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Echinococcus Cyst as a Cause of Chest Wall Tumor
689 Correspondence
3. Bortolotti U, Milano A, Mazzucco A, et al: Results of reoperation for primary tissue failure of porcine bioprostheses. J Thorac Cardiovasc Surg 90:564, 1985
Reply To the Editor: We appreciate Dr. Bortolotti and colleagues for bringing to our attention their report of a patient who underwent reoperation for primary tissue failure of a porcine bioprosthesis implanted in the mitral position [I]. Gross examination of the explanted valve revealed a fragment of the calcific right coronary cusp that was loosely attached to the remnant of the cusp and was easily detached during the handling of the bioprosthesis. This finding was reported as evidence of impending embolization of this calcific cusp fragment [I]. Dr. Bortolotti and co-workers also suggest, rightly so, that some of the major and minor embolic episodes observed in the late postoperative period in patients with xenobioprostheses might be related to detachment of fragments of the degenerated cusps, as in our case report [2]. This observation by a group with extensive experience in the field of porcine bioprostheses [3-61 is important. We also strongly concur with Dr. Bortolotti and colleagues on the need for early replacement of a failing xenograft valve to avoid embolic complications that could be lethal, as in our case report.
Lorenzo Gonzalez-Lavin, M . D. Danna Johnson, M . D . Department of Surgery Deborah Heart and Lung Center Browns Mills, NJ 08015 Department of Pathology Stanford University Medical Center Stanford, CA
References 1. Bortolotti U, Milano A, Thiene G, et al: Evidence of impending embolization of a calcific cusp fragment from a mitral porcine xenograft. J Thorac Cardiovasc Surg 3 0 4 5 , 1982 2. Johnson D, Gonzalez-Lavin L: Myocardial infarction secondary to calcific embolization: an unusual complication of bioprosthetic valve degeneration. Ann Thorac Surg 42:102,1986 3. Gallucci V, Valfre C, Mazzucco A, et al: Heart valve replacement with the Hancock bioprosthesis: a 5-11 year follow-up. In Cohn LH and Gallucci V (eds): Cardiac Bioprostheses: Proceedings of the Second International Symposium. New York: Yorke Medical Books, 1982, pp 9-24 4. Reichart B, Schad N, Bougioukas G, et al: Noninvasive scintigraphic assessment of left and right ventricular function in patients with bioprosthetic mitral valves at long-term risk. In Cohn L H and Gallucci V (eds): Cardiac Bioprostheses: Proceedings of the Second International Symposium. New York: Yorke Medical Books, 1982, pp 113-124 5. Theine G, Arbustini E, Bortolotti U, et al: Pathologic substrates of porcine valve dysfunction. In Cohn LH and Gallucci V (eds): Cardiac Bioprostheses: Proceedings of the Second International Symposium. New York: Yorke Medical Books, 1982, pp 378-400 6. Gallucci V, Bortolotti U, Milano A, et al: The Hancock porcine valve 15 years later: an analysis of 575 patients. In Bodnar E and Yacoub M (eds): Biologic Bioprosthetic Valves: Proceedings of the Third International Symposium. New York: Yorke Medical Books, 1986, pp 91-97
Echinococcus Cyst as a Cause of Chest Wall Tumor To the Editor: We read with interest the article by King and associates concerning primary chest wall tumors (Ann Thorac Surg 41:597, 1986). We noted that among the 90 primary chest wall tumors reviewed no echinococcus cyst was included. In Spain echinococcosis is an endemic disease, and hydatid cyst must be considered a cause of thoracic wall tumor. We recently had a patient with a primary hydatid cyst of chest wall. We would also like to emphasize the value of sonography in the diagnosis of soft-tissue tumors. A 76-year-old man, who smoked 40 cigarettes per day and suffered from chronic obstructive bronchitis and chronic respiratory failure, came to our institution because of pain in his left hemithorax of two months’ duration. Physical examination revealed a hard, deeply attached mass measuring 16 x 8 cm on the posterior wall of left hemithorax. The results of routine blood and urine analyses were normal; the electrocardiogram was also normal. An arterial blood specimen taken while the patient was breathing room air revealed the following: arterial oxygen tension, 56 mm Hg; arterial carbon dioxide tension, 39 mm Hg; alveolar-arterial tension difference, 36.73; and pH, 7.38. Pulmonary function studies showed: forced vital capacity (FVC), 2.13 (62% of predicted); forced expiratory volume in 1 second (FEVI), 0.92 (35% of predicted); and FEVJFVC, 41% (54% of predicted). A tuherculin skin test showed a lesion 25 mm in diameter. On the chest radiograph an extrapleural mass measuring 4 x 4 cm was seen in the left posterior thoracic wall; destruction of the seventh rib was evident. Sonography demonstrated a complex mass containing debris and cysts. The surrounding muscles from the lumbar area to the neck were involved, and many small cysts were visible inside the mass. Computed tomographic scans confirmed the radiographic and sonographic findings; the density values of the masses were those of water (Figure). Cultures (including Lowenstein) and cytologic examination for Mycobacterium tuberculosis were negative; specimens were taken from sputum and bronchial lavage and brushings. Bronchofibroscopy examination and bronchial biopsy showed
Computed tomographic Scan reveals a mass that destroyed the seventh rib and invaded the surrounding soft tissues.
