- Email: [email protected]
Third-Time Lung Transplant Using Extended Criteria Lungs
642
CASE REPORT OTO ET AL THIRD-TIME LUNG TRANSPLANT
Ann Thorac Surg 2007;84:642– 4
developmental tumors (ie, neurofibromas, teratoma, and bronchial cysts), and arterial aneurysms. Cross-sectional imaging, either as magnetic resonance imaging or computed tomography are sufficient for accurate diagnosis of venous and arterial aneurysms and allow for planning of surgical strategy [8]. Cardiopulmonary bypass will often be necessary to allow for safe mobilization and resection. The prognosis after successful resection is very good. There are no reported cases of recurrence or of the development of similar lesions elsewhere. These unusual aneurysms should not be forgotten in the differential diagnosis of a mediastinal mass. Despite being a benign lesion and at low pressure, these masses can rapidly enlarge once they reach a critical size.
References
FEATURE ARTICLES Fig 3. Post-repair image showing A, the innominate vein and B, the bovine pericardial patch.
Potential causes include congenital malformations, trauma, inflammation, infection, and degenerative changes in the vessel wall [3]. In a single case, congenital absence of the longitudinal muscle coat of the adventitia has been reported [4]. There has also been an association between cystic hygromas and venous aneurysms and a common origin of both lymphatics and venous drainage reported [5]. Their clinical significance arises from the complications that they can cause. These complications include: (1) the risk of thromboembolism and venous obstruction, (2) the risk of rupture [6] (ie, traumatic [such as line insertion] or spontaneous), and (3) compression of bordering structures. These features need to be taken into account when planning management, which may be conservative for small, nonexpanding aneurysms [7]. In this case, the size, the rapid expansion, and the development of fresh thrombus within the aneurysm precluded conservative treatment. The appendicitis seemed to be incidental, but serendipitously led to the diagnosis being made. The chronic cough was most likely related to the bronchial irritation and atelectasis caused by the tumor and would suggest that it had been growing for a period of years. A rapidly growing mass is an alarming diagnostic dilemma. Differentials included malignant disease (ie, primary and secondary lung cancers, lymphoma), benign © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Burkill GJ, Burn PR, Padley SP. Aneurysm of the left brachiocephalic vein: an unusual cause of mediastinal widening. Br J Radiol 1997;70:837–9. 2. Schellhammer F, Wöbker G, Turowski B. Asymptomatic aneurysm of the subclavian vein. Acta Radiol 2005;46:366 –7. 3. Shatz IJ, Fine G. Venous aneurysms. N Engl J Med 1962;266: 1310 –2. 4. Ream CR, Giardina A. Congenital superior vena cava aneurysm with complications caused by infectious mononucleosis. Chest 1972;62:755–7. 5. Sabin FR. On the origin of the lymphatic system from the veins and the development of the lymph hearts and thoracic duct in the pig. Am J Anat 1902;1:367–91. 6. Taira A, Akita H. Ruptured venous aneurysm of the persistent left superior vena cava. Angiology 1981;32:656 –9. 7. Tsuji A, Katada Y, Tanimoto M, Fujita M. Congenital giant aneurysm of the left innominate vein: is surgical treatment required? Paediatr Cardiol 2004;25:421–3. 8. Gozdziuk K, Czekajska-Chehab E, Wrona A, Tomaszewski A, Drop A. Saccular aneurysm of the superior vena cava detected by computed tomography and successfully treated with surgery. Ann Thorac Surg 2004;78:e94 –5.
