- Email: [email protected]
Anomalous Pulmonary Venous Return of the Left Upper Lobe in a Donor Lung
Ann Thorac Surg 2015;99:2199–202
CASE REPORT OLLAND ET AL PAPVR IN A DONOR LUNG
References 1. Cole WH. Efforts to explain spontaneous regression of cancer. J Surg Oncol 1981;17:201–9. 2. B egin LR, Eskandari J, Joncas J, Panasci L. Epstein-Barr virus related lymphoepithelioma-like carcinoma of lung. J Surg Oncol 1987;36:280–3. 3. Liang Y, Wang L, Zhu Y, et al. Primary pulmonary lymphoepithelioma-like carcinoma: fifty-two patients with long-term follow-up. Cancer 2012;118:4748–58. 4. Everson TC, Cole WH. Spontaneous regression of cancer. Philadelphia, PA: WB Saunders; 1966:3–10. 5. Kappauf H, Gallmeier WM, Wunsch PH, et al. Complete spontaneous remission in a patient with metastatic non-small-cell lung cancer. Case report, review of the literature, and discussion of possible biological pathways involved. Ann Oncol 1997;8:1031–9. 6. Superduto P, Vaezy A, Bridgman A, Wilkie L. Spontaneous regression of squamous cell lung carcinoma with adrenal metastasis. Chest 1988;94:887–9. 7. Xu W, Tamim H, Shapiro S, Stang MR, Collet JP. Use of antidepressants and risk of colorectal cancer: a nested casecontrol study. Lancet Oncol 2006;7:301–8. 8. Inoue M, Okazaki T, Kitazono T, Mizushima M, Omata M, Ozaki S. Regulation of antigen-specific CTL and Th1 cell activation through 5-hydroxytryptamine 2A receptor. Int Immunopharmacol 2011;11:67–73.
Anomalous Pulmonary Venous Return of the Left Upper Lobe in a Donor Lung
ˇ
Groupe de Transplantation Pulmonaire, Hopitaux Universitaires de Strasbourg, Strasbourg; EA 7293 Stress Vasculaire et Tissulaire en Transplantation, Fédération de Médecine Translationnelle de Strasbourg, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg; and Pole de Radiologie, Hopitaux Universitaires de Strasbourg, Strasbourg, France ˇ
ˇ
We report a case of partial anomalous pulmonary venous return from the left upper lobe in a donor lung discovered during lung transplantation. The upper lobe vein could be implanted successfully into the donor atrial cuff to restore physiologic venous drainage. The abnormality was retrospectively identified on the donor’s chest computed tomographic scan. Cardiac magnetic resonance imaging performed in the recipient 6 months after transplantation demonstrated patent left pulmonary venous drainage. This is the third reported case of partial anomalous pulmonary venous return in a donor lung, but the first description of direct ex vivo suture into the donor cuff. (Ann Thorac Surg 2015;99:2199–202) Ó 2015 by The Society of Thoracic Surgeons
Accepted for publication July 30, 2014.
artial anomalous pulmonary venous return (PAPVR) is a rare congenital condition. According to autopsy series, its incidence ranges from 0.4% to 0.7% in a general population [1–3]. Isolated PAPVR can be asymptomatic in the adult and may be encountered incidentally during lung transplantation in the recipient and in the donor [4, 5]. PAPVR in a donor lung requires restoration of physiologic venous drainage, to avoid lung infarction or massive bleeding following allograft implantation and release of clamps [5]. We report a case in which the donor presented with PAPVR of the left upper lobe draining into the innominate vein. A 50-year-old man with end-stage emphysema was listed for lung transplantation. A brain-dead donor suitable for bilateral lung transplantation was identified and concurrent heart and lung graft retrieval was uneventful. We used the standard technique of sequential bilateral lung transplantation through separate anterolateral thoracotomies without sternal division. During the ex vivo preparation of the left lung allograft, we noticed the stump of an isolated vessel originating from the upper lobe and consistent with a venous structure separate from the atrial donor cuff. An antegrade flush with Perfadex (Vitrolife AB, Kungsbacka, Sweden) through the pulmonary artery determined outflow of fluid from the lower lobe vein but also from the aberrant vessel. We concluded that PAPVR was present. As a consequence, physiologic venous drainage of the upper lobe had to be restored before implanting the allograft. The atrial cuff was large enough to accept a small fenestration into which the vessel could be sutured with a running 5/0 polypropylene suture (Fig 1). The vessel was long enough to avoid tension or kinking. Repeated antegrade flush with Perfadex showed outflow from the upper lobe vein into the donor cuff without any leakage from the suture; testing with a retrograde flush showed outflow from the pulmonary artery. The left lung was subsequently implanted into the recipient following the standard technique. Postoperatively, the chest radiography showed a mild infiltrate of the upper left lobe compatible with reperfusion edema. Blood gas samples showed consistently a PaO2/FiO2 > 300, and the chest radiograph gradually improved to normalize on the third postoperative day. We reviewed retrospectively the donor’s chest computed tomographic (CT) scan to identify the venous drainage of the left upper lobe. Tridimensional reconstruction showed a left upper pulmonary vein draining into the innominate vein (Fig 2). The pulmonary veins were assessed by dynamic cardiac magnetic resonance imaging (MRI). MRI showed a patent venous drainage of the left upper lobe into the left atrium. There was no stenosis on the reimplanted pulmonary vein or on the left atrium suture (Fig 3).
