1020
CORRESPONDENCE
Ann Thorac Surg 1990;50:1019-23
References Mills NL, Everson CT. Right gastroepiploic artery: a third arterial conduit for coronary artery bypass. Ann Thorac Surg 1989;47:70&11. Suma H, Takanashi R. Arteriosclerosis of the gastroepiploic and internal thoracic arteries. Ann Thorac Surg 1990;50:413-6. Van Son JAM, Smedts F, Vincent JG, van Lier HJJ, Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. J Thorac Cardiovasc Surg 1990; 99:70>7. Koike R, Suma H, Kondo K, et al. Pharmacological response of internal mammary artery and gastroepiploic artery. Ann Thorac Surg 1990;50:384-6.
Chest Wall Recurrence of Lung Cancer After Transthoracic Fine Needle Aspiration Biopsy To the Editor: In a recent article, Seyfer and associates [l]described a patient who had chest wall implantation of lung cancer after fine-needle aspiration biopsy. I would like to document another example of this complication with the following case history of a patient from our practice. An asymptomatic 65-year-old woman underwent annual physical examination, which was entirely normal. Chest roentgenogram (Fig 1) revealed a 2-cm cavitary lesion in the posterior segment of the right upper lobe. On computed tomographic scan no other pulmonary lesions were seen and there was no hilar or mediastinal lymphadenopathy. She had smoked cigarettes for over 40 years. Fiberoptic bronchoscopy was normal. She underwent fine-needle aspiration biopsy of the lung lesion through the right posterior chest wall with three passes of a 22-gauge spinal needle. Because pneumothorax resulted, a chest tube was inserted, the lung was reexpanded, and she was admitted to the hospital. Cytological evaluation of the aspirate was reported as "adenocarcinoma." Bone, brain, and liver scans were normal.
A
Fig I . Cnvitary lung cancer in the posterior segment of fhe right upper lobe. Pulmonary function studies indicated that she would tolerate right upper lobectomy. One week later she underwent right thoracotomy. When the pleural space was entered the lung collapsed and no pleural adhesions were found. A 2-cm mass was palpated in the posterior segment of the right upper lobe. The visceral pleura was not grossly involved. No other pulmonary lesions were felt. There was no visible or palpable hilar or mediastinal lymphadenopathy. Right upper lobectomy was carried out. Gross pathological
B
Fig 2. Posteroanterior ( A ) and lateral ( B ) chest roenfgenograms showing chest zuall recurrence ujith rib destruction.
CORRESPONDENCE
Ann Thonc Surg 1990;50:101%23
description of the resected tissue was of a “subpleural 2.5 cm diameter tumor with a central 1 cm diameter cavih . . . no extension through the pleura is seen.” Microscopic examination revealed poorly differentiated squamous cell carcinoma with no metastases in four hilar lymph nodes. The pleural, bronchial, and vascular margins were free of tumor. No lymphatic or vascular invasion was present. The resected tumor was staged as T1 NO MO, stage 1. No further treatment was recommended. Seven months later she was seen in the clinic complaining of weight loss, dyspnea, and pain in the right posterior chest wall. A tender 4 x 7-cm mass was palpated posteriorly in the right upper chest wall. Chest roerttgenogram revealed a large right posterior chest wall mass, with destruction of the posterior portions of ribs 5 through 7 (Fig 2). This mass was at the site of the previous needle aspiration. Aspiration biopsy of the mass revealed non-small cell carcinoma. Metastatic work-up was negative. She received radiation therapy to the chest wall recurrence and died from disseminated disease 6 months later. In this case the evidence for implantation, as opposed to direct extension, seems conclusive. The aspiration was performed at the site of recurrence. A pneumothorax was produced, indicating that the lung was not adherent to the chest wall. At operation the lung was completely free from the chest wall and the tumor did not grossly extend to the visceral pleura. This was confirmed by histological examination. The tumor was not invaded nor disrupted during the lobectomy. Although rare, the potential for tumor implantation must be seriously considered when fine-needle aspiration is recommended for diagnosis of lung lesions with a high likelihood of being malignant, especially when the patient is operable and the lesion is resectable for a potential cure (21.
William R. Hix, M D Division of Cardiothoracic Surgery The George Washington University Medical Center 2150 Pennsylvania Aw, NW Washington, DC 20037
References 1. Seyfer AE, Walsh DS, Graeber GM, Nuno IN, Eliasson AH. Chest wall implantation of lung cancer after thin-needle aspiration biopsy. Ann Thorac Surg 1989;48:284-6. 2. Hix WR, Aaron BL. Needle aspiration in lung cancer. k s k of tumor implantation is not negligible. Chest 1990;9751&7.
