Metastatic Ewing's sarcoma to the right ventricle

Ewing's sarcoma is a round cell neoplasm derived from neural crest cells that is part of the primitive neuroectodermal tumor (PNET) family. It is a rare, aggressive malignancy that affects young people, most commonly in the second decade of life. The treatment of localized disease has improved greatly over the past four decades, but the prognosis for metastatic disease remains poor. Cardiac metastases of Ewing's sarcoma are exceedingly rare, with only a few reported cases. This article presents a case of a 22 year old man with a history of Ewing's sarcoma of the bone involving the right kneepeer-reviewe

Pedicled Latissimus Dorsi Muscle Flap

Bronchopleural fistula and empyema are serious complications after thoracic surgical procedures, and their prevention is paramount. Herein, we review our experience with routine prophylactic use of the pedicled ipsilateral latissimus dorsi muscle flap. From January 2004 through February 2006, 10 surgically high-risk patients underwent intrathoracic transposition of this muscle flap for reinforcement of bronchial-stump closure or obliteration of empyema cavities. Seven of the patients were chronically immunosuppressed, 5 were severely malnourished (median preoperative serum albumin level, 2.4 g/dL), and 5 had severe underlying obstructive pulmonary disease (median forced expiratory volume in 1 second, 44% of predicted level). Three upper lobectomies and 1 completion pneumonectomy were performed in order to treat massive hemoptysis that was secondary to complex aspergilloma. One patient underwent left pneumonectomy due to ruptured-cavitary primary lung lymphoma. One upper lobectomy was performed because of necrotizing, localized Mycobacterium avium-intracellulare infection. One patient underwent right upper lobectomy and main-stem bronchoplasty for carcinoma after chemoradiation therapy. In 3 patients, the pedicled latissimus dorsi muscle was used to obliterate chronic empyema cavities and to buttress the closure of underlying bronchopleural fistulas. No operative deaths or recurrent empyemas resulted. Two patients retained peri-flap air that required no surgical intervention.We conclude that the use of transposed pedicled latissimus dorsi muscle flap effectively and reliably prevents clinically overt bronchopleural fistula and recurrent empyema. We advocate its routine use in first-time and selected reoperative thoracotomies in patients who are undergoing high-risk lung resection or reparative procedures

Resting Physiologic Dead Space as Predictor of Postoperative Pulmonary Complications After Robotic-Assisted Lung Resection: A Pilot Study.

Lung resection surgery carries significant risks of postoperative pulmonary complications (PPC). Cardiopulmonary exercise testing (CPET) is performed to predict risk of PPC in patients with severely reduced predicted postoperative forced expiratory volume in one second (FEV1) and diffusion of carbon monoxide (DLCO). Recently, resting end-tidal partial pressure of carbon dioxide (PETCO2) has been shown as a good predictor for increased risk of PPC. However, breath-breath breathing pattern significantly affects PETCO2. Resting physiologic dead space (VD), and physiologic dead space to tidal volume ratio (VD/VT), may be a better predictor of PPC than PETCO2. The objective of this study was to prospectively determine the utility of resting measurements of VD and VD/VT in predicting PPC in patients who underwent robotic-assisted lung resection for suspected or biopsy-proven lung malignancy. Thirty-five consecutive patients were included in the study. Patients underwent preoperative pulmonary function testing, symptom-limited CPET, and a 6-min walk test. In the first 2 min prior to the exercise portion of the CPET, we obtained resting VT, minute ventilation ( V˙ E), VD (less instrument dead space), VD/VT, PETCO2, and arterial blood gases. PPC within 90 days were recorded. Fourteen (40%) patients had one or more PPC. Patients with PPC had significantly elevated resting VD compared to those without (0.318 ± 0.028 L vs. 0.230 ± 0.017 L (± SE), p < 0.006), and a trend toward increased VD/VT (0.35 ± 0.02 vs. 0.31 ± 0.02, p = 0.051). Area under the receiver operating characteristic (ROC) for VD was 0.81 (p < 0.002), VD/VT was 0.68 (p = 0.077), and PETCO2 was 0.52 (p = 0.840). Peak V˙ O2, V˙ E/ V˙ CO2 slope, pulmonary function tests, 6-min walk distance and arterial blood gases were similar between the two groups. Intensive care unit and total hospital length of stay was significantly longer in those with PPC. In conclusion, preoperative resting VD was significantly elevated in patients with PPC. The observed increase in resting VD may be a potentially useful predictor of PPC in patients undergoing robotic-assisted lung resection surgery for suspected or biopsy-proven lung malignancy. A large prospective study is needed for confirmation

Isolated lung perfusion with melphalan for the treatment of metastatic pulmonary sarcoma

AbstractObjective: Isolated lung perfusion allows the delivery of high-dose chemotherapy to the perfused lung and is an efficacious modality in the treatment of pulmonary metastases in the rat. Melphalan activity in this model was investigated. Methods: Toxicity study: Maximum tolerated dose of melphalan delivered by means of isolated lung perfusion was determined by survival after contralateral pneumonectomy. Pharmacokinetics study: Nineteen rats were treated with melphalan administered either by isolated lung perfusion (2 mg) or intravenously (2 mg or 1 mg). Lung, pulmonary effluent, and serum melphalan were analyzed by high-pressure liquid chromatography. Efficacy study: On day 0, 41 rats received an intravenous injection of 5 × 106 methylcholanthrene induced sarcoma cells. On day 7, rats either received intravenous melphalan (2 mg [n = 10]; 1 mg [n = 8]) or underwent left isolated lung perfusion with 2 mg of melphalan (n = 12). Isolated lung perfusion with buffered hetastarch in sodium chloride (Hespan, n = 11) was used as control. On day 14, pulmonary nodules were counted. Results: Toxicity: Maximum tolerated dose of melphalan delivered buy means of isolated lung perfusion was 2 mg. Pharmacokinetics: Left lung melphalan level was significantly higher in the isolated lung perfusion group (62.2 ± 34.3 μg/gm lung) than in the intravenous treatment groups (6.9 ± 1.9 μg/gm lung and 3.3 ± 0.9 μ g/gm lung, respectively) (p = 0.0002). Efficacy: Significantly fewer left lung nodules were found in animals receiving melphalan by means of isolated lung perfusion (7 ± 10) than in the groups receiving intravenous melphalan (60 ± 21) or buffered hetastarch by isolated lung perfusion (84 ± 52) (p = 0.01 and p = 0.0001, respectively). Conclusion: Isolated lung perfusion with melphalan is safe and effective in the treatment of pulmonary sarcoma metastases in the rat. (J Thorac Cardiovasc Surg 1996;112:1542-8