References 1. Healey JE. An anatomic survey of anomalous pulmonary veins: their clinical significance. J Thoracic Surg 1952;23:433. 2. Kiseleva IP, Malsagov GU. Differential diagnosis of anomalous pulmonary venous return: a clinical-roentgenological study. Cor Vasa 1984;26:140–6. 3. Senocak F, Ozme S, Bilgic A. Partial anomalous pulmonary venous return-evaluation of 51 cases. Jpn Heart J 1994;35: 43–50. 4. Belli EV, Landolfo K, Thomas M, Odell J. Partial anomalous pulmonary venous return in a lung transplant recipient. Ann Thorac Surg 2013;95:1104–6. 5. Schmidt F, McGiffin DC, Zorn G, Young KR, Weill D, Kirklin JK. Management of congenital abnormalities of the donor lung. Ann Thorac Surg 2001;72:935–7.

Long-Term Survival After Local Resection of Cervical Esophageal Cancer Farah Hanif Ali Mohammad, MD, Pauline Go, MD, Tamer Ghanem, MD, Robert Stachler, MD, and Zane Hammoud, MD


Department of General Surgery, Division of Thoracic Surgery, and Department of Otolaryngology, Henry Ford Hospital, Detroit, Michigan

Squamous cell carcinoma of the esophagus may be seen in patients with history of head and neck malignancies. Anatomic factors may limit management options. We present a case of second primary early cervical esophageal squamous cell cancer managed by local resection with reconstruction using a radial forearm flap. (Ann Thorac Surg 2015;99:2202–3) Ó 2015 by The Society of Thoracic Surgeons he concept of “field cancerization” has been used to explain the association of several cancers in the aerodigestive tract. It is defined as exposure of the epithelium of the head and neck, lung, and esophagus to common carcinogenic agents that leads to various carcinomas in these regions [1]. Tobacco and alcohol use has been implicated as major common risk factors especially in esophageal and hypopharyngeal cancers [1, 2]. The prevalence of second primary malignancies has been reported to be 5% to 36% [3]. After therapy, long-term follow-up of patients with head and neck cancers has resulted in more frequent detection of synchronous or metachronous second primary carcinomas of the esophagus [4]. When detected early, such cancers are potentially curable and have an excellent prognosis [5]. Esophagectomy has been the mainstay of definitive treatment. Owing to the high morbidity and mortality associated with esophagectomy, however, other less invasive procedures such as


Accepted for publication Aug 8, 2014. Address correspondence to Dr Hammoud, Henry Ford Hospital, Division of Thoracic Surgery, 2799 W Grand Blvd, Detroit, MI 48202; e-mail: [email protected].

Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier

Ann Thorac Surg 2015;99:2202–3

photocoagulation, laser irradiation, photodynamic therapy, and endoscopic mucosal and segmental resection have been described for superficial esophageal cancer [6]. In addition, various options have been reported for reconstruction of the cervical esophagus, including pedicled cutaneous, musculocutaneous, and visceral transposition flaps [7]. We report a case of second primary early cervical esophageal squamous cell cancer managed by local resection with reconstruction using a radial forearm flap. The patient is a 51-year-old man with a history of tobacco and alcohol use. In 2004, he was diagnosed with T4 N2c squamous cell carcinoma of the base of tongue and was treated with definitive chemoradiation therapy. On subsequent surveillance in December 2010, he was noted to have a nodule in the proximal cervical esophagus. Endoscopic biopsy confirmed squamous cell carcinoma. Staging positron emission tomography showed no evidence of distant disease. Endoscopic ultrasonography revealed a 1.3 cm ulcerated mass 18 cm to 20 cm from the incisors, involving one third of the esophageal circumference and into the submucosa. Therefore, he was not deemed a candidate for endoscopic mucosal resection. Given the location of the mass in an area of previous heavy radiation, additional irradiation was not recommended. Esophagectomy was also not recommended as it would entail a high neck anastomosis in a previously irradiated neck and was considered too aggressive an option given the relatively localized nature of the cancer. Therefore, we devised a plan to perform a local full-thickness resection. The patient was taken to the operating room where upper endoscopy confirmed the location of the mass. The esophagoscope was left in the esophagus to provide guidance to the location of the mass. A standard left-side neck incision was performed, and the esophagus was identified and encircled. With the esophagoscope in place, the lesion was located using a 25G needle. A myotomy was performed, and the esophageal lumen was entered. Working from within, full-thickness resection measuring 5 cm  3 cm, incorporating one third to one half of the esophageal circumference, was performed. Negative margins were confirmed by frozen section analysis. Reconstruction of the esophageal defect then proceeded using a radial forearm free flap based on the left radial artery. A split-thickness skin graft and tracheostomy were also performed. There were no intraoperative complications. The patient’s postoperative course was remarkable for a minor non–ST-segment myocardial infarction. A barium swallow showed no evidence of leak but did show evidence of aspiration. He was discharged to home on postoperative day 7 after removal of his tracheostomy. He took nothing orally, and nutrition was provided parenterally. Pathology examination revealed a moderately differentiated invasive squamous cell cancer involving the mucosa and submucosa (T1b) and negative level 4 and level 5 lymph nodes. All margins were negative. Owing to continued evidence of aspiration on subsequent studies, a gastrostomy tube was placed. An oral diet was resumed 9 weeks postoperatively and was tolerated well thereafter. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.050

Ann Thorac Surg 2015;99:2203–5


The patient continues to do well without any evidence of recurrence nearly 4 years after the resection.


