Eur J Cardiothorac Surg 2008;33:127-129. doi:10.1016/j.ejcts.2007.09.030
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Preoperative embolization in surgical management of giant thoracic sarcomas
Francesco Pumaa,*,
Carlo Luigi Cardinia,
Giovanni Passalacquab,
Mark Ragusaa
a Department of Thoracic Surgery, University of Perugia Medical School, Terni, Italy
b Department of Interventional Radiology, S. Maria Hospital, Terni, Italy
Received 3 August 2007;
received in revised form 12 September 2007;
accepted 27 September 2007.
* Corresponding author. Address: Chirurgia Toracica, Ospedale Civile S. Maria, 05100 Terni, Italy. Tel.: +39 0744 205475/476/460; fax: +39 0744 425271. (Email: francescopuma{at}aospterni.it).
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Abstract
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We report our experience with three cases of giant, highly vascular thoracic sarcomas treated by preoperative embolization and followed, after 48 h by successful excision. With this technique, reduction in tumor size was obtained, ranging from 20% to 32%; perilesional edema facilitated surgical dissection of the mass from the adjacent structures in all cases. Piecemeal removal of the tumor was carried out in two patients with minimal blood loss. In one patient an oligosymptomatic microembolization of the left upper limb was observed with symptoms spontaneously subsiding within 48 h. Preoperative embolization of giant thoracic sarcomas is useful to decrease perioperative blood loss and to facilitate surgery. In huge, highly vascular tumors, preoperative embolization may be essential in order to achieve total excision, especially if piecemeal removal is required.
Key Words: Sarcoma • Thoracic tumors • Preoperative care • Surgery
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1. Introduction
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Surgery of giant, highly vascular thoracic sarcomas can be challenging. The surgical risk is amplified by potential hemorrhage, problematic surgical exposure, difficult handling of the tumor and poor vascular control. We report our experience with the use of preoperative embolization in the surgical management of giant, highly vascular thoracic sarcomas.
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2. Case reports
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2.1 Patient #1
A 59-year-old male presented with a paravertebral tumor infiltrating the spine (T10), and the left 9th and 10th ribs. A fine needle aspiration biopsy (FNAB) indicated a chondrosarcoma. On the basis of angio-computed tomographic scan (CT) and magnetic resonance imaging (MRI) findings, a selective angiography was performed showing a rich vascularization of the tumor by T8–T9–T10–T11 intercostal arteries. The feeding arteries were embolized by 150–250 µm polyvinyl alcohol (PVA) particles (Contour®-PVA Embolization Particles, Target Therapeutics, Boston Scientific, USA) (Fig. 1
). Forty-eight hours after embolization, the patient underwent surgery. The demolitive phase required piecemeal removal for total excision. By a posterior approach, a partial vertebrectomy followed by stabilization with hooks, screws and rods was performed. Subsequently a left posterolateral thoracotomy was carried out to complete the resection by partial corporectomy of T10 and thoracectomy (posterior half of the 8th, 9th and 10th ribs). The vertebral body was reconstructed with a Harms cage containing methylmethacrylate, a plate and two screws at T9 and T11. Stabilization of the chest-wall defect was carried out by a pedicled latissimus dorsi flap. Histopathology confirmed grade 2 chondrosarcoma infiltrating bone and soft tissues. The patient did not undergo adjuvant therapy.
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Fig. 1. Patient #1: (a) RM imaging of giant thoracic chondrosarcoma. (b) Post-embolization RM imaging: tumor shrinking with initial ischemic necrosis.
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2.2 Patient #2
A 47-year-old female presented with a 3-month history of cough and increasing rest dyspnea. Chest X-ray and chest CT-scan disclosed a 20 cm right thoracic tumor compressing and dislocating the heart and mediastinum. Fine needle aspiration biopsy was not diagnostic. An incisional biopsy was carried out through an anterolateral right thoracotomy, followed by severe bleeding. Intraoperative blood transfusions were required. Histopathology disclosed high-grade pulmonary sarcoma. Angiographically, the feeding vessels were selectively catheterized and sequentially embolized by 150–250 µm PVA particles (Fig. 2
). Forty-eight hours after embolization, the patient underwent a large right posterolateral thoracotomy. Piecemeal removal of the tumor was required in order to control the hilar structures and to carry out a straightforward right pneumonectomy extending to the pericardium. Histopathology confirmed a high-grade oat-cell pulmonary sarcoma. No adjuvant therapy was administered.