690 The Annals of Thoracic Surgery Vol 43 No 6 June 1987
no abnormalities. Echinococcus granulosus arc 5 in sera (by crossed-over inmunoelectrophoresis) was positive. Results of radionuclide studies of the liver, spleen, brain, and bone were normal. A perfusion lung scan demonstrated multiple defects secondary to chronic obstructive pulmonary disease. Surgery was not performed because of the patient’s age and poor respiratory function. Mebendazole (1 @day) was given, with no improvement to date. The annual incidence of hydatid disease in Spain is 5 to 9 cases per 100,OOO inhabitants. Chest wall involvement occurs in 2.3% of patients. Hydatid disease should always be suspected as a cause of a soft-tissue mass in endemic countries. Sonography has become an excellent method to study this sort of tumor; it is rapid, simple, inexpensive, and safe. Diagnostic accuracy for thoracic lesions reaches 78.9% when fineneedle percutaneous aspiration guided by sonography is performed [l], but this procedure should be avoided when hydatid cyst is suspected. Although the treatment of choice is surgery, it was not possible in our patient because of his poor respiratory function. In such patients medical treatment with mebendazole should be tried, although its usefulness is not yet clear.
R. Alvarez-Sala, M . D . F . 1. Gomez de Terreros, M . D . Setvicio de Neumologia Hospital del Aire Universidad Complutense Madrid, Spain
cised with the patient supine, considerable abduction and rotation of the flexed hips may be required. In anesthetized patients this is clearly undesirable, and it is contraindicated in the elderly or those with arthritic conditions of these joints. On more than 30 occasions in the last three years we have harvested vein from the lesser saphenous system with the patient on his left side and the surgeon seated facing the patient’s calves. A second surgeon standing on the opposite side of the table works on the right calf, the seated surgeon on the left calf. The incisions are dosed with skin clips, and the patient is then placed supine and redraped while the surgeon rescrubs and regowns. The patient remains on his side for about 30 minutes, and the risk of hip or knee injury is obviated. The lesser saphenous veins have been used to graft up to 5 coronary arteries; this technique has also been applied in 5 patients with unstable angina without complication. In terms of size, thickness, and quality, the lesser saphenous vein is preferable to arm vein and is easy to obtain using the technique described.
Thomas 1. Spyt, F.R.C.S. Ian 1. Reece, F.R.C.S. Department of Cardiac Surgery Royal Infirmary 8-16 Alexandra Parade Glasgow G31 2ER
Reference 1. Raess DH:Lesser saphenous vein as an alternative conduit of choice in coronary bypass operations. Ann Thorac Surg 41:334, 1986
P . Caballero, M . D . Servicio de Radiodiagndstico Centro de Salud Pozuelo de Alarcon Madrid, Spain
Reference 1. Ikezoe 1, Sone S, Higashihara T, et al: Sonographically guided needle biopsy for diagnosis of thoracic lesions. AIR 143229, 1984
Harvesting of Lesser Saphenous Vein To the Editor: Dr. Raess and colleagues [ l ] draw attention to the use of the vein from the lesser saphenous system in situations in which neither the long saphenous vein nor the internal mammary arteries are available for use as a bypass conduit. We agree that this vein will often yield usable lengths of good quality vein even in the presence of severe varicosities of the long saphenous system. However. when the lesser saphenous vein is ex-
Reply To the Editor: I am pleased to hear of Dr. Spyt and Dr. Reece’s experience with harvesting lesser saphenous vein segments for coronary bypass. I continue to find this a useful alternative conduit when long saphenous vein segments are not available. The abduction and rotation of the hips must be applied judiciously, but in our practice we have applied this technique in many elderly patients and have not as yet had a problem. Another advantage to the supine technique includes the ability of another member of the team to harvest the internal mammary pedicle and to perform cannulation while vein harvesting continues. Certainly, in a patient with hip prostheses in place or with severe arthritis, the technique of lateral harvest of the vein is clearly superior. Daniel H . Raess, M . D . Cardiac Surgery Associates of Indiana, lnc. 1500 Albany St, Suite 1011 Beech Grove, IN 461 07
3. Bortolotti U, Milano A, Mazzucco A, et al: Results of reoperation for primary tissue failure of porcine bioprostheses. J Thorac Cardiovasc Surg 90:564, 1985
Reply To the Editor: We appreciate Dr. Bortolotti and colleagues for bringing to our attention their report of a patient who underwent reoperation for primary tissue failure of a porcine bioprosthesis implanted in the mitral position [I]. Gross examination of the explanted valve revealed a fragment of the calcific right coronary cusp that was loosely attached to the remnant of the cusp and was easily detached during the handling of the bioprosthesis. This finding was reported as evidence of impending embolization of this calcific cusp fragment [I]. Dr. Bortolotti and co-workers also suggest, rightly so, that some of the major and minor embolic episodes observed in the late postoperative period in patients with xenobioprostheses might be related to detachment of fragments of the degenerated cusps, as in our case report [2]. This observation by a group with extensive experience in the field of porcine bioprostheses [3-61 is important. We also strongly concur with Dr. Bortolotti and colleagues on the need for early replacement of a failing xenograft valve to avoid embolic complications that could be lethal, as in our case report.