Comment
Address correspondence to Dr Olland, Groupe de Transplantation Pulmonaire, Hopitaux Universitaires de Strasbourg, 1 place de l’Hopital, 67000 Strasbourg, France; e-mail: [email protected]. ˇ
ˇ
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
P
PAPVR has been reported in both the donor and the recipient during lung transplantation [4, 5]. This is the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.085
FEATURE ARTICLES
Anne Olland, MD, MS, J er emie Reeb, MD, Pierre-Emmanuel Falcoz, MD, PhD, Julien Garnon, MD, Philippe Germain, MD, Nicola Santelmo, MD, Romain Kessler, MD, PhD, and Gilbert Massard, MD, PhD
2199
2200
CASE REPORT OLLAND ET AL PAPVR IN A DONOR LUNG
FEATURE ARTICLES
Fig 1. Implantation of partial anomalous pulmonary venous return into the left atrial cuff. (A) Schematic overview of the initial condition of venous drainage of the left lung graft. The upper pulmonary vein is free, and the lower pulmonary vein is normally connected to the atrial cuff. An incision was made into the atrial cuff following the dotted line. (B) Intraoperative photograph during direct suture of the left upper vein into the atrial cuff. A running suture of 5/ 0 polypropylene was used. The atrial cuffed is exposed using several polypropylene stay sutures. (C) Schematic overview of the final result of reconstruction on the inside of the atrial cuff. (D) Photograph of the outside aspect of the left upper vein directly sutured into the atrial cuff. The outer aspect of the suture shows no tension and no stricture on the final calibre of the pulmonary vein. (E) Schematic overview of the final result during allograft implantation into the recipient.
Ann Thorac Surg 2015;99:2199–202
Ann Thorac Surg 2015;99:2199–202
third case of PAPVR in the donor reported during the past decade, demonstrating the rarity of this condition. Nevertheless, one should be aware how to deal with this congenital abnormality. Schmidt and colleagues [5] have described two techniques: using a conduit of autologous pericardium or using an iliac vein graft as a bridge between the anomalous pulmonary vein and the normal pulmonary drainage. To our knowledge, we are the first to report a direct suture into the donor cuff.
2201
Though not mandatory, commonly the superior vena cava (SVC) is clamped during lung and heart retrieval. As PAPVR drains into the upper body systemic veins, hydrostatic pressure can rise during pulmonary artery flush and create edema or endothelial lesions in the PAPVR territory. In the present case, the SVC was clamped, which could explain the infiltrate of the upper left lobe on chest radiography in the recipient on postoperative day 1. Ideally, PAPVR should be diagnosed before starting the surgical procedure for heart and lung retrieval. Avoiding ligation of the SVC could be discussed between cardiac and thoracic surgeon in order to vent the PAPVR and the normal pulmonary veins until the whole preservation fluid has been completely administered. Retrospective review of the donor’s chest CT scan identified the PAPVR. However, in our routine practice of lung procurement, the complete set of images is seldom available at the time of lung proposal. The physician accepting the organ can only rely on the available part of CT slides and the interpretation made by other physicians; therefore, identifying PAPVR before acceptance is nearly impossible. This case also underlines the need for early verification of pulmonary venous drainage during lung transplantation. We regret that we did not perform transesophageal echocardiography in our patient during the surgical procedure. Postoperatively, neither transthoracic nor transesophageal echocardiography could provide reliable information on pulmonary venous drainage. Only cardiac MRI with dynamic imaging demonstrated the patency of the left upper pulmonary vein with adequate drainage. Successful direct implantation of PAPVR into a sufficiently large donor atrial cuff is feasible before implanting the allograft. A narrow atrial cuff can be enlarged with donor pericardium to accept direct implantation, or alternatively interposition of an autologous vein graft (azygos or iliac vein from the donor) between the PAPVR and the recipient’s left atrial appendage can be used. We stress the need for intraoperative assessment of pulmonary vein patency during transplantation, especially in case of PAPVR or other types of pulmonary vein repair.
