- Email: [email protected]
Endoscopic repair of bronchial dehiscence after lung transplantation
Ann Thorac Surg 2001;72:2109 –11
and 50% [1, 2]. Whenever the innominate artery, innominate vein, aortic arch, and right pulmonary artery are injured a thoracotomy might be necessary. Penetrating carotid artery injury is a severe complication. In a retrospective series of 2,923 severely injured patients, the incidence of large supraaortic artery injuries was 0.58% with an overall mortality of 53% [5]. Seventyfive percent of the survivors had a neurologic deficit. In the presence of a huge solid mediastinal mass, like in the patient described, normal anatomic relations are obscured, increasing the risk of major arterial injury [6]. As the latter is a rare but not uncommon complication of mediastinoscopy, does it make sense to perform this procedure in remote hospitals? We think it does; however, in patients presenting with such huge tumor masses and a considerable risk of complications, we recommend that mediastinoscopies be performed only in centers that are near cardiosurgery units. In our patient, bleeding could not be controlled despite immediate sternotomy and tumor mass reduction; the patient had to be transferred to another hospital. Even in a desperate situation like this, fast transportation to a cardiothoracic center is superior to any attempt to control the situation without the aid of cardiopulmonary bypass. However, digital compression of the common carotid artery deeply embedded in the solid tumor mass was life-saving. Although controversial in malignant disease, the use of cardiopulmonary bypass technique was necessary for appropriate repair of this complex vascular lesion. To perform proper cerebral protection, deep hypothermia and circulatory arrest were chosen because partial innominate artery clamping was not possible due to tumor infiltration. Nowadays, the defect could be treated easily by an endovascular procedure. If a common carotid artery injury is suspected and the patient is in stable condition and angiography can be performed, the defect could be sealed by a covered stent. Major artery injury is a serious complication during mediastinoscopy. The initial hemorrhage can be controlled by digital compression. Quick awareness of the situation and fast transportation to a cardiothoracic unit are inevitable to control this life-threatening complication.
References 1. Varela G, Jimenez MF, Lopez S, Minguez F. Descriptive study of complications caused by mediastinoscopy. Arch Bronconeumol 1998;34:119–22. 2. De Francquen P, Vanderhoeft P, Rocmans P. Iatrogenic lesions in a series of 1,250 mediastinoscopies. Acta Chir Belg 1977;76:269–72. 3. Specht G. Risks and complications of mediastinoscopy. Thoraxchir Vask Chir 1977;25:336– 8. 4. Puhakka HJ. Complications of mediastinoscopy. J Laryngol Otol 1989;103:312–5. 5. Laske A, Bauer E, Von Segesser L, et al. Injuries of the large supraaortic arteries. Schweiz Med Wochenschr 1990;120: 1050–5. 6. Meuser W. How great is the risk of injury to vessels during mediastinoscopy? Laryngol Rhinol Otol Stuttg 1978;57:914– 8. © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT MALONEY ET AL REPAIR OF LUNG TRANSPLANT DEHISCENCE
2109
Endoscopic Repair of Bronchial Dehiscence After Lung Transplantation James D. Maloney, MD, Tracey L. Weigel, MD, and Robert B. Love, MD Department of Surgery, University of Wisconsin, Madison, Wisconsin
We report a case of bronchial dehiscence after right single lung transplantation and describe a novel means of management: bronchoscopic closure of the defect with alpha-cyanoacrylate glue. (Ann Thorac Surg 2001;72:2109 –11) © 2001 by The Society of Thoracic Surgeons
T
he Achilles heel of lung transplantation has been the bronchial or tracheal anastomosis. Anastomotic dehiscence continues to adversely affect lung transplant morbidity and mortality. Lethal airway complications occur in approximately 2% of patients [1]. Nonlethal dehiscence may often be managed conservatively with tube drainage, but can result in airway stenosis [2, 3]. We describe the closure of a lung transplant bronchial anastomotic dehiscence by endoscopically applied cyanoacrylate glue. A 48-year-old woman underwent right single lung transplantation for chronic obstructive pulmonary disease. A standard telescoped anastomosis was used without omental buttressing or bronchial artery revascularization. Immunosuppressive therapy, including methylprednisolone, cyclosporine, and azathioprine, was initiated postoperatively. The postoperative course for this patient was complicated. She suffered from acute graft dysfunction and prolonged intubation. On the 14th postoperative day the patient was noted to have an increasing air leak. Bronchoscopic evaluation demonstrated a dehiscence at the posterior aspect of the anastomosis. At the time that the dehiscence