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Repair of complex subvalvular aortic aneurysm with a valved conduit
Volume 90 Number 2
Brief communications
30 3
August. 1985
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nous vein. Long-term results of bilateral internal mammary artery grafting. Ann Thorac Surg 36:540-547, 1983 Barner HB: Double internal mamrnary--eoronary artery bypass. Arch Surg 109:627-630, 1974 Geha AS: Crossed double internal mamrnary-to--eoronary artery grafts. Indications, techniques and results. Arch Surg 111:289-292, 1976 Bical 0, Bachet J, Laurian C, Camilleri JP, Goudot B, Menu P, Guilmet D: Aortocoronary bypass with homologous saphenous vein. Long-term results. Ann Thorac Surg 30:550-557, 1980 Seifert D, Birchs W, Hahle J: Aorto-coronary bypass grafts using cephalic veins (abstr). Thorac Cardiovasc Surg 30:15, 1982 Silver GH, Katshe GE: Clinical experiences with stabilized human umbilical vein in coronary bypass surgery. A preliminary report. Vasc Surg 14: 192, 1980 Sapsford RN, Oakley GD, Talbot S: Early and late patency of expanded polytetrafluoroethylene vascular grafts in aorta-coronary bypass. J THORAC CARDIOVASC SURG 81:860, 1981
Repair of complex subvalvular aortic aneurysm with a valved conduit Jan D. Galla, M.D., M. Arisan Ergin, M.D., Steven L. Lansman, M.D., Robert C. Lowery, M.D., and Randall B. Griepp, M.D., Brooklyn, N. Y. From the Division of Cardia-thoracic Surgery, Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, N. Y.
A subaortic annular aneurysm involving three fourths of the annular circumference was repaired with a valved conduit to which a Teflon felt flange was attached. This unique prosthetic repair assured a strong stable repair and uncompromised coronary flow otherwise unobtainable with previouslydescribed repairs. Once thought to be a rare and almost uniformly fatal condition,"? subvalvular aneurysms are being reported with increasing frequency and, with the aid of current cardiopulmonary bypass techniques, are often being successfully repaired.r" In the subaortic position, however, only four previous successful cases of surgical correction have been recorded.v- 11, 12 three with longterm survival.v 11.12 We now describe a novel technique used in the fifth successful repair of this condition. Case report. A 38-year-old Haitian woman was referred after evaluation of increasingly severe angina pectoris and dyspnea on exertion of 1 year's duration. Past medical history Address for reprints: Dr. R. B. Griepp, Box 40, 450 Clarkson Ave., Brooklyn, N. Y. 11203.
Fig. 1
was negative for congenital heart disease, rheumatic fever, collagen-vascular disease, coronary artery disease, or venereal disease. The patient had tolerated four normal pregnancies without difficulty. Physical examination revealed bounding pulses in the extremities, visible carotid pulsations, a hyperactive precordium, and a Grade 3/6 diastolic blowing murmur along the left sternal border; no apical murmurs were heard. The chest x-ray film showed mild cardiomegaly. At cardiac catheterization, mean right atrial pressure was 9, pulmonary capillary wedge pressure 25, left ventricular pressure 125/32, and aortic pressure 130/50 mrn Hg. The cardiac index was 3.5 L/min/m 2• Injection into the ascending aorta revealed a dilated root with 4+ aortic regurgitation, both valvular and paravalvular in nature. The right and left coronary arteries were normal. A diagnosis of severe aortic regurgitation, possibly secondary to a left ventricular-aortic tunnel, was made. At operation, through sternal splitting and groin incisions, cardiopulmonary bypass was established using left common femoral arterial return. Inspection of the heart revealed a dilated and hypertrophied left ventricle with normal contractility; palpation of the heart revealed aneurysms posterior to the pulmonary artery beneath the left coronary artery and posterior to the aorta on the roof of the left atrium. After aortotomy, a small (2 mm) aorta-left ventricular tunnel was noted at the base of the left coronary sinus, with the ventricular end opening into the subannular aneurysm. Although the aortic and mitral valves were grossly normal, a large multilobulated aneurysm inferior to the aortic valve extended laterally to the left, anteriorly into the septum, and posteriorly onto the roof of the left atrium. Dilation and distortion of the aortic anulus resulted in severe central insufficiency (Fig. 1).
