S. C. Lee

Vagus nerve schwannoma in the middle mediastinum.

Intrathoracic neurogenic tumors are generally located in the posterior mediastinum. They usually arise from an intercostal nerve or a sympathetic chain. Tumors originating from the vagus nerve in the middle mediastinum are extremely rare. This report describes a patient with a huge intrathoracic schwannoma of the vagus nerve in the middle mediastinum and reviews the literature.

Clinical Experience of Nuss Procedure for Pectus Excavatum in Adult Female Patients

BACKGROUND Pectus excavatum (PE) repair by Nuss procedure is well established in pediatrics, but studies of adult female patients are rare. We analyzed the efficacy of the Nuss procedure in adult, female PE patients. METHODS We retrospectively reviewed adult patients who underwent Nuss repair of PE from April 2005 to November 2007. Precise morphologic characterization of the pectus allowed an appropriate shaping of the bars to achieve a symmetric repair. RESULTS Out of 126 consecutive adult patients who underwent the Nuss procedure at our institution, 15 women with a mean age of 24.6 +/- 4.01 years were enrolled in the study. Their preoperative Haller index had a mean of 5.72 +/- 2.38. Seven patients (46.67 %) underwent repair with the insertion of double pectus bars. Complications included transient bilateral pneumothorax (n = 1) and right-sided pleural effusion (n = 1). One patient received a subsequent breast augmentation, which yielded a better thoracic contour. CONCLUSIONS The Nuss procedure offers a high satisfaction rate and an acceptable complication rate for PE repair in adult female patients. A subsequent surgery for breast augmentation can be considered after the Nuss repair has stabilized.

Ectopic Hepatocellular Carcinoma of the Diaphragm

Ectopic hepatocellular carcinoma (HCC) is very rarely reported. It may occur at various sites. To the best of our knowledge, only one case of ectopic HCC of the diaphragm has been reported. We present another such case with invasion to the lung. Subtotal resection of the left hemidiaphragm, wedge resection of the lung (left lower lobe), and splenectomy were undertaken. Postoperative course was unremarkable; the patient received two courses of adjuvant chemotherapy with cisplatin, VP-16, and bleomycin 1 month later. Follow-up computed tomography and ultrasound were performed 8 months later; there was no local recurrence or distal metastasis.

Cystic Seminoma With Elevated Value of Carbohydrate Antigen 19-9 in Tumor Fluid Mimicking Cystic Teratoma

The incidence of cystic lesions of anterior mediastinum is low, which is responsible for approximately 10% of anterior mediastinal tumors. We presented a special case of primary anterior mediastinal tumor with both prominent cystic change and extreme high carbohydrate antigen 19-9 level of cystic fluid here. From the finding of this case report, we suggested that the diagnosis of cystic anterior mediastinal tumors should include both cystic seminoma and mature cystic teratoma.

Positron emission tomography in bronchioloalveolar carcinoma of the lung.

OBJECTIVES This study assessed the maximum standard uptake value of positron emission tomography-computed tomography in patients of pulmonary adenocarcinoma with bronchioloalveolar carcinoma features and whether SUVmax correlates with pathological status, lymph node metastasis, and prognosis. METHODS We retrospectively reviewed 674 patients diagnosed with non-small-cell lung cancer between January 2002 and June 2009. Patients with clinical stage I-II disease underwent a preoperative PET-CT scan followed by anatomic resection. We reviewed the clinical features of 209 patients with an average follow-up of 87 months. RESULTS We analyzed clinical variables for 40 patients with BAC features and 169 patients without BAC features. Age, sex, location, and number of dissected lymph nodes, carcinoembryonic antigen level, and lymphovascular invasion had no difference between the two groups. Compared with non-BAC patients, patients with BAC features had a lower SUVmax (2.51 ± 2.02 vs 4.98 ± 4.03, p < 0.001), lower ratio of SUVmax (1.10 ± 0.34 vs 1.22 ± 0.27, p = 0.014), better tumor differentiation (p < 0.001), and smaller tumor size (2.30 ± 1.41 vs 2.97 ± 1.71, p < 0.03). The negative prediction rate was 87.08% for N2 and 80.80% for N1 disease. All patients in the BAC group were alive after the operation. The five-year survival rate of patients without BAC features was 71.2%. CONCLUSIONS Preoperative SUVmax of PET-CT was more accurate at predicting negative N2 than N1 disease. BAC is associated with markedly better prognosis compared with invasive adenocarcinoma and may be cured with surgical resection Aggressive surgical resection is recommended even for patients with false-negative N2 disease.