Third-Time Lung Transplant Using Extended Criteria Lungs Takahiro Oto, MD, Michael Rowland, FRACS, Anne P. Griffiths, FRCNA, Bronwyn J. Levvey, RN, Donald S. Esmore, FRACS, Trevor J. Williams, FRACP, and Gregory I. Snell, FRACP Lung Transplant Service, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
There is an increasing requirement for lung re-transplants (re-LTx) related to the bronchiolitis obliterans syndrome. Nevertheless, re-LTx, especially second-time re-LTx, poses the dilemma of appropriate allocation of a scarce donor lung resource versus the desire to optimize outcomes for an individual patient. Extended donors have been used to partially alleviate a scarce donor lung Accepted for publication March 9, 2007. Address correspondence to Dr Snell, Department of Allergy, Immunology, and Respiratory Medicine, The Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.03.023
supply with satisfactory outcomes for primary lung transplant. However, the usefulness of the extended donors remains unknown, including donation-after-cardiac-death donors for re-LTx. This report describes a second-time re-LTx using significantly extended donor criteria lungs from a Maastricht category IV donationafter-cardiac-death donor with resultant good clinical outcomes. (Ann Thorac Surg 2007;84:642– 4) © 2007 by The Society of Thoracic Surgeons
W
ith lung transplantation (LTx) as an established therapy for end-stage pulmonary disease, the number of patients potentially requiring a lung retransplant (re-LTx) is increasing related to late graft dysfunction secondary to the bronchiolitis obliterans syndrome (BOS) [1–3]. Nevertheless, lung re-LTx remains a controversial procedure limited by a shortage of donor lungs and potentially inferior outcomes compared with primary LTx [1, 2]. Re-LTx, especially second-time Re-LTx, poses a dilemma of appropriate allocation of a scarce donor lung resource and the desire to optimize outcomes for an individual patient. Extended donors have been used to partially alleviate a scarce donor lung supply with satisfactory outcomes for primary LTx [4, 5]. However, the usefulness of extended donors for re-LTx remains unknown, including donationafter-cardiac-death donors. This report describes a second-time re-LTx using marginal lungs from a Maastricht category IV donation-after-cardiac-death donor. A second-time re-LTx was performed on an otherwise excellent 46-year-old candidate with recurrent BOS using extended donation-after-cardiac-death (Maastricht category IV) donor lungs 4.5 years after the first-time re-LTx. The donor was a larger 27-year-old anoxic brain-dead male who was a marijuana and tobacco smoker with a very abnormal chest roentgenogram, moderate bloody secretions, and deteriorating blood gases (lowest measured Pao2 on 100% oxygen ⫽ 67 mm Hg). The donor left lower lobe had extensive pneumonic change (Fig 1). These organs had been rejected for transplantation by all
CASE REPORT OTO ET AL THIRD-TIME LUNG TRANSPLANT
643
other Australian centers and were not suitable for any other local recipient. Prospective lymphocytotoxic crossmatching was used to avoid pre-sensitization related to previous donors and blood products. During organ procurement, hypoxemia contributed to cardiac arrest (ie, technically a Maastricht category IV donation-aftercardiac-death organ), and the lungs were rapidly procured with minimum warm ischemic time. Prior to implantation, a left lower lobectomy was performed to remove the frankly consolidated left lower lobe and to downsize the graft to allow a bilateral re-LTx. Significant adhesions were observed around the hilar structures bilaterally, and during pneumonectomy specific care was taken not to injure the phrenic nerves. The main bronchus was transected along the previous suture line, and the donor remnant bronchial tissue was resected to avoid posttransplant bronchial strictures. For vascular anastomoses, 5 mm of previous donor vascular cuff (attached to the recipient’s native vascular structures) was preserved to provide sufficient length to place a vascular clamp. Bilateral re-LTx was performed without cardiopulmonary bypass. Lung grafts were implanted with a total ischemic time of 410 minutes on the right side and 525 minutes on the left. The recipient experienced grade 3 primary graft dysfunction in the first 6 hours after transplant (Pao2/Pio2 ⫽ 146 at 0 hour and 179 at 6 hours). However, graft function recovered within the first 72 hours (Pao2/Pio2 ⫽ 205 at 12 hours, 272 at 24 hours, 263 at 48 hours, and 226 at 72 hours). The recipient was able to be extubated at 74 hours posttransplant and was subsequently discharged from the hospital on day 30. Currently she remains very well with pulmonary function at 6 months posttransplant again approaching 85% of predicted values (Fig 2).