was found there was no clinical evidence of mediastinal or pleural infection from leakage of bronchial secretions. Plain radiographs demonstrated pneumomediastinum and pneumothorax without pleural effusion. We elected to repair the defect by application of alpha-cyanoacrylate glue using a flexible Pentax FB19TX bronchoscope. Using a TB syringe, the glue was directed at the defect through a Wang needle sheath with the biopsy needle removed (Fig 1). Three sequential applications of the glue were performed under direct visualization during this therapeutic bronchoscopy. The patient’s pulmonary status improved and the air leak was notably Accepted for publication March 1, 2001. Address reprint requests to Dr Maloney, Department of Surgery, University of Wisconsin, 600 Highland Ave, H/410, Madison, WI 53792; e-mail: [email protected].
0003-4975/01/$20.00 PII S0003-4975(01)02698-4
2110
CASE REPORT MALONEY ET AL REPAIR OF LUNG TRANSPLANT DEHISCENCE
Fig 1. Cyanoacrylate glue applied to posterior dehiscence. Adhesive is directed at the defect with a Wang needle sheath under bronchoscopic guidance.
diminished after the procedure. The right chest tube was removed 2 days later. The patient was weaned from the ventilator and transferred to general care on the 23rd postoperative day. At 3 weeks after application of the cyanoacrylate, the bronchial anastomosis was widely patent. The glue was noted to be intact posteriorly, and the area surrounding the glue visualized. The patient was discharged home 2 months after transplantation. Bronchoscopy was performed at 2-month to 3-month intervals after discharge. At 7 months postoperatively the glue was removed by endoscopic debridement without complication. At 18 months the bronchial anastomosis appeared well healed without evidence of stenosis (Fig 2).
Ann Thorac Surg 2001;72:2109 –11
plantation the authors decreased the airway complication rate to 4% [1]. These complications still occur, however, and can lead to bronchial stenosis, which remains a considerable cause of morbidity [3]. Endoscopic therapies such as dilation, stenting, and laser ablation for stenosis secondary to dehiscence have been described. However, multiple, repeated dilatations are often required to maintain an adequate lumen [2, 3]. No primary bronchoscopic therapy for repair of the bronchial dehiscence after lung transplantation has been reported in the literature. Cyanoacrylate glue has been used effectively for repair of bronchopleural fistulas after pulmonary resections and lung volume reduction surgical procedures. Intraoperative use of the adhesive in conjunction with surgical repair has been reported [5]. Scappaticci and colleagues [6] reported an 83% success rate for endoscopic closure of postoperative bronchopleural fistula with cyanoacrylate glue. Some authors [7] have recommended intraoperative application of monomeric n-butyl-2-cyanoacrylic tissue adhesive prophylactically to reduce the incidence of bronchopleural fistula. This has not been reported in the lung transplant population. The combination of prolonged ventilatory support and acute graft dysfunction increased the risk of dehiscence in this patient. Ultimately, prevention of airway complications by minimizing risk factors was our goal. It was our intent to use the cyanoacrylate glue to seal the dehiscence, thus improving pulmonary function; to decrease the leak of bronchial secretions into the pleural and mediastinal space; and to limit or avoid secondary stenosis. It is not without risk to place a foreign body within the bronchus in an immunocompromised population with high risk of infection. Further study is needed to determine the role of cyanoacrylate glue in bronchial anastomotic dehiscence after lung transplantation, the
Comment Airway complications have been a major source of morbidity and mortality in lung transplantation. Many factors including ischemia, immunosuppression, infection, rejection, and inadequate preservation may increase the risk of anastomotic complications. Ischemia is thought to be one of the foremost variables affecting the rate of dehiscence [2– 4]. Additionally, prolonged ventilator support may increase the risk of airway complications [1]. Innovative techniques such as telescoped anastomoses, buttressing anastomoses with omentum or other wellvascularized tissue, and more recently direct bronchial artery revascularization have been proposed to reduce complication rates [4]. The risk of lethal airway complications is estimated at approximately 2%. Nonlethal dehiscences occur more frequently. In a large series by Date and associates [1], bronchial dehiscence required clinical intervention in 12.8% of patients undergoing lung transplantation. In the last 76 patients undergoing trans-
Fig 2. Endoscopic photograph of bronchial anastomosis 18 months after application of cyanoacrylate glue (arrow).
