Minimally Invasive Video-Assisted Thoracoscopic One-Stage Resection of Left Atrial Myxoma and Right Upper Lobectomy for Lung Cancer: Case Report

We report a case of a 74-year-old man with diagnosis of concomitant primary cardiac tumor and right upper lobe of lung cancer. Both tumors were evaluated to be resectable with no further metastasis. A one-stage resection of both tumors through right mini-thoracotomy with endoscopic assistance was performed. The cardiac tumor resection during cardiopulmonary bypass was performed first, followed by right upper lobectomy and lymph nodes dissection with the same incision and position. Short-term results were satisfying and previous literature was reviewed to evaluate this method.

A 74-year-old man with complaint of shortness of breath on exertion for one month was referred to our hospital because of a mass found in the left atrium of the heart.On admission, transthoracic echocardiography showed a 3.0 cm*2.8 cm immobile cardiac mass in the left atrium (Fig. 1), with a sessile attachment to the atrial septum and partially blocked the entrance of right superior pulmonary vein to the left atrium.Besides, chest CT scan found a 3.0 cm*2.5 cm mass in the right upper lobe of the lung.A further PET/CT was completed (Fig. 1) and revealed the following: (1) unevenly elevated FDG metabolic rate of the mass in upper right lobe of the lung (maximum SUV 6.2), considering malignant; (2) Slight elevated FDG metabolic rate of the cardiac mass (maximum SUV 3.8), possibly primary from the heart; (3) no elevated FDG metabolic rate found in other site of the body.The pulmonary function test revealed no pulmonary malfunctions (FEV1, 1.95L, 85% of predicted, FEV1/FVC 0.8), physical examination was unremarkable, and laboratory studies were within normal range.The American Association of Anesthesiologists (ASA) grading was 2.
Surgical plan was made to do a one-stage resection of both cardiac and lung tumors.At surgery, the patient was placed in the supine position with right side of the chest raised approximately 20 degrees.After general anesthesia, double-lumen endotracheal tube and internal jugular vein catheter were introduced.Single lung ventilation was started.A 6-cm sub-mammary anterior mini-thoracotomy was made in the right 4th ICS for the operation.Three additional small incisions were made: the camera port in right 3rd ICS in the anterior axillary line, the aortic clamp port in right 4th ICS in the mid-axillary line and the traction/drainage port in right 6th ICS in the posterior axillary line (Fig. 2).After heparinization (3 mg/ kg heparin) was achieved (ACT > 480 s), right femoral arterial and venous cannulations were performed using Seldinger technique.Standard aortic root cardioplegia cannula was inserted, partial CPB started, and core temperature of 35 °C was achieved, the ascending aorta was cross-clamped, the cardioplegia (del Nido solution) was delivered, and the heart arrested.The LA was entered through the interatrial groove; a cardiotomy sump sucker was placed.The firm, sessile tumor was well exposed and seen attached to the IAS.It was excised with a part of the surrounding IAS without damaging the LA wall.LA sump sucker was withdrawn, and standard de-airing was done with aortic root suction and maneuvers.LA incision was sutured, taking bites through the defect in the IAS and adjacent right atrium wall.Aortic cross-clamp released, the heart was beating normally, patient was weaned off CPB, femoral artery and vein cannulas were removed in the standard manner, and heparin reversed with protamine (ACT rechecked as 105 s).Hemostasis was checked, and pericardiotomy was closed partially.Using the same position and incision, the patient was tilted leftward, and the right upper lobectomy was performed using staplers.Paratracheal and subcarinal lymph nodes were exposed and dissected by ultrasonic devices.One chest drainage tube was inserted in thoracic cavity and incisions closed.The cross-clamp time was 30 min, total CPB time was 60 min, and total surgery time was 205 min.No blood or blood components were required and post-operative drainage was 350 ml in 24 h.The histopathologic evaluation of the cardiac mass and pulmonary tumor confirmed a left atrial myxoma and a pT2aN0M0 squamous right upper lobe of lung carcinoma (Fig. 2).Patient's recovery was uneventful and was discharged 15 days after surgery.Clinical followup at 4 weeks revealed excellent physical, cosmetic, and oncologic recover.

Discussion
Cardiac myxoma is the most common tumor among all primary cardiac tumors [1].The coexistence of cardiac myxoma and lung cancer is rarely reported.To evaluate surgical indication, it is important to differentiate whether these tumors were benign or malignant, as well as primary or metastatic.In our case, the combinations of enhanced chest CT scan and PET/CT led us to suggest a primary benign cardiac tumor and lung cancer with no metastasis.Cardiac myxomas and lung cancers are both diseases that needed to be treated early at diagnosis.When both situations meet in the same time, it is reasonable to resect them all at once.Compared with staged surgery, one-stage surgery avoids the possibility of tumor metastasis and embolic events to the most extent.The economic cost is also lower.In this case, the one-stage surgery saved 3000 US dollars compared with staged resections.The main concern is safety.Recent meta-analysis reveals that combined heart surgery and lung tumor resection had a low mortality rate and an acceptable complication rate [2].In our case, the patient underwent uneventful surgery and recovery, the crossclamp time, total CPB time, and post-operative drainage were comparable to single cardiac surgery.More cases were needed to prove the safety of this procedure.
The minimally invasive surgical techniques through right thoracotomy have been gradually applied to resect cardiac tumors with excellent results [3], comparing with the conventional median sternotomy approach.This approach was also feasible for complex tumor resection that needed atrial septum or mitral valve reconstructions.The advantages of this technique mainly include less post-operative mediastinitis and more patient satisfaction due to cosmetic effect.With endoscopic assistance, this position provided an excellent surgical field in the performance of both myxoma and lung tumor resection.Concomitant resection through the same incision also eliminated the potential chance of contamination when re-placing the patient.In surgery, we performed myxoma resection first based on the following reasons: (1) myxoma resection is type I incision operation while lobectomy is type II.(2) CPB tend to cause more bleeding if lobectomy was performed first.Van der Merwe [4] resected the lung tumor first arguing that this may minimize the risk of tumor dissemination, while adverse effects of CPB on cancer prognosis have not been confirmed [5] and need to be further investigated.
Overall, for patients with both resectable cardiac and right-sided lung tumors, who have good cardiac and pulmonary function and are fit for one-lung anesthesia, can be considered for single-stage R0 resection with this minimally invasive procedure.This procedure provides fast recovery, better cosmetic result, less financial cost, and overall patient satisfactory.the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.To view a copy of this licence, visit http:// creat iveco mmons.org/ licen ses/ by/4.0/.

Fig. 1 AFig. 2 A
Fig. 1 A Transthoracic echocardiography showed a 3.0 cm*2.8 cm immobile cardiac mass in the left atrium.B PET/CT examination identified a mass located in the right upper lobe of the lung (SUV 6.2)