INTRODUCTION: Lung volume reduction surgery has been shown to be an effective treatment for severe heterogenous emphysema, where there is hyperinflation and parenchymal destruction in one area of the lung and relative preservation of tissue and function in the remaining compressed lung. This case illustrates an unusual situation where the relatively preserved lung was compressed and compromised by the emphysematous hyperinflation and also by a large intrapleural mass. It also demonstrates that very low forced expiratory volume within 1 second (FEV1) is not a contraindication for thoracic surgery if recruitment of viable lung tissue is expected as a result of the surgery.
CASE PRESENTATION: A 66 year old female with severe emphysema presented with gradually worsening dyspnea on exertion over the course of 2 years. A chest x-ray in March 2006 was interpreted as showing elevation of the right hemidiaphragm (image 1). She became increasingly cachectic (body mass index = 14.7) and ultimately oxygen dependent by March 2008. Chest computed tomography scan was obtained showing a large inhomogeneous mass in the base of the right chest cavity with compression of surrounding lung tissue. Her FEV1 was 0.68 Liters (28% predicted), oxygen saturation on room air was 72%, and arterial partial pressure of oxygen (paO2) on room air was 50 torr. She underwent a right thoracotomy under general anesthesia supplemented with a thoracic epidural. A pedunculated 1.5 kilogram benign solitary fibrous tumor of the pleura (SFTP) arising from the visceral pleura of the right lower lobe was removed (image 2). An apical volume reduction-like wedge resection of the most diseased portions of the right upper lobe was performed to assist with lung mobilization difficulties due to chronic pleural adhesions. Post-operative recovery was uncomplicated and an increase in paO2 to 70 torr on room air was noted.
DISCUSSIONS: Solitary fibrous tumors are rare tumors of mesenchymal origin which can arise from a number of anatomical locations. Most commonly they are found originating from the visceral pleura. Nearly 800 cases of SFTP have been reported in the literature to date. Approximately 12% of SFTP are malignant, based mainly on the tumor's histopathologic appearance. Clinically, malignant SFTP are prone to reoccur locally, metastatic disease is rare. Complete surgical resection, when possible, is the treatment of choice in all variants of SFTP, and complete resectability with tumor-free margins is the single most important predictor of favorable outcome.Generally, an expected post-operative FEV1 of less than 0.8 Liters or 40% of predicted is considered a contraindication to thoracic surgery because of the high risk of post-operative morbidity and mortality. However, each case must be evaluated for individual factors that may predict otherwise. In the described case, not only was the underlying mass considered resectable, careful evaluation of the available images suggested that a significant amount of viable lung tissue was being compromised by the mass effect. Removal of the mass would permit reexpansion of the underlying compressed lung with likely relatively preserved function. It was also felt that diaphragmatic function would be likely improved with the removal of the 1.5 kilogram mass impeding its normal movement.
CONCLUSION: Evaluation of patients’ suitability for thoracic surgery is of vital importance, especially in cases of severe lung disease. Consideration should be given to cases otherwise deemed inoperable if, by the nature of the surgery (improved mechanics of breathing, volume reduction of nonfunctioning lung, etc.) the lung function is predicted to improve.
DISCLOSURE: Lorenzo Klein, No Financial Disclosure Information; No Product/Research Disclosure Information