Comment Re-LTx remains a challenging surgical and medical procedure. We believe that this is the first report to describe a second-time re-LTx (a third-time LTx). At the Alfred Hospital, 595 LTx (315 bilateral, 221 single, and 59 heartlung) operations were performed before November 2006, Fig 1. An extended donor lung from Maastricht category IV donation after cardiac death donor: (A) darkred, solid, edematous left lower lobe compared to white, soft left upper lobe, and (B) severely damaged left lower lobe was unsuitable for transplant, and lobectomy was performed. Remnant left upper lobe and contralateral lung was successfully used for bilateral re-transplantation.
FEATURE ARTICLES
Ann Thorac Surg 2007;84:642– 4
644
CASE REPORT MA ET AL ONE-STAGE SURGERY OF INTRAVENOUS UTERINE LEIOMYOSARCOMATOSIS
Ann Thorac Surg 2007;84:644 –7
donors, may provide greater LTx opportunities for re-LTx candidates.
References
Fig 2. Recipient forced expiratory volume in 1 second before and after lung re-transplant. Recipient’s predicted forced expiratory volume in 1 second was 3.1 L.
FEATURE ARTICLES
and 11 (1.8%) of these were re-LTx for 10 recipients (n ⫽ 1, second re-LTx). Our policy for re-LTx has evolved with emerging medical literature that suggests carefully selected, ambulatory, nonventilated patients with BOS surviving beyond 2 years post-primary transplants are the best re-LTx candidates [1]. Intrinsically we undertook this transplant with these donor organs because of the belief that the recipient ultimately represented good protoplasm and that the young donor organs could recover, particularly by taking the unusual step of excising the pneumonic lobe. Theoretically an ideal donor is desirable for any high-risk procedure; however with a general donor shortage this is not practical. The donor lungs described in this case report were certainly extended criteria lungs due to the falling oxygenation in the setting of a solid current smoking history, secretions, and pneumonia, on top of cardiac arrest and the surgical challenge of a donor-recipient size mismatch. Evolving clinical practice has seen a tendency to perform bilateral LTx with these extended donors, using an interleukin-2 blocking agent with lower corticosteroid doses and calcineurin-inhibitor levels. Mycophenolate mofetil and rapamycin-related medications provide potent alternative immunosuppressive choices to hopefully decrease the prospect of BOS returning rapidly in the re-LTx allograft. An aggressive stance is taken with antibiotic, antifungal, and antiviral prophylaxis and early treatment of infection. In the current case, the seesaw lung function after the second transplant (Fig 2) represented serious Aspergillus bronchitis and was avoided after the third transplant by using aggressive voriconazole prophylaxis. Second-time re-LTx is feasible and could be an option to treat recurrent BOS. We believe that this challenging case resets the definitions of donor and recipient lung transplantation acceptability, proving that we still have yet to understand where the true boundaries of lung transplantation lie. Although further research is needed on long-term survival and BOS, ideal donors are not exclusively required for re-LTx, and using extended criteria donors, including donation-after-cardiac-death © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Novick RJ, Stitt LW, Al-Kattan K, et al. Pulmoary retransplantation: predictors of graft function and survival in 230 patients. Ann Thorac Surg 1998;65:227–34. 2. Brugiere O, Thabut G, Castier Y, et al. Lung retransplantation for bronchiolitis obliterans syndrome. Chest 2003; 123:1832–7. 3. Struber M, Fischer S, Gottlieb J, et al. Long-term outcome after pulmonary retransplantation. J Thorac Cardiovasc Surg 2006;132:407–12. 4. Orens JB, Boehler A, de Perrot M, et al. A review of lung transplant donor acceptability criteria. J Heart Lung Transplant 2003;22:1183–200. 5. Oto T, Levvey BJ, Whitford H, et al. Feasibility and utility of a lung donor score: correlation with early post-transplant outcomes. Ann Thorac Surg 2007;83:257– 63.
