Surgical resection for advanced thymic malignancy with pulmonary hilar invasion using hemi-clamshell approach

Fujiwara, Ayako; Funaki, Soichiro; Ose, Naoko; Kanou, Takashi; Kanzaki, Ryu; Minami, Masato; Shintani, Yasushi

doi:10.21037/jtd.2018.11.73

Cited by 12 publications

(7 citation statements)

References 19 publications

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“…HCST ( 7 - 10 ) was developed from the classic and famous Masaoka’s anterior approach ( 11 ) and is generally performed using a combination of longitudinal partial sternotomy and anterolateral thoracotomy ( Figure 3A ). In the present case, we used an enlarged modified HCST, combining full sternotomy, separation of caudal rib cartilage, large lateral fifth intercostal incision, and a supraclavicular transverse incision ( Figure 3B ).…”

Section: Discussionmentioning

confidence: 99%

Life-threatening massive bleeding in the pulmonary trunk adjacent to the right ventricular outflow tract during the resection of a large mediastinal germ cell tumor: proposed safety measures in the absence of cardiovascular surgeons: a case report

Nakai¹,

Suda²,

Nakada³

et al. 2021

Mediastinum

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This report presents an unusual case of life-threatening massive bleeding in the pulmonary trunk adjacent to the right ventricular outflow tract during resection of a large primary mediastinal nonseminomatous germ cell tumor (PMNSGCT) in the absence of cardiovascular surgeons. The patient was a 21-year-old male whose large mediastinal tumor was diagnosed as an extragonadal PMNSGCT, which was a mixture of a yolk sac tumor and an immature teratoma. Generally, chemotherapy causes extensive peripheral tumor necrosis of PMNSGCTs, thus enabling their complete resection. In this case, surgeons considered the resection as possible by dissecting the peripheral necrotic tissue, and cardiovascular surgeons were thus not consulted. Enlarged modified left hemi-clamshell thoracotomy (HCST) was applied. While dissecting around the pulmonary trunk, the assistant-held forceps accidentally touched the tensed pulmonary trunk, which caused bleeding. We immediately contacted the collaborating cardiac surgery department at another hospital for assistance. Meanwhile, massive bleeding occurred, leading to hemorrhagic shock, and thus direct cardiac massage was required. Our team managed to establish a venoarterial (VA) extracorporeal membrane oxygenation (ECMO). After the arrival of cardiac surgeons, a suction circuit was added, and bleeding was stopped using sutures. Finally, complete resection of the tumor was achieved, and the patient awoke the following day without any brain dysfunction. After discussions with all the members involved in the surgery, we developed an in-hospital consensus on how to perform surgeries for large thoracic tumors safely at our cancer center without the cardiovascular surgery department. We herein present the case and consensus and discuss the relevant issues.

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Section: Discussionmentioning

confidence: 99%

Life-threatening massive bleeding in the pulmonary trunk adjacent to the right ventricular outflow tract during the resection of a large mediastinal germ cell tumor: proposed safety measures in the absence of cardiovascular surgeons: a case report

Nakai¹,

Suda²,

Nakada³

et al. 2021

Mediastinum

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“…For avoiding injury to vital organs such as the aortic arch and PA trunk during surgery, the intention was to leave the tumor adjacent to them. The surgery for patients with advanced thymoma was performed as a median sternotomy or that with a lateral thoracotomy (11,12).…”

Section: Treatmentmentioning

confidence: 99%

Role of tumor reduction surgery in multimodality therapy for advanced thymoma—case series

Shintani¹,

Funaki²,

Miyashita³

et al. 2022

J Vis Surg

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Background: Optimal treatment for advanced thymoma remains controversial. This study aimed to elucidate the effectiveness of intended tumor reduction in multimodality therapy for patients with an unresectable thymoma.Methods: Between 2007 and 2018, six patients with an unresectable Masaoka stage III or IV thymoma underwent surgical resection using multimodality therapy. These cases were retrospectively reviewed. Tumor resection rate was calculated based on pre-and post-surgery computed tomography (CT) findings using a modified commercially available software package to determine resection-targeted tumor volume change. Results:The study population included four men and two women, with a mean age of 49 (range, 38-68) years. Preoperative Masaoka stage was III in one and IVa in five, while the histological type was B2 in four and B3 in two patients. Preoperative chemotherapy was performed for all except Case 5 because of encephalitis of unknown origin. All were treated with radiotherapy (RT) at a dose of 50-60 Gy. Each showed a grossly reduced tumor, with reduction ranging from 29-89% in the portion located adjacent to the aorta in four, arch vessels in one, and PA trunk in one. Postoperative Masaoka stage was III in one and IVa in five.One patient died from another disease 11 months after the operation, while the others remained alive at the time of writing with controlled disease after RT for a mean 89 (range, 27-149) months, with tumor reduction rates from 69-98%.Conclusions: Tumor reduction surgery as part of multimodality therapy for advanced thymoma may be effective in selected patients.

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“…To obtain a wider view during surgery and increase the safety of surgical manipulation, a hemi-clamshell (HCS) incision is useful. Recently, our group reported that an HCS approach was helpful for lung resection and dissemination around the thoracic cavity performed for advanced thymic malignancy with hilar invasion by providing multiple access paths to the tumor and hilum, allowing for a sufficient surgical margin (23). (27).…”

Section: Selection Of Surgical Approachmentioning

confidence: 99%

Surgical treatment strategies for invasive thymoma

Funaki¹,

Shintani²,

Fukui³

et al. 2020

J Thorac Dis

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A thymoma is a common anterior thymus mediastinal tumor composed of atypical epithelial tumor cells, though the morbidity rate is lower as compared to other types of thoracic malignancy such as lung cancer and lung metastasis from another primary cancer. As a result, clinical data regarding thymomas have not been well discussed as compared to those of other carcinomas. Also, because of the low morbidity rate and insufficient clinical experience, oncological characteristics and clinical treatment options are poorly understood. Surgical complete resection is the most reliable option for clinical treatment of a thymoma. This tumor can easily develop adjacent to several different structures and nearby organs, such as the pericardium, lungs, and great vessels, which are easily invaded when the size is large, and a combined resection is then needed. When en bloc resection is considered to be difficult based on evaluation with preoperative modalities, induction chemotherapy followed by surgery is recommended. Moreover, when pleural dissemination is revealed during pre-or peri-operative procedures, volume reduction surgery has been reported by several groups to extend prognosis. On the other hand, in cases with a small-sized tumor, a minimally invasive surgical procedure, such as video-assisted thoracic surgery (VATS) or robotic-assisted thoracic surgery (RATS), is usually selected. Because of the wide variety of cases with thymoma, a deliberate strategy and skillful techniques are necessary for effectual surgical treatment. In this review, we discuss strategies that have been shown to be effective for treating patients with early and advanced thymoma, including those with involved adjacent organs.

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Surgical resection for advanced thymic malignancy with pulmonary hilar invasion using hemi-clamshell approach

Cited by 12 publications

References 19 publications

Life-threatening massive bleeding in the pulmonary trunk adjacent to the right ventricular outflow tract during the resection of a large mediastinal germ cell tumor: proposed safety measures in the absence of cardiovascular surgeons: a case report

Life-threatening massive bleeding in the pulmonary trunk adjacent to the right ventricular outflow tract during the resection of a large mediastinal germ cell tumor: proposed safety measures in the absence of cardiovascular surgeons: a case report

Role of tumor reduction surgery in multimodality therapy for advanced thymoma—case series

Surgical treatment strategies for invasive thymoma

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