Soon-Ho Chon

Primary peripheral pulmonary adenoid cystic carcinoma: Report of a case diagnosed by fine needle aspiration cytology

Adenoid cystic carcinoma (ACC) arising from anatomic sites other than the salivary gland is rare and those occurring in the lung are extremely rare. When arising from the lung, the tumor generally arises from extrapulmonary bronchi, originating from bronchial glands. Primary ACC of the lung located peripherally within lung parenchyme is an even rarer event. To the best of our knowledge, this is the first case of primary peripheral pulmonary ACC preoperatively diagnosed by fine needle aspiration cytology (FNAC). We report a case of primary peripheral ACC of the anterior segment of the right upper lobe in a 46‐year‐old woman diagnosed by FNAC and a brief review of the literature. Diagn. Cytopathol. 2011;39:283–287.

An unusual case of bronchogenic cyst mimicking thyroid cystic tumor.

Bronchogenic cysts are rare congenital anomalies of the ventral foregut and are related to abnormal budding of the tracheobronchial tree during embryological development. The majority of these occur in the mediastinum or within the pulmonary parenchyma and rarely in the neck. Those existing in the cervical region, especially in the thyroid or perithyroid area, are quite rare. To the best of our knowledge, there are only few other cases cited in the English-language literature. We herein describe a rare case of bronchogenic cyst that mimicks a thyroid tumor. A 40-year-old woman was admitted to our hospital for further evaluation of thyroid mass incidentally diagnosed at a local clinic. She had a history of dysphagia for three months. Results of routine laboratory tests including complete blood cell count, electrolytes, and urine analysis were within normal limits. There was no evidence of endocrine or metabolic abnormalities. A simple chest x-ray showed an increased soft tissue density in the left upper paratracheal area. A cervical computed tomogram (CT) showed a homogeneous cystic mass that measured 5 4 cm in cross diameters in the lower pole of the left thyroid gland (Fig 1). The left thyroid gland and trachea were deviated to the right side. Cervical lymph nodes were not enlarged. A preoperative fine needle aspiration cytology was performed, but the cytology was not diagnostic. The exact nature of the mass was questionable, and because a tumor in the left thyroid gland could not be ruled out, thyroid resection was scheduled. The patient underwent surgical exploration of the neck. The cystic mass showed fibrous adhesion to the lower pole of the left thyroid gland. A resection of the left lobe of the thyroid gland with the cystic mass was performed. Grossly, the mass presented a tan, smooth, and glistening outer surface, and the unilocular cyst contained thick brownish mucoid material. Microscopically, the cyst revealed only a lining of pseudostratified ciliated columnar epithelium. The stratified squamous epithelium was not noted. The cyst wall showed fibrous connective

A simple method of substernal bar removal after the Nuss procedure

The Nuss procedure for pectus excavatum is a well-known technique. Although there are numerous reports on the Nuss procedure, the reports on its removal are few. Removal has been done with many variations in the supine position, which involves bending the bar or bringing the bar beneath the operating table, which can prove to be troublesome and dangerous. Our simple technique allows easy removal of the substernal bar without bar bending. This technique was used in 21 patients without complication.

Polyostotic rib fibrous dysplasia resected by video-assisted thoracoscopic surgery with preservation of the overlying periosteum.

Video-assisted thoracoscopic rib resection has rarely been reported, but a relatively simple procedure that uses readily available instruments can prove to be feasible. A conventional approach would involve an incision greater than the length of the mass itself. Such an approach would require significant resection of the chest wall musculature and could lead to significant postoperative morbidity and decrease in quality of life. Multiple rib tumors would require an even more extensive incision and may require multiple incisions to facilitate exposure and removal. We report the removal of 2 expansile bone tumors by video-assisted thoracoscopic surgery while preserving the periosteum to allow for bone formation. To the best of our knowledge, no such attempts

Double primary tumor, thymic mass and posterior mediastinal neurogenic tumor, in a patient with acute pancreatitis performed with single-staged robotic-assisted thoracoscopic surgery.

