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Usefulness of ultrasonography in operation for pulmonary arteriovenous fistula
Ann Thorac Surg 1996;61:1821-3
5. Salzer GM, Muller LC, Kroesen G. Resection of tracheal bifurcation through a left thoracotomy. Eur J Cardiothorac Surg 1987;1:125-8. 6. Kulka F. Successful resection of the tracheal bifurcation through a left thoracotomy [Letter]. Eur J Cardiothorac Surg 1988;2:133. 7. Maeda M, Nakamoto K, Tsubota N, et al. Operative approaches for left-sided carinoplasty. Ann Thorac Surg 1993; 56:441-6. 8. Newton JR Jr, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272-80.
Usefulness of Ultrasonography in Operation for Pulmonary Arteriovenous Fistula Makoto Sugita, MD, Hirokazu Aikawa, MD, Shigefumi Fujimura, MD, Takashi Kondo, MD, and Gunji Okaniwa, MD Department of Surgery, Sendai Kosei Hospital, Sendai, Japan
A 54-year-old woman presented with nonhereditary, bilateral pulmonary arteriovenous fistulas. One of them was small (10 × 10 mm) and embedded in the parenchyma; it was neither visible nor palpable from the pleural surface. We therefore used intraoperative ultrasonography and succeeded in detecting and enucleating the small fistula with minimal resection of the normal lung tissue. (Ann Thorac Surg 1996;61:1821-3)
CASE REPORT SUGITAET AL INTRAOPERATIVEULTRASONOGRAPHY
1821
examinations until the year before the admittance. The chest d y n a m i c c o m p u t e d tomographic study revealed three i n t r a p u l m o n a r y masses, which were e n h a n c e d at the s a m e density as the major vessels. A p u l m o n a r y arteriographic study confirmed the diagnosis of PAVFs (Fig 1). O n the basis of the results of preoperative e x a m i n a t i o n s , we c o n c l u d e d that t h e r e w e r e t h r e e PAVFs: one in the right posterior basal s e g m e n t (30 × 35 mm), one in the right m e d i a l s e g m e n t (10 x 10 mm), a n d one in the left apicoposterior s e g m e n t (25 x 22 mm). W e excluded the possibility of R e n d u - O s l e r - W e b e r disease from the patient's past a n d family history of illness a n d the results of her brain a n d a b d o m i n a l c o m p u t e d tomographic studies. To minimize the reduction of postoperative p u l m o n a r y function a n d to achieve complete removal of all three fistulas in both lungs with one operation, we p l a n n e d a sequential bilateral m u s c l e - s p a r i n g thoracotomy through the triangle of auscultation for enucleation of the three PAVFs. W e p r e f e r r e d this a p p r o a c h over m e d i a n sternoto m y for this case because exposure a n d removal of the PAVF in the posterior basal s e g m e n t were expected to be difficult by the m e d i a n approach. The fistula in the right m e d i a l s e g m e n t was small a n d e m b e d d e d in the p a r e n ehyma, about I cm from the most proximal pleura, so that difficulty in finding this fistula was also expected. To facilitate t r e a t m e n t of the small fistula, we d e c i d e d to use u l t r a s o n o g r a p h y intraoperatively. W e e m p l o y e d a rigid laparoscopic u l t r a s o u n d probe (UST-5522-7.5; Aloka Inc, Tokyo, Japan) that was 12 m m in m a x i m u m d i a m e t e r and 405 m m in length. The p r o b e was e q u i p p e d with a 7.5-MHz side linear t r a n s d u c e r a n d h a d a 38-mm scanning width. A right thoracotomy was p e r f o r m e d as planned. As
ince Churton [1] described the first case of p u l m o n a r y arteriovenous fistula (PAVF) in 1897, m a n y such cases have b e e n r e p o r t e d in the literature [2, 3]. Embolization of PAVF has b e e n r e p o r t e d recently [4]; however, this p r o c e d u r e is still controversial. Today, the p r e f e r r e d t r e a t m e n t for PAVF is still m i n i m a l resection to remove the entire fistula [5, 6]. In some cases of PAVF, it is difficult to locate the fistula during operation because it is small or e m b e d d e d in the p a r e n c h y m a . In the p r e s e n t case, before the operation, one of the PAVFs was considered too small a n d too far away from the pleura to be recognized during the operation using a n g i o g r a p h y a n d dynamic c o m p u t e d tomography. To solve the problem, we u s e d u l t r a s o n o g r a p h y intraoperatively a n d succeeded in locating a n d enucleating the fistula.
