostic factor in Masaoka stage IVa thymomas, it was impossible to conserve the lung because of tumor invasion to the hilum especially to the main pulmonary artery in both cases; thus, we considered that a pleuropneumonectomy was a feasible approach in these present cases. Several reports of a pleuropneumonectomy procedure for stage IVa thymoma have demonstrated it to be technically feasible and showed short-term good results [6, 7]. A pleuropneumonectomy would seem to be warranted for a small number of highly selected patients with advanced or recurrent thymoma extensively involving the pleural space. Thymoma is a malignancy with a generally good prognosis ; thus, further evaluation of the long-term outcomes is needed to determine the indications for pleuropneumonectomy for patients with advanced thymoma.
Generally, the intrathoracic vessels and main bronchus are dissected using a thoracotomy during a pleuropneumonectomy for patients with a malignant mesothelioma. However, in that procedure for patients with a thymoma, pulmonary vessels cannot be dissected because of tumor invasion to the hilum of the lung. Furthermore, a median sternotomy or posterolateral thoracotomy alone is not adequate for pleural exploration. Although the combination of a partial median sternotomy with an anterior thoracotomy (hemi-clamshell) facilitates exposure of the pleural cavity, this approach is not adequate for pleuropneumonectomy. Thus, we dissected pulmonary vessels in the pericardium using a median incision in the present cases. Yang et al. reported that a median sternotomy was added for en bloc total thymectomy immediately after resecting the lungs and pleura via a posterolateral thoracotomy . We prefer to secure pulmonary great vessels before pulmonary resection to avoid massive bleeding from lung parenchyma; thus, we first dissected pulmonary vessels in the pericardium using a median incision. In addition, the main bronchus was easily excised and cut within the main bronchus about 2 cm below the carina through a median sternotomy. A short mainstem bronchial stump is optimal when performing pneumonectomy and pleuropneumonectomy; thus, this approach may be useful for these patients. Thereafter, the median incision was closed and a posterolateral thoracotomy at the fifth intercostal incision was made following a position change from a spine to lateral decubitus position, thus allowing the pleuropneumonectomy to be safely performed. Our approach may result in a safe procedure for resection of a large thymoma invading the hilum of the lung with pleural dissemination. Our second case developed cardiac herniation and underwent a re-thoracotomy for repair. Defects in the pericardium are larger with a thymothymectomy combined with a pleuropneumonectomy using median and posterolateral incisions as compared to a pleuropneumonectomy using a posterolateral incision; thus, pericardial defects should be carefully repaired with a strong material.
We treated two patients with a large thymoma with invasion to the hilum of the lung and pleural dissemination. The median sternotomy allowed safe dissection of pulmonary vessels surrounding the hilum of the lung and, in combination with a posterolateral thoracotomy, was required for performing a pleuropneumonectomy in patients with a huge thymoma with pleural dissemination.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
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- Fabre D, Fadel E, Mussot S, Mercier O, Petkova B, Besse B, et al. Long-term outcome of pleuropneumonectomy for Masaoka stage IVa thymoma. Eur J Cardiothorac Surg. 2011;39(5):e133–8. doi:10.1016/j.ejcts.2010.12.064.PubMedView ArticleGoogle Scholar
- Kim ES, Putnam JB, Komaki R, Walsh GL, Ro JY, Shin HJ, et al. Phase II study of a multidisciplinary approach with induction chemotherapy, followed by surgical resection, radiation therapy, and consolidation chemotherapy for unresectable malignant thymomas: final report. Lung Cancer. 2004;44(3):369–79. doi:10.1016/j.lungcan.2003.12.010.PubMedView ArticleGoogle Scholar
- Ishikawa Y, Matsuguma H, Nakahara R, Suzuki H, Ui A, Kondo T, et al. Multimodality therapy for patients with invasive thymoma disseminated into the pleural cavity: the potential role of extrapleural pneumonectomy. Ann Thorac Surg. 2009;88(3):952–7. doi:10.1016/j.athoracsur.2009.05.019.PubMedView ArticleGoogle Scholar
- Kondo K. Therapy for thymic epithelial tumors. Gen Thorac Cardiovasc Surg. 2014;62(8):468–74. doi:10.1007/s11748-014-0420-z.PubMedView ArticleGoogle Scholar
- Attaran S, Acharya M, Anderson JR, Punjabi PP. Does surgical debulking for advanced stages of thymoma improve survival? Interact Cardiovasc Thorac Surg. 2012;15(3):494–7. doi:10.1093/icvts/ivs263.PubMedView ArticlePubMed CentralGoogle Scholar
- Wright CD. Pleuropneumonectomy for the treatment of Masaoka stage IVA thymoma. Ann Thorac Surg. 2006;82(4):1234–9. doi:10.1016/j.athoracsur.2006.05.028.PubMedView ArticleGoogle Scholar
- Okuda K, Yano M, Yoshino I, Okumura M, Higashiyama M, Suzuki K, et al. Thymoma patients with pleural dissemination: nationwide retrospective study of 136 cases in Japan. Ann Thorac Surg. 2014;97(5):1743–8. doi:10.1016/j.athoracsur.2014.01.042.PubMedView ArticleGoogle Scholar
- Tagawa T, Yamasaki N, Tsuchiya T, Miyazaki T, Morino S, Akamine S, et al. Thoracoscopic versus transsternal resection for early stage thymoma: long-term outcomes. Surg Today. 2014;44(12):2275–80. doi:10.1007/s00595-013-0829-5.PubMedView ArticleGoogle Scholar
- Yang HC, Yoon YS, Kim HK, Choi YS, Kim K, Shim YM, et al. En bloc extended total thymectomy and extrapleural pneumonectomy in Masaoka stage IVA thymomas. J Cardiothorac Surg. 2011;6:28. doi:10.1186/1749-8090-6-28.PubMedView ArticlePubMed CentralGoogle Scholar