Chapter 96

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1646 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations A B C Figure 96-8. A and B: Intraoperative series demonstrates a posterior approach to resection of a superior, left-sided Ewing sarcoma of the chest wall. The muscles on the medial side of the scapula are divided and it is reflected laterally and superiorly. After the ribs are divided, that portion of the lung that is adherent to the chest wall tumor is divided with a stapler to deliver the chest wall, tumor, and lung en bloc. The remaining chest wall defect will be closed with Marlex mesh. D Ewing sarcoma; the muscles on the medially side of the scapula are divided and it is reflected laterally. Intraoperative considerations include one-lung ventilation and epidural catheter placement. The former allows confirmation of which ribs must be removed and facilitates the resection of contiguous structures as the adjacent lung which may or may not be adherent to the tumor; the latter provides good postoperative analgesia. With this careful planning and approach, large areas of chest wall can be safely resected in sections up to six ribs (and seven intercostal spaces) in height. 27 Figure 96–9 shows a large Ewing sarcoma on the left chest wall after resection. Pulmonary Neoplasms Primary neoplasms of the lung in children, including bronchogenic carcinoma, bronchial carcinoid tumor, and pleuropulmonary blastoma, are extremely rare. 28 Metastatic disease to the lung is more common, and this entity will be briefly reviewed in this section. Many neoplasms may develop metastatic disease, including those listed in Table 96–3. Osteogenic sarcoma, alveolar soft part sarcoma, and adrenocortical carcinoma are tumors which can result in pulmonary metastases and are associated with a more favorable clinical outcome with pulmonary metastasectomy; the other six tumors listed have unclear or no impact on clinical outcome. 29 When preoperatively assessing candidates for pulmonary metastasectomy, it is important to consider the number of lesions, the size of the lesions, whether the lesions are unilateral or bilateral, the proximity of the lesions to major bronchi and main pulmonary vessels, and the anticipated amount of lung that will need to be resected to obtain clear surgical margins (and the corollary: how much lung will remain). In addition, it is important to recognize and plan for resecting more pulmonary lesions than are identified on CT scan; this is particularly relevant with metastatic disease from osteogenic sarcoma, where one study has reported that more than half of the lesions that are ≤5 mm will be missed on CT scan. 8 Figure 96–10 demonstrates a very small right-sided lung lesion that is typical of metastatic osteogenic sarcoma.
CHAPTER 96 ■ Thoracic Surgery: Surgical Considerations 1647 Figure 96-9. A large Ewing sarcoma on the left chest wall after resection. The ribs are oriented anterior to the mass as though the tumor were still in vivo. The surgical team must consider the surgical approach: (1) bilateral posteriolateral thoracotomies give optimal access to the lung in each hemithorax, but such approaches may be limited if a relatively large amount of lung parenchyma will need to be resected (in addition, such approaches make postoperative pain difficult); (2) median sternotomy gives access to both hemithoraces simultaneously and are associated with less postoperative pain, but it is difficult to assess and resect pulmonary lesions in the posterior portions of the lung with this approach; and (3) staged unilateral posteriolateral thoracotomies allow for optimal access to the lung in each hemithorax, are better if it is anticipated that a large amount of lung will need to be resected, but do require a second anesthetic. Usually, a 2-week hiatus between procedures allows the ipsilateral lung to recover from postoperative hemorrhage and edema before resection of parts of the contralateral lung. It is this author’s preference to optimize surgical exposure and resectability of these pulmonary lesions by using the latter approach for bilateral lung lesions. Preoperative pulmonary function tests (PFT) are required to assess changes in respiratory function between thoracotomies and may predict the need for postoperative critical care bed needs; in general, PFTs are not effective in predicting whether a patient will tolerate one-lung ventilation or not. Intraoperative considerations mandate that one-lung ventilation be established to allow optimal palpation of the entire lung and resect all metastatic lesions; TABLE 96-3. Types of Neoplasms Linked to Pulmonary Metastatic Disease, by Indication for Surgical Metastasectomy Indicated Controversial Generally Not Indicated (increases (may increase (likely has no impact survival) survival) on survival) Osteogenic Wilm Tumor Neuroblastoma sarcoma Alveolar soft Ewing sarcoma Rhabdomyosarcoma part sarcoma Adrenocortical Hepatoblastoma Differentiated carcinoma thyroid cancer Figure 96-10. Computed tomography scan (axial) of a very small right-sided lung lesion (arrow) typical of metastatic osteogenic sarcoma. classically, the lesions associated with osteogenic sarcoma can be very small (
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Chapter 96

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