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Blindness: A Rare and Serious Complication After Extensive Mediastinal Resection
CASE REPORTS
Blindness: A Rare and Serious Complication After Extensive Mediastinal Resection
swelling, edema of the head and upper limbs, and dyspnea. We describe a case in which superior vena cava syndrome resulted in blindness.
George P. Akkersdijk, MD, and Albertus N. van Geel, MD, PhD
A 20-year-old man had extragonadal manifestations of a nonseminomatous germ cell tumor in the right upper mediastinum. He had shortness of breath, an inspiratory stridor, and difficulty and pain when swallowing. His weight loss was 9 kilograms. Primary treatment with a four-course regimen of paclitaxel, bleomycin sulfate, and etoposide phosphate resulted in only a partial response. The ␣-fetoprotein level initially was 32,435 g/L, then dropped to 260 g/L (reference, 0 –9 g/L), where it remained. A computer tomography showed a large residual mediastinal tumor was present (Fig 1). According to our protocol, a decision was made to resect the mass. Optimal exposure of the anterior mediastinum was achieved by means of a median sternotomy in combination with a sixth intercostal anterolateral thoracotomy. The thymus, subclavian vein, right lung, and pericardium were encaged in the tumor. A radical resection was performed that included the right lung and what was thought to be the subclavian vein. Overnight, superior vena cava syndrome developed, with edema of the head. Fundoscopy showed edema of the right and left optic discs. Phlebographic evaluation revealed that a portion of the superior vena cava rather than the subclavian vein had been resected. A second operation was performed on the first postoperative day. The greater saphenous vein was harvested and opened along its long axis, then reconstructed radially to form a conduit 1 cm in diameter that was used to reconstruct the superior vena cava.
Departments of Vascular Surgery and Surgical Oncology, Erasmus Medical Center, Daniel den Hoed Cancer Center, Rotterdam, the Netherlands
We describe the case of a patient in whom blindness developed as a result of superior vena cava syndrome after resection of a primary mediastinal nonseminomatous germ cell tumor. (Ann Thorac Surg 2008;85:1426 –7) © 2008 by The Society of Thoracic Surgeons
P
FEATURE ARTICLES
erformance of extensive surgical procedures in the upper mediastinum may be challenging, especially in instances when tumors disturb the anatomic relationship. Serious complications reported include prolonged ventilation (2%), repeated bleeding (2%–10%), phrenic nerve damage (2%), mediastinitis (1%), vena cava (graft) occlusion (1%), pulmonary artery thrombosis (1%), and atrial fibrillation (1%) [1, 2]. The perioperative mortality rate is 0% to 6% [1, 2]. Superior vena cava syndrome is another possible complication, with symptoms of venous Accepted for publication Oct 2, 2007. Address correspondence to Dr van Geel, Department of Surgical Oncology, Erasmus Medical Center, Daniel den Hoed Cancer Center, PO Box 5201, Rotterdam, 3008 AE, the Netherlands; e-mail: a.n.vangeel@ erasmusmc.nl.
Fig 1. Panel A–D shows a computed tomography scan performed after chemotherapy, representing transections from a lower to an upper position in the thorax respectively. A large residual mediastinal nonseminomatous germ cell tumor is predominantly seen at the levels shown in panels B and C.
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.10.011
Ann Thorac Surg 2008;85:1427–9
Comment Blindness has been extensively described in idiopathic cranial hypertension [3, 4]. There is a clear theoretical basis for increased intracranial pressure caused by an outflow obstruction due to superior vena cava syndrome. The increased venous pressure causes a disturbed hydrostatic pressure gradient over the arachnoid villi, disturbing cerebral spinal fluid exchange and leading to increased intracranial pressure [5]. To our knowledge, blindness has not previously been described as a result of acute superior vena cava syndrome after mediastinal surgery. When considering surgical procedures, the clinician must be aware of this complication. Signs of developing superior vena cava syndrome are alarming. Diagnostic procedures are urgent and should be given the highest priority. In cases of superior vena cava syndrome, reoperation should be performed immediately.