Ann Thorac Surg 2001;72:2111–3
appropriate timing for removal of the glue, and its associated infectious risks.
References 1. Date H, Trulock E, Arcidi J, et al. Improved airway healing after lung transplantation. J Thorac Cardiovasc Surg 1995;110: 1424–32. 2. Schafers HJ, Haydock DA, Cooper JD. The prevalence and management of bronchial anastomotic complications in lung transplant. J Thorac Cardiovasc Surg 1991;101:1044–52. 3. Shennib H, Massard G. Airway complications in lung transplantation. Ann Thorac Surg 1994;57:506–11. 4. Anderson MB, Kriet JM, Harrel J, et al. Lung and heart-lung transplantation, techniques for bronchial anastomosis. J Heart Lung Transplant 1995;14:1090– 4. 5. Horsley WS, Miller JI. Management of the uncontrollable pulmonary air leak with cyanoacrylate glue. Ann Thorac Surg 1997;63:1492–3. 6. Scappaticci E, Ardissone F, Ruffini E, Baldi S, Mancuso M. Postoperative bronchopleural fistula: endoscopic closure in 12 patients. Ann Thorac Surg 1994;57:119–22. 7. Sabanathan A, Sabanathan S, Shah R, Richardson J. Tissue adhesive in bronchial closure. Ann Thorac Surg 1997;63:899 – 900.
Unusual Cause of Recurrent Pneumothorax: Excavated Metastasis of Osteosarcoma Gwenae¨ lle Le Garff, MD, Herve´ Le´ na, MD, Herve´ Corbineau, MD, Pierre Kerbrat, MD, and Philippe Delaval, MD Service de Pneumologie and Service de Chirurgie Thoracique et Cardio-Vasculaire, Centre Cardio-Pneumologique, Hoˆ pital Pontchaillou-CHU, and Service d’Oncologie Me´ dicale, Centre Euge`ne Marquis, Rennes, France
We report the case of a recurrent right pneumothorax, revealing metastasis of an osteosarcoma, 40 months after complete remission. Seven years after surgical excision, the patient is still considered in complete remission. Pneumothorax is rarely the first manifestation of lung metastasis. Osteosarcoma is the most frequent primary tumor. Chest computed tomography detects excavated or subpleural lung metastasis. Differential diagnosis between benign and malignant bullous lesions is important because surgical excision affects survival in some malignancies. (Ann Thorac Surg 2001;72:2111–3) © 2001 by The Society of Thoracic Surgeons
CASE REPORT Le GARFF ET AL RECURRENT PNEUMOTHORAX
2111
extremity of the left femur was diagnosed in 1989 and treated by neoadjuvant chemotherapy, followed by a limb-sparing surgical procedure with insertion of a knee prosthesis and then adjuvant chemotherapy. In the initial extension assessment, chest tomography revealed no metastasis. Complete remission was obtained in September 1989. In January 1993, the patient was hospitalized with a completely spontaneous right pneumothorax, which required placement of a chest tube. A chest computed tomographic scan revealed a thin-walled cavity with a small calcified nodule in its inner edge, in the upper right axillary region (Fig 1). The possibility of a secondary location was considered and we decided to perform computed tomography 2 months later to evaluate the progression of the cavitary lesion. The patient did not show up for this examination. In August 1993, the patient was hospitalized for a first relapse of spontaneous right pneumothorax, and was again treated by means of a chest tube. This first recurrence was rapidly followed by a second. A chest computed tomographic scan showed the same cystic lesion, scarcely increased. The calcified nodule was unchanged. However, the wall of the cavitary lesion appeared thickened. There was perilobular and pleural thickening close to the lesion, which remained unique. The nodule