S
A 54-year-old w o m a n was referred to our institution a n d a d m i t t e d to our affiliated hospital, Sendal Kosei Hospital, for a b n o r m a l s h a d o w s on her chest roentgenograrn. No abnormalities h a d b e e n suggested on her yearly physical Accepted for publication Nov 10, 1995. Address reprint requests to Dr Sugita, Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryomachi,Aoba-ku, Sendal, 980-77Japan. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Preoperative pulmonary arteriographic study confirming three arteriovenous fistulas: one in the right posterior basal segment (A), one in the right medial segment (]3), and one in the left apicoposterior segment (C). 0003-4975/96/$15.00 SSDI 0003-4975(95)01161-7
1822
CASEREPORT SUGITAET AL INTRAOPERATIVEULTRASONOGRAPHY
Ann Thorac Surg 1996;61:1821-3
z
Fig 2. Intraoperative ultrasonographic studies. (.4) The fistula in the right basal segment (arrow). (B) The fistula in the right medial segment (arrow).
-.
'7"
B
expected, the fistula in the basal segment was found easily by visual observation of the pleural surface. The fistula itself a n d vessels r u n n i n g through the fistula were visualized (Fig 2A) by ultrasonography, a n d it was enucleated without any trouble. The fistula in the medial segment could not be located despite both observation and squeezing of the lung around the segment. No thrill was palpable. We inserted the ultrasonographic probe and started searching for the fistula from the surface of the collapsed lung. Because a left-sided d o u b l e - l u m e n endotracheal tube had b e e n placed, we were able to collapse the operated lung. The fistula was easily depicted by ultrasonography (Fig 2B); therefore, it was successfully enucleated with m i n i m a l dissection of the s u r r o u n d i n g normal lung tissue. Subsequently, a left thoracotomy was performed as planned. The fistula in the apicoposterior segment was detected a n d enucleation was attempted. Because the oxygen saturation dropped to 93% during the attempt, we performed a partial resection to reduce the operative time. The patient had an u n e v e n t f u l postoperative course and was discharged 2 weeks after the procedure. Postoperatively, p u l m o n a r y function tests, arterial blood gas analyses, and a p u l m o n a r y arteriography study were
performed. A reduction of the rate of right-to-left s h u n t (Table 1) was observed, and no r e m a i n i n g PAVF was found on the p u l m o n a r y arteriography study. Histologic examination confirmed the diagnosis of PAVF.
Comment For removing i n t r a p u l m o n a r y n o n m a l i g n a n t soft masses, the operative procedure should allow complete resection of the masses, m i n i m a l resection of the normal lung tissue, a n d m a x i m u m sparing of respiratory muscles. In the present case, bilateral PAVFs were apparent before the operation, a n d one of the nodules was expected to be small, soft, a n d e m b e d d e d in the parenchyma. To minimize the effort to localize the PAVF, we prepared for ultrasonography. As expected, the PAVF could not be f o u n d despite both visual examination of the pleural surface and squeezing of the lung. By using intraoperative ultrasonography on the surface of the collapsed lung, we located the PAVF easily and successfully enucleated the fistula with m i n i m a l resection of normal lung tissue. In conclusion, intraoperative ultrasonography is valuable for searching for i n t r a p u l m o n a r y masses that are neither visible nor palpable on the surface of the lung.