Fig 3. Cardiac magnetic resonance imaging performed in the recipient to assess patency and function of the left upper venous drainage into the left atrium. The arrow designates the anomalous pulmonary vein.
FEATURE ARTICLES
Fig 2. Three-dimensional reconstruction of the donor’s chest computed tomographic scan, showing the left upper pulmonary vein originating from the left upper lobe and draining into the innominate vein.
CASE REPORT OLLAND ET AL PAPVR IN A DONOR LUNG
2202
CASE REPORT ALI MOHAMMAD ET AL LOCAL RESECTION OF ESOPHAGEAL CANCER
References 1. Healey JE. An anatomic survey of anomalous pulmonary veins: their clinical significance. J Thoracic Surg 1952;23:433. 2. Kiseleva IP, Malsagov GU. Differential diagnosis of anomalous pulmonary venous return: a clinical-roentgenological study. Cor Vasa 1984;26:140–6. 3. Senocak F, Ozme S, Bilgic A. Partial anomalous pulmonary venous return-evaluation of 51 cases. Jpn Heart J 1994;35: 43–50. 4. Belli EV, Landolfo K, Thomas M, Odell J. Partial anomalous pulmonary venous return in a lung transplant recipient. Ann Thorac Surg 2013;95:1104–6. 5. Schmidt F, McGiffin DC, Zorn G, Young KR, Weill D, Kirklin JK. Management of congenital abnormalities of the donor lung. Ann Thorac Surg 2001;72:935–7.
Long-Term Survival After Local Resection of Cervical Esophageal Cancer Farah Hanif Ali Mohammad, MD, Pauline Go, MD, Tamer Ghanem, MD, Robert Stachler, MD, and Zane Hammoud, MD
FEATURE ARTICLES
Department of General Surgery, Division of Thoracic Surgery, and Department of Otolaryngology, Henry Ford Hospital, Detroit, Michigan
Squamous cell carcinoma of the esophagus may be seen in patients with history of head and neck malignancies. Anatomic factors may limit management options. We present a case of second primary early cervical esophageal squamous cell cancer managed by local resection with reconstruction using a radial forearm flap. (Ann Thorac Surg 2015;99:2202–3) Ó 2015 by The Society of Thoracic Surgeons he concept of “field cancerization” has been used to explain the association of several cancers in the aerodigestive tract. It is defined as exposure of the epithelium of the head and neck, lung, and esophagus to common carcinogenic agents that leads to various carcinomas in these regions [1]. Tobacco and alcohol use has been implicated as major common risk factors especially in esophageal and hypopharyngeal cancers [1, 2]. The prevalence of second primary malignancies has been reported to be 5% to 36% [3]. After therapy, long-term follow-up of patients with head and neck cancers has resulted in more frequent detection of synchronous or metachronous second primary carcinomas of the esophagus [4]. When detected early, such cancers are potentially curable and have an excellent prognosis [5]. Esophagectomy has been the mainstay of definitive treatment. Owing to the high morbidity and mortality associated with esophagectomy, however, other less invasive procedures such as
T
Accepted for publication Aug 8, 2014. Address correspondence to Dr Hammoud, Henry Ford Hospital, Division of Thoracic Surgery, 2799 W Grand Blvd, Detroit, MI 48202; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;99:2202–3
photocoagulation, laser irradiation, photodynamic therapy, and endoscopic mucosal and segmental resection have been described for superficial esophageal cancer [6]. In addition, various options have been reported for reconstruction of the cervical esophagus, including pedicled cutaneous, musculocutaneous, and visceral transposition flaps [7]. We report a case of second primary early cervical esophageal squamous cell cancer managed by local resection with reconstruction using a radial forearm flap. The patient is a 51-year-old man with a history of tobacco and alcohol use. In 2004, he was diagnosed with T4 N2c squamous cell carcinoma of the base of tongue and was treated with