Plastic Struts for Delayed Sternal Closure To the Editor: Fanning and associates ( 11 reported that delayed sternal closure may be lifesaving in the management of patients with cardiac dilatation after open heart operations. In less severe cases, simply leaving the sternum unsutured and closing the skin provided sufficient room for the enlarged heart to function satisfactorily. More severe degrees of cardiac dilatation or the presence of stiff, engorged lungs required more space, and in these cases the wound was left open because closure of the skin tended to pull the sternal edges together. The wound was covered with a plastic drape or prosthetic material between the skin edges. Such cases can be difficult to manage because the sternum is unstable and movement may cause cardiac compression, and also because the open wound requires special attention. Recently 2 of my patients (one adult, one child) who were on maximal inotropic and vasodilator support were not able to tolerate sternal closure at the end of a cardiac operation because of cardiac dilatation and lung engorgement. Closure of the skin
1021
Fig 2 . Transverse section through the chest to show the strut and the wire keeping the sternal edges separated by a fixed distance. alone, even after mobilization, was also not tolerated. Therefore the sternal edges were splinted open using the following technique: a length of stiff intercostal drainage tube about 5 cm (2 inches) long was cut (Meredith No. 22 for the pediatric patient and No. 28 for the adult patient) and a stainless steel wire was threaded through it. The ends of the wire were inserted parasternally on each side from the inside of the chest, brought out, and twisted together presternally (Fig 1). The sternal edges were thus immobilized at a fixed distance. Two such wired struts were used for the child and three for the adult patient. The skin that was mobilized could now be closed without compromising the cardiac output. Both patients were returned to the cardiac intensive care ward where inotrope doses were reduced. Some days later the struts could be removed and the sternal wounds closed. With this technique management of these patients was facilitated, particularly the physiotherapy, transport, and nursing of these patients because (1) the sternum was remarkably stable and (2) skin closure was achieved. Aljafri A. Majid, FRCSfEd)
Deprtnrent of Surgery University of Malaya Kuala Lumpur 59100 Malaysia
Reference 1. Fanning WJ, Vasko JS, K h a n JW. Delayed sternal closure
after cardiac surgery. Ann Thorac Surg 1987;44:169-72.
How Should the Risk of Bank Blood Transfusion in Open Heart Operations Be Minimized? To the Editor: We read with interest the work of Alajmo and associates [ I ] concerning blood salvage in cardiac operations obtained by means of infusion of aprotinin (Trasylol) in association with autotransfusion. Their results are confirmed by our experience, here briefly summarized especially with regard to the clinical requisites for autotransfusion, the application of this method, and the remarkable reduction in the incidence of posttransfusion hepatitis.
CORRESPONDENCE
Ann Thorac Surg 1990;50:1019-23
References Mills NL, Everson CT. Right gastroepiploic artery: a third arterial conduit for coronary artery bypass. Ann Thorac Surg 1989;47:70&11. Suma H, Takanashi R. Arteriosclerosis of the gastroepiploic and internal thoracic arteries. Ann Thorac Surg 1990;50:413-6. Van Son JAM, Smedts F, Vincent JG, van Lier HJJ, Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. J Thorac Cardiovasc Surg 1990; 99:70>7. Koike R, Suma H, Kondo K, et al. Pharmacological response of internal mammary artery and gastroepiploic artery. Ann Thorac Surg 1990;50:384-6.
Chest Wall Recurrence of Lung Cancer After Transthoracic Fine Needle Aspiration Biopsy To the Editor: In a recent article, Seyfer and associates [l]described a patient who had chest wall implantation of lung cancer after fine-needle aspiration biopsy. I would like to document another example of this complication with the following case history of a patient from our practice. An asymptomatic 65-year-old woman underwent annual physical examination, which was entirely normal. Chest roentgenogram (Fig 1) revealed a 2-cm cavitary lesion in the posterior segment of the right upper lobe. On computed tomographic scan no other pulmonary lesions were seen and there was no hilar or mediastinal lymphadenopathy. She had smoked cigarettes for over 40 years. Fiberoptic bronchoscopy was normal. She underwent fine-needle aspiration biopsy of the lung lesion through the right posterior chest wall with three passes of a 22-gauge spinal needle. Because pneumothorax resulted, a chest tube was inserted, the lung was reexpanded, and she was admitted to the hospital. Cytological evaluation of the aspirate was reported as "adenocarcinoma." Bone, brain, and liver scans were normal.
A
Fig I . Cnvitary lung cancer in the posterior segment of fhe right upper lobe. Pulmonary function studies indicated that she would tolerate right upper lobectomy. One week later she underwent right thoracotomy. When the pleural space was entered the lung collapsed and no pleural adhesions were found. A 2-cm mass was palpated in the posterior segment of the right upper lobe. The visceral pleura was not grossly involved. No other pulmonary lesions were felt. There was no visible or palpable hilar or mediastinal lymphadenopathy. Right upper lobectomy was carried out. Gross pathological
B
Fig 2. Posteroanterior ( A ) and lateral ( B ) chest roenfgenograms showing chest zuall recurrence ujith rib destruction.
