POSTOPERATIVE DIAGNOSIS: Malignant Neoplasm, Upper Lobe of Left Lung
INDICATIONS: This patient who is a female was admitted to Medical Center Hospital with a hemorrhagic stroke. The etiology of the stroke was presumed to be embolus from atrial fibrillation and subsequent hemorrhage. At the time of her admission, a lesion in the left upper lobe was identified. On CT scan, there was an irregularly shaped nodule in the anterior portion of the left lung. On PET imaging, one small portion of this had avid FDG uptake. The remainder of the lesion had no uptake. It measured 1.6 cm by CT and there were no abnormal lymph nodes.
PROCEDURE: Under satisfactory general anesthesia, the left chest: was entered through a limited posterolateral thoracotomy incision with preservation of the serratus anterior muscle. The patient had almost no chest wall musculature. The interspace that was actually entered on counting the ribs on the inside was the sixth intercostal space and therefore both the fifth and sixth ribs were sheared at the transverse process to permit adequate visualization of the lesion. The lesion was actually at the junction between the lingual and the anterior segments anteriorly. This made an anatomic segmentectomy difficult if the lesion proved malignant based on its anatomic location within the lobe. Our original plan had been to do an anatomic segmentectomy if this proved to be malignant. Having decided this would be a poor choice. We went ahead and did a wide wedge resection of the lesion to permit both diagnosis and treatment. A frozen section diagnosis of papillary adenocarcinoma was made. We therefore opened the fissure and explored the takeoff of the left upper lobe and left lower lobe bronchi. There were only a few less than 0.5 cm lymph nodes in the area. We carefully dissected these off the pulmonary artery and submitted biopsies for permanent histology. We estimated that the margin on the wedge resection approximated the diameter of the tumor and the wedge resection was carried out with an Endo-GIA medium stapler. There was minimal blood loss. When we had accomplished this, we put one 24 chest tube in the chest and secured it to the skin with a 0 silk ligature. The chest was then closed with running #2 Vicryl to approximate the ribs, running 0 Vicryl to approximate the muscles, running 2-0 Vicryl to approximate the skin and the skin was closed with a running 3-0 subcuticular suture.
Your time and help is appreciated.
Thank you!
INDICATIONS: This patient who is a female was admitted to Medical Center Hospital with a hemorrhagic stroke. The etiology of the stroke was presumed to be embolus from atrial fibrillation and subsequent hemorrhage. At the time of her admission, a lesion in the left upper lobe was identified. On CT scan, there was an irregularly shaped nodule in the anterior portion of the left lung. On PET imaging, one small portion of this had avid FDG uptake. The remainder of the lesion had no uptake. It measured 1.6 cm by CT and there were no abnormal lymph nodes.
PROCEDURE: Under satisfactory general anesthesia, the left chest: was entered through a limited posterolateral thoracotomy incision with preservation of the serratus anterior muscle. The patient had almost no chest wall musculature. The interspace that was actually entered on counting the ribs on the inside was the sixth intercostal space and therefore both the fifth and sixth ribs were sheared at the transverse process to permit adequate visualization of the lesion. The lesion was actually at the junction between the lingual and the anterior segments anteriorly. This made an anatomic segmentectomy difficult if the lesion proved malignant based on its anatomic location within the lobe. Our original plan had been to do an anatomic segmentectomy if this proved to be malignant. Having decided this would be a poor choice. We went ahead and did a wide wedge resection of the lesion to permit both diagnosis and treatment. A frozen section diagnosis of papillary adenocarcinoma was made. We therefore opened the fissure and explored the takeoff of the left upper lobe and left lower lobe bronchi. There were only a few less than 0.5 cm lymph nodes in the area. We carefully dissected these off the pulmonary artery and submitted biopsies for permanent histology. We estimated that the margin on the wedge resection approximated the diameter of the tumor and the wedge resection was carried out with an Endo-GIA medium stapler. There was minimal blood loss. When we had accomplished this, we put one 24 chest tube in the chest and secured it to the skin with a 0 silk ligature. The chest was then closed with running #2 Vicryl to approximate the ribs, running 0 Vicryl to approximate the muscles, running 2-0 Vicryl to approximate the skin and the skin was closed with a running 3-0 subcuticular suture.
Your time and help is appreciated.
Thank you!