Pulmonary carcinosarcoma successfully resected using the rib-cross thoracotomy approach: report of a case

Pulmonary carcinosarcoma is extremely rare and disease prognosis is very poor. A solid large tumor occupying the left thorax was detected in a 66-year-old female. Rib-cross thoracotomy was performed to excise the tumor; the 5th and 6th ribs and intercostal muscles and vessels were cut along the mid-axillary line, and the thorax was entered posteriorly at the 4th intercostal space and anteriorly at the 6th intercostal space, providing wide exposure of the entire thorax. Left pneumonectomy combined with chest wall resection was successfully performed, followed by chest reconstruction to achieve complete resection. Histopathologically, adenocarcinoma and spindle cell sarcoma containing rhabdomyosarcoma components were identified; the patient was diagnosed with pT3N1M0 stage IIIA true pulmonary carcinosarcoma. Postoperative adjuvant chemotherapy containing cisplatin and vinorelbine was administered. There was no recurrence of the disease 20 months after surgery. Aggressive excision may result in favorable outcomes for pulmonary carcinosarcoma.     

泌尿系统肉瘤样癌和癌肉瘤八例报告并文献复习

目的 探讨泌尿系统肉瘤样癌和癌肉瘤的组织学特点、临床表现、治疗和预后.方法 泌尿系统肉瘤样癌和癌肉瘤8例.其中膀胱肉瘤样癌4例,男3例,女1例,年龄58、63、78、79岁,均因无痛性肉眼血尿就诊,肿瘤直径平均4.5(1.5～6.7)cm,为不规则、广基的浸润性肿物.行膀胱部分切除术2例,TURBt 1例,膀胱癌根治术1例.肾肉瘤样癌1例,男,64岁,因肉眼血尿就诊,伴同侧肾上腺和胰腺转移,行肾癌根治术和胰腺体尾切除术.转移性右肾上腺肉瘤样癌1例,男,47岁,原发灶为左肺肉瘤样癌,行左肺下叶和右肾上腺切除术.肾盂癌肉瘤1例,女,64岁,表现为无痛性肉眼血尿,行左肾、输尿管及部分膀胱切除术.膀胱癌肉瘤1例,男,77岁,无痛性肉眼血尿,肿瘤直径2.5～3.0 cm,行TURBt术.8例均经病理检查确诊.8例均获随访,随访时间36～96个月.结果 膀胱肉瘤样癌4例中:1例G_3、T_(2a)者行TURBt,术后行丝裂霉素膀胱灌注化疗,随访96个月无瘤生存;1例63岁女性先行TURBt,术后病理为肉瘤样癌、T_1伴有原位癌(T_m),1个月后行膀胱癌根治切除术.随访36个月无瘤生存;1例T3a者行膀胱部分切除术,术后辅以放疗,随访36个月无瘤生存;1例T4a者行姑息性膀胱部分切除术,术后病理切缘阳性,术后2个月死于肿瘤多脏器转移.肾肉瘤样癌患者术后2个月开始化疗(盐酸吉西他滨加卡铂),又出现肝、肺转移,术后5个月死亡.转移性右肾上腺肉瘤样癌患者术后在外院行3个疗程化疗(顺铂加依托泊苷),5个月后出现左肾上腺转移,术后7个月死亡.肾盂癌肉瘤患者的肿瘤以软骨肉瘤为主,伴少许鳞状细胞癌及未分化癌,随访60个月无瘤生存.膀胱癌肉瘤患者肿瘤病理分期为T2a,主要是平滑肌肉瘤,伴有鳞状细胞痛和腺癌,术后予以全身化疗(盐酸吉西他滨加卡铂),随访12个月死于慢性阻塞性肺气肿、肺部感染.结论 泌尿系统肉瘤样癌和癌肉瘤少见,多见于老年男性,恶性程度高,浸润性强,预后差.肿瘤的病理分期和治疗是影响预后的因素,早期诊断和积极的综合治疗可望获得较好的治疗结果、延长患者生存期.     

A case of pulmonary metastasis of malignant fibrous histiocytoma with left atrial infiltration via the pulmonary vein

We report a case of a woman who at age 58 had an operation on the right femur for malignant fibrous histiocytoma (MFH). At age 63, a chest X-ray examination disclosed a tumor shadow, for which we suspected metastasis from the MFH. Chest computed tomography showed that the tumor had infiltrated to the left atrium via the pulmonary vein. We operated on the patient, first dividing the arterial supply to the lower lobe, and then opening the pericardium. We blocked the lower pulmonary vein and left atrium with a Cooley-Dera clamp and resected the tumor. The tumor was polypoid and had invaded the left atrium. Fifteen months after this lung surgery, the patient was diagnosed with a brain tumor, which was resected. Invasive primary lung cancer to the left atrium via the pulmonary vein is common, but metastasis from a sarcoma such as MFH to the left atrium via the pulmonary vein is extremely rare.     