Table 1. Results of Preoperative and Postoperative Pulmonary Function Tests
(mm Hg)
SaO2 (%)
PaCO 2 (ram Hg)
PvO2 (ram Hg)
SvO2 (%)
SF (%)
VC (L)
%VC
F E V 1 (%)
67.8 80.9~
91.9 96.1
36.3 40.5~
37.9 36.7"~
72.2 71.1
24 7"1
2.74
114.6
88.4
1.75 b
73.2
90.7 b
PaO2
Time Before operation After operation
Data on the 22nd postoperative day. b Data on the 21st postoperative day. FEV1 - forced expiratory volume in 1 second; PaCO2 partialpressure of carbon dioxide in arterial blood; PaO2 partialpressure of oxygen in arterialblood; PvO2- partial oxygenpressure in mixedvenousblood; S a O 2 oxygensaturationin arterialblood; SF - right-to-leftshunt fraction; SvO2 venousoxygen saturation; VC = ventilatorycapacity.
Ann Thorac Surg 1996;61:1823-4
CASE REPORT MURRAHET AL PULMONARYRESECTIONOF METASTATICMENINGIOMA
References
a n d was re-excised twice, in 1989 a n d 1992. A fourth recurrence was noted in late 1993, this time accompanied by multiple nodules observed on chest radiographs. The patient was without p u l m o n a r y symptoms. The m e n i n gioma was again excised in early 1994. Thoracic computed tomography was performed in June 1994 a n d revealed nine p u l m o n a r y masses. Three each were located in the right u p p e r a n d right lower lobes of the lung. Two were located in the left u p p e r lobe, a n d one large mass was located in the left lower lobe. Fine-needle aspiration biopsy was done. This showed metastatic meningioma. A trial with the investigational drug RU486 was attempted at an outside hospital a n d failed. Workup revealed no metastases to other organs. The patient had a d e q u a t e p u l m o n a r y function a n d was d e e m e d an acceptable operative risk. Due to the large left lower lobe mass, staged thoracotomies were done rather than a m e d i a n sternotomy. Left thoracotomy was done in July 1994. A firm 4.5 × 3 × 2-cm mass was found in the left lower lobe. There were two nodules m e a s u r i n g 2 × 1.5 × 1 cm each in the periphery of the left u p p e r lobe. These were excised using electrocautery. The surgical beds were cauterized using the argon b e a m coagulator to secure hemostasis. This was followed by left lower lobectomy a n d removal of nine left hilar and mediastinal lymph nodes. Right thoracotomy was done in September 1994. A total of six nodules m e a s u r i n g 1 to 3 cm in greatest d i m e n s i o n were f o u n d in the right lung. Three each were located in the right u p p e r and lower lobes. All of the nodules were excised using electrocautery and the argon b e a m coagulator. Eight right hilar a n d mediastinal lymph nodes were also removed. The patient tolerated each of the operations well. O n gross examination, compression and extension of the t u m o r into the bronchial a n d arterial walls was noted. All of the lesions excised were found by light and electron microscopy as well as i m m u n o h i s t o c h e m i s t r y to be consistent with the primary tumor. The t u m o r approached but did not invade the visceral pleura. I m m u noperoxidase stains were positive for vimentin, locally positive for neuron-specific enolase, a n d negative for epithelial m e m b r a n e antigen. T u m o r was identified in one of the 17 hilar a n d mediastinal lymph nodes.
1. Churton T. Multiple aneurysms of pulmonary artery. BMJ 1897;1:1223. 2. Dines DE, Seward JB, Bernatz PE. Pulmonary arteriovenous fistulas. Mayo Clin Proc 1983;58:176-81. 3. Prager RL, Laws KH, Bender HW. Arteriovenous fistula of the lung. Ann Thorac Surg 1983;36:231-9. 4. Nogimura H, Imaizumi T, Tomii M, et al. Surgery versus detachable balloon embolization of pulmonary arteriovenous fistula: clinical experience. Kyobu Geka 1992;45:595-7. 5. Parker EF, Stallworth JM, Charleston SC. Arteriovenous fistula of the lung treated by dissection and excision without pulmonary excision. Surgery 1951;32:31-8. 6. Bamba J, Tomoyasu H, Tanimura S, Masaki M, Nishiyama S, Matsushita H. Pulmonary arteriovenous fistula. Kyobu Geka 1984;37:370-5.
