Título

ROBOTIC-ASSISTED THORACOSCOPIC SURGERY FOR THE DIAGNOSIS OF INTRAPERICARDIAL LESION.

Objetivo

Cardiac masses can be lethal, even though 75% of them are benign. Indeed, metastatic
deposits amount the vast majority of cardiac malignant masses. Cardiac involvement by
lymphoma at autopsy has been described in 18% of patients with non-Hodgkin disease,
occurring at a media of 20 months after initial diagnosis . Clinical presentation can be tricky
and the diagnosis arduous. The contrast enhanced CT-scan and MRI are helpfully and the
nuclear imaging permit the assessment on treatment response . Minimally invasive surgery
has proven less surgical trauma, time of hospitalization and postoperative pain . The new
robotic platforms with endowrist technology allow us to go beyond on the accesses and
extension of surgical boundaries.

Resumo do vídeo

We present a case of a female in her 50s, diagnosed with Diffuse Large B Cell Lymphoma
(DLBCL) that was on total remission of the disease after the first line of treatment with R-CHOP
(rituximab plus cyclophosphamide/doxorubicin/vincristine/prednisone) for 6 cycles. Although in
complete remission after therapy, the disease-free interval was only 9 months. She was
hospitalized due to facial paralysis, myoclonus and loss of strength on the left arm. After a
normal brain and cervical Magnetic Resonance Imaging’s (MRI), it was performed a lumbar
puncture that showed relapse of the DLBCL on the subarachnoid space. The Positron Emission
Tomography (PET) scan-FDG showed an intense focal capture of FDG between the left
pulmonary veins and the left atrial appendage with mild focal densification of epicardial fat.
SUV – 9,9 Deauville score 5. Confirmed by heart MRI.
Therefore, after a multidisciplinary board discussion, on account of a central nervous
system involvement and a suspicious lesion on mediastinum, it was decided on the need to
have a histological evaluation of the mediastinal lesion in view of the different chemotherapy
modalities in case the involvement is restricted to the central nervous system or also with the
mediastinal lesion, which would characterize systemic recurrence.
We performed a Robotic-assisted thoracoscopic surgery (RATS) using Da Vinci Xi®
surgical platform with the four-arm technique.
The surgery begins by dissecting the pulmonary ligament and subsequent
lymphadenectomy until the left inferior pulmonary vein. All nodes were negative on frozen
section. Following the dissection through the space between the superior and inferior left
pulmonary veins, the absence of extra pericardial lesion was noted, as expected, afterwards we
proceed to the opening of the pericardium and, surprisingly, the lesion was infiltrating the left
atrium wall. After establish the boundaries of a safer area, we went on an incisional biopsy
without complications. All the material for vascular control were on the surgical table.
The frozen section suggested lymphoproliferative disease, confirming enough tissue and the final
pathology confirmed DLBCL relapse.
The postoperative was uneventful and the systemic treatment begins started right after surgical
recovery.