Finding 2 primary benign lesions at 2 extremes of the mediastinum is a rare event. A minimal invasive operation performed in a single-staged procedure can prove to be difficult, especially when the procedure is performed with a robot. We discuss the positioning and details of the procedure carried out in a 52-year-old woman with acute pancreatitis.

Rib xanthoma resected by video-assisted thoracoscopic surgery using a bone punch.

Xanthomas of the rib are extremely rare benign neoplasms, most commonly reported in soft tissue, but rarely in bone. We report a case of a 4-cm xanthoma of the rib resected by video-assisted thoracoscopic surgery and pulled through a 2-cm port incision around the patients areola. To the best of our knowledge, there are only 8 other such cases, and none of which were removed by thoracoscopic surgery.

Silastic molding method for pectus excavatum correction using a polyvinyl alcohol (ivalon) sponge.

Pectus excavatum is rare, but it is the most common type of sternal congenital disorder. There are many surgical methods to correct pectus excavatum such as the Ravitch method, Wada method, Silastic mold method, and the Nuss operation. We report a case of minimal invasive surgery for pectus excavatum using a polyvinyl alcohol sponge.

Rhabdomyolysis in a chronic kidney disease patient after lung surgery

Rhabdomyolysis is the rapid lysis of the rhabdomyoma due to muscular tissue damage, which leads to circulation of myoglobin, which causes nonspecific clinical syndromes [1]. Rhabdomyolysis can occur post-traumatically or from metabolic derangements [1]. Rhabdomyolysis is a well-known cause of acute renal failure (ARF), but in patients with chronic kidney disease (CKD), the characteristic symptoms of rhabdomyolysis are not so obvious and variations in biochemical tests can be similar to CKD patients [2]. We report a CKD patient who developed rhabdomyolysis after a lung surgery under general anesthesia. The patient was a diabetic 64-year-old male who was receiving intermittent hemodialysis after being diagnosed with CKD a year ago. He was taking aspirin and clopidogrel due to a right thalamic infarction; irbesartan, isosorbide dinitrate, and nifedipine for high blood pressure; and insulin due to diabetes. After one year observation of a 2 cm nodule discovered in his left lingular segment at the time of CKD diagnosis, small cell lung carcinoma and adenoma was diagnosed. A left lingular segmentectomy of upper lobe by thoracotomy was scheduled. Patient received hemodialysis 36 hours before surgery, and laboratory data showed a Ca2+ level of 8.5 mg/dl, K+ 5.6 mEq/L, phosphate 5.1 mg/dl, urea 58 mg/dl, creatine 11.0 mg/dl, albumin 4.1 g/dl, uric acid 8.7 mg/dl, and CK 91 U/L (Table 1). There were no signs of K+ elevation in electrocardiogram. Table 1 Perioperative Laboratory Data Tracheal intubation was done with a left sided double lumen tube using pentothal sodium 250 mg. Atracurium 30 mg, 1% lidocaine 80 mg and fentanyl 100 µg. Anesthesia was maintained using 2.0-6.0 vol% desflurane with 100% oxygen and remifentanil. Mechanical ventilation was started with a tidal volume of 450 ml at a frequency of 15 per minutes. Total time under general anesthesia was 285 minutes; systolic blood pressure was maintained between 100 and 130 mmHg and diastolic blood pressure was maintained between 60 and 80 mmHg. Body temperature was kept around 36.0℃. To maintain muscle relaxation during surgery, injection of atracurium was started 15 minutes after intubation. About 30 minutes after one lung ventilation, the patients SpO2 suddenly decreased. Arterial blood gas analysis (ABGA) showed a pH of 7.39, PaCO2 32 mmHg, PaO2 51 mmHg, BE -5.1 mEq/L, Na+ 137 mEq/L, K+ 7.15 mEq/L and Ca2+ 1.11 mg/dl. One gram of calcium gluconate, 