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Resection of residual mediastinal germ cell masses with the Cavitron ultrasonic surgical aspirator
J THORAC CARDIOVASC SURG 1991;102:425-6
Resection of residual mediastinal germ cell masses with the Cavitron ultrasonic surgical aspirator Residual mediastinal masses after chemotherapy for germ cell tumors should be resected. Complete excision of bulky residual masses may sometimes be difficult because of problems with exposure in the region of the great vessels and important nerves. Two cases are presented in which the Cavitron ultrasonic surgical aspirator (VaUeylab Inc., Surgical Systems Division, Stamford, Conn.) facilitated excision of large masses after intensive chemotherapy. We found that the collapsed pseudocapsule remaining after aspiration of tumor mass allowed early improved exposure and safer dissection from neighboring vessels and neural structures. Complete excisions were accomplished and no viable tumor was found, so that the patients were spared the immediate need for further therapy. Both had uneventful recoveries.
James C. Harvey, MD,a Erik H. Fleischman, DO,b and Harry Applebaum, MD,a
LosAngeles. Calif.
Residual mediastinal masses after chemotherapy for germ cell tumors, primary or secondary, should be completely excised whenever possible. I, 2 Decisions regarding subsequent therapy depend on pathologicfindings. Some patients may be spared further toxic chemotherapy or irradiation when the residual mass contains no viable tumor and the patient's tumor markers are not elevated.v" Mediastinal masses are sometimes difficult to excise completely becauseof tumor bulk and closeproximitywith important vascularand neural structures. The Cavitronultrasonic surgical aspirator (CUSA) (ValleylabInc.,SurgicalSystemsDivision, Stamford, Conn.) has been employed for similar problems involving tumors elsewhere.' Recently we have found the CUSA to be particularlyusefulin the resectionof two residualmasses after chemotherapyfor germ cell tumors. Case reports CASE I. A 24-year-old man when first seen at the hospital complained of shortness of breath and fever. Chest x-ray examination revealed a large left anterior mediastinal mass. Computed tomography showed tumor in the subaortic nodes as well. Biopsyconfirmed this to be a seminoma. There was no concur-
From the Departments of Surgery" and Radiation Oncology," Southern California Permanente Medical Group, Los Angeles, Calif. Received for publication March 13, 1990. Accepted for publication Aug. 8, 1990. Address for reprints: James C. Harvey, MD, David B. Kriser Lung Cancer Center, Department of Surgery, Beth Israel Medical Center, New York, NY 10003.
12/1/24593
rent testicular mass. Tumor marker levels (,B-human chorionic gonadotropin, o-fetoprotein, lactate dehydrogenase, and carcinoembryonic antigen) were not elevated. He was treated with chemotherapy consisting of cis-platinum, VP-16 (etoposide), and bleomycin for four courses during a period of2 months, with a cumulative dose of bleomycin of 360 mg. Chest x-ray examination revealed partial shrinkage, with the persistence of a large residual mass (Fig. I). He was then referred for surgical management. During thoracotomy the mass was found to originate in the anterosuperior mediastinum, displacing and obscuring the main pulmonary artery and the superior pulmonary vein. The upper lobe was nearly totally compressed. The CUSA was then inserted into the tumor mass with purse-string sutures placed about the instrument to prevent tumor spill. After decompression it became easier to establish tissue planes and to completely dissect the tumor pseudocapsule from the lung and the underlying great vessels. Pericardium was taken with the specimen because phrenic nerve paralysis had been confirmed and the mass was directly adherent. A complete mediastinal node dissection was also performed. No residual seminoma was discovered in the pathologic specimen. The patient had an uneventful recovery and is well 4 months after the procedure without further therapy. CASE 2. A 32-year-old man came to the hospital with gastrointestinal complaints, and in the work-up a routine chest x-ray film disclosed a large paratracheal mass and multiple pulmonary nodules. An excision of one of the lung nodules revealed metastatic embryonal carcinoma with yolk sac elements. The «-fetoprotein level was markedly elevated. Physical examination of the testicles revealed no abnormalities but ultrasound examination demonstrated a 2 ern hypoechoic mass in the left testicle. Computed tomography confirmed the chest x-ray findings, as well as extensive retroperitoneal masses. He underwent four courses of cis-platinum, VP-16, and bleomycin during a period of 2 months. The pulmonary nodules disappeared. Mediastinal and retroperitoneal masses decreased in size, but
425
The Journal of Thoracic and Cardiovascular Surgery
426 Harvey, Fleischman, Applebaum
Fig. 1. Case 1. Preoperative chest x-ray film.