was completely excised surgically by means of thoracotomy. The nodule showed histologic features of metastasis of osteosarcoma with pleural extension. Two neoplastic arterial emboli were noted. Two months after the operation, a chest computed tomographic scan revealed a stapler’s line, surrounded by linear thickenings and ground-glass areas, with pleural thickening occupying the space left by excision. This was considered to be secondary to the surgical procedure and had partly disappeared on a computed tomographic scan performed 14 months later (Fig 2). In 2000, in the absence of any other specific treatment, the patient was considered in complete remission.
M
etastatic causes of pneumothorax are rare but must be considered in patients with a history of neoplastic disease. We report the case of a man (born in 1962) with recurrent pneumothorax. Osteoblastic osteosarcoma of the inferior
Accepted for publication Mar 1, 2001. Address reprint requests to Dr Delaval, Service de Pneumologie, Centre Cardio-Pneumologique, Hoˆ pital Pontchaillou-CHU, 35033 Rennes Cedex, France; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Thin-walled cavity, with small calcified nodule, in the upper right axillary region. 0003-4975/01/$20.00 PII S0003-4975(01)02694-7
and 50% [1, 2]. Whenever the innominate artery, innominate vein, aortic arch, and right pulmonary artery are injured a thoracotomy might be necessary. Penetrating carotid artery injury is a severe complication. In a retrospective series of 2,923 severely injured patients, the incidence of large supraaortic artery injuries was 0.58% with an overall mortality of 53% [5]. Seventyfive percent of the survivors had a neurologic deficit. In the presence of a huge solid mediastinal mass, like in the patient described, normal anatomic relations are obscured, increasing the risk of major arterial injury [6]. As the latter is a rare but not uncommon complication of mediastinoscopy, does it make sense to perform this procedure in remote hospitals? We think it does; however, in patients presenting with such huge tumor masses and a considerable risk of complications, we recommend that mediastinoscopies be performed only in centers that are near cardiosurgery units. In our patient, bleeding could not be controlled despite immediate sternotomy and tumor mass reduction; the patient had to be transferred to another hospital. Even in a desperate situation like this, fast transportation to a cardiothoracic center is superior to any attempt to control the situation without the aid of cardiopulmonary bypass. However, digital compression of the common carotid artery deeply embedded in the solid tumor mass was life-saving. Although controversial in malignant disease, the use of cardiopulmonary bypass technique was necessary for appropriate repair of this complex vascular lesion. To perform proper cerebral protection, deep hypothermia and circulatory arrest were chosen because partial innominate artery clamping was not possible due to tumor infiltration. Nowadays, the defect could be treated easily by an endovascular procedure. If a common carotid artery injury is suspected and the patient is in stable condition and angiography can be performed, the defect could be sealed by a covered stent. Major artery injury is a serious complication during mediastinoscopy. The initial hemorrhage can be controlled by digital compression. Quick awareness of the situation and fast transportation to a cardiothoracic unit are inevitable to control this life-threatening complication.