Lorenzo Gonzalez-Lavin, M . D. Danna Johnson, M . D . Department of Surgery Deborah Heart and Lung Center Browns Mills, NJ 08015 Department of Pathology Stanford University Medical Center Stanford, CA
References 1. Bortolotti U, Milano A, Thiene G, et al: Evidence of impending embolization of a calcific cusp fragment from a mitral porcine xenograft. J Thorac Cardiovasc Surg 3 0 4 5 , 1982 2. Johnson D, Gonzalez-Lavin L: Myocardial infarction secondary to calcific embolization: an unusual complication of bioprosthetic valve degeneration. Ann Thorac Surg 42:102,1986 3. Gallucci V, Valfre C, Mazzucco A, et al: Heart valve replacement with the Hancock bioprosthesis: a 5-11 year follow-up. In Cohn LH and Gallucci V (eds): Cardiac Bioprostheses: Proceedings of the Second International Symposium. New York: Yorke Medical Books, 1982, pp 9-24 4. Reichart B, Schad N, Bougioukas G, et al: Noninvasive scintigraphic assessment of left and right ventricular function in patients with bioprosthetic mitral valves at long-term risk. In Cohn L H and Gallucci V (eds): Cardiac Bioprostheses: Proceedings of the Second International Symposium. New York: Yorke Medical Books, 1982, pp 113-124 5. Theine G, Arbustini E, Bortolotti U, et al: Pathologic substrates of porcine valve dysfunction. In Cohn LH and Gallucci V (eds): Cardiac Bioprostheses: Proceedings of the Second International Symposium. New York: Yorke Medical Books, 1982, pp 378-400 6. Gallucci V, Bortolotti U, Milano A, et al: The Hancock porcine valve 15 years later: an analysis of 575 patients. In Bodnar E and Yacoub M (eds): Biologic Bioprosthetic Valves: Proceedings of the Third International Symposium. New York: Yorke Medical Books, 1986, pp 91-97
Echinococcus Cyst as a Cause of Chest Wall Tumor To the Editor: We read with interest the article by King and associates concerning primary chest wall tumors (Ann Thorac Surg 41:597, 1986). We noted that among the 90 primary chest wall tumors reviewed no echinococcus cyst was included. In Spain echinococcosis is an endemic disease, and hydatid cyst must be considered a cause of thoracic wall tumor. We recently had a patient with a primary hydatid cyst of chest wall. We would also like to emphasize the value of sonography in the diagnosis of soft-tissue tumors. A 76-year-old man, who smoked 40 cigarettes per day and suffered from chronic obstructive bronchitis and chronic respiratory failure, came to our institution because of pain in his left hemithorax of two months’ duration. Physical examination revealed a hard, deeply attached mass measuring 16 x 8 cm on the posterior wall of left hemithorax. The results of routine blood and urine analyses were normal; the electrocardiogram was also normal. An arterial blood specimen taken while the patient was breathing room air revealed the following: arterial oxygen tension, 56 mm Hg; arterial carbon dioxide tension, 39 mm Hg; alveolar-arterial tension difference, 36.73; and pH, 7.38. Pulmonary function studies showed: forced vital capacity (FVC), 2.13 (62% of predicted); forced expiratory volume in 1 second (FEVI), 0.92 (35% of predicted); and FEVJFVC, 41% (54% of predicted). A tuherculin skin test showed a lesion 25 mm in diameter. On the chest radiograph an extrapleural mass measuring 4 x 4 cm was seen in the left posterior thoracic wall; destruction of the seventh rib was evident. Sonography demonstrated a complex mass containing debris and cysts. The surrounding muscles from the lumbar area to the neck were involved, and many small cysts were visible inside the mass. Computed tomographic scans confirmed the radiographic and sonographic findings; the density values of the masses were those of water (Figure). Cultures (including Lowenstein) and cytologic examination for Mycobacterium tuberculosis were negative; specimens were taken from sputum and bronchial lavage and brushings. Bronchofibroscopy examination and bronchial biopsy showed
Computed tomographic Scan reveals a mass that destroyed the seventh rib and invaded the surrounding soft tissues.
