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Situs Inversus Totalis and Lung Cancer

1990; Elsevier BV; Volume: 97; Issue: 5 Linguagem: Inglês

10.1378/chest.97.5.1274

1931-3543

Ken Kodama, Osamu Doi, M Tatsuta,

Congenital Diaphragmatic Hernia Studies

To the Editor:We encountered a patient with visceral inversion and lung cancer and performed surgical resection of the cancer. Our literature survey found no reports of operation on such a case.The patient was a 68-year-old man. He visited our hospital on August 23, 1988 with major complaints of chest pain and hemosputum. Chest x-ray examination revealed dextrocardia, a tumor (8 × 7 cm), and a clear margin in the left middle lung field (Fig 1). As a result of TV-brushing, squamous cell carcinoma was proven by cytodiagnosis from a bronchus, which was apparently a left middle lobe bronchus. On the other hand, gastrographic and echographic examination revealed abdominal visceral inversion. The spleen was normal in size and on the right side.Thoracotomy was performed by a left postero-lateral incision. The sixth and seventh ribs, in which infiltration was directly observed, were resected jointly. The left lung showed good lobulation of the upper and middle lobes, whereas the middle and lower lobes were only slightly demarcated and had an external appearance as if the middle lobe was part of the lower lobe. Most of the tumor was present in the middle lobe, but part of the tumor extended to the medial basal (S7) and anterior basal (S8) segments across the vague boundary of the two lobes. Therefore, the pulmonary parenchyma of S7 and S8 was resected at a healthy region using a GIA autosuture apparatus. When pulmonary vessels were stripped, the middle lobe artery was found to arise as a single vessel from the interlobar portion of the left pulmonary artery and was ligated and divided. Segmental arteries leading to S7 and S8 were three in number, and each artery arose independently from the common basal artery. Each of those three arteries were ligated and divided. On the other hand, the middle lobe vein was found to arise from the superior pulmonary vein, contrary to the status of lobulation (ie, the middle lobe had an appearance as if it was part of the lower lobe). The veins leading to S7 and S8 were found to have been cut, together with the pulmonary parenchyma, at the time of resection with the autosuture apparatus. A branch of the superior segmental vein (V6) communicated with the posterior segment of the upper lobe. Middle lobe bronchus was found to originate from the anterior surface of the bronchus intermedius. The medial basal bronchus (B7) was observed to arise at almost a right angle from the anteromedial surface of the basal stem bronchus. Two rami of the anterior basal bronchus (B8) were seen to arise separately at almost right angles from the anterolateral aspect of the basal trunk (Fig 2). At the time of mediastinal lymph node dissection, it was found that the superior caval vein, right atrium, azygos vein and bronchial artery were mirror images of the normal disposition.Figure 2Surgical schema illustrates a scene after completion of resection of the left middle lobe and S7 and S8 segments.View Large Image Figure ViewerDownload (PPT)Situs inversus totalis is a rare deformity and its incidence in the population is between 1:4,0001Katsuhara K Kawamoto S Wakabayashi T Belsky JL Situs inversus totalis and Kartagener's syndrome in a Japanese population.Chest. 1972; 61: 56-61Crossref PubMed Scopus (93) Google Scholar and 1:12,000.2Caplan SM Dextrocardia with situs inversus. Report of eight cases with a review of the literature on dextrocardia.Nav Med Bull. 1946; 46: 1011-1016PubMed Google Scholar Neither Kartagener's syndrome nor other cardiac anomalies were found in the patient. On the other hand, the corrected incidence of lung cancer in Osaka in 1985 was 23.6:100,000.3Osaka Cancer Registry. Annual report of Osaka Cancer Registry—cancer incidence and medical care of cancer patients. Department of Health Osaka Prefecture, 1988; 45:26–27Google Scholar Surgical treatment is possible in only about 30 percent of these patients. Accordingly, it can be said that there are very few cases who have situs inversus totalis plus lung cancer and undergo operation for the cancer.Local anatomy revealed that the arrangement of organs and various structures was nealy a mirror image of the normal arrangement. However, some variations were seen in the courses of blood