Fig. 2. Case 2. Preoperative chest x-ray film.
persisted. Tumor markers fell to normal ranges at completion of chemotherapy. Fig. 2 shows the postchemotherapy x-ray film. At thoracotomy an 8 em mass was found to be adherent to superior mediastinal structures. Purse-string sutures were placed on the tumor pseudocapsule to prevent postdecompression spillage, and the CUSA was then inserted. After decompression the pseudocapsule was carefully dissected from the vena cava, airway, and innominate artery. A complete mediastinal node dissection was also performed. Histopathologic study revealed no viable tumor. One month later a radical left orchiectomy and retroperitoneal node dissection likewise showed no viable tumor. The patient is currently without evidence of disease. Tumor markers remain within normal limits.
pseudocapsules, are spared," After aspiration of the soft inner portion of the mass, the surgeon is left with a collapsed pseudocapsule that may be grasped and retracted without tumor spillage, which allows safe dissection within tissue planes.
Discussion
3. Reynolds T, Yagoda A, Ungren D, Golby R. Chemotherapy of mediastinal germ cell tumors. Semin Oncol 1979;
The CUSA provides a speedy means of improving exposure for dissections of residual mediastinal masses from important vascular and neural structures. This leads to reduced blood loss, decreased operating time, and the better opportunity for a complete resection. The device combines continuous fragmentation, irrigation, and aspiration in one compact unit. Tissues with higher water content are selectively fragmented and aspirated while elastin-rich and collagen-rich tissues, such as vessels and
REFERENCES 1. Martini N, Golby RH, Hajdi SJ, et al. Primary mediastinal germ cell tumors. Cancer 1974;33:763-9. 2. Economou J, Trump D, Holmes EC, Eggleston J. Management of primary germ cell tumors of the mediastinum. J
THORAC CARDIOVASC SURG 1982;83:643-9. 6:113-5. 4. Kay PH, Wells FC, Goldstrau P. A multidisciplinary approach to primary non-seminomatous germ cell tumors of the mediastinum. Ann Thorac Surg 1987;44:578-82. 5. Addonizio JC, Chondury MS. Cavitron in urologic surgery. Urol Clin North Am 1986;13:445-54. 6. Loo R, Applebaum H, Takasugi J, Hurwitz R. Resection of advanced stage neuroblastoma with the Cavitron Ultrasonic Surgical Aspirator. J Pediatr Surg 1988;23:1135-8.
Resection of residual mediastinal germ cell masses with the Cavitron ultrasonic surgical aspirator Residual mediastinal masses after chemotherapy for germ cell tumors should be resected. Complete excision of bulky residual masses may sometimes be difficult because of problems with exposure in the region of the great vessels and important nerves. Two cases are presented in which the Cavitron ultrasonic surgical aspirator (VaUeylab Inc., Surgical Systems Division, Stamford, Conn.) facilitated excision of large masses after intensive chemotherapy. We found that the collapsed pseudocapsule remaining after aspiration of tumor mass allowed early improved exposure and safer dissection from neighboring vessels and neural structures. Complete excisions were accomplished and no viable tumor was found, so that the patients were spared the immediate need for further therapy. Both had uneventful recoveries.
James C. Harvey, MD,a Erik H. Fleischman, DO,b and Harry Applebaum, MD,a
LosAngeles. Calif.
Residual mediastinal masses after chemotherapy for germ cell tumors, primary or secondary, should be completely excised whenever possible. I, 2 Decisions regarding subsequent therapy depend on pathologicfindings. Some patients may be spared further toxic chemotherapy or irradiation when the residual mass contains no viable tumor and the patient's tumor markers are not elevated.v" Mediastinal masses are sometimes difficult to excise completely becauseof tumor bulk and closeproximitywith important vascularand neural structures. The Cavitronultrasonic surgical aspirator (CUSA) (ValleylabInc.,SurgicalSystemsDivision, Stamford, Conn.) has been employed for similar problems involving tumors elsewhere.' Recently we have found the CUSA to be particularlyusefulin the resectionof two residualmasses after chemotherapyfor germ cell tumors. Case reports CASE I. A 24-year-old man when first seen at the hospital complained of shortness of breath and fever. Chest x-ray examination revealed a large left anterior mediastinal mass. Computed tomography showed tumor in the subaortic nodes as well. Biopsyconfirmed this to be a seminoma. There was no concur-
From the Departments of Surgery" and Radiation Oncology," Southern California Permanente Medical Group, Los Angeles, Calif. Received for publication March 13, 1990. Accepted for publication Aug. 8, 1990. Address for reprints: James C. Harvey, MD, David B. Kriser Lung Cancer Center, Department of Surgery, Beth Israel Medical Center, New York, NY 10003.
