Clamshell Approach for Growing Teratoma Syndrome
The patient underwent four cycles of chemotherapy. Following
chemotherapy, serum markers were normalized. However, the mass did not
shrink and symptoms worsened. In fact, chest CT demonstrated a further
increase in size. The authors suspected a case of growing teratoma
syndrome and the patient was evaluated for surgery. Clamshell incision
was the chosen approach. The patient preparation included a thoracic
epidural catheter and a double lumen endotracheal tube, placed to allow
selective one-lung ventilation. The patient was prepared for
cardiopulmonary bypass. Transesophageal echocardiogram was positioned as
well as jugular central venous cannula. The femoral artery and vein
were isolated. The patient was lying in a supine position with arms
abducted. The anterior chest was prepped and draped in sterile fashion,
leaving the midaxillary lines free on both sides. The clamshell incision
allows for the exposure of the mediastinum and both pleural spaces.
Median sternotomy was not chosen due to the potential involvement of
left PA and veins. The tumor was too large and anterior for a
posterolateral thoracotomy, since it could put the patient at risk of
mediastinal compression during positioning and manipulation. A bilateral
submammary incision was made, extending from one midaxillary line to
the opposite. The pectoralis major was separated from its inferior
attachments. Laterally, division of the serratus was required to allow
for wider exposure. Intercostal muscles were divided, giving access to
the fourth intercostal space. After opening the bilateral intercostal
spaces, the internal mammary vessels were isolated and ligated. A
substernal space was obtained by blunt finger dissection. The sternum
was cut with a transverse incision using a sternal saw. A Sellor rib
spreader was placed on either side. Cautious opening of the retractors
exposed both pleural cavities and the mediastinum. Development of a
dissection plane, anterior to the pericardium, was achieved by a
combination of sharp, blunt finger dissection and cautery.
Circumferential dissection of all adhesions was performed and the entire
mass was gradually exposed. Care must be taken to both achieve en bloc
resection and avoid inadvertent breach of the capsule during
manipulation. The left superior pulmonary vein was encircled to ensure
its control in case of lung involvement. The underlying left lung was
freed of the compressing mass, which was a 2500 g tumor measuring 23 x
16 x 15 cm. A small area of consolidation of the superior lobe was
resected because it appeared solid and covered with fibrotic pleura.
Double lung ventilation was restored, with satisfactory reinflation of
left lung parenchyma.
Prior to closure, four 28F
chest drains were inserted. Three PDS Cord pericostal sutures were
placed on either side to approximate the intercostal space, and two were
used to close the sternum. The serratus anterior and pectoralis major
muscles were approximated with number 1 Vycril. The subcutaneous tissue
layer was closed using 2-0 Vycril. The skin was closed with subcuticular
suture using 4-0 Monosyn. The postoperative period was uneventful. Pain
was controlled with an epidural catheter which was removed on
postoperative day five. Postoperative chest X-ray demonstrated fully
expanded lungs. After ten days, he was transferred to a Pulmonary
Rehabilitation Center where he stayed during the following three weeks.
Final pathology report demonstrated a mature teratoma. Resected
parenchymal wedge was a pulmonary hemorrhagic infarction. Follow-up at
three months revealed complete resolution of symptoms. The surgical
wound healed well. Seven months after resection, he is alive and well,
with no signs of recurrence. Growing teratoma syndrome describes the
phenomenon by which germ cell tumors enlarge after chemotherapy, despite
normalization of serum markers and complete eradication of malignant
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