definitive chemoradiation therapy. On subsequent surveillance in December 2010, he was noted to have a nodule in the proximal cervical esophagus. Endoscopic biopsy confirmed squamous cell carcinoma. Staging positron emission tomography showed no evidence of distant disease. Endoscopic ultrasonography revealed a 1.3 cm ulcerated mass 18 cm to 20 cm from the incisors, involving one third of the esophageal circumference and into the submucosa. Therefore, he was not deemed a candidate for endoscopic mucosal resection. Given the location of the mass in an area of previous heavy radiation, additional irradiation was not recommended. Esophagectomy was also not recommended as it would entail a high neck anastomosis in a previously irradiated neck and was considered too aggressive an option given the relatively localized nature of the cancer. Therefore, we devised a plan to perform a local full-thickness resection. The patient was taken to the operating room where upper endoscopy confirmed the location of the mass. The esophagoscope was left in the esophagus to provide guidance to the location of the mass. A standard left-side neck incision was performed, and the esophagus was identified and encircled. With the esophagoscope in place, the lesion was located using a 25G needle. A myotomy was performed, and the esophageal lumen was entered. Working from within, full-thickness resection measuring 5 cm 3 cm, incorporating one third to one half of the esophageal circumference, was performed. Negative margins were confirmed by frozen section analysis. Reconstruction of the esophageal defect then proceeded using a radial forearm free flap based on the left radial artery. A split-thickness skin graft and tracheostomy were also performed. There were no intraoperative complications. The patient’s postoperative course was remarkable for a minor non–ST-segment myocardial infarction. A barium swallow showed no evidence of leak but did show evidence of aspiration. He was discharged to home on postoperative day 7 after removal of his tracheostomy. He took nothing orally, and nutrition was provided parenterally. Pathology examination revealed a moderately differentiated invasive squamous cell cancer involving the mucosa and submucosa (T1b) and negative level 4 and level 5 lymph nodes. All margins were negative. Owing to continued evidence of aspiration on subsequent studies, a gastrostomy tube was placed. An oral diet was resumed 9 weeks postoperatively and was tolerated well thereafter. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.050
CASE REPORT OLLAND ET AL PAPVR IN A DONOR LUNG
References 1. Cole WH. Efforts to explain spontaneous regression of cancer. J Surg Oncol 1981;17:201–9. 2. B egin LR, Eskandari J, Joncas J, Panasci L. Epstein-Barr virus related lymphoepithelioma-like carcinoma of lung. J Surg Oncol 1987;36:280–3. 3. Liang Y, Wang L, Zhu Y, et al. Primary pulmonary lymphoepithelioma-like carcinoma: fifty-two patients with long-term follow-up. Cancer 2012;118:4748–58. 4. Everson TC, Cole WH. Spontaneous regression of cancer. Philadelphia, PA: WB Saunders; 1966:3–10. 5. Kappauf H, Gallmeier WM, Wunsch PH, et al. Complete spontaneous remission in a patient with metastatic non-small-cell lung cancer. Case report, review of the literature, and discussion of possible biological pathways involved. Ann Oncol 1997;8:1031–9. 6. Superduto P, Vaezy A, Bridgman A, Wilkie L. Spontaneous regression of squamous cell lung carcinoma with adrenal metastasis. Chest 1988;94:887–9. 7. Xu W, Tamim H, Shapiro S, Stang MR, Collet JP. Use of antidepressants and risk of colorectal cancer: a nested casecontrol study. Lancet Oncol 2006;7:301–8. 8. Inoue M, Okazaki T, Kitazono T, Mizushima M, Omata M, Ozaki S. Regulation of antigen-specific CTL and Th1 cell activation through 5-hydroxytryptamine 2A receptor. Int Immunopharmacol 2011;11:67–73.