304
The Journal of Thoracic and Cardiovascular Surgery
Brief communications
Fig. 3
Because of the size and extent of the aneurysm, repair by primary or patch closure did not appear feasible. Accordingly, after excision of the distorted aortic valve, a composite graft consisting of a 25 mm Ionescu-Shiley valved conduit, with 1.2 cm Teflon felt washer fixed to the sewing ring, was sewn to the left ventricular crest with interrupted pledget-supported horizontal mattress sutures, excluding the subannular aneurysm (Figs. 2 and 3). Care was taken to place the conduit anterior to the mitral anulus to avoid compromise of mitral valve function. The left coronary artery, on an aortic button, was reimplanted on the graft, and the graft and distal ascending aorta were then anastomosed. A button of aorta containing the right coronary
artery was sutured to the conduit anteriorly. The patient was uneventfully weaned from bypass; the pericardium was closed with glutaraldehyde-preserved pericardium, and the chest was closed in routine fashion. Except for implantation of a permanent demand pacemaker on the second postoperative day, following two episodes of third degree atrioventricular block, the patient's postoperative course was uneventful. A follow-upcatheterization was performed 3 weeks postoperatively. At that time, the chest x-ray film revealed mild cardiomegaly and clear lungs. The electrocardiogram showed sinus tachycardia, left axis deviation, and a right bundle branch block. At catheterization, left ventricular and aortic
Volume 90 Number 2
Brief communications
30 5
August, 1985
Fig. 4 pressures were 155/8 and 145/75 mm Hg, respectively, and the ejection fracture was 0.52. No aortic regurgitation was demonstrated, but mild mitral insufficiency was seen, with a systolic bulge of the anterior mitral valve leaflet (Fig. 4, A). These changes were consistent with positioning of the prosthesis. The aortogram in Fig. 4, B demonstrates the wide separation between the coronary arteries and the aortic valve prosthesis. The patient was asymptomatic when seen I year postoperatively. She is presently in New York Heart Association Class I and requires no medications.
Discussion. Previously described repairs of subaortic annular aneurysms utilized either primary>!' or patchv" closure of the aneurysm with aortic valve replacement. In the present case, closure of the aneurysm would have required a patch encircling three fourths of the circumference of the left ventricular outflow tract. The decreased visualization of this area through the normal-sized aorta, resulting from the 2 em downward displacement of the left ventricular outflow tract crest below the aortic anulus, made placement of a large patch technically difficult. We believed that the easiest repair of the defect was to place a valved conduit on the crest of the septum, thereby excluding the aneurysm. The dilatation of the left ventricular outflow tract, however, precluded this repair with a standard valved conduit. Accordingly, the flanged prosthesis was constructed by suturing a 12 mm piece of Teflon felt to the valved conduit. This flanged construction permitted a firm anchoring of the valved conduit to the dilated ventricular crest. Anastomosis of the coronary artery orifices to the conduit and sewing of the conduit to the ascending aorta were easily accomplished. By this technique, the aneurysm was completely excluded from the ventricular outflow and the coronary arteries were connected without tension or angulation. Composite grafts have frequently been used to repair
ascending aortic aneurysms.'>" The present case, however, is the first reported use of a composite graft to repair a subannular aneurysm. The development of pseudoaneurysms or perianastomotic hemorrhages, sometimes associated with composite grafts," has not occurred. The complete heart block seen in this patient was accepted as an effect of the repair. This was easily treated with a pacemaker, and sinus rhythm had reappeared by the time of the postoperative angiogram 3 weeks later. The long-term results of this repair are comparable to those of earlier authors," II. 12 with the patient able to resume her normal symptom-free lifestyle. We believethat the use of a flanged valved conduit in the repair of subaortic annular aneurysms offers an acceptable approach to this difficult surgical problem and should be considered whenever correction of this defect is attempted.