12/1/24593
rent testicular mass. Tumor marker levels (,B-human chorionic gonadotropin, o-fetoprotein, lactate dehydrogenase, and carcinoembryonic antigen) were not elevated. He was treated with chemotherapy consisting of cis-platinum, VP-16 (etoposide), and bleomycin for four courses during a period of2 months, with a cumulative dose of bleomycin of 360 mg. Chest x-ray examination revealed partial shrinkage, with the persistence of a large residual mass (Fig. I). He was then referred for surgical management. During thoracotomy the mass was found to originate in the anterosuperior mediastinum, displacing and obscuring the main pulmonary artery and the superior pulmonary vein. The upper lobe was nearly totally compressed. The CUSA was then inserted into the tumor mass with purse-string sutures placed about the instrument to prevent tumor spill. After decompression it became easier to establish tissue planes and to completely dissect the tumor pseudocapsule from the lung and the underlying great vessels. Pericardium was taken with the specimen because phrenic nerve paralysis had been confirmed and the mass was directly adherent. A complete mediastinal node dissection was also performed. No residual seminoma was discovered in the pathologic specimen. The patient had an uneventful recovery and is well 4 months after the procedure without further therapy. CASE 2. A 32-year-old man came to the hospital with gastrointestinal complaints, and in the work-up a routine chest x-ray film disclosed a large paratracheal mass and multiple pulmonary nodules. An excision of one of the lung nodules revealed metastatic embryonal carcinoma with yolk sac elements. The «-fetoprotein level was markedly elevated. Physical examination of the testicles revealed no abnormalities but ultrasound examination demonstrated a 2 ern hypoechoic mass in the left testicle. Computed tomography confirmed the chest x-ray findings, as well as extensive retroperitoneal masses. He underwent four courses of cis-platinum, VP-16, and bleomycin during a period of 2 months. The pulmonary nodules disappeared. Mediastinal and retroperitoneal masses decreased in size, but
425
The Journal of Thoracic and Cardiovascular Surgery
426 Harvey, Fleischman, Applebaum
Fig. 1. Case 1. Preoperative chest x-ray film.
Fig. 2. Case 2. Preoperative chest x-ray film.
persisted. Tumor markers fell to normal ranges at completion of chemotherapy. Fig. 2 shows the postchemotherapy x-ray film. At thoracotomy an 8 em mass was found to be adherent to superior mediastinal structures. Purse-string sutures were placed on the tumor pseudocapsule to prevent postdecompression spillage, and the CUSA was then inserted. After decompression the pseudocapsule was carefully dissected from the vena cava, airway, and innominate artery. A complete mediastinal node dissection was also performed. Histopathologic study revealed no viable tumor. One month later a radical left orchiectomy and retroperitoneal node dissection likewise showed no viable tumor. The patient is currently without evidence of disease. Tumor markers remain within normal limits.
pseudocapsules, are spared," After aspiration of the soft inner portion of the mass, the surgeon is left with a collapsed pseudocapsule that may be grasped and retracted without tumor spillage, which allows safe dissection within tissue planes.
Discussion
3. Reynolds T, Yagoda A, Ungren D, Golby R. Chemotherapy of mediastinal germ cell tumors. Semin Oncol 1979;
The CUSA provides a speedy means of improving exposure for dissections of residual mediastinal masses from important vascular and neural structures. This leads to reduced blood loss, decreased operating time, and the better opportunity for a complete resection. The device combines continuous fragmentation, irrigation, and aspiration in one compact unit. Tissues with higher water content are selectively fragmented and aspirated while elastin-rich and collagen-rich tissues, such as vessels and
REFERENCES 1. Martini N, Golby RH, Hajdi SJ, et al. Primary mediastinal germ cell tumors. Cancer 1974;33:763-9. 2. Economou J, Trump D, Holmes EC, Eggleston J. Management of primary germ cell tumors of the mediastinum. J
THORAC CARDIOVASC SURG 1982;83:643-9. 6:113-5. 4. Kay PH, Wells FC, Goldstrau P. A multidisciplinary approach to primary non-seminomatous germ cell tumors of the mediastinum. Ann Thorac Surg 1987;44:578-82. 5. Addonizio JC, Chondury MS. Cavitron in urologic surgery. Urol Clin North Am 1986;13:445-54. 6. Loo R, Applebaum H, Takasugi J, Hurwitz R. Resection of advanced stage neuroblastoma with the Cavitron Ultrasonic Surgical Aspirator. J Pediatr Surg 1988;23:1135-8.