References 1. Varela G, Jimenez MF, Lopez S, Minguez F. Descriptive study of complications caused by mediastinoscopy. Arch Bronconeumol 1998;34:119–22. 2. De Francquen P, Vanderhoeft P, Rocmans P. Iatrogenic lesions in a series of 1,250 mediastinoscopies. Acta Chir Belg 1977;76:269–72. 3. Specht G. Risks and complications of mediastinoscopy. Thoraxchir Vask Chir 1977;25:336– 8. 4. Puhakka HJ. Complications of mediastinoscopy. J Laryngol Otol 1989;103:312–5. 5. Laske A, Bauer E, Von Segesser L, et al. Injuries of the large supraaortic arteries. Schweiz Med Wochenschr 1990;120: 1050–5. 6. Meuser W. How great is the risk of injury to vessels during mediastinoscopy? Laryngol Rhinol Otol Stuttg 1978;57:914– 8. © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT MALONEY ET AL REPAIR OF LUNG TRANSPLANT DEHISCENCE
2109
Endoscopic Repair of Bronchial Dehiscence After Lung Transplantation James D. Maloney, MD, Tracey L. Weigel, MD, and Robert B. Love, MD Department of Surgery, University of Wisconsin, Madison, Wisconsin
We report a case of bronchial dehiscence after right single lung transplantation and describe a novel means of management: bronchoscopic closure of the defect with alpha-cyanoacrylate glue. (Ann Thorac Surg 2001;72:2109 –11) © 2001 by The Society of Thoracic Surgeons
T
he Achilles heel of lung transplantation has been the bronchial or tracheal anastomosis. Anastomotic dehiscence continues to adversely affect lung transplant morbidity and mortality. Lethal airway complications occur in approximately 2% of patients [1]. Nonlethal dehiscence may often be managed conservatively with tube drainage, but can result in airway stenosis [2, 3]. We describe the closure of a lung transplant bronchial anastomotic dehiscence by endoscopically applied cyanoacrylate glue. A 48-year-old woman underwent right single lung transplantation for chronic obstructive pulmonary disease. A standard telescoped anastomosis was used without omental buttressing or bronchial artery revascularization. Immunosuppressive therapy, including methylprednisolone, cyclosporine, and azathioprine, was initiated postoperatively. The postoperative course for this patient was complicated. She suffered from acute graft dysfunction and prolonged intubation. On the 14th postoperative day the patient was noted to have an increasing air leak. Bronchoscopic evaluation demonstrated a dehiscence at the posterior aspect of the anastomosis. At the time that the dehiscence was found there was no clinical evidence of mediastinal or pleural infection from leakage of bronchial secretions. Plain radiographs demonstrated pneumomediastinum and pneumothorax without pleural effusion. We elected to repair the defect by application of alpha-cyanoacrylate glue using a flexible Pentax FB19TX bronchoscope. Using a TB syringe, the glue was directed at the defect through a Wang needle sheath with the biopsy needle removed (Fig 1). Three sequential applications of the glue were performed under direct visualization during this therapeutic bronchoscopy. The patient’s pulmonary status improved and the air leak was notably Accepted for publication March 1, 2001. Address reprint requests to Dr Maloney, Department of Surgery, University of Wisconsin, 600 Highland Ave, H/410, Madison, WI 53792; e-mail: [email protected].
0003-4975/01/$20.00 PII S0003-4975(01)02698-4
2110
CASE REPORT MALONEY ET AL REPAIR OF LUNG TRANSPLANT DEHISCENCE
Fig 1. Cyanoacrylate glue applied to posterior dehiscence. Adhesive is directed at the defect with a Wang needle sheath under bronchoscopic guidance.
diminished after the procedure. The right chest tube was removed 2 days later. The patient was weaned from the ventilator and transferred to general care on the 23rd postoperative day. At 3 weeks after application of the cyanoacrylate, the bronchial anastomosis was widely patent. The glue was noted to be intact posteriorly, and the area surrounding the glue visualized. The patient was discharged home 2 months after transplantation. Bronchoscopy was performed at 2-month to 3-month intervals after discharge. At 7 months postoperatively the glue was removed by endoscopic debridement without complication. At 18 months the bronchial anastomosis appeared well healed without evidence of stenosis (Fig 2).