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REFERENCES Burn CG, Hollander AG, Crawford JH: Rare cardiac aneurysm in a child. Am Heart J 26:415-481, 1942 Lurie AO: Left ventricular aneurysm in the African. Br Heart J 22:181-188, 1960 Robertson JH, Jackson JG: Cardiac aneurysms in Nigeria. J Pathol 80:101-109, 1960 Waldhausen JA, Petry EL, Kurlander GJ: Successful repair of subvalvular annular aneurysm of the left ventricle. N Engl J Med 72:984-987, 1966 Collins JJ, Matloff JM, Harken DE: Surgical repair of subaortic annular aneurysm. J THORAC CARDIOVASC SURG 57:764-769,1969 Puig-Massana M, Murtra M, Castells E, Revuelta JM: Repair and long-term follow-up of a subaortic annular aneurysm. J THoRAc CARDIOVASC SURG 61:397-402, 1971 Asano K, Hirono T, Matsukawa T: Subvalvular annular
3 0 6 Brief communications
8
9
10
II
12
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15
aneurysm of the left ventricle. Case report of a Japanese girl with successful surgical treatment. J Cardiovasc Surg 19:238-242, 1973 Villani M, Velitti F, Bianchi T, Vanini V, Locatelli G, Tiraboschi R, Parenzan L: Aneurisma del ventricolo sinistro in eta pediatrica. G Ital Cardiol 6:501-508, 1976 Wolpowitz A, Arman B, Barnard MS, Barnard CN: Annular subvalvular idiopathic left ventricular aneurysm in the black African. Ann Thorac Surg 27:350-355, 1979 Thadani U, Lynn RB, Parker JO: Submitral annular left ventricular aneurysm. Unusual echocardiographic and angiographic features. Cathet Cardiovasc Diagn 4:163174,1978 Olowoyeye JO, Thadini U, Charrette EJP, Salerno TA, Parker JO: Subaortic annular left ventricular aneurysm. An unusual cause of aortic regurgitation. Cathet Cardiavase Diagn 6:285-291, 1980 Lavee J, Milo S, Pelled B, Tov AS, Neufeld HN, Goor DA: Successful surgical repair of subaortic annular aneurysm, discrete membranous subaortic stenosis, and valvular aortic stenosis and incompetence. Case report and review of the literature. J THORAC CARDIOVASC SURG 82:79-793, 1981 Mayer JE Jr, Lindsay WG, Wang Y, Jorgensen GR, Nicoloff DM: Composite replacement of the aortic valve and ascending aorta. J THORAC CARDIOVASC SURG 76:816-823,1978 Singh MP, Bentall HH: Complete replacement of the ascending aorta and the aortic valve for the treatment of aortic aneurysm. J THORAC CARDIOVASC SURG 63:218225, 1972 Kouchoukos NT, Karp RB, Blackstone EH, Kirklin JW, Pacifico AD, Zorn GL: Replacement of the ascending aorta and aortic valvewith a composite graft. Results in 86 patients. Ann Surg 192:403-413, 1980
the Journal of Thoracic and Cardiovascular Surgery
Tumors of the thymus gland are rare anterior mediastinal tumors.I' Thymomas may be associated with myasthenia gravis in a proportion of patients. The incidence of thymolipoma, which is a mixed tumor of thymic and adipose tissue, is low-reportedly 2% to 9% of all thymic tumors. I, 3-6 To our knowledge the presentation of a thymolipoma in association with proved Hodgkin's disease has not been previously reported. Case report. A 20-year-old asymptomatic man had an enlarged gland on the right side of the neck. A biopsyspecimen of this gland showed Hodgkin's disease, and the man underwent exploratory laparotomy and splenectomy, A chest x-ray film showed a large opacity extending from the anterior mediastinum into the right hemithorax (Fig. 1). This opacity effectively filled the angle between the right hemidiaphragm and the