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OLD INTRAPLEURAL HEMATOMA WITH RECENT SUPERIOR VENA CAVAL OBSTRUCTION
OLD INTRAPLEURAL HEMATOMA W I T H RECENT SUPERIOR V E N A CAVAL
OBSTRUCTION
A Case Report John H. Mayer, Jr., M.D.*
Hector W. Benoit, Jr.,
and Martin L. Crow, M.D.,***
M.D.**
Kansas City, Mo.
S
vena caval obstruction is a discouraging and ominous sign because in a high percentage of cases the obstruction is due to an inoperable malignancy. In 64 cases reviewed by Effler and Groves,1 48 patients had malignant neoplasms and only 16 had obstruction due to benign disease. Although it is generally agreed that surgical interference in cases of superior vena caval obstruction due to malignancy yields uniformly unrewarding results, an occasional patient with benign disease has been surgically benefited. Therefore, it is important that surgery be considered in a patient in whom there is reasonable evidence that the obstruction is due to benign disease. The following case presents just such a problem. The recent onset of superior vena caval obstruction in the presence of long-standing calcined intrapleural hematoma makes the case unusual and constitutes a difficult diagnostic and technical problem. UPERIOR
CASE REPORT This 57-year-old Negro blacksmith was admitted to the hospital on April 13, 1962, with the chief complaint of "swelling" in his neck. For two weeks prior to his admission he had noted a steady and progressive increase in neck size and distention of the vessels. I n 1938 he had been stabbed in the suprasternal notch and was treated for "internal bleeding" in a hospital. In the fall of 1938 he was treated in another hospital with multiple thoracenteses on the right side in an a t t e m p t to evacuate the hematoma. He was told there was nothing further to be done for him. I n J u l y of 1961 he underwent an elective herniorrhaphy and made an uneventful recovery. He had had progressive exertional dyspnea for a number of years. From the Thoracic Surgery Service of St. Mary's Hospital and Kansas City General Hospital and Medical Center, Kansas City, Mo. Received for publication Dec. 26, 1962. •Chief of Thoracic Surgery Service, Kansas City General Hospital and Medical Center; Active Staff, St. Mary's Hospital, Kansas City, Mo. ••Active Staff of St. Mary's Hospital and Kansas City General Hospital and Medical Center, Kansas City, Mo. •••Resident in Surgery, Kansas City General Hospital and Medical Center, Kansas City, Mo. 725
726
MAYER, B E N O I T , CROW
J. Thoracic and Cardiovas. Surg.
F i g . 1 . — R o e n t g e n o g r a m d a t e d Sept. 5, 1951, s h o w s t h e l a r g e h e m a t o m a w i t h calcification present. F i g . 2 . — R o e n t g e n o g r a m d a t e d April 15, 1962, s h o w s t h e h e m a t o m a h a s i n c r e a s e d in size, a n d a n e w d e n s i t y is p r e s e n t in t h e r i g h t s u p e r i o r m e d i a s t i n a l a r e a .
F i g . 3 . — V e n o g r a m d a t e d April 23, 1962, s h o w s t h e site of o b s t r u c t i o n .
Vol. 45. No. 6
June, 1963
I N T R A P L E U R A L HEMATOMA
727
Physical Examination.—This was a well-developed, well-nourished, muscular Negro man with a soft mass in the suprasternal notch, which proved to be dilated tortuous veins. The blood pressure was 104/86 mm. H g in both arms. The trachea was shifted to the left. The left lung field was clear. There was dullness over the entire right chest and breath sounds were absent. No bruit was heard. The heart was slightly enlarged, with regular rhythm and without murmur. Examination of the abdomen revealed only a well-healed right inguinal herniorrhaphy scar. Laboratory Work.—Hemogram, blood chemistry studies, and urinalysis were within normal limits, and remained so throughout his hospital stay. An electrocardiogram showed right auricular and ventricular strain with low QRS complexes.
Fig. 4.—May 8, 1962, postoperative chest film shows good expansion and return of the trachea to the midline.