Ann Thorac Surg 2001;72:2109 –11
plantation the authors decreased the airway complication rate to 4% [1]. These complications still occur, however, and can lead to bronchial stenosis, which remains a considerable cause of morbidity [3]. Endoscopic therapies such as dilation, stenting, and laser ablation for stenosis secondary to dehiscence have been described. However, multiple, repeated dilatations are often required to maintain an adequate lumen [2, 3]. No primary bronchoscopic therapy for repair of the bronchial dehiscence after lung transplantation has been reported in the literature. Cyanoacrylate glue has been used effectively for repair of bronchopleural fistulas after pulmonary resections and lung volume reduction surgical procedures. Intraoperative use of the adhesive in conjunction with surgical repair has been reported [5]. Scappaticci and colleagues [6] reported an 83% success rate for endoscopic closure of postoperative bronchopleural fistula with cyanoacrylate glue. Some authors [7] have recommended intraoperative application of monomeric n-butyl-2-cyanoacrylic tissue adhesive prophylactically to reduce the incidence of bronchopleural fistula. This has not been reported in the lung transplant population. The combination of prolonged ventilatory support and acute graft dysfunction increased the risk of dehiscence in this patient. Ultimately, prevention of airway complications by minimizing risk factors was our goal. It was our intent to use the cyanoacrylate glue to seal the dehiscence, thus improving pulmonary function; to decrease the leak of bronchial secretions into the pleural and mediastinal space; and to limit or avoid secondary stenosis. It is not without risk to place a foreign body within the bronchus in an immunocompromised population with high risk of infection. Further study is needed to determine the role of cyanoacrylate glue in bronchial anastomotic dehiscence after lung transplantation, the
Comment Airway complications have been a major source of morbidity and mortality in lung transplantation. Many factors including ischemia, immunosuppression, infection, rejection, and inadequate preservation may increase the risk of anastomotic complications. Ischemia is thought to be one of the foremost variables affecting the rate of dehiscence [2– 4]. Additionally, prolonged ventilator support may increase the risk of airway complications [1]. Innovative techniques such as telescoped anastomoses, buttressing anastomoses with omentum or other wellvascularized tissue, and more recently direct bronchial artery revascularization have been proposed to reduce complication rates [4]. The risk of lethal airway complications is estimated at approximately 2%. Nonlethal dehiscences occur more frequently. In a large series by Date and associates [1], bronchial dehiscence required clinical intervention in 12.8% of patients undergoing lung transplantation. In the last 76 patients undergoing trans-
Fig 2. Endoscopic photograph of bronchial anastomosis 18 months after application of cyanoacrylate glue (arrow).
Ann Thorac Surg 2001;72:2111–3
appropriate timing for removal of the glue, and its associated infectious risks.
References 1. Date H, Trulock E, Arcidi J, et al. Improved airway healing after lung transplantation. J Thorac Cardiovasc Surg 1995;110: 1424–32. 2. Schafers HJ, Haydock DA, Cooper JD. The prevalence and management of bronchial anastomotic complications in lung transplant. J Thorac Cardiovasc Surg 1991;101:1044–52. 3. Shennib H, Massard G. Airway complications in lung transplantation. Ann Thorac Surg 1994;57:506–11. 4. Anderson MB, Kriet JM, Harrel J, et al. Lung and heart-lung transplantation, techniques for bronchial anastomosis. J Heart Lung Transplant 1995;14:1090– 4. 5. Horsley WS, Miller JI. Management of the uncontrollable pulmonary air leak with cyanoacrylate glue. Ann Thorac Surg 1997;63:1492–3. 6. Scappaticci E, Ardissone F, Ruffini E, Baldi S, Mancuso M. Postoperative bronchopleural fistula: endoscopic closure in 12 patients. Ann Thorac Surg 1994;57:119–22. 7. Sabanathan A, Sabanathan S, Shah R, Richardson J. Tissue adhesive in bronchial closure. Ann Thorac Surg 1997;63:899 – 900.