heart, and it extended as far as the lateral chest wall. A lateral chest x-ray film confirmed complete aeration of the right lung lying posterior to the opacity. The patient received chemotherapy for 6 months and had a complete remission of his Hodgkin's disease. However, there was no change in the chest x-ray appearances. A computed axial tomographic (CAT) scan showed a semisolidmass arising from the anterior mediastinum, containing translucencies of fat density (Fig. 2). There was no clinical or radiologic evidence of residual Hodgkin's disease. Because of the unknown nature of this lesion, recommendation was made to the patient to undergo exploratory thoracotomy. At operation a large lipomatous mass was found lying on the right hemidiaphragm. The tumor extended into the anterior mediastinum and was fed by a large vascular trunk arising from the anterior mediastinum. After incision of the mediastinal pleura, the mass was readily enucleated in toto. The postoperative recovery was entirely uneventful. Histopathology. The mediastinal tumor weighed 1,450gm. The normal thymic lobulation was preserved and the entire surface was covered by a thin capsule. It was soft, and the cut surface showed the yellow color of fat interspersed with a fine mesh of thin white strands. Microscopically, the tumor
Thymolipoma in association with Hodgkin's disease Ravi Pillai, F.R.C.S., Noel Yeoh, F.R.C.S., Bruce Addis, M.R.C.Path., Michael Peckham, F.R.C.R., and Peter Goldstraw, F.R.C.S., London and Sutton,
England From the Brompton Hospital, London, and the Royal Marsden Hospital, Sutton, England.
Thymolipomas are rare mediastinal tumors. They have been described with a variety of systemic diseases. To our knowledge they have never been described in association with Hodgkin's disease. The significance of this association is unknown. Address for correspondence: Peter Goldstraw, Brompton Hospital, Fulham Road, London SW3 6HP, England.
Fig. 1. Chest x-ray film showing the mediastinal mass arising from the mediastinum and extending into the right pleural cavity.
Brief communications
30 3
August. 1985
12 13
14
15
16
17
nous vein. Long-term results of bilateral internal mammary artery grafting. Ann Thorac Surg 36:540-547, 1983 Barner HB: Double internal mamrnary--eoronary artery bypass. Arch Surg 109:627-630, 1974 Geha AS: Crossed double internal mamrnary-to--eoronary artery grafts. Indications, techniques and results. Arch Surg 111:289-292, 1976 Bical 0, Bachet J, Laurian C, Camilleri JP, Goudot B, Menu P, Guilmet D: Aortocoronary bypass with homologous saphenous vein. Long-term results. Ann Thorac Surg 30:550-557, 1980 Seifert D, Birchs W, Hahle J: Aorto-coronary bypass grafts using cephalic veins (abstr). Thorac Cardiovasc Surg 30:15, 1982 Silver GH, Katshe GE: Clinical experiences with stabilized human umbilical vein in coronary bypass surgery. A preliminary report. Vasc Surg 14: 192, 1980 Sapsford RN, Oakley GD, Talbot S: Early and late patency of expanded polytetrafluoroethylene vascular grafts in aorta-coronary bypass. J THORAC CARDIOVASC SURG 81:860, 1981
Repair of complex subvalvular aortic aneurysm with a valved conduit Jan D. Galla, M.D., M. Arisan Ergin, M.D., Steven L. Lansman, M.D., Robert C. Lowery, M.D., and Randall B. Griepp, M.D., Brooklyn, N. Y. From the Division of Cardia-thoracic Surgery, Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, N. Y.