References 1. Bacha EA, Chapelier AR, Macchiarini P, Fadel E, Dartevelle PG. Surgery for invasive mediastinal tumors. Ann Thorac Surg 1998;66:234 –9. 2. Park BJ, Bachetta M, Bains MS, et al. Surgical management of malignancies invading the heart or great vessels. Ann Tharac Surg 2004;78:1024 –30. 3. Krajewski KJ, Gurwood AS. Idiopathic intracranial hypertension: pseudotumor cerebri. Optometry 2002;73:546 –52. 4. Purvin V, Kawasaki A. Neuro-ophthalmic emergencies for the neurologist. Neurologist 2005;11:195–233. 5. Kollar CD, Johnston IH, Sholler GF. Communicating hydrocephalus secondary to a cardiac tumor compressing the superior vena cava. Childs Nerv Syst 2001;17:117–20. © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
1427
Radical Excision of Thymic Adenocarcinoma with Selective Cerebral Perfusion Masakazu Yoshioka, MD, Osamu Ichiguchi, MD, Touitsu Hirayama, MD, Toshiharu Sassa, MD, and Takihiro Kamio, MD Departments of Thoracic Surgery, Cardiovascular Surgery, and Pathology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
Most cases of thymic carcinoma have some invasion to neighboring organs when diagnosed, and it is generally difficult to completely remove. We adopted selective cerebral perfusion as a cerebral protection and successfully performed resection of a thymic adenocarcinoma that involved the superior vena cava, left brachiocephalic vein, right brachiocephalic artery and vein, and left common carotid artery in a 47-year-old woman. Even if multiple great vessels were involved by mediastinal malignant tumor, complete resection with selective cerebral perfusion could be safely performed. (Ann Thorac Surg 2008;85:1427–9) © 2008 by The Society of Thoracic Surgeons
I
n most cases of mediastinal malignant tumor, tumors often involve neighboring organs (ie, the great vessels, lungs, pericardium, nerves, or trachea) [1, 2]. Thymic carcinoma is believed to have a dismal prognosis as compared with that of thymoma because most of these tumors have some invasion to neighboring organs when diagnosed [3]. Although some invasion occurs, acceptable prognosis will be obtained by surgery if complete resection is carried out [1]. This is the first report of successful excision with selective cerebral perfusion of a thymic carcinoma that involved great vessels. A 47-year-old woman was identified as having a mediastinal abnormal shadow in chest computed tomography in a health screening. She had been suffering from an abnormal sensation in her throat during swallowing for the past 3 months. She did not have concomitant myasthenia gravis. She was referred to our hospital for examination and treatment in November 2006. A contrast medium-enhanced computed tomographic scan showed an anterior upper mediastinal tumor with a diameter of approximately 7 ⫻ 5 cm that had invaded and involved the superior vena cava (SVC), right brachiocephalic artery and vein, left brachiocephalic vein, and left common carotid artery (LCCA) (Fig 1). The tumor was faintly enhanced by contrast medium. In the fluorodeoxyglucose positron
Accepted for publication Oct 23, 2007. Address correspondence to Dr Yoshioka, Department of Thoracic Surgery, Saiseikai Kumamoto Hospital, Chikami 5-3-1, Kumamoto, 861-4193, Japan; e-mail: [email protected].
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.10.075
FEATURE ARTICLES
There was thrombosis of the conduit on the fourth postoperative day, which was treated with embolectomy by opening the subclavian vein and right atrium using a Fogarty catheter (Edwards Lifesciences, Irvine, CA). The superior vena cava syndrome resolved completely. After recovery from mechanical ventilation and severe infectious complications 1 month after the operation, blindness was noted. Multiple computed tomography scans and a magnetic resonance image showed no cerebral disorder. There was patent venous flow from the brain. Fundoscopy performed after several months revealed atrophic optic discs but without the venous swelling that is seen with superior vena cava syndrome. The patient has been followed up for 9 years. The ␣-fetoprotein level is low, and there are no signs of tumor recurrence. In a medicolegal proceeding, extensive ophthalmologic and neurologic examination revealed no hidden cause for the blindness and superior vena cava syndrome was deemed responsible.