Anomalous Pulmonary Venous Return of the Left Upper Lobe in a Donor Lung
ˇ
Groupe de Transplantation Pulmonaire, Hopitaux Universitaires de Strasbourg, Strasbourg; EA 7293 Stress Vasculaire et Tissulaire en Transplantation, Fédération de Médecine Translationnelle de Strasbourg, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg; and Pole de Radiologie, Hopitaux Universitaires de Strasbourg, Strasbourg, France ˇ
ˇ
We report a case of partial anomalous pulmonary venous return from the left upper lobe in a donor lung discovered during lung transplantation. The upper lobe vein could be implanted successfully into the donor atrial cuff to restore physiologic venous drainage. The abnormality was retrospectively identified on the donor’s chest computed tomographic scan. Cardiac magnetic resonance imaging performed in the recipient 6 months after transplantation demonstrated patent left pulmonary venous drainage. This is the third reported case of partial anomalous pulmonary venous return in a donor lung, but the first description of direct ex vivo suture into the donor cuff. (Ann Thorac Surg 2015;99:2199–202) Ó 2015 by The Society of Thoracic Surgeons
Accepted for publication July 30, 2014.
artial anomalous pulmonary venous return (PAPVR) is a rare congenital condition. According to autopsy series, its incidence ranges from 0.4% to 0.7% in a general population [1–3]. Isolated PAPVR can be asymptomatic in the adult and may be encountered incidentally during lung transplantation in the recipient and in the donor [4, 5]. PAPVR in a donor lung requires restoration of physiologic venous drainage, to avoid lung infarction or massive bleeding following allograft implantation and release of clamps [5]. We report a case in which the donor presented with PAPVR of the left upper lobe draining into the innominate vein. A 50-year-old man with end-stage emphysema was listed for lung transplantation. A brain-dead donor suitable for bilateral lung transplantation was identified and concurrent heart and lung graft retrieval was uneventful. We used the standard technique of sequential bilateral lung transplantation through separate anterolateral thoracotomies without sternal division. During the ex vivo preparation of the left lung allograft, we noticed the stump of an isolated vessel originating from the upper lobe and consistent with a venous structure separate from the atrial donor cuff. An antegrade flush with Perfadex (Vitrolife AB, Kungsbacka, Sweden) through the pulmonary artery determined outflow of fluid from the lower lobe vein but also from the aberrant vessel. We concluded that PAPVR was present. As a consequence, physiologic venous drainage of the upper lobe had to be restored before implanting the allograft. The atrial cuff was large enough to accept a small fenestration into which the vessel could be sutured with a running 5/0 polypropylene suture (Fig 1). The vessel was long enough to avoid tension or kinking. Repeated antegrade flush with Perfadex showed outflow from the upper lobe vein into the donor cuff without any leakage from the suture; testing with a retrograde flush showed outflow from the pulmonary artery. The left lung was subsequently implanted into the recipient following the standard technique. Postoperatively, the chest radiography showed a mild infiltrate of the upper left lobe compatible with reperfusion edema. Blood gas samples showed consistently a PaO2/FiO2 > 300, and the chest radiograph gradually improved to normalize on the third postoperative day. We reviewed retrospectively the donor’s chest computed tomographic (CT) scan to identify the venous drainage of the left upper lobe. Tridimensional reconstruction showed a left upper pulmonary vein draining into the innominate vein (Fig 2). The pulmonary veins were assessed by dynamic cardiac magnetic resonance imaging (MRI). MRI showed a patent venous drainage of the left upper lobe into the left atrium. There was no stenosis on the reimplanted pulmonary vein or on the left atrium suture (Fig 3).
Comment
Address correspondence to Dr Olland, Groupe de Transplantation Pulmonaire, Hopitaux Universitaires de Strasbourg, 1 place de l’Hopital, 67000 Strasbourg, France; e-mail: [email protected]. ˇ
ˇ
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
P
PAPVR has been reported in both the donor and the recipient during lung transplantation [4, 5]. This is the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.085
FEATURE ARTICLES
Anne Olland, MD, MS, J er emie Reeb, MD, Pierre-Emmanuel Falcoz, MD, PhD, Julien Garnon, MD, Philippe Germain, MD, Nicola Santelmo, MD, Romain Kessler, MD, PhD, and Gilbert Massard, MD, PhD
2199
2200
CASE REPORT OLLAND ET AL PAPVR IN A DONOR LUNG
FEATURE ARTICLES
Fig 1. Implantation of partial anomalous pulmonary venous return into the left atrial cuff. (A) Schematic overview of the initial condition of venous drainage of the left lung graft. The upper pulmonary vein is free, and the lower pulmonary vein is normally connected to the atrial cuff. An incision was made into the atrial cuff following the dotted line. (B) Intraoperative photograph during direct suture of the left upper vein into the atrial cuff. A running suture of 5/ 0 polypropylene was used. The atrial cuffed is exposed using several polypropylene stay sutures. (C) Schematic overview of the final result of reconstruction on the inside of the atrial cuff. (D) Photograph of the outside aspect of the left upper vein directly sutured into the atrial cuff. The outer aspect of the suture shows no tension and no stricture on the final calibre of the pulmonary vein. (E) Schematic overview of the final result during allograft implantation into the recipient.