Unusual Cause of Recurrent Pneumothorax: Excavated Metastasis of Osteosarcoma Gwenae¨ lle Le Garff, MD, Herve´ Le´ na, MD, Herve´ Corbineau, MD, Pierre Kerbrat, MD, and Philippe Delaval, MD Service de Pneumologie and Service de Chirurgie Thoracique et Cardio-Vasculaire, Centre Cardio-Pneumologique, Hoˆ pital Pontchaillou-CHU, and Service d’Oncologie Me´ dicale, Centre Euge`ne Marquis, Rennes, France
We report the case of a recurrent right pneumothorax, revealing metastasis of an osteosarcoma, 40 months after complete remission. Seven years after surgical excision, the patient is still considered in complete remission. Pneumothorax is rarely the first manifestation of lung metastasis. Osteosarcoma is the most frequent primary tumor. Chest computed tomography detects excavated or subpleural lung metastasis. Differential diagnosis between benign and malignant bullous lesions is important because surgical excision affects survival in some malignancies. (Ann Thorac Surg 2001;72:2111–3) © 2001 by The Society of Thoracic Surgeons
CASE REPORT Le GARFF ET AL RECURRENT PNEUMOTHORAX
2111
extremity of the left femur was diagnosed in 1989 and treated by neoadjuvant chemotherapy, followed by a limb-sparing surgical procedure with insertion of a knee prosthesis and then adjuvant chemotherapy. In the initial extension assessment, chest tomography revealed no metastasis. Complete remission was obtained in September 1989. In January 1993, the patient was hospitalized with a completely spontaneous right pneumothorax, which required placement of a chest tube. A chest computed tomographic scan revealed a thin-walled cavity with a small calcified nodule in its inner edge, in the upper right axillary region (Fig 1). The possibility of a secondary location was considered and we decided to perform computed tomography 2 months later to evaluate the progression of the cavitary lesion. The patient did not show up for this examination. In August 1993, the patient was hospitalized for a first relapse of spontaneous right pneumothorax, and was again treated by means of a chest tube. This first recurrence was rapidly followed by a second. A chest computed tomographic scan showed the same cystic lesion, scarcely increased. The calcified nodule was unchanged. However, the wall of the cavitary lesion appeared thickened. There was perilobular and pleural thickening close to the lesion, which remained unique. The nodule was completely excised surgically by means of thoracotomy. The nodule showed histologic features of metastasis of osteosarcoma with pleural extension. Two neoplastic arterial emboli were noted. Two months after the operation, a chest computed tomographic scan revealed a stapler’s line, surrounded by linear thickenings and ground-glass areas, with pleural thickening occupying the space left by excision. This was considered to be secondary to the surgical procedure and had partly disappeared on a computed tomographic scan performed 14 months later (Fig 2). In 2000, in the absence of any other specific treatment, the patient was considered in complete remission.
M
etastatic causes of pneumothorax are rare but must be considered in patients with a history of neoplastic disease. We report the case of a man (born in 1962) with recurrent pneumothorax. Osteoblastic osteosarcoma of the inferior
Accepted for publication Mar 1, 2001. Address reprint requests to Dr Delaval, Service de Pneumologie, Centre Cardio-Pneumologique, Hoˆ pital Pontchaillou-CHU, 35033 Rennes Cedex, France; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Thin-walled cavity, with small calcified nodule, in the upper right axillary region. 0003-4975/01/$20.00 PII S0003-4975(01)02694-7