Original Article
Extraction of mediastinal teratoma contents for complete thoracoscopic resection
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(1) 42–45 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314536173 aan.sagepub.com
Hiroyoshi Tsubochi1, Shunsuke Endo2, Tomoyuki Nakano2, Kentaro Minegishi2, Kenji Tetsuka2 and Tsuyoshi Hasegawa2
Abstract Objectives: Video-assisted thoracic surgery is widely applied for resection of mediastinal tumors. The mediastinal mature teratoma, however, is usually operated on via an open approach because it is generally large, making it difficult to dissect under a thoracoscopic view and remove it from the thoracic cavity. We attempted to extract intracystic material during video-assisted thoracic surgery to facilitate dissection and removal of the tumor from the thoracic cavity. Methods: From January 1998 to April 2013, 13 patients (9 women, 4 men; mean age 33 years, range 17–54 years) with mediastinal mature teratomas were operated on via video-assisted thoracic surgery. Intracystic contents of the tumor were aspirated before dissection or after the teratoma was dissected and placed in the retrieval pouch. Results: None of the patients required conversion to an open procedure. Operating time was 95–184 min (mean 132 min). Blood loss during the operation amounted to 10–300 mL (mean 78 mL). The tumor size ranged from 5 to 12 cm (mean 8 cm). In all cases, the tumors were confirmed pathologically to be mature cystic teratomas with no malignant components. During and after follow-up, all patients continue to do well without recurrence. Conclusion: Extraction of intracystic contents enabled thoracoscopic resection of large mature mediastinal teratomas.
Keywords Cysts, mediastinal neoplasms, teratoma, thoracic surgery, video-assisted
Introduction Video-assisted thoracic surgery (VATS) is widely used to remove small, benign mediastinal tumors such as neurogenic tumors, thymic cysts, and bronchogenic cysts. Large mature mediastinal cystic teratomas however are usually approached via thoracotomy or sternotomy because it is difficult to retract the removed tissue through a VATS port because of the size. We hypothesized that we could facilitate the mobility, dissection, and removal of mature cystic teratomas by VATS if we first punctured the cystic component and aspirated its fluid content. We have used this method successfully in 13 cases of cystic teratoma. We review these cases in this report.
Patients and methods From January 1998 to April 2013, 17 patients with mature mediastinal teratomas were operated on at
our institution. Among them, 13 patients were operated on using VATS and are the subjects of this study. Four other patients, whose tumors perforated the lung or the pericardium and caused aspiration pneumonia or cardiac tamponade, underwent emergency surgery through an open approach: median sternotomy in 2 cases and lateral thoracotomy in the other 2. These 4 patients were excluded from the study. All patients who underwent VATS were asymptomatic. Physical examination revealed no abnormalities. 1 Department of General Thoracic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan 2 Department of General Thoracic Surgery, Jichi Medical University, Tochigi, Japan
Corresponding author: Hiroyoshi Tsubochi, MD, Department of General Thoracic Surgery, Saitama Medical Center, Jichi Medical University, Amanuma 1-847, Omiya, Saitama 350-1241, Japan. Email: [email protected]
Tsubochi et al.