A subaortic annular aneurysm involving three fourths of the annular circumference was repaired with a valved conduit to which a Teflon felt flange was attached. This unique prosthetic repair assured a strong stable repair and uncompromised coronary flow otherwise unobtainable with previouslydescribed repairs. Once thought to be a rare and almost uniformly fatal condition,"? subvalvular aneurysms are being reported with increasing frequency and, with the aid of current cardiopulmonary bypass techniques, are often being successfully repaired.r" In the subaortic position, however, only four previous successful cases of surgical correction have been recorded.v- 11, 12 three with longterm survival.v 11.12 We now describe a novel technique used in the fifth successful repair of this condition. Case report. A 38-year-old Haitian woman was referred after evaluation of increasingly severe angina pectoris and dyspnea on exertion of 1 year's duration. Past medical history Address for reprints: Dr. R. B. Griepp, Box 40, 450 Clarkson Ave., Brooklyn, N. Y. 11203.
Fig. 1
was negative for congenital heart disease, rheumatic fever, collagen-vascular disease, coronary artery disease, or venereal disease. The patient had tolerated four normal pregnancies without difficulty. Physical examination revealed bounding pulses in the extremities, visible carotid pulsations, a hyperactive precordium, and a Grade 3/6 diastolic blowing murmur along the left sternal border; no apical murmurs were heard. The chest x-ray film showed mild cardiomegaly. At cardiac catheterization, mean right atrial pressure was 9, pulmonary capillary wedge pressure 25, left ventricular pressure 125/32, and aortic pressure 130/50 mrn Hg. The cardiac index was 3.5 L/min/m 2• Injection into the ascending aorta revealed a dilated root with 4+ aortic regurgitation, both valvular and paravalvular in nature. The right and left coronary arteries were normal. A diagnosis of severe aortic regurgitation, possibly secondary to a left ventricular-aortic tunnel, was made. At operation, through sternal splitting and groin incisions, cardiopulmonary bypass was established using left common femoral arterial return. Inspection of the heart revealed a dilated and hypertrophied left ventricle with normal contractility; palpation of the heart revealed aneurysms posterior to the pulmonary artery beneath the left coronary artery and posterior to the aorta on the roof of the left atrium. After aortotomy, a small (2 mm) aorta-left ventricular tunnel was noted at the base of the left coronary sinus, with the ventricular end opening into the subannular aneurysm. Although the aortic and mitral valves were grossly normal, a large multilobulated aneurysm inferior to the aortic valve extended laterally to the left, anteriorly into the septum, and posteriorly onto the roof of the left atrium. Dilation and distortion of the aortic anulus resulted in severe central insufficiency (Fig. 1).
304
The Journal of Thoracic and Cardiovascular Surgery
Brief communications
Fig. 3
Because of the size and extent of the aneurysm, repair by primary or patch closure did not appear feasible. Accordingly, after excision of the distorted aortic valve, a composite graft consisting of a 25 mm Ionescu-Shiley valved conduit, with 1.2 cm Teflon felt washer fixed to the sewing ring, was sewn to the left ventricular crest with interrupted pledget-supported horizontal mattress sutures, excluding the subannular aneurysm (Figs. 2 and 3). Care was taken to place the conduit anterior to the mitral anulus to avoid compromise of mitral valve function. The left coronary artery, on an aortic button, was reimplanted on the graft, and the graft and distal ascending aorta were then anastomosed. A button of aorta containing the right coronary
artery was sutured to the conduit anteriorly. The patient was uneventfully weaned from bypass; the pericardium was closed with glutaraldehyde-preserved pericardium, and the chest was closed in routine fashion. Except for implantation of a permanent demand pacemaker on the second postoperative day, following two episodes of third degree atrioventricular block, the patient's postoperative course was uneventful. A follow-upcatheterization was performed 3 weeks postoperatively. At that time, the chest x-ray film revealed mild cardiomegaly and clear lungs. The electrocardiogram showed sinus tachycardia, left axis deviation, and a right bundle branch block. At catheterization, left ventricular and aortic
Volume 90 Number 2
Brief communications
30 5
August, 1985
Fig. 4 pressures were 155/8 and 145/75 mm Hg, respectively, and the ejection fracture was 0.52. No aortic regurgitation was demonstrated, but mild mitral insufficiency was seen, with a systolic bulge of the anterior mitral valve leaflet (Fig. 4, A). These changes were consistent with positioning of the prosthesis. The aortogram in Fig. 4, B demonstrates the wide separation between the coronary arteries and the aortic valve prosthesis. The patient was asymptomatic when seen I year postoperatively. She is presently in New York Heart Association Class I and requires no medications.