Bocntgenograms.—Periodic roentgenograms dating to 1951 showed a large, partially calcified density occupying most of the right hemithorax (Fig. 1). Over the course of 11 years there had been progressive shift of the mediastinum to the left. On recent roentgenograms there was an additional shadow in the right superior mediastinal area (Fig. 2 ) . A venogram revealed the site of vena caval obstruction (Fig. 3 ) . The venous pressure in the right arm was 412 mm. of water. Course in Hospital.—On April 16, 1962, bronchoscopic examination revealed marked shift of the trachea to the left without intrinsic lesions. There was considerable extrinsic compression of the right lower lobe orifices. Scalene fat pad dissection revealed a hematomatous mass. Microscopic examination of bronchial secretions and scalene fat pad was negative for malignancy. On April 21, 1962, 1,200 c.c. of chocolate-colored fluid was removed from the intrapleural hematoma by thoracentesis, with relief of dyspnea but without any appreciable diminution in neck vein size. On April 26, 1962, a right thoracotomy was performed. A large, partially calcified intrapleural hematoma was found and was removed with considerable difficulty. A
MAYER, B E N O I T , CROW
728
J. Thoracic and C'ardiovas. Surg.
second smaller hematoma under pressure, containing old blood, was overlying and markedly compressing the posterolateral wall of the superior vena cava. A fibrous band was connecting the two hematomas. The obstructing hematoma was saucerized and its contents removed. Following evacuation of this hematoma, the superior vena cava was noted to fill well, and the anesthesiologist commented t h a t the neck vein distention had markedly decreased. The postoperative roentgenogram revealed a well-expanded right lung (Fig. 4 ) . The venous pressure in the right arm was reduced to 130 mm. of water. The patient was discharged 10 days after thoracotomy. DISCUSSION
Superior vena caval obstruction is one of the clinical criteria of inoperability in malignancy. However, the practical problem that occasionally presents is the patient with caval obstruction whose radiographic lesion suggests malignancy, but in whom tissue confirmation cannot be obtained, short of thoracotomy. Thoracotomy in such a patient has a significant technical and postoperative hazard, and is best avoided if possible. The appearance in this patient of a new superior mediastinal shadow with the onset of superior vena caval obstruction raised the serious question of malignancy. Inasmuch as we were unable to incriminate malignancy as the cause of the obstruction, we believed exploration was warranted. This decision was influenced by the presence of the large intrapleural hematoma. We were hopeful that the superior vena caval obstruction was in some way related to this process and would lend itself to surgical relief. Early pulmonary decortication for intrapleural hematoma has been generally accepted as the treatment of choice. This case was unusual because the hematoma remained untreated for such a long time. The ability of the lung to re-expand after 24 years of compression was gratifying, and a key factor in the uneventful postoperative course of this patient. Even in the present era of antibiotics, the elimination of the pleural space is essential in the prevention of complications. Potential infection and decreased vital capacity should be given consideration as indications for the decortication of old intrapleural hematoma.2 The exact etiology of the delayed enlargement of the mediastinal hematoma is somewhat vague. The adsorption of fluid into the hematoma probably was the major factor, but why it took twenty-four years to produce symptoms is an interesting question. We have postulated that the fibrous connection between the lesser and greater hematomas originally was a channel, which recently became obliterated. Thereafter, the smaller hematoma became progressively distended by fluid adsorption and compressed the superior vena cava.3 SUMMARY
A case is presented of an intrapleural hematoma of twenty-four years' duration, with superior vena caval obstruction of 2 weeks' duration. This was successfully treated by operation. Even though the technical hazards of late decortication are appreciable, it is justified to prevent infections, loss of vital capacity, or, as in this case, relief of severe caval obstruction. The important relationship of malignancy and superior vena caval obstruction is discussed and emphasized.
Vol. 45, No. 6 June, 1963
INTBAPLETJRAL HEMATOMA
729
REFERENCES
1. Effler, D. B., and Groves, L. K.: Superior Vena Cava Obstruction, J. THORACIC SURG. 4 3 : 574-584, 1962. 2. Samson, P . C , and Burford, T. H . : Total Pulmonary Decortication, J . THORACIC SURG. 16: 127-144, 1947. 3. Cote, J., Hodgson, C. H., and Ellis, F . H . : Traumatic Mediastinal Hematonia, Staff Meet. Mayo Clin. 34: 264-268, 1959.