CASE REPORT YOSHIOKA ET AL RADICAL EXCISION OF THYMIC ADENOCARCINOMA
Blindness: A Rare and Serious Complication After Extensive Mediastinal Resection
swelling, edema of the head and upper limbs, and dyspnea. We describe a case in which superior vena cava syndrome resulted in blindness.
George P. Akkersdijk, MD, and Albertus N. van Geel, MD, PhD
A 20-year-old man had extragonadal manifestations of a nonseminomatous germ cell tumor in the right upper mediastinum. He had shortness of breath, an inspiratory stridor, and difficulty and pain when swallowing. His weight loss was 9 kilograms. Primary treatment with a four-course regimen of paclitaxel, bleomycin sulfate, and etoposide phosphate resulted in only a partial response. The ␣-fetoprotein level initially was 32,435 g/L, then dropped to 260 g/L (reference, 0 –9 g/L), where it remained. A computer tomography showed a large residual mediastinal tumor was present (Fig 1). According to our protocol, a decision was made to resect the mass. Optimal exposure of the anterior mediastinum was achieved by means of a median sternotomy in combination with a sixth intercostal anterolateral thoracotomy. The thymus, subclavian vein, right lung, and pericardium were encaged in the tumor. A radical resection was performed that included the right lung and what was thought to be the subclavian vein. Overnight, superior vena cava syndrome developed, with edema of the head. Fundoscopy showed edema of the right and left optic discs. Phlebographic evaluation revealed that a portion of the superior vena cava rather than the subclavian vein had been resected. A second operation was performed on the first postoperative day. The greater saphenous vein was harvested and opened along its long axis, then reconstructed radially to form a conduit 1 cm in diameter that was used to reconstruct the superior vena cava.
Departments of Vascular Surgery and Surgical Oncology, Erasmus Medical Center, Daniel den Hoed Cancer Center, Rotterdam, the Netherlands
We describe the case of a patient in whom blindness developed as a result of superior vena cava syndrome after resection of a primary mediastinal nonseminomatous germ cell tumor. (Ann Thorac Surg 2008;85:1426 –7) © 2008 by The Society of Thoracic Surgeons
P
FEATURE ARTICLES
erformance of extensive surgical procedures in the upper mediastinum may be challenging, especially in instances when tumors disturb the anatomic relationship. Serious complications reported include prolonged ventilation (2%), repeated bleeding (2%–10%), phrenic nerve damage (2%), mediastinitis (1%), vena cava (graft) occlusion (1%), pulmonary artery thrombosis (1%), and atrial fibrillation (1%) [1, 2]. The perioperative mortality rate is 0% to 6% [1, 2]. Superior vena cava syndrome is another possible complication, with symptoms of venous Accepted for publication Oct 2, 2007. Address correspondence to Dr van Geel, Department of Surgical Oncology, Erasmus Medical Center, Daniel den Hoed Cancer Center, PO Box 5201, Rotterdam, 3008 AE, the Netherlands; e-mail: a.n.vangeel@ erasmusmc.nl.
Fig 1. Panel A–D shows a computed tomography scan performed after chemotherapy, representing transections from a lower to an upper position in the thorax respectively. A large residual mediastinal nonseminomatous germ cell tumor is predominantly seen at the levels shown in panels B and C.
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.10.011
Ann Thorac Surg 2008;85:1427–9
Comment Blindness has been extensively described in idiopathic cranial hypertension [3, 4]. There is a clear theoretical basis for increased intracranial pressure caused by an outflow obstruction due to superior vena cava syndrome. The increased venous pressure causes a disturbed hydrostatic pressure gradient over the arachnoid villi, disturbing cerebral spinal fluid exchange and leading to increased intracranial pressure [5]. To our knowledge, blindness has not previously been described as a result of acute superior vena cava syndrome after mediastinal surgery. When considering surgical procedures, the clinician must be aware of this complication. Signs of developing superior vena cava syndrome are alarming. Diagnostic procedures are urgent and should be given the highest priority. In cases of superior vena cava syndrome, reoperation should be performed immediately.