Discussion. Previously described repairs of subaortic annular aneurysms utilized either primary>!' or patchv" closure of the aneurysm with aortic valve replacement. In the present case, closure of the aneurysm would have required a patch encircling three fourths of the circumference of the left ventricular outflow tract. The decreased visualization of this area through the normal-sized aorta, resulting from the 2 em downward displacement of the left ventricular outflow tract crest below the aortic anulus, made placement of a large patch technically difficult. We believed that the easiest repair of the defect was to place a valved conduit on the crest of the septum, thereby excluding the aneurysm. The dilatation of the left ventricular outflow tract, however, precluded this repair with a standard valved conduit. Accordingly, the flanged prosthesis was constructed by suturing a 12 mm piece of Teflon felt to the valved conduit. This flanged construction permitted a firm anchoring of the valved conduit to the dilated ventricular crest. Anastomosis of the coronary artery orifices to the conduit and sewing of the conduit to the ascending aorta were easily accomplished. By this technique, the aneurysm was completely excluded from the ventricular outflow and the coronary arteries were connected without tension or angulation. Composite grafts have frequently been used to repair
ascending aortic aneurysms.'>" The present case, however, is the first reported use of a composite graft to repair a subannular aneurysm. The development of pseudoaneurysms or perianastomotic hemorrhages, sometimes associated with composite grafts," has not occurred. The complete heart block seen in this patient was accepted as an effect of the repair. This was easily treated with a pacemaker, and sinus rhythm had reappeared by the time of the postoperative angiogram 3 weeks later. The long-term results of this repair are comparable to those of earlier authors," II. 12 with the patient able to resume her normal symptom-free lifestyle. We believethat the use of a flanged valved conduit in the repair of subaortic annular aneurysms offers an acceptable approach to this difficult surgical problem and should be considered whenever correction of this defect is attempted.
2 3 4
5
6
7
REFERENCES Burn CG, Hollander AG, Crawford JH: Rare cardiac aneurysm in a child. Am Heart J 26:415-481, 1942 Lurie AO: Left ventricular aneurysm in the African. Br Heart J 22:181-188, 1960 Robertson JH, Jackson JG: Cardiac aneurysms in Nigeria. J Pathol 80:101-109, 1960 Waldhausen JA, Petry EL, Kurlander GJ: Successful repair of subvalvular annular aneurysm of the left ventricle. N Engl J Med 72:984-987, 1966 Collins JJ, Matloff JM, Harken DE: Surgical repair of subaortic annular aneurysm. J THORAC CARDIOVASC SURG 57:764-769,1969 Puig-Massana M, Murtra M, Castells E, Revuelta JM: Repair and long-term follow-up of a subaortic annular aneurysm. J THoRAc CARDIOVASC SURG 61:397-402, 1971 Asano K, Hirono T, Matsukawa T: Subvalvular annular
3 0 6 Brief communications
8
9
10
II
12
13
14
15
aneurysm of the left ventricle. Case report of a Japanese girl with successful surgical treatment. J Cardiovasc Surg 19:238-242, 1973 Villani M, Velitti F, Bianchi T, Vanini V, Locatelli G, Tiraboschi R, Parenzan L: Aneurisma del ventricolo sinistro in eta pediatrica. G Ital Cardiol 6:501-508, 1976 Wolpowitz A, Arman B, Barnard MS, Barnard CN: Annular subvalvular idiopathic left ventricular aneurysm in the black African. Ann Thorac Surg 27:350-355, 1979 Thadani U, Lynn RB, Parker JO: Submitral annular left ventricular aneurysm. Unusual echocardiographic and angiographic features. Cathet Cardiovasc Diagn 4:163174,1978 Olowoyeye JO, Thadini U, Charrette EJP, Salerno TA, Parker JO: Subaortic annular left ventricular aneurysm. An unusual cause of