Should the pectus bar be removed before pregnancy? Two case reports

The Nuss procedure is a minimally invasive repair for pectus excavatum in children and adults. However, it is unclear whether or not the stainless steel bar should be removed before pregnancy. We report on two adult females who had undergone a Nuss repair for pectus excavatum and successfully delivered prior to removal of the pectus bar.

Cystic pulmonary tuberculoma.

Pulmonary tuberculosis (TB) is a medical and social problem, particularly in developing countries. Early diagnosis and treatment is important. Chest radiography is usually the first diagnostic tool when there is a suspicion of pulmonary TB. A computed tomography (CT) scan provides more accurate information on the extent and distribution of pulmonary TB. We present here a young, immunocompetent male patient with unusual imaging findings for pulmonary TB. We discuss the clinical presentation and management.

Pulmonary carcinosarcoma in a 25-year-old male patient--a case report.

Abstract Pulmonary carcinosarcoma is a rare malignancy composed of epithelial and mesenchymal elements. In general, these neoplasms occur in older individuals at the age of 60 on average and are more commonly found in males who are heavy smokers. We report a 25-year-old male with a tumour shadow of the right middle lobe that was revealed by chest X-ray during a health checkup and was confirmed by subsequent computed tomography. The patient underwent thoracotomy with right middle lobe lobectomy. Histological examination of the resected specimen showed adeno-carcinoma and undifferentiated sarcoma components. The clinical and histopathologic features of this rare tumour are discussed with a review of the literature.

Gastrointestinal: Transdiaphragmatic intercostal hernia

A 74-year-old man was investigated because of a 2-day history of nausea, vomiting and abdominal pain. There was a longer history of dyspnea on exercise that had been attributed to chronic obstructive pulmonary disease. On examination, he had a soft tissue mass, approximately 10 cm in diameter, between the 8 and 9 ribs on his left side. A contrast-enhanced computed tomography (CT) scan showed bowel loops within the intercostal space (Fig. 1). The tip of a naso-gastric tube in the stomach is outlined in the center of the image. A coronal image (Fig. 2) shows herniation of mesentery and small bowel through the diaphragm into the left lower pleural space. The third part of the duodenum and some loops of jejunum appear to be mildly dilated. The heart is designated with a H. The diagnosis was that of a transdiaphragmatic intercostal hernia and he was treated with an emergency thoracotomy and diaphragm repair. His postoperative course was uncomplicated and he had a normal chest x-ray on follow-up, 2 months after surgery. Transdiaphragmatic intercostal hernias appear to be rare as there have only been a few case reports over the past 50 years. The hernia results from disruption of both the diaphragm and the chest wall. The most common cause is trauma to the chest wall with tears in the diaphragm and intercostal muscles, often associated with fractures of the 9th and 10th ribs. Occasionally, transdiaphragmatic intercostal hernias can result from violent coughing, heavy lifting or massage. A helpful clinical feature is a palpable mass in the chest wall that increases in size with inspiration or a Valsalva maneuver and decreases in size with expiration. The diaphragmatic defect can often be detected on a plain radiograph of the chest but additional information can be obtained with a CT scan, as illustrated in the above patient. Treatment includes surgical repair of the defects since the hernia is usually symptomatic with either respiratory or gastrointestinal symptoms.