Ann Thorac Surg 1995;60:228-34
relating to the operation, but the postoperative outcome may be tedious. Thus, patient selection regarding pulmonary function must be done very carefully.
Percutaneous Transthoracic Needle Biopsy of the Lung
M. Murat Demirta~, MD Hacz Akar, MD Mehmet Kaplan, MD Sabri Da~,sah, MD
It may be a settled question to some, And excuse me if I appear just a little dumb, But I think that the needle biopsy of the lung Is a procedure that is often overdone.
Ahmet ~elebi Mah, Siimbiilzade Sok No. 20/3, CIskiidar-IstanbuI Turkey
What's the problem? You may ask; This all has been settled in the past. Well, not in my little neck of the woods; The procedure is done more often than it should.
Reference 1. Medalion B, Elami A, Milgalter E, Merin G. O p e n heart operation after pneumonectomy. A n n Thorac Surg 1994;58: 882-4.
Inadequacy, Mortality, and Thoracoscopy To the Editor: We appreciate that the editorial board felt that our case report  and the report by Fry and colleagues  describing tumor implantations after video-assisted thoracic resections were of sufficient importance to dedicate an editorial written by Drs Allen a n d Pairolero on the subject . Doctors Allen and Pairolero unfortunately misinterpreted or misread one point, which requires clarification. Nowhere in our article did we state or imply that a thoracoscopic approach was chosen because our patient was too debilitated to undergo an open procedure. Her co-morbidities were listed to highlight why a video-assisted thoracic surgical procedure was selected as an "initial" diagnostic procedure. Further pulmonary resection was planned if the lesion on frozen section was a bronchogenic primary tumor. Their inaccurate comments detract somewhat from the important point that we and Dr Fry and colleagues were raising: thoracoscopic procedures must be used with great caution w h e n dealing with suspected intrathoracic malignancies. Severe local and potentially lethal complications may result. It behooves us to communicate openly and freely with our surgical colleagues, especially w h e n new techniques are being used and procedurerelated complications are identified.
Garrett L. Walsh, MD Jonathan C. Nesbitt, MD Department of Thoracic and Cardiovascular Surgery The University of Texas MD Anderson Cancer Center Texas Medical Center 1515 Holcombe Blvd Houston, TX 77030 References 1. Walsh GL, Nesbitt JC. Tumor implants after thoracoscopic resection of a metastatic sarcoma. A n n Thorac Surg 1995;59: 215-6. 2. Fry WA, Siddiqui A, Pensler JM, Mostafavi H. Thoracoscopic implantation of cancer with a fatal outcome. A n n Thorac Surg 1995;59:42-5. 3. Allen MS, Pairolero PC. Inadequacy, mortality, and thoracoscopy [Editorial]. A n n Thorac Surg 1995;59:6.
To the Editor:
Now wouldn't everything be just wonderful If, whenever we see a solitary pulmonary nodule, With a small-gauge transthoracic needle so fast, We could diagnose with certainty any suspicious mass. But much to our chagrin a n d to be quite fair, A benign diagnosis from the needle is extremely rare. So with an operable patient with an SPN, As far as I'm concerned, needle biopsy is not necessarily in. Please don't get me wrong and jump to conclusions; I really don't have any grand delusions, To think that I could change the way things are done By spouting a few words in rhyme somewhat in fun. Needle biopsies can be quite benefitting, Especially in the correct clinical setting. With a superior sulcus tumor, for instance, You need a diagnosis before radiotherapy will commence. With multiple lesions of the lungs the yield is great; A needle biopsy can help predict the patient's fate. In this diagnostic instance, that's all you need, And major surgery can be avoided, and all are pleased. The problem comes in the operable patient with the SPN. He's sent to the radiologist to have a needle put in. Please tell me what is going to change? W h e n negative or positive, surgery should be arranged. The often quoted reason which I've heard said, If it's small cell carcinoma you treat with drugs instead. To most thoracic surgeons I need not declare, Peripheral small cell tumors are very rare. And, if and w h e n small cells are found, A surgical approach would still be sound. T1 small cell lesions really do quite well; After resection the prognosis is swell. And in half the cases in which small cells are called, Histologic sections reveal no small cells at all. So a wary eye the surgeon must retain W h e n aspirated small cells from the lung are named. Other proponents have noted operative time saved; It's true, that some OR minutes may be waived, But excisional biopsies take little time to perform; While waiting for the frozen, dissection should be the norm. And what are the true percentages of complications, Pneumothoraces, hemoptysis, and other negations? Needle tract tumors carry very little fear; However, I've seen two in the last 10 years. But the most important problem that I see Concerning percutaneous transthoracic needle biopsy Is that the experience of the thoracic surgeon Can be completely left out of the decision equation.