A case of true carcinosarcoma in bladder diverticulum]

We report a case of carcinosarcoma arising from a bladder diverticulum. A 71-year-old male was referred to our hospital for macroscopic hematuria. Two diverticula were identified in the left wall of the urinary bladder, one of which showed a broad-based tumor. The bladder tumor was resected using a transuretheral approach and the tumor was histologically diagnosed as leiomyosarcoma. The patient underwent partial resection of the bladder including the two diverticula and the tumor. Pathological examination revealed that the resected specimen was composed of three elements, transitional cell carcinoma (G3), squamous cell carcinoma, and leiomyosarcoma. Thus, the patient was diagnosed with carcinosarcoma. He died 5 months after surgery to remove the panperitonitis carcinomatosa. This case is the 38th reported case of bladder carcinosarcoma in Japan.     

Surgery for pulmonary actinomycosis that was difficult to differentiate from lung cancer; report of a case

We herein report a case of pulmonary actinomycosis that was difficult to differentiate from lung cancer. The patient was a 53-year-old man who visited our hospital with a chief complaint of bloody sputum. Computed tomography (CT) showed a tumor in the anterior basal segment (S8) of the left lower lobe that contained a low density area, and because elevated C-reactive protein (CRP) was also observed, the patient was diagnosed with a lung abscess. As no improvements were seen after 4 months of antibiotic administration, and accumulation was observed at the same site on positron emission tomography (PET), the patient was diagnosed with lung cancer and underwent surgery. Following segmental resection, the patient was found to have pulmonary actinomycosis. It is necessary to consider pulmonary actinomycosis in patients with lung tumors.     

Concomitant surgery of a left atrial myxoma and a pulmonary carcinoma

We report the first successful outcome of a patient undergoing concomitant surgery for a left atrial myxoma and a squamous cell carcinoma of the lung. Preoperative evaluations revealed lung cancer and a left atrial tumor of undetermined origin. An operation to excise both cardiac and pulmonary tumors was performed. The cardiac tumor was first resected with the aid of cardiopulmonary bypass. The histopathological diagnosis was myxoma. Resection of the left upper pulmonary lobe and mediastinal lymph nodes followed. The postoperative course was uneventful, and the patient is well without evidence of recurrence 7 years after the operation.     

Anomalous V2 of the left pulmonary vein detected using three-dimensional computed tomography in a patient with lung cancer: A case report

We report one of the rare anatomical variations of the pulmonary vein wherein the left V2 drained into the inferior pulmonary vein. A 63-year-old man was referred to our hospital because of an abnormal shadow in the left lower lung field that was noted on chest X-ray. Computed tomography (CT) revealed a tumor in the left lower lobe. A biopsied tumor specimen was diagnosed as an adenocarcinoma, and thus, left lower lobectomy was performed. Preoperative three-dimensional CT revealed that an anomalous V2 of the left lung drained from the superior segment into the inferior pulmonary vein. This variation type was confirmed during thoracoscopic left lower lobectomy. We were able to perform left lower lobectomy with the preservation of the anomalous V2. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. It is important to identify anatomical variations of the pulmonary vein and reliably preserve and process the affected area to prevent postoperative complications.     

Ex-situ-Manschettenresektion mit Autotransplantation des linken Lungenunterlappens nach erweiterter Pneumonektomie

A 69-year-old patient with reduced pulmonary function was diagnosed as suffering from non-small cell lung cancer of the left lung invading the main bronchus, pulmonary artery and left atrium. Staging examinations were negative. Using cardiopulmonary bypass, an extended pneumonectomy with partial resection of the left atrium was performed. The cardiac defect was closed with a pericardial patch. The lower lobe was divided ex situ from the upper lobe and reimplanted with anastomosis of the lower pulmonary vein to the left auricle. After a totally uneventful course the patient is in good condition and free of tumor recurrence 2.5 years postoperatively.     

