Ann Thorac Surg 1995;59:1490
© 1995 The Society of Thoracic Surgeons
INVITED COMMENTARY
Mark B. Orringer, MD
Section of Thoracic Surgery, The University of Michigan, Taubman Health Care Center, 1500 E Medical Center Dr, Rm 2110, Ann Arbor, MI 48109
 |
Introduction
|
|---|
 Top
 Introduction
|
|---|
See also page 1490.
With one of the world's most extensive experiences with the evaluation and surgical treatment of patients with thromboembolic pulmonary artery occlusive disease, Anderson and associates now have reported what is perhaps the largest single experience with the operative therapy of pulmonary artery sarcomas. On the basis of the data presented, however, it is difficult to accept the conclusion of the article that ``total surgical resection [of pulmonary artery sarcomas] with the addition of chemotherapy, radiotherapy, or both, or excision of all gross tumor in combination with adjuvant treatment should offer these patients significant palliation and an opportunity for increased length of survival.'' The dismal survival of their patients (five deaths at 5, 7, 8, 11, and 19 months, and only 1 patient alive after 6 months of follow-up) would suggest that pulmonary artery sarcomas are almost invariably incurable. As pointed out by Anderson and associates, the clinical history (dyspnea, respiratory distress, and right ventricular dysfunction) of patients with pulmonary artery tumors is not significantly different from that of patients with chronic thromboembolic disease. Although two thirds (4/6) of their patients with tumors had no prior history of thromboembolism or deep venous thrombosis, 50% of their pulmonary thromboendarterectomy patients similarly had a negative history for prior thromboembolic disease, so this is not a true differentiating feature between these groups. The reality is that very few patients presenting with a clinical history consistent with pulmonary thromboembolic disease and requiring a pulmonary thromboendarterectomy (4% in Anderson and associates' extensive experience) will be found on frozen section evaluation of the resected clot to have a pulmonary artery sarcoma. There is generally little reason to consider this diagnosis preoperatively, except in the occasional patient with an atypical pattern for pulmonary embolism on ventilation-perfusion scan or pedunculated lesions with ``to and fro'' motion on pulmonary angiography. New biologic scanning techniques such as the Gd-DTPA--enhanced magnetic resonance imaging scan may differentiate a vascular tumor from intraluminal thrombus.
Unfortunately, it is easily concluded from this article that the incidental finding of sarcomatous elements in the thromboendarterectomy specimen of patients undergoing surgical treatment for presumed chronic pulmonary thromboembolic disease signifies a virtually fatal tumor for which current therapy seems totally inadequate. Would it not provide a better margin of resection in these patients if the involved pulmonary artery were resected and replaced with a homograft rather than ``shelling out'' a primary malignancy of the arterial wall using traditional techniques of thromboendarterectomy? At the present time, a planned surgical approach to patients with primary pulmonary artery malignancies rarely will occur because few are diagnosed preoperatively, and most of these tumors will be ``stumbled across'' during performance of a thromboendarterectomy for presumed chronic thromboembolic disease. Routine performance of a frozen section on the thromboendarterectomy specimen will establish the diagnosis, and it remains to be seen if traditional principles of full-thickness resection of the involved blood vessel and reconstruction have a meaningful role in the treatment of pulmonary artery sarcomas.