aortic regurgitation. Cathet Cardiavase Diagn 6:285-291, 1980 Lavee J, Milo S, Pelled B, Tov AS, Neufeld HN, Goor DA: Successful surgical repair of subaortic annular aneurysm, discrete membranous subaortic stenosis, and valvular aortic stenosis and incompetence. Case report and review of the literature. J THORAC CARDIOVASC SURG 82:79-793, 1981 Mayer JE Jr, Lindsay WG, Wang Y, Jorgensen GR, Nicoloff DM: Composite replacement of the aortic valve and ascending aorta. J THORAC CARDIOVASC SURG 76:816-823,1978 Singh MP, Bentall HH: Complete replacement of the ascending aorta and the aortic valve for the treatment of aortic aneurysm. J THORAC CARDIOVASC SURG 63:218225, 1972 Kouchoukos NT, Karp RB, Blackstone EH, Kirklin JW, Pacifico AD, Zorn GL: Replacement of the ascending aorta and aortic valvewith a composite graft. Results in 86 patients. Ann Surg 192:403-413, 1980
the Journal of Thoracic and Cardiovascular Surgery
Tumors of the thymus gland are rare anterior mediastinal tumors.I' Thymomas may be associated with myasthenia gravis in a proportion of patients. The incidence of thymolipoma, which is a mixed tumor of thymic and adipose tissue, is low-reportedly 2% to 9% of all thymic tumors. I, 3-6 To our knowledge the presentation of a thymolipoma in association with proved Hodgkin's disease has not been previously reported. Case report. A 20-year-old asymptomatic man had an enlarged gland on the right side of the neck. A biopsyspecimen of this gland showed Hodgkin's disease, and the man underwent exploratory laparotomy and splenectomy, A chest x-ray film showed a large opacity extending from the anterior mediastinum into the right hemithorax (Fig. 1). This opacity effectively filled the angle between the right hemidiaphragm and the heart, and it extended as far as the lateral chest wall. A lateral chest x-ray film confirmed complete aeration of the right lung lying posterior to the opacity. The patient received chemotherapy for 6 months and had a complete remission of his Hodgkin's disease. However, there was no change in the chest x-ray appearances. A computed axial tomographic (CAT) scan showed a semisolidmass arising from the anterior mediastinum, containing translucencies of fat density (Fig. 2). There was no clinical or radiologic evidence of residual Hodgkin's disease. Because of the unknown nature of this lesion, recommendation was made to the patient to undergo exploratory thoracotomy. At operation a large lipomatous mass was found lying on the right hemidiaphragm. The tumor extended into the anterior mediastinum and was fed by a large vascular trunk arising from the anterior mediastinum. After incision of the mediastinal pleura, the mass was readily enucleated in toto. The postoperative recovery was entirely uneventful. Histopathology. The mediastinal tumor weighed 1,450gm. The normal thymic lobulation was preserved and the entire surface was covered by a thin capsule. It was soft, and the cut surface showed the yellow color of fat interspersed with a fine mesh of thin white strands. Microscopically, the tumor
Thymolipoma in association with Hodgkin's disease Ravi Pillai, F.R.C.S., Noel Yeoh, F.R.C.S., Bruce Addis, M.R.C.Path., Michael Peckham, F.R.C.R., and Peter Goldstraw, F.R.C.S., London and Sutton,
England From the Brompton Hospital, London, and the Royal Marsden Hospital, Sutton, England.
Thymolipomas are rare mediastinal tumors. They have been described with a variety of systemic diseases. To our knowledge they have never been described in association with Hodgkin's disease. The significance of this association is unknown. Address for correspondence: Peter Goldstraw, Brompton Hospital, Fulham Road, London SW3 6HP, England.
Fig. 1. Chest x-ray film showing the mediastinal mass arising from the mediastinum and extending into the right pleural cavity.