Ann Thorac Surg 2015;99:2199–202
Ann Thorac Surg 2015;99:2199–202
third case of PAPVR in the donor reported during the past decade, demonstrating the rarity of this condition. Nevertheless, one should be aware how to deal with this congenital abnormality. Schmidt and colleagues [5] have described two techniques: using a conduit of autologous pericardium or using an iliac vein graft as a bridge between the anomalous pulmonary vein and the normal pulmonary drainage. To our knowledge, we are the first to report a direct suture into the donor cuff.
2201
Though not mandatory, commonly the superior vena cava (SVC) is clamped during lung and heart retrieval. As PAPVR drains into the upper body systemic veins, hydrostatic pressure can rise during pulmonary artery flush and create edema or endothelial lesions in the PAPVR territory. In the present case, the SVC was clamped, which could explain the infiltrate of the upper left lobe on chest radiography in the recipient on postoperative day 1. Ideally, PAPVR should be diagnosed before starting the surgical procedure for heart and lung retrieval. Avoiding ligation of the SVC could be discussed between cardiac and thoracic surgeon in order to vent the PAPVR and the normal pulmonary veins until the whole preservation fluid has been completely administered. Retrospective review of the donor’s chest CT scan identified the PAPVR. However, in our routine practice of lung procurement, the complete set of images is seldom available at the time of lung proposal. The physician accepting the organ can only rely on the available part of CT slides and the interpretation made by other physicians; therefore, identifying PAPVR before acceptance is nearly impossible. This case also underlines the need for early verification of pulmonary venous drainage during lung transplantation. We regret that we did not perform transesophageal echocardiography in our patient during the surgical procedure. Postoperatively, neither transthoracic nor transesophageal echocardiography could provide reliable information on pulmonary venous drainage. Only cardiac MRI with dynamic imaging demonstrated the patency of the left upper pulmonary vein with adequate drainage. Successful direct implantation of PAPVR into a sufficiently large donor atrial cuff is feasible before implanting the allograft. A narrow atrial cuff can be enlarged with donor pericardium to accept direct implantation, or alternatively interposition of an autologous vein graft (azygos or iliac vein from the donor) between the PAPVR and the recipient’s left atrial appendage can be used. We stress the need for intraoperative assessment of pulmonary vein patency during transplantation, especially in case of PAPVR or other types of pulmonary vein repair.
Fig 3. Cardiac magnetic resonance imaging performed in the recipient to assess patency and function of the left upper venous drainage into the left atrium. The arrow designates the anomalous pulmonary vein.
FEATURE ARTICLES
Fig 2. Three-dimensional reconstruction of the donor’s chest computed tomographic scan, showing the left upper pulmonary vein originating from the left upper lobe and draining into the innominate vein.
CASE REPORT OLLAND ET AL PAPVR IN A DONOR LUNG
2202
CASE REPORT ALI MOHAMMAD ET AL LOCAL RESECTION OF ESOPHAGEAL CANCER
References 1. Healey JE. An anatomic survey of anomalous pulmonary veins: their clinical significance. J Thoracic Surg 1952;23:433. 2. Kiseleva IP, Malsagov GU. Differential diagnosis of anomalous pulmonary venous return: a clinical-roentgenological study. Cor Vasa 1984;26:140–6. 3. Senocak F, Ozme S, Bilgic A. Partial anomalous pulmonary venous return-evaluation of 51 cases. Jpn Heart J 1994;35: 43–50. 4. Belli EV, Landolfo K, Thomas M, Odell J. Partial anomalous pulmonary venous return in a lung transplant recipient. Ann Thorac Surg 2013;95:1104–6. 5. Schmidt F, McGiffin DC, Zorn G, Young KR, Weill D, Kirklin JK. Management of congenital abnormalities of the donor lung. Ann Thorac Surg 2001;72:935–7.