Resection of Multiple Pulmonary Metastases From a Recurrent Intracranial Meningioma C. Patrick Murrah, MD, Edward R. Ferguson, MD, Richard L. Jennelle, MD, Barton L. Guthrie, MD, a n d William L. Holman, MD Divisions of Cardiothoracic Surgery, Neurosurgery, and Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
Surgical resection of multiple pulmonary metastases from a recurrent intracranial m e n i n g i o m a in a 53-yearold w o m a n is presented. The primary tumor was diagnosed in 1984 and partially excised in early 1985. The tumor recurred and was re-excised in 1989 and 1992. A fourth intracranial recurrence was noted in 1993, accompanied by multiple bilateral pulmonary metastases. The metastases were excised using staged thoracotomies in July and September 1994. The patient is surviving with cranial tumor residual.
(Ann Thorac Surg 1996;61:1823-4) eningiomas are usually b e n i g n intracranial tumors that only rarely metastasize. In 1987, Stoller and associates [1] found 113 extracranial metastatic cases. Sixty-one percent of these cases had lung metastasis. The lung was the only site of extracranial metastasis in 32%. Only 13% had greater than three metastases. This case illustrates surgical m a n a g e m e n t of a patient with nine bilateral p u l m o n a r y metastases from a recurrent intracranial meningioma.
M
The patient is a 53-year-old w o m a n who was found to have a mass in the left frontal hemispheric convexity in 1984. The mass was excised in early 1985, a n d was diagnosed as a meningioma. The m e n i n g i o m a recurred Accepted for publicationDec 22, 1995. Address reprint requests to Dr Holman,Departmentof SurgeD',University, of Alabamaat Birmingham,UniversityStation, Birmingham,AL 35294. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1823
Comment M i n i m u m criteria for resection of p u l m o n a r y metastases were described by Ehrenhaft a n d associates in 1958 [2]. These criteria have u n d e r g o n e little change since that time. There is almost universal agreement on the following criteria: (1) control of the primary neoplasm, (2) absence of metastasis to other organs, a n d (3) ability to resect all p u l m o n a r y metastases with acceptable operative risk and adequate residual p u l m o n a r y function [3]. This case represents an interesting application, b u t the principles remain the same. Other factors such as the n u m b e r of metastases, disease-free interval, histologic type, a n d t u m o r doubling time, although not individually 0003-4975/96/$15.00 Pll S0003-4975(96)00064-1
5. Salzer GM, Muller LC, Kroesen G. Resection of tracheal bifurcation through a left thoracotomy. Eur J Cardiothorac Surg 1987;1:125-8. 6. Kulka F. Successful resection of the tracheal bifurcation through a left thoracotomy [Letter]. Eur J Cardiothorac Surg 1988;2:133. 7. Maeda M, Nakamoto K, Tsubota N, et al. Operative approaches for left-sided carinoplasty. Ann Thorac Surg 1993; 56:441-6. 8. Newton JR Jr, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272-80.
Usefulness of Ultrasonography in Operation for Pulmonary Arteriovenous Fistula Makoto Sugita, MD, Hirokazu Aikawa, MD, Shigefumi Fujimura, MD, Takashi Kondo, MD, and Gunji Okaniwa, MD Department of Surgery, Sendai Kosei Hospital, Sendai, Japan
A 54-year-old woman presented with nonhereditary, bilateral pulmonary arteriovenous fistulas. One of them was small (10 × 10 mm) and embedded in the parenchyma; it was neither visible nor palpable from the pleural surface. We therefore used intraoperative ultrasonography and succeeded in detecting and enucleating the small fistula with minimal resection of the normal lung tissue. (Ann Thorac Surg 1996;61:1821-3)
CASE REPORT SUGITAET AL INTRAOPERATIVEULTRASONOGRAPHY
1821
examinations until the year before the admittance. The chest d y n a m i c c o m p u t e d tomographic study revealed three i n t r a p u l m o n a r y masses, which were e n h a n c e d at the s a m e density as the major vessels. A p u l m o n a r y arteriographic study confirmed the diagnosis of PAVFs (Fig 1). O n the basis of the results of preoperative e x a m i n a t i o n s , we c o n c l u d e d that t h e r e w e r e t h r e e PAVFs: one in the right posterior basal s e g m e n t (30 × 35 mm), one in the right m e d i a l s e g m e n t (10 x 10 mm), a n d one in the left apicoposterior s e g m e n t (25 x 22 mm). W e excluded the possibility of R e n d u - O s l e r - W e b e r disease from the patient's past a n d family history of illness a n d the results of her brain a n d a b d o m i n a l c o m p u t e d tomographic studies. To minimize the reduction of postoperative p u l m o n a r y