© 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50
The insurance gatekeepers now will often arrange To have a needle placed, if it's in the needle's range, Without obtaining a thoracic surgeon's opinion. Cancer of the lung should be the thoracic surgeon's dominion. The ideal m a n a g e m e n t of suspicious lesions of the lung Would be a formal presentation where specialists come With expertise in radiology and oncology, Thoracic surgery, radiotherapy, and pulmonology. Alas, things aren't always as they should be, And too much has been written that needles are necessary. But as a thoracic surgeon I will repeat my refrain: Cancer of the lung is the thoracic surgeon's domain.
Robert B. Wagner, MD 50 W Edmonston Dr Rockville, MD 20852 Cardiac Papillary Fibroelastoma To the Editor: The report by Shahian and associates  was an excellent compilation of previous literature in relation to those interesting endocardial lesions referred to as papillary fibroelastomas (PFEs). We additionally bring to Shahian and associates' attention a report from our group  that compared the histology of PFEs and Lambl's excrescences (LEs). In that study we described 10 PFEs (6 aortic valve, 2 pulmonary valve, 1 tricuspid valve, and 1 posterior right atrial wall). These PFEs were compared with 20 LEs (all aortic, with two coexistent on mitral valve). In our comparison of PFEs and LEs we found most were microscopically indistinguishable, suggesting similar origin. What was distinct about the two groups was the variety of locations over the valve surfaces where the PFEs could be found, whereas the LEs were confined to the closing margins of the valve, and sat particularly in the midline. In 7 cases the LEs were accompanied by valve free edge fibrous tags (illustrated in our
Ann Thorac Surg 1995;60:228 -34
report). Papillary fibroelastomas tended to be larger than LEs and to have smaller stalks. The conclusion from our study, and our review of the literature, was that PFEs and LEs likely represent degenerative lesions of similar origin. Papillary fibroelastomas are unusual grossly, however, in that they tend to be larger (and so are now more frequently diagnosed with various noninvasive imaging techniques) and have variant locations when compared with the much commoner LEs. With improved imaging techniques it seems likely that LEs also will become diagnosable clinically, and whether the separation of the two lesions continues to have merit will be the subject of further debate, we are sure.
Virginia M. Walley, MD Sharon A. Boone, MD Anatomical Pathology Laboratory Medicine The University of Ottawa Heart Institute at the Ottawa Civic Hospital 1053 Carling Ave Ottawa, ON Canada K1Y 4E9 References 1. Shahian DM, Labib SB, Chang G. Cardiac papillary fibroelastoma. Ann Thorac Surg 1995;59:538-41. 2. Boone SA, Campagna M, Walley VM. Lambl's excrescences and papillary fibroelastomas: are they different? Can J Cardiol 1992;8:372-6.
CORRECTION Pagano D, Carey JA, Patel RL, et al. Retrograde cerebral perfusion: clinical experience in emergency and elective aortic operations. Ann Thorac Surg 1995;59:393-7. The name of one author of this article was misspelled as Mustafa H. Faroqui. The correct spelling is Muzaffar H. Faroqui.
© 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50