Long-Term Survival After Local Resection of Cervical Esophageal Cancer Farah Hanif Ali Mohammad, MD, Pauline Go, MD, Tamer Ghanem, MD, Robert Stachler, MD, and Zane Hammoud, MD
FEATURE ARTICLES
Department of General Surgery, Division of Thoracic Surgery, and Department of Otolaryngology, Henry Ford Hospital, Detroit, Michigan
Squamous cell carcinoma of the esophagus may be seen in patients with history of head and neck malignancies. Anatomic factors may limit management options. We present a case of second primary early cervical esophageal squamous cell cancer managed by local resection with reconstruction using a radial forearm flap. (Ann Thorac Surg 2015;99:2202–3) Ó 2015 by The Society of Thoracic Surgeons he concept of “field cancerization” has been used to explain the association of several cancers in the aerodigestive tract. It is defined as exposure of the epithelium of the head and neck, lung, and esophagus to common carcinogenic agents that leads to various carcinomas in these regions [1]. Tobacco and alcohol use has been implicated as major common risk factors especially in esophageal and hypopharyngeal cancers [1, 2]. The prevalence of second primary malignancies has been reported to be 5% to 36% [3]. After therapy, long-term follow-up of patients with head and neck cancers has resulted in more frequent detection of synchronous or metachronous second primary carcinomas of the esophagus [4]. When detected early, such cancers are potentially curable and have an excellent prognosis [5]. Esophagectomy has been the mainstay of definitive treatment. Owing to the high morbidity and mortality associated with esophagectomy, however, other less invasive procedures such as
T
Accepted for publication Aug 8, 2014. Address correspondence to Dr Hammoud, Henry Ford Hospital, Division of Thoracic Surgery, 2799 W Grand Blvd, Detroit, MI 48202; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;99:2202–3
photocoagulation, laser irradiation, photodynamic therapy, and endoscopic mucosal and segmental resection have been described for superficial esophageal cancer [6]. In addition, various options have been reported for reconstruction of the cervical esophagus, including pedicled cutaneous, musculocutaneous, and visceral transposition flaps [7]. We report a case of second primary early cervical esophageal squamous cell cancer managed by local resection with reconstruction using a radial forearm flap. The patient is a 51-year-old man with a history of tobacco and alcohol use. In 2004, he was diagnosed with T4 N2c squamous cell carcinoma of the base of tongue and was treated with definitive chemoradiation therapy. On subsequent surveillance in December 2010, he was noted to have a nodule in the proximal cervical esophagus. Endoscopic biopsy confirmed squamous cell carcinoma. Staging positron emission tomography showed no evidence of distant disease. Endoscopic ultrasonography revealed a 1.3 cm ulcerated mass 18 cm to 20 cm from the incisors, involving one third of the esophageal circumference and into the submucosa. Therefore, he was not deemed a candidate for endoscopic mucosal resection. Given the location of the mass in an area of previous heavy radiation, additional irradiation was not recommended. Esophagectomy was also not recommended as it would entail a high neck anastomosis in a previously irradiated neck and was considered too aggressive an option given the relatively localized nature of the cancer. Therefore, we devised a plan to perform a local full-thickness resection. The patient was taken to the operating room where upper endoscopy confirmed the location of the mass. The esophagoscope was left in the esophagus to provide guidance to the location of the mass. A standard left-side neck incision was performed, and the esophagus was identified and encircled. With the esophagoscope in place, the lesion was located using a 25G needle. A myotomy was performed, and the esophageal lumen was entered. Working from within, full-thickness resection measuring 5 cm 3 cm, incorporating one third to one half of the esophageal circumference, was performed. Negative margins were confirmed by frozen section analysis. Reconstruction of the esophageal defect then proceeded using a radial forearm free flap based on the left radial artery. A split-thickness skin graft and tracheostomy were also performed. There were no intraoperative complications. The patient’s postoperative course was remarkable for a minor non–ST-segment myocardial infarction. A barium swallow showed no evidence of leak but did show evidence of aspiration. He was discharged to home on postoperative day 7 after removal of his tracheostomy. He took nothing orally, and nutrition was provided parenterally. Pathology examination revealed a moderately differentiated invasive squamous cell cancer involving the mucosa and submucosa (T1b) and negative level 4 and level 5 lymph nodes. All margins were negative. Owing to continued evidence of aspiration on subsequent studies, a gastrostomy tube was placed. An oral diet was resumed 9 weeks postoperatively and was tolerated well thereafter. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.050