Pulmonary metastatic giant cell tumors presenting as totally hyalinized and ossified nodules

We report a case of giant cell tumor of the left distal femur with simultaneous bilateral pulmonary metastases. Pathologic examination of the left lung nodule showed a metastatic giant cell tumor with a noncontinuous ossified rim, and the right lung nodules were totally hyalinized or ossified without residual giant cell tumor components. Hyalinization was a consistent finding in both the primary bone lesion and the pulmonary metastases. Because the patient did not receive chemotherapy or radiotherapy before her surgical procedure, we believe that these changes represent spontaneous tumor regression.     

Prolonged survival after repeat resection of pulmonary metastasis from hepatocellular carcinoma

We report a patient in whom two pulmonary resections were performed for lung metastasis after hepatic resection of hepatocellular carcinoma (HCC). A 56-year-old Japanese man with an 8-year history of chronic liver disease was admitted with elevated serum alpha-fetoprotein (AFP) and a liver tumor that had been detected by ultrasonography. Computed tomography showed a 6-cm tumor in the medial segment of the liver, and partial resection of the medial segment was performed. Thirty-six months after the first operation, pulmonary resection was performed for a solitary metastasis in the left lung. Fifty-one months after the second operation, a solitary metastatic tumor was detected in the right lung, without any evidence of recurrence or other metastatic foci, and thoracoscopic partial resection of the right lung was performed as the third operation. The patient is alive 36 months after the second pulmonary resection, has a normal AFP value, and shows no signs of recurrent or metastatic foci. Repeat pulmonary resection for metastasis from HCC resulted in long-term survival in this patient. Received: September 21, 2001 / Accepted: April 2, 2002     

Carcinosarcoma of the renal pelvis and ureter: a case report

We report a case of carcinosarcoma of the renal pelvis and ureter arising in an 89-year-old man who presented at our hospital with gross hematuria. Abdominal computed tomography, excretory pyelography, and retrograde pyelography demonstrated that left hydronephrosis was caused by an ureteral tumor. Left urine cytology indicated transitional cell carcinoma. The patient underwent chemotherapy and radiation therapy. However, gross hematuria recurred, and the patient underwent left nephroureterectomy. The surgical specimen showed carcinosarcoma in the renal pelvis and ureter histologically. He has been free of cancer for 1.5 years.     

Large cell carcinoma with chest wall infiltration combined with contralateral giant bulla

A 48-year-old male consulted the department of respiratory medicine for right precordial pain occurring from the beginning of May 2004. Chest X-ray indicated a tumorous shadow in the right upper lung field and a large left lung cyst. Although chest wall infiltration was suspected based on computed tomography (CT) demonstrating a mass lesion in the right S2, there was no significant swelling of the mediastinal lymph node. On the left side, the lung was markedly compressed by a large cyst in the left upper lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery based on a suspicion of malignant pulmonary tumor. Considering both the risk of perioperative complications due to the left cystic lesion at surgery for right lung lesion and the improvement of respiratory function by removing cystic lesion of the left lung, the left side operation was preceded by the right side. Although postoperative examinations of respiratory function did not demonstrate any particular improvement, the results of selective right pulmonary artery obstruction test supported the possibility of pulmonary lobectomy. Therefore, the right upper lobectomy and ND 2a mediastinal dissection combined with chest wall resection was subsequently performed. Postoperative pathological diagnosis revealed that the tumor was a stage IIB large cell carcinoma of pT3N0M0 with costal infiltration.     

Carcinosarcoma of the lung with hypertrophic pulmonary osteoarthropathy

Carcinosarcoma of the lung is a rare malignancy. Endobronchial and parenchymal variants are classically described. Clinicopathological features are often related to anatomical location, as is the case for most lung neoplasms. This case report details the surgical management of a carcinosarcoma in a patient seen with pulmonary osteoarthropathy.     

Air embolism following computed tomography-guided lung needle marking; report of a case

We report air embolism following computed tomography (CT)-guided lung needle marking. A 55-year-old man was admitted to our hospital with left pulmonary tumor, characterized as ground glass opacity (GGO). To localize the tumor, lung needle marking under CT guidance was performed. Almost immediately, the patient experienced symptoms of cerebral arterial air embolism. CT revealed air in the left ventricle. About 2.5 hours later the symptoms and the air disappeared. Three days later a video-assisted thoracoscopic wedge resection was performed. The patient's postoperative course was uneventful, and he was discharged in good condition.     