function a n d to achieve complete removal of all three fistulas in both lungs with one operation, we p l a n n e d a sequential bilateral m u s c l e - s p a r i n g thoracotomy through the triangle of auscultation for enucleation of the three PAVFs. W e p r e f e r r e d this a p p r o a c h over m e d i a n sternoto m y for this case because exposure a n d removal of the PAVF in the posterior basal s e g m e n t were expected to be difficult by the m e d i a n approach. The fistula in the right m e d i a l s e g m e n t was small a n d e m b e d d e d in the p a r e n ehyma, about I cm from the most proximal pleura, so that difficulty in finding this fistula was also expected. To facilitate t r e a t m e n t of the small fistula, we d e c i d e d to use u l t r a s o n o g r a p h y intraoperatively. W e e m p l o y e d a rigid laparoscopic u l t r a s o u n d probe (UST-5522-7.5; Aloka Inc, Tokyo, Japan) that was 12 m m in m a x i m u m d i a m e t e r and 405 m m in length. The p r o b e was e q u i p p e d with a 7.5-MHz side linear t r a n s d u c e r a n d h a d a 38-mm scanning width. A right thoracotomy was p e r f o r m e d as planned. As
ince Churton [1] described the first case of p u l m o n a r y arteriovenous fistula (PAVF) in 1897, m a n y such cases have b e e n r e p o r t e d in the literature [2, 3]. Embolization of PAVF has b e e n r e p o r t e d recently [4]; however, this p r o c e d u r e is still controversial. Today, the p r e f e r r e d t r e a t m e n t for PAVF is still m i n i m a l resection to remove the entire fistula [5, 6]. In some cases of PAVF, it is difficult to locate the fistula during operation because it is small or e m b e d d e d in the p a r e n c h y m a . In the p r e s e n t case, before the operation, one of the PAVFs was considered too small a n d too far away from the pleura to be recognized during the operation using a n g i o g r a p h y a n d dynamic c o m p u t e d tomography. To solve the problem, we u s e d u l t r a s o n o g r a p h y intraoperatively a n d succeeded in locating a n d enucleating the fistula.
S
A 54-year-old w o m a n was referred to our institution a n d a d m i t t e d to our affiliated hospital, Sendal Kosei Hospital, for a b n o r m a l s h a d o w s on her chest roentgenograrn. No abnormalities h a d b e e n suggested on her yearly physical Accepted for publication Nov 10, 1995. Address reprint requests to Dr Sugita, Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryomachi,Aoba-ku, Sendal, 980-77Japan. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Preoperative pulmonary arteriographic study confirming three arteriovenous fistulas: one in the right posterior basal segment (A), one in the right medial segment (]3), and one in the left apicoposterior segment (C). 0003-4975/96/$15.00 SSDI 0003-4975(95)01161-7
1822
CASEREPORT SUGITAET AL INTRAOPERATIVEULTRASONOGRAPHY
Ann Thorac Surg 1996;61:1821-3
z
Fig 2. Intraoperative ultrasonographic studies. (.4) The fistula in the right basal segment (arrow). (B) The fistula in the right medial segment (arrow).
-.
'7"
B
expected, the fistula in the basal segment was found easily by visual observation of the pleural surface. The fistula itself a n d vessels r u n n i n g through the fistula were visualized (Fig 2A) by ultrasonography, a n d it was enucleated without any trouble. The fistula in the medial segment could not be located despite both observation and squeezing of the lung around the segment. No thrill was palpable. We inserted the ultrasonographic probe and started searching for the fistula from the surface of the collapsed lung. Because a left-sided d o u b l e - l u m e n endotracheal tube had b e e n placed, we were able to collapse the operated lung. The fistula was easily depicted by ultrasonography (Fig 2B); therefore, it was successfully enucleated with m i n i m a l dissection of the s u r r o u n d i n g normal lung tissue. Subsequently, a left thoracotomy was performed as planned. The fistula in the apicoposterior segment was detected a n d enucleation was attempted. Because the oxygen saturation dropped to 93% during the attempt, we performed a partial resection to reduce the operative time. The patient had an u n e v e n t f u l postoperative course and was discharged 2 weeks after the procedure. Postoperatively, p u l m o n a r y function tests, arterial blood gas analyses, and a p u l m o n a r y arteriography study were
performed. A reduction of the rate of right-to-left s h u n t (Table 1) was observed, and no r e m a i n i n g PAVF was found on the p u l m o n a r y arteriography study. Histologic examination confirmed the diagnosis of PAVF.