One-Stage Surgery of Low-Grade Malignant Intravenous Uterine Leiomyosarcomatosis With Right Atrium Extension Liang Ma, MD, ShengJun Wu, MD, Yu Zou, MD, WeiDong Li, MD, Liang Gong, MD, Gabrielle Gerelle, MD, and YiMing Ni, MD Department of Cardiothoracic Surgery, 1st Affiliated Hospital, College of Medicine, ZheJiang University, HangZhou, The People’s Republic of China
Uterine leiomyosarcoma is a rare and aggressive malignant tumor arising from the smooth muscle cells of the myometrium, which rarely metastasizes to the heart. We report the case of a 49-year-old Chinese woman who underwent a successful one-stage surgical intervention after an initial diagnosis of intravenous uterine leiomyomatosis. However, her postoperative biopsy showed the presence of low-grade malignant uterine leiomyosarcoma with intravenous and right atrium extension. It is our conclusion that surgical resection is the mainstay treatment for this type of condition. (Ann Thorac Surg 2007;84:644 –7) © 2007 by The Society of Thoracic Surgeons
C
ardiac neoplasms of uterine origin are rare and have seldom been reported in clinical practice. In our report we will present a case of a patient with uterine leiomyosarcoma with metastasis in the right common iliac vein, inferior vena cava, and right atrium. We will describe the combined surgical treatment that we undertook before discussing the rare reports that have described cases of cardiac metastases of uterine origin. Accepted for publication March 19, 2007. Address correspondence to Dr Ni, Department of Cardiothoracic Surgery, 1st Affiliated Hospital, College of Medicine, ZheJiang University, HangZhou, 310003, The People’s Republic of China; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.03.056
CASE REPORT OTO ET AL THIRD-TIME LUNG TRANSPLANT
Ann Thorac Surg 2007;84:642– 4
developmental tumors (ie, neurofibromas, teratoma, and bronchial cysts), and arterial aneurysms. Cross-sectional imaging, either as magnetic resonance imaging or computed tomography are sufficient for accurate diagnosis of venous and arterial aneurysms and allow for planning of surgical strategy [8]. Cardiopulmonary bypass will often be necessary to allow for safe mobilization and resection. The prognosis after successful resection is very good. There are no reported cases of recurrence or of the development of similar lesions elsewhere. These unusual aneurysms should not be forgotten in the differential diagnosis of a mediastinal mass. Despite being a benign lesion and at low pressure, these masses can rapidly enlarge once they reach a critical size.
References
FEATURE ARTICLES Fig 3. Post-repair image showing A, the innominate vein and B, the bovine pericardial patch.