OBSTRUCTION
A Case Report John H. Mayer, Jr., M.D.*
Hector W. Benoit, Jr.,
and Martin L. Crow, M.D.,***
M.D.**
Kansas City, Mo.
S
vena caval obstruction is a discouraging and ominous sign because in a high percentage of cases the obstruction is due to an inoperable malignancy. In 64 cases reviewed by Effler and Groves,1 48 patients had malignant neoplasms and only 16 had obstruction due to benign disease. Although it is generally agreed that surgical interference in cases of superior vena caval obstruction due to malignancy yields uniformly unrewarding results, an occasional patient with benign disease has been surgically benefited. Therefore, it is important that surgery be considered in a patient in whom there is reasonable evidence that the obstruction is due to benign disease. The following case presents just such a problem. The recent onset of superior vena caval obstruction in the presence of long-standing calcined intrapleural hematoma makes the case unusual and constitutes a difficult diagnostic and technical problem. UPERIOR
CASE REPORT This 57-year-old Negro blacksmith was admitted to the hospital on April 13, 1962, with the chief complaint of "swelling" in his neck. For two weeks prior to his admission he had noted a steady and progressive increase in neck size and distention of the vessels. I n 1938 he had been stabbed in the suprasternal notch and was treated for "internal bleeding" in a hospital. In the fall of 1938 he was treated in another hospital with multiple thoracenteses on the right side in an a t t e m p t to evacuate the hematoma. He was told there was nothing further to be done for him. I n J u l y of 1961 he underwent an elective herniorrhaphy and made an uneventful recovery. He had had progressive exertional dyspnea for a number of years. From the Thoracic Surgery Service of St. Mary's Hospital and Kansas City General Hospital and Medical Center, Kansas City, Mo. Received for publication Dec. 26, 1962. •Chief of Thoracic Surgery Service, Kansas City General Hospital and Medical Center; Active Staff, St. Mary's Hospital, Kansas City, Mo. ••Active Staff of St. Mary's Hospital and Kansas City General Hospital and Medical Center, Kansas City, Mo. •••Resident in Surgery, Kansas City General Hospital and Medical Center, Kansas City, Mo. 725
726
MAYER, B E N O I T , CROW
J. Thoracic and Cardiovas. Surg.
F i g . 1 . — R o e n t g e n o g r a m d a t e d Sept. 5, 1951, s h o w s t h e l a r g e h e m a t o m a w i t h calcification present. F i g . 2 . — R o e n t g e n o g r a m d a t e d April 15, 1962, s h o w s t h e h e m a t o m a h a s i n c r e a s e d in size, a n d a n e w d e n s i t y is p r e s e n t in t h e r i g h t s u p e r i o r m e d i a s t i n a l a r e a .
F i g . 3 . — V e n o g r a m d a t e d April 23, 1962, s h o w s t h e site of o b s t r u c t i o n .
Vol. 45. No. 6
June, 1963
I N T R A P L E U R A L HEMATOMA
727
Physical Examination.—This was a well-developed, well-nourished, muscular Negro man with a soft mass in the suprasternal notch, which proved to be dilated tortuous veins. The blood pressure was 104/86 mm. H g in both arms. The trachea was shifted to the left. The left lung field was clear. There was dullness over the entire right chest and breath sounds were absent. No bruit was heard. The heart was slightly enlarged, with regular rhythm and without murmur. Examination of the abdomen revealed only a well-healed right inguinal herniorrhaphy scar. Laboratory Work.—Hemogram, blood chemistry studies, and urinalysis were within normal limits, and remained so throughout his hospital stay. An electrocardiogram showed right auricular and ventricular strain with low QRS complexes.
Fig. 4.—May 8, 1962, postoperative chest film shows good expansion and return of the trachea to the midline.