CORRESPONDENCE
Ann Thonc Surg 1990;50:101%23
description of the resected tissue was of a “subpleural 2.5 cm diameter tumor with a central 1 cm diameter cavih . . . no extension through the pleura is seen.” Microscopic examination revealed poorly differentiated squamous cell carcinoma with no metastases in four hilar lymph nodes. The pleural, bronchial, and vascular margins were free of tumor. No lymphatic or vascular invasion was present. The resected tumor was staged as T1 NO MO, stage 1. No further treatment was recommended. Seven months later she was seen in the clinic complaining of weight loss, dyspnea, and pain in the right posterior chest wall. A tender 4 x 7-cm mass was palpated posteriorly in the right upper chest wall. Chest roerttgenogram revealed a large right posterior chest wall mass, with destruction of the posterior portions of ribs 5 through 7 (Fig 2). This mass was at the site of the previous needle aspiration. Aspiration biopsy of the mass revealed non-small cell carcinoma. Metastatic work-up was negative. She received radiation therapy to the chest wall recurrence and died from disseminated disease 6 months later. In this case the evidence for implantation, as opposed to direct extension, seems conclusive. The aspiration was performed at the site of recurrence. A pneumothorax was produced, indicating that the lung was not adherent to the chest wall. At operation the lung was completely free from the chest wall and the tumor did not grossly extend to the visceral pleura. This was confirmed by histological examination. The tumor was not invaded nor disrupted during the lobectomy. Although rare, the potential for tumor implantation must be seriously considered when fine-needle aspiration is recommended for diagnosis of lung lesions with a high likelihood of being malignant, especially when the patient is operable and the lesion is resectable for a potential cure (21.
William R. Hix, M D Division of Cardiothoracic Surgery The George Washington University Medical Center 2150 Pennsylvania Aw, NW Washington, DC 20037
References 1. Seyfer AE, Walsh DS, Graeber GM, Nuno IN, Eliasson AH. Chest wall implantation of lung cancer after thin-needle aspiration biopsy. Ann Thorac Surg 1989;48:284-6. 2. Hix WR, Aaron BL. Needle aspiration in lung cancer. k s k of tumor implantation is not negligible. Chest 1990;9751&7.
Plastic Struts for Delayed Sternal Closure To the Editor: Fanning and associates ( 11 reported that delayed sternal closure may be lifesaving in the management of patients with cardiac dilatation after open heart operations. In less severe cases, simply leaving the sternum unsutured and closing the skin provided sufficient room for the enlarged heart to function satisfactorily. More severe degrees of cardiac dilatation or the presence of stiff, engorged lungs required more space, and in these cases the wound was left open because closure of the skin tended to pull the sternal edges together. The wound was covered with a plastic drape or prosthetic material between the skin edges. Such cases can be difficult to manage because the sternum is unstable and movement may cause cardiac compression, and also because the open wound requires special attention. Recently 2 of my patients (one adult, one child) who were on maximal inotropic and vasodilator support were not able to tolerate sternal closure at the end of a cardiac operation because of cardiac dilatation and lung engorgement. Closure of the skin
1021
Fig 2 . Transverse section through the chest to show the strut and the wire keeping the sternal edges separated by a fixed distance. alone, even after mobilization, was also not tolerated. Therefore the sternal edges were splinted open using the following technique: a length of stiff intercostal drainage tube about 5 cm (2 inches) long was cut (Meredith No. 22 for the pediatric patient and No. 28 for the adult patient) and a stainless steel wire was threaded through it. The ends of the wire were inserted parasternally on each side from the inside of the chest, brought out, and twisted together presternally (Fig 1). The sternal edges were thus immobilized at a fixed distance. Two such wired struts were used for the child and three for the adult patient. The skin that was mobilized could now be closed without compromising the cardiac output. Both patients were returned to the cardiac intensive care ward where inotrope doses were reduced. Some days later the struts could be removed and the sternal wounds closed. With this technique management of these patients was facilitated, particularly the physiotherapy, transport, and nursing of these patients because (1) the sternum was remarkably stable and (2) skin closure was achieved. Aljafri A. Majid, FRCSfEd)
Deprtnrent of Surgery University of Malaya Kuala Lumpur 59100 Malaysia
Reference 1. Fanning WJ, Vasko JS, K h a n JW. Delayed sternal closure
after cardiac surgery. Ann Thorac Surg 1987;44:169-72.
How Should the Risk of Bank Blood Transfusion in Open Heart Operations Be Minimized? To the Editor: We read with interest the work of Alajmo and associates [ I ] concerning blood salvage in cardiac operations obtained by means of infusion of aprotinin (Trasylol) in association with autotransfusion. Their results are confirmed by our experience, here briefly summarized especially with regard to the clinical requisites for autotransfusion, the application of this method, and the remarkable reduction in the incidence of posttransfusion hepatitis.