References 1. Bacha EA, Chapelier AR, Macchiarini P, Fadel E, Dartevelle PG. Surgery for invasive mediastinal tumors. Ann Thorac Surg 1998;66:234 –9. 2. Park BJ, Bachetta M, Bains MS, et al. Surgical management of malignancies invading the heart or great vessels. Ann Tharac Surg 2004;78:1024 –30. 3. Krajewski KJ, Gurwood AS. Idiopathic intracranial hypertension: pseudotumor cerebri. Optometry 2002;73:546 –52. 4. Purvin V, Kawasaki A. Neuro-ophthalmic emergencies for the neurologist. Neurologist 2005;11:195–233. 5. Kollar CD, Johnston IH, Sholler GF. Communicating hydrocephalus secondary to a cardiac tumor compressing the superior vena cava. Childs Nerv Syst 2001;17:117–20. © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
1427
Radical Excision of Thymic Adenocarcinoma with Selective Cerebral Perfusion Masakazu Yoshioka, MD, Osamu Ichiguchi, MD, Touitsu Hirayama, MD, Toshiharu Sassa, MD, and Takihiro Kamio, MD Departments of Thoracic Surgery, Cardiovascular Surgery, and Pathology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
Most cases of thymic carcinoma have some invasion to neighboring organs when diagnosed, and it is generally difficult to completely remove. We adopted selective cerebral perfusion as a cerebral protection and successfully performed resection of a thymic adenocarcinoma that involved the superior vena cava, left brachiocephalic vein, right brachiocephalic artery and vein, and left common carotid artery in a 47-year-old woman. Even if multiple great vessels were involved by mediastinal malignant tumor, complete resection with selective cerebral perfusion could be safely performed. (Ann Thorac Surg 2008;85:1427–9) © 2008 by The Society of Thoracic Surgeons
I
n most cases of mediastinal malignant tumor, tumors often involve neighboring organs (ie, the great vessels, lungs, pericardium, nerves, or trachea) [1, 2]. Thymic carcinoma is believed to have a dismal prognosis as compared with that of thymoma because most of these tumors have some invasion to neighboring organs when diagnosed [3]. Although some invasion occurs, acceptable prognosis will be obtained by surgery if complete resection is carried out [1]. This is the first report of successful excision with selective cerebral perfusion of a thymic carcinoma that involved great vessels. A 47-year-old woman was identified as having a mediastinal abnormal shadow in chest computed tomography in a health screening. She had been suffering from an abnormal sensation in her throat during swallowing for the past 3 months. She did not have concomitant myasthenia gravis. She was referred to our hospital for examination and treatment in November 2006. A contrast medium-enhanced computed tomographic scan showed an anterior upper mediastinal tumor with a diameter of approximately 7 ⫻ 5 cm that had invaded and involved the superior vena cava (SVC), right brachiocephalic artery and vein, left brachiocephalic vein, and left common carotid artery (LCCA) (Fig 1). The tumor was faintly enhanced by contrast medium. In the fluorodeoxyglucose positron
Accepted for publication Oct 23, 2007. Address correspondence to Dr Yoshioka, Department of Thoracic Surgery, Saiseikai Kumamoto Hospital, Chikami 5-3-1, Kumamoto, 861-4193, Japan; e-mail: [email protected].
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.10.075
FEATURE ARTICLES
There was thrombosis of the conduit on the fourth postoperative day, which was treated with embolectomy by opening the subclavian vein and right atrium using a Fogarty catheter (Edwards Lifesciences, Irvine, CA). The superior vena cava syndrome resolved completely. After recovery from mechanical ventilation and severe infectious complications 1 month after the operation, blindness was noted. Multiple computed tomography scans and a magnetic resonance image showed no cerebral disorder. There was patent venous flow from the brain. Fundoscopy performed after several months revealed atrophic optic discs but without the venous swelling that is seen with superior vena cava syndrome. The patient has been followed up for 9 years. The ␣-fetoprotein level is low, and there are no signs of tumor recurrence. In a medicolegal proceeding, extensive ophthalmologic and neurologic examination revealed no hidden cause for the blindness and superior vena cava syndrome was deemed responsible.
CASE REPORT YOSHIOKA ET AL RADICAL EXCISION OF THYMIC ADENOCARCINOMA