J Thorac Cardiovasc Surg 1998;116:666-667
© 1998 Mosby, Inc.
Reply
Takatsugu Shimono, MDa,
Motoshi Takao, MDa,
Taizo Shiraishi, MDb,
Isao Yada, MDa
Tsu, Mie, Japan
Department of Thoracic and Cardiovascular Surgerya, Division of Surgical Pathologyb, Mie University, School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
Reply to the Editor:
We thank Babatasi, Massetti, Galateau, and Khayat for their interest in our article. We shall first respond to their comment that the tumor in the second case originated in the atrial wall and extended into the pulmonary vein. Because of space limitations in our article, we did not show the photographs of the operative specimen and histologic findings in detail. On the macroscopic findings, the tumor filled the left lower pulmonary vein and was strongly attached to the wall of the pulmonary vein. Most of the intra-atrial tumor was free from the atrial wall and weakly attached to the atrial wall around the orifice of the pulmonary vein (Fig 1). Therefore, the tumor, the left lung, and the left side of the left atrial wall were excised en bloc. Histologic examination revealed that the tumor arose from the media of the pulmonary vein at the point where it was strongly attached (Fig 2).
View larger version (128K):
[in this window]
[in a new window]
|
Fig. 1. A, Left pneumonectomy specimen with the tumor mass and the left atrial wall. B, Macroscopic finding of the left lower pulmonary vein and the tumor. The tumor is strongly attached to the wall of the pulmonary vein (arrow).
|
|
Second, concerning surgical approach, they recommend a median sternotomy. We have used sternotomies in two cases of resected leiomyosarcoma originating in the left atrial walls close to the mitral anuli. In the reported case, the intra-atrial portion of the tumor was extremely large and filled most of the left atrium and the left lower pulmonary vein. Compared with our previous experiences, it seemed difficult to excise the tumor, the left atrial wall, and the left lung en bloc through a median sternotomy. Moreover, according to preoperative findings of computed tomography, magnetic resonance imaging, cineangiography, and echocardiography, the tumor appeared to be attached to only the left wall of the atrium around the orifice of the lower pulmonary vein. Therefore we chose the left thoracotomy approach. If the tumor had been on the right side of the left atrium, we would have chosen a median sternotomy as in the previous report.
1 Visualization of the remaining portion of the left atrial wall after resection of the tumor was good and the repair of the left atrium was very easy. Although it is not clear whether Babatasi and colleagues recommend a median sternotomy referring to their own experiences using both approaches, the surgical approach for this kind of lesion should be flexible, based on the preoperative findings of location and extension of the tumor.
Finally, efficacy of chemotherapy and/or radiation after surgery is still controversial for primary sarcoma of lung. 2-4 Although multimodality treatments are used with some success in advanced tumors, insufficient numbers of cases have been reported to confirm the benefit of adjuvant therapy after radical resection. At this moment, the two patients from our report are well and have no evidence of recurrence 30 months and 20 months after the operations, respectively.
References
-
Gyhra AS, Santander CK, Alarcon EC, Mucientes FH, Carrillo H. Leiomyosarcoma of the pulmonary veins with extension to the left atrium. Ann Thorac Surg 1996;61:1840-1. [Abstract/Free Full Text]
-
Jassen JP, Mulder JJS, Wagenaar SS, Elbers HRJ, van den Bosch JMM. Primary sarcoma of the lung: a clinical study with long-term follow-up. Ann Thorac Surg 1994;58:1151-5. [Abstract]
-
Martini N. Invited commentary. Ann Thorac Surg 1994;58:1155.
-
Zerkowski HR, Hofmann HS, Gybels I, Knolle J. Primary sarcoma of pulmonary artery and valve: multimodality treatment by chemotherapy and homograft replacement. J Thorac Cardiovasc Surg 1996;112:1122-4. [Free Full Text]