Comment For removing i n t r a p u l m o n a r y n o n m a l i g n a n t soft masses, the operative procedure should allow complete resection of the masses, m i n i m a l resection of the normal lung tissue, a n d m a x i m u m sparing of respiratory muscles. In the present case, bilateral PAVFs were apparent before the operation, a n d one of the nodules was expected to be small, soft, a n d e m b e d d e d in the parenchyma. To minimize the effort to localize the PAVF, we prepared for ultrasonography. As expected, the PAVF could not be f o u n d despite both visual examination of the pleural surface and squeezing of the lung. By using intraoperative ultrasonography on the surface of the collapsed lung, we located the PAVF easily and successfully enucleated the fistula with m i n i m a l resection of normal lung tissue. In conclusion, intraoperative ultrasonography is valuable for searching for i n t r a p u l m o n a r y masses that are neither visible nor palpable on the surface of the lung.
Table 1. Results of Preoperative and Postoperative Pulmonary Function Tests
(mm Hg)
SaO2 (%)
PaCO 2 (ram Hg)
PvO2 (ram Hg)
SvO2 (%)
SF (%)
VC (L)
%VC
F E V 1 (%)
67.8 80.9~
91.9 96.1
36.3 40.5~
37.9 36.7"~
72.2 71.1
24 7"1
2.74
114.6
88.4
1.75 b
73.2
90.7 b
PaO2
Time Before operation After operation
Data on the 22nd postoperative day. b Data on the 21st postoperative day. FEV1 - forced expiratory volume in 1 second; PaCO2 partialpressure of carbon dioxide in arterial blood; PaO2 partialpressure of oxygen in arterialblood; PvO2- partial oxygenpressure in mixedvenousblood; S a O 2 oxygensaturationin arterialblood; SF - right-to-leftshunt fraction; SvO2 venousoxygen saturation; VC = ventilatorycapacity.
Ann Thorac Surg 1996;61:1823-4
CASE REPORT MURRAHET AL PULMONARYRESECTIONOF METASTATICMENINGIOMA
References
a n d was re-excised twice, in 1989 a n d 1992. A fourth recurrence was noted in late 1993, this time accompanied by multiple nodules observed on chest radiographs. The patient was without p u l m o n a r y symptoms. The m e n i n gioma was again excised in early 1994. Thoracic computed tomography was performed in June 1994 a n d revealed nine p u l m o n a r y masses. Three each were located in the right u p p e r a n d right lower lobes of the lung. Two were located in the left u p p e r lobe, a n d one large mass was located in the left lower lobe. Fine-needle aspiration biopsy was done. This showed metastatic meningioma. A trial with the investigational drug RU486 was attempted at an outside hospital a n d failed. Workup revealed no metastases to other organs. The patient had a d e q u a t e p u l m o n a r y function a n d was d e e m e d an acceptable operative risk. Due to the large left lower lobe mass, staged thoracotomies were done rather than a m e d i a n sternotomy. Left thoracotomy was done in July 1994. A firm 4.5 × 3 × 2-cm mass was found in the left lower lobe. There were two nodules m e a s u r i n g 2 × 1.5 × 1 cm each in the periphery of the left u p p e r lobe. These were excised using electrocautery. The surgical beds were cauterized using the argon b e a m coagulator to secure hemostasis. This was followed by left lower lobectomy a n d removal of nine left hilar and mediastinal lymph nodes. Right thoracotomy was done in September 1994. A total of six nodules m e a s u r i n g 1 to 3 cm in greatest d i m e n s i o n were f o u n d in the right lung. Three each were located in the right u p p e r and lower lobes. All of the nodules were excised using electrocautery and the argon b e a m coagulator. Eight right hilar a n d mediastinal lymph nodes were also removed. The patient tolerated each of the operations well. O n gross examination, compression and extension of the t u m o r into the bronchial a n d arterial walls was noted. All of the lesions excised were found by light and electron microscopy as well as i m m u n o h i s t o c h e m i s t r y to be consistent with the primary tumor. The t u m o r approached but did not invade the visceral pleura. I m m u noperoxidase stains were positive for vimentin, locally positive for neuron-specific enolase, a n d negative for epithelial m e m b r a n e antigen. T u m o r was identified in one of the 17 hilar a n d mediastinal lymph nodes.