Potential causes include congenital malformations, trauma, inflammation, infection, and degenerative changes in the vessel wall [3]. In a single case, congenital absence of the longitudinal muscle coat of the adventitia has been reported [4]. There has also been an association between cystic hygromas and venous aneurysms and a common origin of both lymphatics and venous drainage reported [5]. Their clinical significance arises from the complications that they can cause. These complications include: (1) the risk of thromboembolism and venous obstruction, (2) the risk of rupture [6] (ie, traumatic [such as line insertion] or spontaneous), and (3) compression of bordering structures. These features need to be taken into account when planning management, which may be conservative for small, nonexpanding aneurysms [7]. In this case, the size, the rapid expansion, and the development of fresh thrombus within the aneurysm precluded conservative treatment. The appendicitis seemed to be incidental, but serendipitously led to the diagnosis being made. The chronic cough was most likely related to the bronchial irritation and atelectasis caused by the tumor and would suggest that it had been growing for a period of years. A rapidly growing mass is an alarming diagnostic dilemma. Differentials included malignant disease (ie, primary and secondary lung cancers, lymphoma), benign © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Burkill GJ, Burn PR, Padley SP. Aneurysm of the left brachiocephalic vein: an unusual cause of mediastinal widening. Br J Radiol 1997;70:837–9. 2. Schellhammer F, Wöbker G, Turowski B. Asymptomatic aneurysm of the subclavian vein. Acta Radiol 2005;46:366 –7. 3. Shatz IJ, Fine G. Venous aneurysms. N Engl J Med 1962;266: 1310 –2. 4. Ream CR, Giardina A. Congenital superior vena cava aneurysm with complications caused by infectious mononucleosis. Chest 1972;62:755–7. 5. Sabin FR. On the origin of the lymphatic system from the veins and the development of the lymph hearts and thoracic duct in the pig. Am J Anat 1902;1:367–91. 6. Taira A, Akita H. Ruptured venous aneurysm of the persistent left superior vena cava. Angiology 1981;32:656 –9. 7. Tsuji A, Katada Y, Tanimoto M, Fujita M. Congenital giant aneurysm of the left innominate vein: is surgical treatment required? Paediatr Cardiol 2004;25:421–3. 8. Gozdziuk K, Czekajska-Chehab E, Wrona A, Tomaszewski A, Drop A. Saccular aneurysm of the superior vena cava detected by computed tomography and successfully treated with surgery. Ann Thorac Surg 2004;78:e94 –5.
Third-Time Lung Transplant Using Extended Criteria Lungs Takahiro Oto, MD, Michael Rowland, FRACS, Anne P. Griffiths, FRCNA, Bronwyn J. Levvey, RN, Donald S. Esmore, FRACS, Trevor J. Williams, FRACP, and Gregory I. Snell, FRACP Lung Transplant Service, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
There is an increasing requirement for lung re-transplants (re-LTx) related to the bronchiolitis obliterans syndrome. Nevertheless, re-LTx, especially second-time re-LTx, poses the dilemma of appropriate allocation of a scarce donor lung resource versus the desire to optimize outcomes for an individual patient. Extended donors have been used to partially alleviate a scarce donor lung Accepted for publication March 9, 2007. Address correspondence to Dr Snell, Department of Allergy, Immunology, and Respiratory Medicine, The Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.03.023
supply with satisfactory outcomes for primary lung transplant. However, the usefulness of the extended donors remains unknown, including donation-after-cardiac-death donors for re-LTx. This report describes a second-time re-LTx using significantly extended donor criteria lungs from a Maastricht category IV donationafter-cardiac-death donor with resultant good clinical outcomes. (Ann Thorac Surg 2007;84:642– 4) © 2007 by The Society of Thoracic Surgeons
W