vessels and bronchi. Therefore, when such a patient must be operated on, it is important to carefully observe, identify and handle the vascular and bronchial branches which lead to the planned region of resection. To the Editor: We encountered a patient with visceral inversion and lung cancer and performed surgical resection of the cancer. Our literature survey found no reports of operation on such a case. The patient was a 68-year-old man. He visited our hospital on August 23, 1988 with major complaints of chest pain and hemosputum. Chest x-ray examination revealed dextrocardia, a tumor (8 × 7 cm), and a clear margin in the left middle lung field (Fig 1). As a result of TV-brushing, squamous cell carcinoma was proven by cytodiagnosis from a bronchus, which was apparently a left middle lobe bronchus. On the other hand, gastrographic and echographic examination revealed abdominal visceral inversion. The spleen was normal in size and on the right side. Thoracotomy was performed by a left postero-lateral incision. The sixth and seventh ribs, in which infiltration was directly observed, were resected jointly. The left lung showed good lobulation of the upper and middle lobes, whereas the middle and lower lobes were only slightly demarcated and had an external appearance as if the middle lobe was part of the lower lobe. Most of the tumor was present in the middle lobe, but part of the tumor extended to the medial basal (S7) and anterior basal (S8) segments across the vague boundary of the two lobes. Therefore, the pulmonary parenchyma of S7 and S8 was resected at a healthy region using a GIA autosuture apparatus. When pulmonary vessels were stripped, the middle lobe artery was found to arise as a single vessel from the interlobar portion of the left pulmonary artery and was ligated and divided. Segmental arteries leading to S7 and S8 were three in number, and each artery arose independently from the common basal artery. Each of those three arteries were ligated and divided. On the other hand, the middle lobe vein was found to arise from the superior pulmonary vein, contrary to the status of lobulation (ie, the middle lobe had an appearance as if it was part of the lower lobe). The veins leading to S7 and S8 were found to have been cut, together with the pulmonary parenchyma, at the time of resection with the autosuture apparatus. A branch of the superior segmental vein (V6) communicated with the posterior segment of the upper lobe. Middle lobe bronchus was found to originate from the anterior surface of the bronchus intermedius. The medial basal bronchus (B7) was observed to arise at almost a right angle from the anteromedial surface of the basal stem bronchus. Two rami of the anterior basal bronchus (B8) were seen to arise separately at almost right angles from the anterolateral aspect of the basal trunk (Fig 2). At the time of mediastinal lymph node dissection, it was found that the superior caval vein, right atrium, azygos vein and bronchial artery were mirror images of the normal disposition. Situs inversus totalis is a rare deformity and its incidence in the population is between 1:4,0001Katsuhara K Kawamoto S Wakabayashi T Belsky JL Situs inversus totalis and Kartagener's syndrome in a Japanese population.Chest. 1972; 61: 56-61Crossref PubMed Scopus (93) Google Scholar and 1:12,000.2Caplan SM Dextrocardia with situs inversus. Report of eight cases with a review of the literature on dextrocardia.Nav Med Bull. 1946; 46: 1011-1016PubMed Google Scholar Neither Kartagener's syndrome nor other cardiac anomalies were found in the patient. On the other hand, the corrected incidence of lung cancer in Osaka in 1985 was 23.6:100,000.3Osaka Cancer Registry. Annual report of Osaka Cancer Registry—cancer incidence and medical care of cancer patients. Department of Health Osaka Prefecture, 1988; 45:26–27Google Scholar Surgical treatment is possible in only about 30 percent of these patients. Accordingly, it can be said that there are very few cases who have situs inversus totalis plus lung cancer and undergo operation for the cancer. Local anatomy revealed that the arrangement of organs and various structures was nealy a mirror image of the normal arrangement. However, some variations were seen in the courses of blood vessels and bronchi. Therefore, when such a patient must be operated on, it is important to carefully observe, identify and handle the vascular and bronchial branches which lead to the planned region of resection.