Pulmonary blastoma

We describe a resected pulmonary blastoma in an 84-year-old male, the oldest of previously reported patients. A chest X-ray showed a 2 cm-sized abnormal shadow in the left lung field. Five months later computed tomography demonstrated a well-demarcated heterogenous mass, measuring 12 cm in diameter, in the left lower lobe of the lung. This mass was diagnosed as a carcinoma using echo-guided percutaneous biopsy. The patient underwent a left lower lobectomy. The resected specimen revealed the tumor to be a pulmonary blastoma arising from lung tissue. Preoperative diagnosis of pulmonary blastoma is extremely difficult because of the histological heterogeneity of tumor. Since it has been noted that pulmonary blastoma rapidly progresses in a short period of time, surgical treatment should be undertaken as quickly as possible when such a tumor is suspected.     

Bilateral pulmonary metastases from hepatocellular carcinoma successfully treated by surgical resection and stereotactic radiotherapy; report of a case

We report a case of 68-year-old-man with pulmonary metastases from hepatocellular carcinoma (HCC). Following right hepatic lobectomy in January 2005, 4 pulmonary metastases in the right lung were detected by chest computed tomography (CT) in September 2007. As chemotherapy was not effective, surgical resection (right upper lobectomy, partial resection of middle and lower lobe ) was performed. Secondary metastases in the left lung was detected in March 2008, and stereotactic radiotherapy was performed considering the site of tumor location and poor pulmonary function. Two years after radiotherapy, the patient is alive without recurrence.     

Post-renal transplant pulmonary cryptococcosis, which was difficult to differentiate from a pulmonary tumor

A 61-year-old man, with a history of renal transplant for immunoglobulin A (IgA) nephropathy and surgery for advanced gastric carcinoma, was noted to have a nodular shadow of 1.3 cm in diameter in the left lung( S8) based on chest computed tomography( CT), and was suspected to have primary pulmonary carcinoma or a metastatic pulmonary tumor, for which surgical resection was performed. A rapid pathological diagnosis of inflammatory granuloma was made, and the patient was finally diagnosed as having pulmonary cryptococcosis based on the histopathology, and received fluconazole postoperatively. Patients with organ transplant history showing a nodular shadow in the lung should undergo a careful workup in consideration of both malignant tumor and infection.     

Pulmonary blastoma

We describe a resected pulmonary blastoma in an 84-year-old male, the oldest of previously reported patients. A chest X-ray showed a 2 cm-sized abnormal shadow in the left lung field. Five months later computed tomography demonstrated a well-demarcated heterogenous mass, measuring 12 cm in diameter, in the left lower lobe of the lung. This mass was diagnosed as a carcinoma using echo-guided percutaneous biopsy. The patient underwent a left lower lobectomy. The resected specimen revealed the tumor to be a pulmonary blastoma arising from lung tissue. Preoperative diagnosis of pulmonary blastoma is extremely difficult because of the histological heterogeneity of tumor. Since it has been noted that pulmonary blastoma rapidly progresses in a short period of time, surgical treatment should be undertaken as quickly as possible when such a tumor is suspected.     

Involvement of the inferior caval vein in adrenal metastasis.

A patient was referred to our hospital for resection of a large renal cell carcinoma with invasion of the inferior caval vein, diagnosed as such with CT, angiography and cavography. The history mentioned partial resection of the left lung for lung carcinoma 16 months before. At operation the tumor could not be removed, the patient died because of postoperative pulmonary complications. Autopsy and histopathological examination revealed a large metastatic tumor of the previous lung carcinoma in the left adrenal gland. The clinical implications and some diagnostic methods are discussed.     

A case of carcinosarcoma arising in the submandibular gland.

A 54-year-old man presented with an 8-year history of a hard asymptomatic mass of the left submandibular area. Total excision of the left submandibular gland with radical neck dissection was performed under a diagnosis of a submandibular tumor, probably a malignant mixed tumor. The pathologic diagnosis was carcinosarcoma consisting of carcinomatous and sarcomatous elements. The epithelial component was composed of squamous cell carcinoma, undifferentiated carcinoma, and adenocarcinoma. The nonepithelial component was composed of chondrosarcoma, osteosarcoma, spindle cell sarcoma, rhabdomyosarcoma, and liposarcoma. In the central area of the tumor, a few remnants of benign pleomorphic adenoma were identifiable. The finding suggested that in our patient, the carcinosarcoma arose from a preexisting pleomorphic adenoma. In view of the expected aggressive nature of the tumor, the patient was treated with postoperative radiotherapy of 60 Gy total, in 30 daily fractions of 2 Gy, and chemotherapy. He currently remains well and free of disease 24 months after treatment.