43
Table 1. Characteristics of patients with mediastinal mature teratoma treated by video-assisted thoracic surgery. Case Age Diameter Operative Blood Outcome no. Sex (years) (cm) time (min) loss (mL) (months) 1 2 3 4 5 6 7 8 9 10 11 12 13
F F F F F M F F M M F F M
27 35 54 45 24 33 35 24 42 17 32 23 38
5 10 9 11 10 9 5 7 10 8 5 7 12
165 130 180 165 125 95 108 99 106 184 98 100 258
20 10 100 300 150 50 10 70 20 150 10 50 450
Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive
(152) (104) (68) (68) (56) (44) (32) (32) (13) (11) (9) (4) (4)
They were referred to our hospital because of an abnormal shadow on chest radiography. There were 9 female and 4 male patients with a mean age of 33 years (range 17–54 years; Table 1). Computed tomography, performed in all patients, revealed a lobulated, cystic mass with calcification and fat components in the anterior mediastinum. Serum tumor markers (carcinoembryonic antigen, a-fetoprotein, human gonadotropin-b, squamous cell carcinoma antigen) were within the normal range in all patients. Fine-needle aspiration biopsy was not performed in any case. All tumors were considered mature teratomas based on preoperative radiological evaluation. Tumor removal by VATS was planned in each case. After selective unilateral ventilation and anesthesia with double-lumen endotracheal intubation, the operations were performed with the patient in the lateral decubitus position. Three to 5 ports were used: an 11.5-mm trocar was inserted through the 6th intercostal space (ICS) at the mid-axillary line, and a 45 angled thoracoscope was introduced into the thoracic cavity. Two other 11.5-mm trocars were then inserted: one through the 6th ICS in the posterior axillary line and the other through the 6th ICS in the anterior axillary line. In some cases, 1 or 2 additional ports were inserted, with either one or both ports at the 4th ICS in the anterior axillary line or a port at the 8th ICS in the posterior axillary line. The tumors were mainly dissected using an ultrasonic scalpel, although dissection near the phrenic nerve was performed using shears to avoid thermal damage. The ultrasonic scalpel was also used to transect small vessels such as thymic veins. When removing resected and freed tumors from the thoracic cavity, we initially placed the tumor in a
retrieval pouch and then pulled the pouch through a port that was extended to 2–3 cm in length. To facilitate removal of the tumor, the contents of the tumor were evacuated using a balloon catheter, followed by making a 1-cm incision on the surface of the tumor in the pouch. As the tumor in the pouch deflated, it was gradually drawn from the thoracic cavity and then completely removed. Part of the aspirated fluid component of the tumor was examined cytologically during the operation. If the solid component of the tumor was relatively large and difficult to extract from the thoracic cavity, the skin incision was extended to 4–5 cm, as needed. For especially large tumors that were difficult to visualize satisfactorily with the thoracoscope, we evacuated the contents of the tumor completely while it was still in the thoracic cavity, before dissecting the tumor. We thus gained better tumor mobility and a clearer thoracoscopic view. A balloon catheter 5 mm in diameter was inserted into the tumor through a small pore on the tumor surface made by shears. The contents of the tumor including hair and sebaceous debris were then extracted. This procedure facilitated traction of the tumor. The extirpated tumor pieces were contained in the pouch and removed from the thoracic cavity through a port. The thoracic cavity was washed throughout with saline at body temperature to remove any remnants of the tumor and its contents. Finally, one or two 24F chest drainage tubes were inserted and the skin incisions were closed. Postoperatively, the chest drainage tube was removed when the pleural effusion was 5 cm (the largest one reaching 11 cm), thoracoscopic surgery was completed in all cases without conversion to an open procedure. Also, there were no major complications or tumor recurrences in any of these cases. When we apply thoracoscopic surgery to a large teratoma, we first try to extirpate it without extracting the contents which are not removed until the tumor has been safely transferred to the retrieval pouch. Tensional cysts can easily rupture or interfere with the thoracoscopic view and surgical manoeuvres. In such cases, we puncture the cystic portion of the tumor and aspirate its fluid content and debris prior to resecting and moving the tumor into the pouch. This method facilitates grasping and manipulating