5 units of insulin, and 40 mEq of sodium bicarbonate were immediately injected to prevent side effects from hyperkalemia. Results of additional ABGA showed pH 7.41, PaCO2 30 mmHg. PaO2 72 mmHg, BE -3.9 mEq/L, Na+ 139 mEq/L, K+ 6.30 mEq/L, Ca2+ 1.08 mg/dl, and blood sugar test at 187. One gram of calcium gluconate, 5 units of insulin, and 40 mEq of sodium bicarbonate were additionally administered. Operation time was 210 minutes. After surgery, patient was moved to intensive care unit (ICU) and 2 hours after surgery (operative day), his K+ level measured 5.6 mEq/L. Nine hours later (postoperative day 1), it increased to 8.9 mEq/L, so calcium gluconate and polystyrene sulfonate calcium were administered and kalimate enema was done (Table 1). Eleven hours after surgery, K+ level increased again (8.9 mEq/L), thus, continuous renal replacement therapy (CRRT) was done. At the second postoperative day, K+ level increased again to 7.4 mEq/L. At this time possibility of rhabdomyolysis was suspected so supplementary laboratory test were done in which CPK, myoglobin and CK-MB levels were 1,948 U/L, 5,815 ng/ml and 15.2 ng/dl, respectively; thus, rhabdomyolysis was diagnosed and hemodialysis and hydration were done. Common clinical symptoms of muscle swelling or pain seen in rhabdomyolysis were absent in the patient. Ten days after surgery, CPK decreased to normal range (61 U/L) and myoglobin kept decreasing (282 ng/ml). The patient was moved from the ICU to the general ward (Table 1). Diagnosis of rhabdomyolysis may be masked in CKD patients due to the fact that the characteristic clinical symptoms of this syndrome such as muscle pain or weakness and dark-brown urine are absent [1,2]. CKD patients may not display the characteristic biochemical changes and symptoms of rhabdomyolysis because metabolic disorders due to CKD include hyperphosphatemia and hypocalcemia, and patients who receive dialysis commonly display hyperkalemia and increased CPK after surgery [2]. Therefore, recognition and diagnosis of rhabdomyolysis in a CKD patient can be difficult and elusive [1,2]. We can not say for sure when rhabdomyolysis started in our patient because biochemical blood tests to confirm it was done in the second day after surgery. Laboratory analysis showed a CPK (1,948 IU/L) 5 times higher than normal [1,3], myoglobin (5,815 ng/ml) more than 83 times higher, and CK-MB (15.2 ng/ml) more than 3 times higher. Phosphate (6.3 mg/dl) increased, but Ca2+ (8.5 mg/dl) was within the normal range, probably because the patient was injected with calcium during surgery and in ICU. The medications used in our patient regarding anesthesia had little association with rhabdomyolysis [2,4]. Considering the fact that our patient received hemodialysis 36 hours before surgery, electrolyte disorders as a possible cause of it is unlikely. Also medications that our patient was taking, are not related with rhabdomyolysis [2]. Myoglubinuria and rhabdomyolysis has been reported in CKD patients after undergoing surgery in the supine position for 8 hours and after undergoing surgery in the lateral position for over 4 hours [3,5]. The patient in our case underwent general anesthesia in left lateral position for more than 4 hours and considering the history of cerebral infarction, it could be the cause for rhabdomyolysis. In conclusion, recognizing rhabdomyolysis induced ARF due to traumatic or non-traumatic muscle damage is relatively easy, but in CKD patients, diagnosing rhabdomyolysis is not so obvious because the characteristic symptoms and biochemical findings are masked by CKD itself. Especially, in CKD patients who show increased CK-MB and myoglobin, the possibility of rhabdomyolysis should not be overlooked, regardless of how small or big the operation may be.