Y. L. Cheng

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.

Prognostic value of 18-FDG uptake in early stage NSCLC.

BACKGROUND We assessed whether the standard uptake of 18-fluorodeoxyglucose (18-FDG) in non-small cell lung cancers (NSCLC) differed between stage I and non-stage I tumors. METHODS We reviewed 163 patients with NSCLC who underwent surgical lymph node dissection after tumor resection in 2002-2003. Patients with clinical stage I NSCLC who were investigated with preoperative positron emission tomography integrated computed tomography (PET-CT) scans using 18-FDG uptake were included; those with N2 disease were excluded. We reviewed 55 patients with a mean follow-up of 68 months. RESULTS We analyzed 36 patients with stage I (Group 1) and 19 patients with non-stage I NSCLC (Group 2; 8 stage II, 7 stage III and 4 stage IV). There were no statistical differences in sex, age, tumor size, histological type, location or tumor differentiation between the groups. Group 1 had lower maximum standard 18-FDG uptake values (SUVmax) than Group 2 (4.9 +/- 2.7 vs. 8.1 +/- 3.8; P = 0.001). Using multiple logistic regression, patients with higher preoperative SUVmax and serum carcinoembryonic antigen (CEA) levels showed advanced tumor stages postoperatively (SUVmax > 4.7, odds ratio 7.65; CEA > 3.5 ng/mL, odds ratio 8.39). High 18-FDG uptake was significantly associated with reduced median survival (62.69 months for SUVmax < 4.7 and 40.89 months for SUVmax > 4.7). CONCLUSIONS High preoperative 18-FDG uptake of tumors was significantly associated with reduced overall patient survival. The SUVmax of the tumor and serum CEA levels demonstrated aggressive tumors and could be helpful preoperatively when considering patients for induction therapy or resection.

Spontaneous regression of a mediastinal thymoma

Thymoma is a common tumor in the anterior mediastinum. Thymoma may be symptomatic, but 20% to 30% of affected patients have symptoms related to compression of the mediastinum. Surgical excision is the keystone of therapy. Reports of the spontaneous regression of thymoma are rare in the English-language literature. Here we present a case of spontaneous remission of a mediastinal thymoma and a review of the literature.

Septic Arthritis of the Sternoclavicular Joint caused by Salmonella in a Healthy Person

Abstract The sternoclavicular (SC) joint is an unusual site for septic arthritis in healthy people. It is mostly described as affecting intravenous drug abusers. We report a rare case of sternoclavicular osteo-arthritis caused by non-typhoid salmonella in an immunocompetent person. The patient presented with general weakness, dizziness, epigastric and anterior chest pain that had persisted for one week. Peptic ulcer disease was diagnosed by gastro-intestinal endoscopy. Computed tomography (CT) revealed fluid accumulation around the left sternoclavicular joint. Surgical exploration revealed pus, which was drained. The pus culture grew salmonella enterica serotype D. After repeated debridement and appropriate antibiotic treatment, the patient was discharged home four weeks later.

Lung cancer with isolated skip metastasis to an abdominal lymph node

Lung cancer is usually diagnosed at an advanced stage with metastases present in 40% of patients. The preferential sites of extrapulmonary spread include lymph nodes, liver, brain, adrenal gland, and bone. Direct lymphatic metastases to abdominal lymph nodes without involvement of lobar, hilar or mediastinal lymph nodes is rare. Case Report: We report a case of adenocarcinoma of the lung in the left lower lobe, with isolated metastasis to an abdominal lymph node detected by positron emission tomography (PET), followed by confirmation with surgical exploration. Conclusion: The low incidence reported for skip metastasis to the abdominal lymph nodes may be attributed to an underestimation in the past. With the advent of PET computed tomography (PET-CT) and its use as a standard pre-operative staging modality for lung cancer, one should anticipate an increased incidence of skip metastasis.

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.

Unusual Presentation of Right Aberrant Subclavian Artery: Case Report

Background: Dysphagia due to an aberrant subclavian artery is termed dysphagia lusoria. Although right aberrant subclavian artery is a congenital anomaly, dysphagia lusoria is rare and generally develops during the 4th decade of life. We present a young patient who had had chest pain and mild dysphagia for 3 months. A barium contrast study and computed tomography of chest revealed an aberrant right subclavian artery passing behind the esophagus; Magnetic resonance angiography of the aorta confirmed the diagnosis. Usually, aberrant subclavian artery does not lead to symptoms; however, sometimes dysphagia develops. Barium contrast study of the esophagus will reveal the abnormality.

An unusual cystic lung lesion

An 80-year-old man was admitted because he had experienced haemoptysis for 4 days. He had smoked 40 cigarettes daily for 50 years. He had no medical history except for …

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.