1. Churton T. Multiple aneurysms of pulmonary artery. BMJ 1897;1:1223. 2. Dines DE, Seward JB, Bernatz PE. Pulmonary arteriovenous fistulas. Mayo Clin Proc 1983;58:176-81. 3. Prager RL, Laws KH, Bender HW. Arteriovenous fistula of the lung. Ann Thorac Surg 1983;36:231-9. 4. Nogimura H, Imaizumi T, Tomii M, et al. Surgery versus detachable balloon embolization of pulmonary arteriovenous fistula: clinical experience. Kyobu Geka 1992;45:595-7. 5. Parker EF, Stallworth JM, Charleston SC. Arteriovenous fistula of the lung treated by dissection and excision without pulmonary excision. Surgery 1951;32:31-8. 6. Bamba J, Tomoyasu H, Tanimura S, Masaki M, Nishiyama S, Matsushita H. Pulmonary arteriovenous fistula. Kyobu Geka 1984;37:370-5.
Resection of Multiple Pulmonary Metastases From a Recurrent Intracranial Meningioma C. Patrick Murrah, MD, Edward R. Ferguson, MD, Richard L. Jennelle, MD, Barton L. Guthrie, MD, a n d William L. Holman, MD Divisions of Cardiothoracic Surgery, Neurosurgery, and Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
Surgical resection of multiple pulmonary metastases from a recurrent intracranial m e n i n g i o m a in a 53-yearold w o m a n is presented. The primary tumor was diagnosed in 1984 and partially excised in early 1985. The tumor recurred and was re-excised in 1989 and 1992. A fourth intracranial recurrence was noted in 1993, accompanied by multiple bilateral pulmonary metastases. The metastases were excised using staged thoracotomies in July and September 1994. The patient is surviving with cranial tumor residual.
(Ann Thorac Surg 1996;61:1823-4) eningiomas are usually b e n i g n intracranial tumors that only rarely metastasize. In 1987, Stoller and associates [1] found 113 extracranial metastatic cases. Sixty-one percent of these cases had lung metastasis. The lung was the only site of extracranial metastasis in 32%. Only 13% had greater than three metastases. This case illustrates surgical m a n a g e m e n t of a patient with nine bilateral p u l m o n a r y metastases from a recurrent intracranial meningioma.
M
The patient is a 53-year-old w o m a n who was found to have a mass in the left frontal hemispheric convexity in 1984. The mass was excised in early 1985, a n d was diagnosed as a meningioma. The m e n i n g i o m a recurred Accepted for publicationDec 22, 1995. Address reprint requests to Dr Holman,Departmentof SurgeD',University, of Alabamaat Birmingham,UniversityStation, Birmingham,AL 35294. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
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Comment M i n i m u m criteria for resection of p u l m o n a r y metastases were described by Ehrenhaft a n d associates in 1958 [2]. These criteria have u n d e r g o n e little change since that time. There is almost universal agreement on the following criteria: (1) control of the primary neoplasm, (2) absence of metastasis to other organs, a n d (3) ability to resect all p u l m o n a r y metastases with acceptable operative risk and adequate residual p u l m o n a r y function [3]. This case represents an interesting application, b u t the principles remain the same. Other factors such as the n u m b e r of metastases, disease-free interval, histologic type, a n d t u m o r doubling time, although not individually 0003-4975/96/$15.00 Pll S0003-4975(96)00064-1