ith lung transplantation (LTx) as an established therapy for end-stage pulmonary disease, the number of patients potentially requiring a lung retransplant (re-LTx) is increasing related to late graft dysfunction secondary to the bronchiolitis obliterans syndrome (BOS) [1–3]. Nevertheless, lung re-LTx remains a controversial procedure limited by a shortage of donor lungs and potentially inferior outcomes compared with primary LTx [1, 2]. Re-LTx, especially second-time Re-LTx, poses a dilemma of appropriate allocation of a scarce donor lung resource and the desire to optimize outcomes for an individual patient. Extended donors have been used to partially alleviate a scarce donor lung supply with satisfactory outcomes for primary LTx [4, 5]. However, the usefulness of extended donors for re-LTx remains unknown, including donationafter-cardiac-death donors. This report describes a second-time re-LTx using marginal lungs from a Maastricht category IV donation-after-cardiac-death donor. A second-time re-LTx was performed on an otherwise excellent 46-year-old candidate with recurrent BOS using extended donation-after-cardiac-death (Maastricht category IV) donor lungs 4.5 years after the first-time re-LTx. The donor was a larger 27-year-old anoxic brain-dead male who was a marijuana and tobacco smoker with a very abnormal chest roentgenogram, moderate bloody secretions, and deteriorating blood gases (lowest measured Pao2 on 100% oxygen ⫽ 67 mm Hg). The donor left lower lobe had extensive pneumonic change (Fig 1). These organs had been rejected for transplantation by all
CASE REPORT OTO ET AL THIRD-TIME LUNG TRANSPLANT
643
other Australian centers and were not suitable for any other local recipient. Prospective lymphocytotoxic crossmatching was used to avoid pre-sensitization related to previous donors and blood products. During organ procurement, hypoxemia contributed to cardiac arrest (ie, technically a Maastricht category IV donation-aftercardiac-death organ), and the lungs were rapidly procured with minimum warm ischemic time. Prior to implantation, a left lower lobectomy was performed to remove the frankly consolidated left lower lobe and to downsize the graft to allow a bilateral re-LTx. Significant adhesions were observed around the hilar structures bilaterally, and during pneumonectomy specific care was taken not to injure the phrenic nerves. The main bronchus was transected along the previous suture line, and the donor remnant bronchial tissue was resected to avoid posttransplant bronchial strictures. For vascular anastomoses, 5 mm of previous donor vascular cuff (attached to the recipient’s native vascular structures) was preserved to provide sufficient length to place a vascular clamp. Bilateral re-LTx was performed without cardiopulmonary bypass. Lung grafts were implanted with a total ischemic time of 410 minutes on the right side and 525 minutes on the left. The recipient experienced grade 3 primary graft dysfunction in the first 6 hours after transplant (Pao2/Pio2 ⫽ 146 at 0 hour and 179 at 6 hours). However, graft function recovered within the first 72 hours (Pao2/Pio2 ⫽ 205 at 12 hours, 272 at 24 hours, 263 at 48 hours, and 226 at 72 hours). The recipient was able to be extubated at 74 hours posttransplant and was subsequently discharged from the hospital on day 30. Currently she remains very well with pulmonary function at 6 months posttransplant again approaching 85% of predicted values (Fig 2).
Comment Re-LTx remains a challenging surgical and medical procedure. We believe that this is the first report to describe a second-time re-LTx (a third-time LTx). At the Alfred Hospital, 595 LTx (315 bilateral, 221 single, and 59 heartlung) operations were performed before November 2006, Fig 1. An extended donor lung from Maastricht category IV donation after cardiac death donor: (A) darkred, solid, edematous left lower lobe compared to white, soft left upper lobe, and (B) severely damaged left lower lobe was unsuitable for transplant, and lobectomy was performed. Remnant left upper lobe and contralateral lung was successfully used for bilateral re-transplantation.
FEATURE ARTICLES
Ann Thorac Surg 2007;84:642– 4
644
CASE REPORT MA ET AL ONE-STAGE SURGERY OF INTRAVENOUS UTERINE LEIOMYOSARCOMATOSIS
Ann Thorac Surg 2007;84:644 –7
donors, may provide greater LTx opportunities for re-LTx candidates.
References
Fig 2. Recipient forced expiratory volume in 1 second before and after lung re-transplant. Recipient’s predicted forced expiratory volume in 1 second was 3.1 L.