References 1. Wynder EL, Dodo H, Bloch DA, Gantt RC, Moore OS. Epidemiologic investigation of multiple primary cancer of the upper alimentary and respiratory tracts. Cancer 1969;24: 730–9. 2. Schottenfield D, Gantt RC, Wynder EL. The role of alcohol and tobacco in multiple primary cancers of the upper digestive system, larynx and lung: a prospective study. Prev Med 1974;3:277–93. 3. Vaamonde P, Martin C, Del Rio M, Labella T. Second primary malignancies in patients with cancer of the head and neck. Otolaryngol Head Neck Surg 2003;129:65–70. 4. Wind P, Roullet M-H, Quinaux D, Laccoureye O, Brasnu D, Cugnenc P-H. Long-term results after esophagectomy for squamous cell carcinoma of the esophagus associated with head and neck cancer. Am J Surg 1999;178:251–5. 5. Tachibana M, Kinugasa S, Shibakita M, et al. Surgical treatment of superficial esophageal cancer. Langenbecks Arch Surg 2006;391:304–21. 6. Kato H, Tachimori Y, Mizobuchi S, Igaki H, Ochiai A. Cervical, mediastinal, and abdominal lymph node dissection (three-field dissection) for superficial carcinoma of the thoracic esophagus. Cancer 1993;72:2879–82. 7. Dodd AR, Goodnight JE, Pu LL. Successful management of cervicoesophageal anastomosis leak after microsurgical esophageal reconstruction: a case report and review of the literature. Ann Plast Surg 2010;65:110–4. 8. Coleman JJ. Reconstruction of the pharynx and cervical esophagus. Semin Surg Oncol 1995;11:208–20. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier

Mitral Valve Stenosis Progression Due to Severe Calcification on Glutaraldehyde-Treated Autologous Pericardium: Word of Caution for an Attractive Repair Technique Naoto Fukunaga, MD, Takehiko Matsuo, MD, Yoshiaki Saji, MD, Yukihiro Imai, MD, and Tadaaki Koyama, MD Departments of Cardiovascular Surgery and Pathology, Kobe City Medical Center General Hospital, Kobe, Japan

A 42-year-old woman presented with a 6-month history of palpitations and progressive dyspnea on exertion. She had undergone aortic and mitral valve repair using glutaraldehyde-treated autologous pericardium for active infective endocarditis 5 years prior. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification of the glutaraldehyde-treated pericardial patch on the anterior mitral leaflet was observed. Double valve replacement was performed with pulmonary vein isolation. Pathologic examination showed calcification of the glutaraldehyde-treated autologous pericardium. The patient was discharged on postoperative day 11 with oral anticoagulant therapy. (Ann Thorac Surg 2015;99:2203–5) Ó 2015 by The Society of Thoracic Surgeons


lutaraldehyde-treated autologous pericardium is an attractive material for mitral valve repair, with good long-term durability [1]. We experienced a patient with progressive mitral stenosis owing to calcification of an autologous pericardial patch despite optimal glutaraldehyde treatment. A 42-year-old woman was admitted to our hospital for redo valvular surgery. She did not have a history of rheumatic fever. She had undergone aortic and mitral valve repair for active infective endocarditis 5 years prior, with no pathogen identified. Her previous surgery included debridement of the infected tissue and patch repair of the anterior leaflet of the mitral valve using 0.625% glutaraldehyde-treated autologous pericardium. The aortic valve was also repaired using the same patch of autologous pericardium patch, and myectomy was performed for hypertrophic obstructive cardiomyopathy. She was followed up every 6 months at the outpatient clinic. Approximately 6 months prior to the current admission,

Accepted for publication July 30, 2014. Address correspondence to Dr Fukunaga, Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan; e-mail: [email protected].

0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.087


Squamous cell carcinoma of the mid and cervical esophagus may be seen in patients with a history of head and neck cancers. Although long-term surveillance after management of head and neck cancers may allow early detection of these cancers, anatomic factors can sometimes limit the therapeutic options. The definitive treatment of localized esophageal cancer includes esophagectomy, a procedure associated with significant morbidity and some mortality. Given the low rate of lymph node involvement and distant disease in superficial esophageal cancers [6], several alternatives to esophagectomy have been proposed for these high-risk patients [7]. Segmental resection of these cancers and replacement with a jejunal free autograft or radial forearm free flap has increased success rate for most hypopharyngeal, and even in some cervical, esophageal tumors [8]. In our patient with cervical esophageal cancer, the prior history of full-dose neck irradiation did not allow further radiation, and the location and depth of tumor did not permit endoscopic resection. Therefore, an open, complete local resection was performed under endoscopic guidance. We then used a radial artery–based free forearm muscle flap for coverage of the resultant esophageal defect. That avoided the complexity and additional possible complications of a jejunal free flap. The patient has done well and has achieved a durable oncologic outcome. Our report demonstrates the feasibility of this individualized approach to the management of these cancers.


Long-Term Survival After Local Resection of Cervical Esophageal Cancer.

Squamous cell carcinoma of the esophagus may be seen in patients with history of head and neck malignancies. Anatomic factors may limit management opt...
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