the tumor. A similar procedure has been reported for laparoscopic surgery of a dermoid cyst of the ovary.4 A technique that uses a cannula with a balloon catheter has also been described for cystic mediastinal tumors.5,6 Whereas complete tumor deflation makes it difficult to identify the margins of cystic tumors (e.g. a bronchogenic cyst or thymic cyst), when extirpating a mature teratoma we extract the tumor contents completely because the wall of the teratoma is usually thick enough to identify its margin. One of the fears associated with this method is the possibility of spilling malignant cells into the thoracic cavity from a tumor with a malignant component. The reported incidence of mediastinal teratomas with malignant transformation ranges from 1.7% to 8.0 %.7 Some reports have revealed teratomas with malignant transformation,8–10 and postoperative recurrences have been reported.9,10 These reports described tumors that had
Tsubochi et al. been diagnosed as benign mature cystic teratomas and ruptured during the operation due to dense adhesions. Because the malignant component is usually so small it is undetectable during the first pathology survey, in general it is difficult to determine radiologically whether the teratoma contains a malignant component before surgery. We should therefore be aware of the possibility that the teratoma might include malignant cells even if it was deemed benign. Also, in cases in which we remove the tumor’s contents before dissection, it is important to minimize spillage and carefully clean the entire thoracic cavity so no tumor debris remains. Another worrying possibility is chemical contamination of the thoracic cavity by the tumor’s contents. Mature teratomas frequently contain pancreatic tissue which can produce digestive enzymes. Also, ovarian mature teratomas have been reported to cause nonbacterial peritonitis following laparoscopic removal.11 Finally, iatrogenic leakage of the contents of a mediastinal teratoma might cause postoperative pleuritis, although there have been no reports of such an event to our knowledge. From this point of view, however, careful rinsing with saline is important to avoid pleural irritation that might be caused by the intracystic fluid of the teratomas. In conclusion, extraction of tumor contents makes thoracoscopic surgery applicable for large mature cystic teratomas by facilitating the dissection and removal of the tumor from the thoracic cavity. Neither major complications nor tumor recurrences were recorded after VATS removal of the mature teratomas in our patients. We should consider thoracoscopic surgery as an alternative to an open approach for large mature cystic teratomas. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
45 References 1. Takeo S and Fukuyama S. Video-assisted thoracoscopic resection of a giant anterior mediastinal tumor (lipoma) using an original sternum-lifting technique. Jpn J Thorac Cardiovasc Surg 2005; 53: 565–568. 2. Gossot D, Izquierdo RR, Girard P, Stern JB and Magdeleinat P. Thoracoscopic resection of bulky intrathoracic benign lesions. Eur J Cardiothorac Surg 2007; 32: 848–851. 3. Cheng YJ, Huang MF and Tsai KB. Video-assisted thoracoscopic management of an anterior mediastinal teratoma: report of a case. Surg Today 2000; 30: 1019–1021. 4. Mecke H and Savvas V. Laparoscopic surgery of dermoid cysts—intraoperative spillage and complications. Eur J Obstet Gynecol Reprod Biol 2001; 96: 80–84. 5. Iwasaki A, Hiratsuka M, Kawahara K and Shirakusa T. New technique for the cystic mediastinal tumor by videoassisted thoracoscopy. Ann Thorac Surg 2001; 72: 632–633. 6. Shimokawa S, Watanabe S, Sakasegawa K, Nakamura Y, Hisashi Y and Sakata R. Balloon catheter for cyst aspiration in a thoracoscopic resection of mediastinal cysts. Surg Today 2001; 31: 284–286. 7. Moran CA and Suster S. Primary germ cell tumors of the mediastinum: I. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging. Cancer 1997; 80: 681–690. 8. Shimizu K, Nakata M, Hirami Y, Akiyama T and Tanemoto K. Teratoma with malignant transformation in the anterior mediastinum. J Thorac Cardiovasc Surg 2008; 136: 225–227. 9. Sakurai H, Miyashita Y and Oyama T. Adenocarcinoma arising in anterior mediastinal mature cystic teratoma: report of a case. Surg Today 2008; 38: 348–351. 10. Chang CC, Chang YL and Lee YC. Cystic malignant teratoma with early recurrence after intraoperative spillage. Ann Thorac Surg 2008; 86: 1971–1973. 11. Shamshirsaz AA, Shamshirsaz AA, Vibhakar JL, Broadwell C and Van Voorhis BJ. Laparoscopic management of chemical peritonitis caused by dermoid cyst spillage. JSLS 2011; 15: 403–405.