690 The Annals of Thoracic Surgery Vol 43 No 6 June 1987
no abnormalities. Echinococcus granulosus arc 5 in sera (by crossed-over inmunoelectrophoresis) was positive. Results of radionuclide studies of the liver, spleen, brain, and bone were normal. A perfusion lung scan demonstrated multiple defects secondary to chronic obstructive pulmonary disease. Surgery was not performed because of the patient’s age and poor respiratory function. Mebendazole (1 @day) was given, with no improvement to date. The annual incidence of hydatid disease in Spain is 5 to 9 cases per 100,OOO inhabitants. Chest wall involvement occurs in 2.3% of patients. Hydatid disease should always be suspected as a cause of a soft-tissue mass in endemic countries. Sonography has become an excellent method to study this sort of tumor; it is rapid, simple, inexpensive, and safe. Diagnostic accuracy for thoracic lesions reaches 78.9% when fineneedle percutaneous aspiration guided by sonography is performed [l], but this procedure should be avoided when hydatid cyst is suspected. Although the treatment of choice is surgery, it was not possible in our patient because of his poor respiratory function. In such patients medical treatment with mebendazole should be tried, although its usefulness is not yet clear.
R. Alvarez-Sala, M . D . F . 1. Gomez de Terreros, M . D . Setvicio de Neumologia Hospital del Aire Universidad Complutense Madrid, Spain
cised with the patient supine, considerable abduction and rotation of the flexed hips may be required. In anesthetized patients this is clearly undesirable, and it is contraindicated in the elderly or those with arthritic conditions of these joints. On more than 30 occasions in the last three years we have harvested vein from the lesser saphenous system with the patient on his left side and the surgeon seated facing the patient’s calves. A second surgeon standing on the opposite side of the table works on the right calf, the seated surgeon on the left calf. The incisions are dosed with skin clips, and the patient is then placed supine and redraped while the surgeon rescrubs and regowns. The patient remains on his side for about 30 minutes, and the risk of hip or knee injury is obviated. The lesser saphenous veins have been used to graft up to 5 coronary arteries; this technique has also been applied in 5 patients with unstable angina without complication. In terms of size, thickness, and quality, the lesser saphenous vein is preferable to arm vein and is easy to obtain using the technique described.
Thomas 1. Spyt, F.R.C.S. Ian 1. Reece, F.R.C.S. Department of Cardiac Surgery Royal Infirmary 8-16 Alexandra Parade Glasgow G31 2ER
Reference 1. Raess DH:Lesser saphenous vein as an alternative conduit of choice in coronary bypass operations. Ann Thorac Surg 41:334, 1986
P . Caballero, M . D . Servicio de Radiodiagndstico Centro de Salud Pozuelo de Alarcon Madrid, Spain
Reference 1. Ikezoe 1, Sone S, Higashihara T, et al: Sonographically guided needle biopsy for diagnosis of thoracic lesions. AIR 143229, 1984
Harvesting of Lesser Saphenous Vein To the Editor: Dr. Raess and colleagues [ l ] draw attention to the use of the vein from the lesser saphenous system in situations in which neither the long saphenous vein nor the internal mammary arteries are available for use as a bypass conduit. We agree that this vein will often yield usable lengths of good quality vein even in the presence of severe varicosities of the long saphenous system. However. when the lesser saphenous vein is ex-
Reply To the Editor: I am pleased to hear of Dr. Spyt and Dr. Reece’s experience with harvesting lesser saphenous vein segments for coronary bypass. I continue to find this a useful alternative conduit when long saphenous vein segments are not available. The abduction and rotation of the hips must be applied judiciously, but in our practice we have applied this technique in many elderly patients and have not as yet had a problem. Another advantage to the supine technique includes the ability of another member of the team to harvest the internal mammary pedicle and to perform cannulation while vein harvesting continues. Certainly, in a patient with hip prostheses in place or with severe arthritis, the technique of lateral harvest of the vein is clearly superior. Daniel H . Raess, M . D . Cardiac Surgery Associates of Indiana, lnc. 1500 Albany St, Suite 1011 Beech Grove, IN 461 07