Bocntgenograms.—Periodic roentgenograms dating to 1951 showed a large, partially calcified density occupying most of the right hemithorax (Fig. 1). Over the course of 11 years there had been progressive shift of the mediastinum to the left. On recent roentgenograms there was an additional shadow in the right superior mediastinal area (Fig. 2 ) . A venogram revealed the site of vena caval obstruction (Fig. 3 ) . The venous pressure in the right arm was 412 mm. of water. Course in Hospital.—On April 16, 1962, bronchoscopic examination revealed marked shift of the trachea to the left without intrinsic lesions. There was considerable extrinsic compression of the right lower lobe orifices. Scalene fat pad dissection revealed a hematomatous mass. Microscopic examination of bronchial secretions and scalene fat pad was negative for malignancy. On April 21, 1962, 1,200 c.c. of chocolate-colored fluid was removed from the intrapleural hematoma by thoracentesis, with relief of dyspnea but without any appreciable diminution in neck vein size. On April 26, 1962, a right thoracotomy was performed. A large, partially calcified intrapleural hematoma was found and was removed with considerable difficulty. A
MAYER, B E N O I T , CROW
728
J. Thoracic and C'ardiovas. Surg.
second smaller hematoma under pressure, containing old blood, was overlying and markedly compressing the posterolateral wall of the superior vena cava. A fibrous band was connecting the two hematomas. The obstructing hematoma was saucerized and its contents removed. Following evacuation of this hematoma, the superior vena cava was noted to fill well, and the anesthesiologist commented t h a t the neck vein distention had markedly decreased. The postoperative roentgenogram revealed a well-expanded right lung (Fig. 4 ) . The venous pressure in the right arm was reduced to 130 mm. of water. The patient was discharged 10 days after thoracotomy. DISCUSSION
Superior vena caval obstruction is one of the clinical criteria of inoperability in malignancy. However, the practical problem that occasionally presents is the patient with caval obstruction whose radiographic lesion suggests malignancy, but in whom tissue confirmation cannot be obtained, short of thoracotomy. Thoracotomy in such a patient has a significant technical and postoperative hazard, and is best avoided if possible. The appearance in this patient of a new superior mediastinal shadow with the onset of superior vena caval obstruction raised the serious question of malignancy. Inasmuch as we were unable to incriminate malignancy as the cause of the obstruction, we believed exploration was warranted. This decision was influenced by the presence of the large intrapleural hematoma. We were hopeful that the superior vena caval obstruction was in some way related to this process and would lend itself to surgical relief. Early pulmonary decortication for intrapleural hematoma has been generally accepted as the treatment of choice. This case was unusual because the hematoma remained untreated for such a long time. The ability of the lung to re-expand after 24 years of compression was gratifying, and a key factor in the uneventful postoperative course of this patient. Even in the present era of antibiotics, the elimination of the pleural space is essential in the prevention of complications. Potential infection and decreased vital capacity should be given consideration as indications for the decortication of old intrapleural hematoma.2 The exact etiology of the delayed enlargement of the mediastinal hematoma is somewhat vague. The adsorption of fluid into the hematoma probably was the major factor, but why it took twenty-four years to produce symptoms is an interesting question. We have postulated that the fibrous connection between the lesser and greater hematomas originally was a channel, which recently became obliterated. Thereafter, the smaller hematoma became progressively distended by fluid adsorption and compressed the superior vena cava.3 SUMMARY
A case is presented of an intrapleural hematoma of twenty-four years' duration, with superior vena caval obstruction of 2 weeks' duration. This was successfully treated by operation. Even though the technical hazards of late decortication are appreciable, it is justified to prevent infections, loss of vital capacity, or, as in this case, relief of severe caval obstruction. The important relationship of malignancy and superior vena caval obstruction is discussed and emphasized.
Vol. 45, No. 6 June, 1963
INTBAPLETJRAL HEMATOMA
729
REFERENCES
1. Effler, D. B., and Groves, L. K.: Superior Vena Cava Obstruction, J. THORACIC SURG. 4 3 : 574-584, 1962. 2. Samson, P . C , and Burford, T. H . : Total Pulmonary Decortication, J . THORACIC SURG. 16: 127-144, 1947. 3. Cote, J., Hodgson, C. H., and Ellis, F . H . : Traumatic Mediastinal Hematonia, Staff Meet. Mayo Clin. 34: 264-268, 1959.