Extraction of mediastinal teratoma contents for complete thoracoscopic resection
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(1) 42–45 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314536173 aan.sagepub.com
Hiroyoshi Tsubochi1, Shunsuke Endo2, Tomoyuki Nakano2, Kentaro Minegishi2, Kenji Tetsuka2 and Tsuyoshi Hasegawa2
Abstract Objectives: Video-assisted thoracic surgery is widely applied for resection of mediastinal tumors. The mediastinal mature teratoma, however, is usually operated on via an open approach because it is generally large, making it difficult to dissect under a thoracoscopic view and remove it from the thoracic cavity. We attempted to extract intracystic material during video-assisted thoracic surgery to facilitate dissection and removal of the tumor from the thoracic cavity. Methods: From January 1998 to April 2013, 13 patients (9 women, 4 men; mean age 33 years, range 17–54 years) with mediastinal mature teratomas were operated on via video-assisted thoracic surgery. Intracystic contents of the tumor were aspirated before dissection or after the teratoma was dissected and placed in the retrieval pouch. Results: None of the patients required conversion to an open procedure. Operating time was 95–184 min (mean 132 min). Blood loss during the operation amounted to 10–300 mL (mean 78 mL). The tumor size ranged from 5 to 12 cm (mean 8 cm). In all cases, the tumors were confirmed pathologically to be mature cystic teratomas with no malignant components. During and after follow-up, all patients continue to do well without recurrence. Conclusion: Extraction of intracystic contents enabled thoracoscopic resection of large mature mediastinal teratomas.
Keywords Cysts, mediastinal neoplasms, teratoma, thoracic surgery, video-assisted
Introduction Video-assisted thoracic surgery (VATS) is widely used to remove small, benign mediastinal tumors such as neurogenic tumors, thymic cysts, and bronchogenic cysts. Large mature mediastinal cystic teratomas however are usually approached via thoracotomy or sternotomy because it is difficult to retract the removed tissue through a VATS port because of the size. We hypothesized that we could facilitate the mobility, dissection, and removal of mature cystic teratomas by VATS if we first punctured the cystic component and aspirated its fluid content. We have used this method successfully in 13 cases of cystic teratoma. We review these cases in this report.
Patients and methods From January 1998 to April 2013, 17 patients with mature mediastinal teratomas were operated on at
our institution. Among them, 13 patients were operated on using VATS and are the subjects of this study. Four other patients, whose tumors perforated the lung or the pericardium and caused aspiration pneumonia or cardiac tamponade, underwent emergency surgery through an open approach: median sternotomy in 2 cases and lateral thoracotomy in the other 2. These 4 patients were excluded from the study. All patients who underwent VATS were asymptomatic. Physical examination revealed no abnormalities. 1 Department of General Thoracic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan 2 Department of General Thoracic Surgery, Jichi Medical University, Tochigi, Japan
Corresponding author: Hiroyoshi Tsubochi, MD, Department of General Thoracic Surgery, Saitama Medical Center, Jichi Medical University, Amanuma 1-847, Omiya, Saitama 350-1241, Japan. Email: [email protected]
Tsubochi et al.