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Fig. 2. Patient #2: (a) Preliminary angiography showing tumor feeding vessels from a hypertrophic bronchial artery. (b) Postembolization angiography showing no residual blood flow to the mass.
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2.3 Patient #3
A 59-year-old male presented with a history of multi-recurrent left pleural fibrosarcoma. The patient underwent tumor resections 11, 6 and 3 years earlier, in different sites of the left pleural cavity, followed by adjuvant chemotherapy. Three months prior to admission a new, fast growing, left thoracic tumor was discovered. Chest CT-scan showed a highly vascular 13 cm tumor, compressing the mediastinal structures. Forty-eight hours after embolization (PVA particles 250–235 µm), through a combined sequential approach (median sternotomy and left posterolateral thoracotomy), the neoplasm was separated from mediastinal structures and removed in one piece. Histopathology disclosed high-grade pleural fibrosarcoma. After surgery chemotherapy was administered.
2.4 Results
The tumor volume, pre- and post-embolization, was calculated by analysis of the imaging by Agfa IMPAX WEB 1000 software (Agfa-Gevaert, Mortsel, Belgium). Forty-eight hours after embolization, reduction in tumor volume was demonstrated, ranging from 20% to 32%. Two patients (#1 and #2) presented with fever the day after the procedure, ending immediately after surgery and patient #3 complained of paresthesia and mild pain in the left forearm, spontaneously subsiding within a couple of days. R0-resection was achieved in all patients. In two cases (#2 and #3) piecemeal excision was required and the procedure was almost bloodless. Patient #2, submitted to piecemeal excision of the tumor followed by right pneumonectomy, the cytologic evaluation of the final surgical irrigation fluid was negative. The postoperative course was smooth and the patients were discharged home on the 19th, 10th and 11th postoperative day, respectively. No patients had local recurrences. Patient #1 and #2 are alive without evidence of disease at 64 and 51 months postoperatively. Patient #3 is alive with pulmonary metastases at 23 months from surgery.
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3. Discussion
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Surgery of giant thoracic sarcomas may be challenging both for dimension and vascularity of the lesions. Completeness of resection is the priority. Resectability is sometimes questionable because any chosen operative route could prove inadequate for satisfactory surgical exposure. In such circumstances reduction of tumor size is required in order to allow a complete and safe resection. Decrease in tumor bulk can rarely be achieved by induction chemo or radiotherapy for the low response rate of such malignancies.
Few single case reports of preoperative embolization of pleural or mediastinal tumors are available in the literature [1–4]. One of the main benefits of such treatment is the reduction in tumor volume that we evaluated ranging from 20% to 32% in our patients. In huge sarcomas even such a shrinking of the tumor mass could be insufficient for adequate surgical exposure. In such circumstances the only possibility left to the surgeon is preliminary piecemeal excision of the tumor. Without preoperative embolization, piecemeal removal of giant thoracic sarcomas may be unattainable because of the risk of severe or lethal bleeding. In one patient in our series, a simple open biopsy was followed by severe hemorrhage, controlled only by intrathoracic packing. Forty-eight hours after embolization, the tumor surface can be cut with the cautery without significant bleeding. In our series, both patients treated in such fashion did not show local recurrence with a long-term follow-up. The ischemia-induced perilesional edema is the third advantage of preoperative embolization, facilitating dissection of the tumor from the adjacent structures.
Tumor vascularity must be preliminarily assessed by angio-CT scanning. In fact in a previous case of ours (bleeding giant thymoma) a CT scan performed without media contrast led to a useless angiography [5].
Complications related to embolization are mainly due to devascularization of areas adjacent to the lesion: in certain regions, such as the spine, the potential damage can be very important functionally [6]. The literature does not report complications related to embolization of intrathoracic masses, even though in one of our cases we observed transient ischemic symptoms in the left upper limb.
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References
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Abstract
1. Introduction