FEATURE ARTICLES
and 11 (1.8%) of these were re-LTx for 10 recipients (n ⫽ 1, second re-LTx). Our policy for re-LTx has evolved with emerging medical literature that suggests carefully selected, ambulatory, nonventilated patients with BOS surviving beyond 2 years post-primary transplants are the best re-LTx candidates [1]. Intrinsically we undertook this transplant with these donor organs because of the belief that the recipient ultimately represented good protoplasm and that the young donor organs could recover, particularly by taking the unusual step of excising the pneumonic lobe. Theoretically an ideal donor is desirable for any high-risk procedure; however with a general donor shortage this is not practical. The donor lungs described in this case report were certainly extended criteria lungs due to the falling oxygenation in the setting of a solid current smoking history, secretions, and pneumonia, on top of cardiac arrest and the surgical challenge of a donor-recipient size mismatch. Evolving clinical practice has seen a tendency to perform bilateral LTx with these extended donors, using an interleukin-2 blocking agent with lower corticosteroid doses and calcineurin-inhibitor levels. Mycophenolate mofetil and rapamycin-related medications provide potent alternative immunosuppressive choices to hopefully decrease the prospect of BOS returning rapidly in the re-LTx allograft. An aggressive stance is taken with antibiotic, antifungal, and antiviral prophylaxis and early treatment of infection. In the current case, the seesaw lung function after the second transplant (Fig 2) represented serious Aspergillus bronchitis and was avoided after the third transplant by using aggressive voriconazole prophylaxis. Second-time re-LTx is feasible and could be an option to treat recurrent BOS. We believe that this challenging case resets the definitions of donor and recipient lung transplantation acceptability, proving that we still have yet to understand where the true boundaries of lung transplantation lie. Although further research is needed on long-term survival and BOS, ideal donors are not exclusively required for re-LTx, and using extended criteria donors, including donation-after-cardiac-death © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Novick RJ, Stitt LW, Al-Kattan K, et al. Pulmoary retransplantation: predictors of graft function and survival in 230 patients. Ann Thorac Surg 1998;65:227–34. 2. Brugiere O, Thabut G, Castier Y, et al. Lung retransplantation for bronchiolitis obliterans syndrome. Chest 2003; 123:1832–7. 3. Struber M, Fischer S, Gottlieb J, et al. Long-term outcome after pulmonary retransplantation. J Thorac Cardiovasc Surg 2006;132:407–12. 4. Orens JB, Boehler A, de Perrot M, et al. A review of lung transplant donor acceptability criteria. J Heart Lung Transplant 2003;22:1183–200. 5. Oto T, Levvey BJ, Whitford H, et al. Feasibility and utility of a lung donor score: correlation with early post-transplant outcomes. Ann Thorac Surg 2007;83:257– 63.
One-Stage Surgery of Low-Grade Malignant Intravenous Uterine Leiomyosarcomatosis With Right Atrium Extension Liang Ma, MD, ShengJun Wu, MD, Yu Zou, MD, WeiDong Li, MD, Liang Gong, MD, Gabrielle Gerelle, MD, and YiMing Ni, MD Department of Cardiothoracic Surgery, 1st Affiliated Hospital, College of Medicine, ZheJiang University, HangZhou, The People’s Republic of China
Uterine leiomyosarcoma is a rare and aggressive malignant tumor arising from the smooth muscle cells of the myometrium, which rarely metastasizes to the heart. We report the case of a 49-year-old Chinese woman who underwent a successful one-stage surgical intervention after an initial diagnosis of intravenous uterine leiomyomatosis. However, her postoperative biopsy showed the presence of low-grade malignant uterine leiomyosarcoma with intravenous and right atrium extension. It is our conclusion that surgical resection is the mainstay treatment for this type of condition. (Ann Thorac Surg 2007;84:644 –7) © 2007 by The Society of Thoracic Surgeons
C
ardiac neoplasms of uterine origin are rare and have seldom been reported in clinical practice. In our report we will present a case of a patient with uterine leiomyosarcoma with metastasis in the right common iliac vein, inferior vena cava, and right atrium. We will describe the combined surgical treatment that we undertook before discussing the rare reports that have described cases of cardiac metastases of uterine origin. Accepted for publication March 19, 2007. Address correspondence to Dr Ni, Department of Cardiothoracic Surgery, 1st Affiliated Hospital, College of Medicine, ZheJiang University, HangZhou, 310003, The People’s Republic of China; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.03.056