43
Table 1. Characteristics of patients with mediastinal mature teratoma treated by video-assisted thoracic surgery. Case Age Diameter Operative Blood Outcome no. Sex (years) (cm) time (min) loss (mL) (months) 1 2 3 4 5 6 7 8 9 10 11 12 13
F F F F F M F F M M F F M
27 35 54 45 24 33 35 24 42 17 32 23 38
5 10 9 11 10 9 5 7 10 8 5 7 12
165 130 180 165 125 95 108 99 106 184 98 100 258
20 10 100 300 150 50 10 70 20 150 10 50 450
Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive
(152) (104) (68) (68) (56) (44) (32) (32) (13) (11) (9) (4) (4)
They were referred to our hospital because of an abnormal shadow on chest radiography. There were 9 female and 4 male patients with a mean age of 33 years (range 17–54 years; Table 1). Computed tomography, performed in all patients, revealed a lobulated, cystic mass with calcification and fat components in the anterior mediastinum. Serum tumor markers (carcinoembryonic antigen, a-fetoprotein, human gonadotropin-b, squamous cell carcinoma antigen) were within the normal range in all patients. Fine-needle aspiration biopsy was not performed in any case. All tumors were considered mature teratomas based on preoperative radiological evaluation. Tumor removal by VATS was planned in each case. After selective unilateral ventilation and anesthesia with double-lumen endotracheal intubation, the operations were performed with the patient in the lateral decubitus position. Three to 5 ports were used: an 11.5-mm trocar was inserted through the 6th intercostal space (ICS) at the mid-axillary line, and a 45 angled thoracoscope was introduced into the thoracic cavity. Two other 11.5-mm trocars were then inserted: one through the 6th ICS in the posterior axillary line and the other through the 6th ICS in the anterior axillary line. In some cases, 1 or 2 additional ports were inserted, with either one or both ports at the 4th ICS in the anterior axillary line or a port at the 8th ICS in the posterior axillary line. The tumors were mainly dissected using an ultrasonic scalpel, although dissection near the phrenic nerve was performed using shears to avoid thermal damage. The ultrasonic scalpel was also used to transect small vessels such as thymic veins. When removing resected and freed tumors from the thoracic cavity, we initially placed the tumor in a
retrieval pouch and then pulled the pouch through a port that was extended to 2–3 cm in length. To facilitate removal of the tumor, the contents of the tumor were evacuated using a balloon catheter, followed by making a 1-cm incision on the surface of the tumor in the pouch. As the tumor in the pouch deflated, it was gradually drawn from the thoracic cavity and then completely removed. Part of the aspirated fluid component of the tumor was examined cytologically during the operation. If the solid component of the tumor was relatively large and difficult to extract from the thoracic cavity, the skin incision was extended to 4–5 cm, as needed. For especially large tumors that were difficult to visualize satisfactorily with the thoracoscope, we evacuated the contents of the tumor completely while it was still in the thoracic cavity, before dissecting the tumor. We thus gained better tumor mobility and a clearer thoracoscopic view. A balloon catheter 5 mm in diameter was inserted into the tumor through a small pore on the tumor surface made by shears. The contents of the tumor including hair and sebaceous debris were then extracted. This procedure facilitated traction of the tumor. The extirpated tumor pieces were contained in the pouch and removed from the thoracic cavity through a port. The thoracic cavity was washed throughout with saline at body temperature to remove any remnants of the tumor and its contents. Finally, one or two 24F chest drainage tubes were inserted and the skin incisions were closed. Postoperatively, the chest drainage tube was removed when the pleural effusion was 5 cm (the largest one reaching 11 cm), thoracoscopic surgery was completed in all cases without conversion to an open procedure. Also, there were no major complications or tumor recurrences in any of these cases. When we apply thoracoscopic surgery to a large teratoma, we first try to extirpate it without extracting the contents which are not removed until the tumor has been safely transferred to the retrieval pouch. Tensional cysts can easily rupture or interfere with the thoracoscopic view and surgical manoeuvres. In such cases, we puncture the cystic portion of the tumor and aspirate its fluid content and debris prior to resecting and moving the tumor into the pouch. This method facilitates grasping and manipulating the tumor. A similar procedure has been reported for laparoscopic surgery of a dermoid cyst of the ovary.4 A technique that uses a cannula with a balloon catheter has also been described for cystic mediastinal tumors.5,6 Whereas complete tumor deflation makes it difficult to identify the margins of cystic tumors (e.g. a bronchogenic cyst or thymic cyst), when extirpating a mature teratoma we extract the tumor contents completely because the wall of the teratoma is usually thick enough to identify its margin. One of the fears associated with this method is the possibility of spilling malignant cells into the thoracic cavity from a tumor with a malignant component. The reported incidence of mediastinal teratomas with malignant transformation ranges from 1.7% to 8.0 %.7 Some reports have revealed teratomas with malignant transformation,8–10 and postoperative recurrences have been reported.9,10 These reports described tumors that had
Tsubochi et al. been diagnosed as benign mature cystic teratomas and ruptured during the operation due to dense adhesions. Because the malignant component is usually so small it is undetectable during the first pathology survey, in general it is difficult to determine radiologically whether the teratoma contains a malignant component before surgery. We should therefore be aware of the possibility that the teratoma might include malignant cells even if it was deemed benign. Also, in cases in which we remove the tumor’s contents before dissection, it is important to minimize spillage and carefully clean the entire thoracic cavity so no tumor debris remains. Another worrying possibility is chemical contamination of the thoracic cavity by the tumor’s contents. Mature teratomas frequently contain pancreatic tissue which can produce digestive enzymes. Also, ovarian mature teratomas have been reported to cause nonbacterial peritonitis following laparoscopic removal.11 Finally, iatrogenic leakage of the contents of a mediastinal teratoma might cause postoperative pleuritis, although there have been no reports of such an event to our knowledge. From this point of view, however, careful rinsing with saline is important to avoid pleural irritation that might be caused by the intracystic fluid of the teratomas. In conclusion, extraction of tumor contents makes thoracoscopic surgery applicable for large mature cystic teratomas by facilitating the dissection and removal of the tumor from the thoracic cavity. Neither major complications nor tumor recurrences were recorded after VATS removal of the mature teratomas in our patients. We should consider thoracoscopic surgery as an alternative to an open approach for large mature cystic teratomas. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
45 References 1. Takeo S and Fukuyama S. Video-assisted thoracoscopic resection of a giant anterior mediastinal tumor (lipoma) using an original sternum-lifting technique. Jpn J Thorac Cardiovasc Surg 2005; 53: 565–568. 2. Gossot D, Izquierdo RR, Girard P, Stern JB and Magdeleinat P. Thoracoscopic resection of bulky intrathoracic benign lesions. Eur J Cardiothorac Surg 2007; 32: 848–851. 3. Cheng YJ, Huang MF and Tsai KB. Video-assisted thoracoscopic management of an anterior mediastinal teratoma: report of a case. Surg Today 2000; 30: 1019–1021. 4. Mecke H and Savvas V. Laparoscopic surgery of dermoid cysts—intraoperative spillage and complications. Eur J Obstet Gynecol Reprod Biol 2001; 96: 80–84. 5. Iwasaki A, Hiratsuka M, Kawahara K and Shirakusa T. New technique for the cystic mediastinal tumor by videoassisted thoracoscopy. Ann Thorac Surg 2001; 72: 632–633. 6. Shimokawa S, Watanabe S, Sakasegawa K, Nakamura Y, Hisashi Y and Sakata R. Balloon catheter for cyst aspiration in a thoracoscopic resection of mediastinal cysts. Surg Today 2001; 31: 284–286. 7. Moran CA and Suster S. Primary germ cell tumors of the mediastinum: I. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging. Cancer 1997; 80: 681–690. 8. Shimizu K, Nakata M, Hirami Y, Akiyama T and Tanemoto K. Teratoma with malignant transformation in the anterior mediastinum. J Thorac Cardiovasc Surg 2008; 136: 225–227. 9. Sakurai H, Miyashita Y and Oyama T. Adenocarcinoma arising in anterior mediastinal mature cystic teratoma: report of a case. Surg Today 2008; 38: 348–351. 10. Chang CC, Chang YL and Lee YC. Cystic malignant teratoma with early recurrence after intraoperative spillage. Ann Thorac Surg 2008; 86: 1971–1973. 11. Shamshirsaz AA, Shamshirsaz AA, Vibhakar JL, Broadwell C and Van Voorhis BJ. Laparoscopic management of chemical peritonitis caused by dermoid cyst spillage. JSLS 2011; 15: 403–405.
