Hemangiopericytoma of the pleura causing massive hemothorax.

Hemangiopericytoma is an unusual soft tissue tumor. A 54-year-old man presented with sudden onset of chest pain and dyspnea for 1 day. The initial chest x-ray showed a massive left pleural effusion. A contrast-enhanced computed tomographic scan of the chest showed a homogenously enhanced mass in the intrathoracic extrapulmonary space. A tube thoracostomy was performed and hemothorax was confirmed. A posterolateral thoracotomy was performed and a tumor in the parietal pleura of the left chest wall was resected. Grossly, the resected tumor arose from the parietal pleura, and the cut surface was elastic, soft, and pale yellow. There were several cystic formations and hemorrhages. Based on histologic findings, hemangiopericytoma with lower grade malignancy was diagnosed. The patient was alive and free from tumor recurrence 1 year after surgery. Intrathoracic extrapulmonary hemangiopericytoma is extremely rare, and surgical excision is the treatment of choice. Adjuvant chemotherapy or radiotherapy is indicated because of the high risk of recurrence and potential malignancy.     

Diagnosis and treatment of hemothorax in malignant trophoblastic tumors]

From 1949 to 1988, 32 cases of hemothorax were seen in our hospital. The incidence rate of hemothorax among the cases of choriocarcinoma and invasive mole in the whole series were 2.6% and 1.4% respectively. The most frequent symptoms were chest pain, cough, dyspnea, and hemoptysis. Before 1965, when 6-MP was the only agent used, 7 of the 16 patients with hemothorax died directly due to severe intrathoracic hemorrhage, from 1966 to 1988, when intravenous infusion of 5-FU and intrathoracic injection of 5-FU were used, only 4 of the 16 cases died, there was no death directly related to hemothorax. About 75% were followed up for more than 10 years, the longest duration of follow up being more than 28 years in 6 cases. Repeated examinations with serum hCG determination and chest film revealed no evidence of recurrence, nor pleural adhesion and thickening or pulmonocardiac diseases.     

Hemothorax due to metastatic hepatocellular carcinoma presenting with massive hemoptysis.

Hemoperitoneum caused by ruptured hepatocellular carcinoma (HCC) is not uncommon in patients with HCC. Hemothorax due to rupture of metastatic HCC, however, is a very rare complication with high mortality because of uncontrollable hemorrhage. We describe a 42-year-old male HCC patient with chest wall metastasis complicated by hemothorax with an unusual presentation of massive hemoptysis. He received tube thoracotomy immediately and emergency surgery because of persistent bleeding. Hemostasis was achieved transiently. Despite intensive care, he died of multiple organ failure on the 6th postoperative day. We conclude that hemothorax due to a ruptured HCC, as in this case, indicates a very poor prognosis despite intensive treatment.     

Prospective trial of the six hour rule in stab wounds of the chest

Stab wounds of the chest may be associated with a spectrum of injuries ranging from the lethal to the insignificant. The management of asymptomatic patients with stab wounds of the chest is controversial. The results of previous reports have asserted that asymptomatic patients with stab wounds of the chest do not have delayed complications develop if roentgenograms of the chest taken six hours after the injury are normal. This "rule" has not been validated. A three year, prospective study of patients with stab wounds of the chest was done. Patients were excluded from the study if they had symptoms on arrival, evidence of physiologic derangement caused by intrathoracic injury, wounds near the subclavian vessels or precordial wounds. Patients with lower thoracic stab wounds were evaluated by diagnostic peritoneal lavage. If findings from lavage were negative, the patients were included in the study. One hundred and five patients met the criteria for inclusion in the study group. All of the patients were hospitalized and examined serially. All had roentgenograms of the chest performed at admission, at six hours and at 24 hours. Four patients had a pneumothorax or hemothorax develop between the time of admission and six hours of hospitalization. In the remaining 101 patients, none had a pneumothorax or hemothorax between six and 24 hours. No patient asymptomatic on admission had a tension pneumothorax develop later. No patient had delayed evidence of abdominal injury. An asymptomatic patient with a stab wound of the chest that is not precordial, not in proximity to the subclavian artery and not suspected of diaphragmatic penetration should be serially examined and have a follow-up roentgenogram of the chest at six hours. If the patient remains asymptomatic and the six hour film is normal, delayed complications are rarely, if ever, encountered and the patient does not require further studies or hospitalization. The six hour rule for stab wounds of the chest is valid.     

Recurrent giant cell tumor of the thoracic spine with bilateral pulmonary metastases.

Giant cell tumor (GCT) of bone is a challenging clinicopathologic entity. Despite its benign designation, it has the capacity to recur locally and develop rare pulmonary metastasis. We report a case of histologically proven recurrent GCT of the spine (T7-8) involving spinal cord compression, direct extension to 1 lung, and bilateral pulmonary metastases. A 30-year-old woman presented with back pain, and underwent anterior reconstruction for GCT of the T7 at another hospital. As her symptoms deteriorated, she underwent laminectomy at the same hospital 2 months after the first surgery. One year after the first surgery, she was referred to our hospital on account of a progressive neurological deficit and intractable back pain, and underwent an anterior tumor resection at T7-8 and reconstruction, due to tumor recurrence. Postoperatively, the patient did not show neurologic improvement, but her pain decreased. The patient displayed no respiratory difficulties and no apparent change in follow-up chest radiographs for more than 2 years since surgery. This is the first reported case of bilateral pulmonary metastases from GCT of the thoracic spine.     

子宫平滑肌瘤长入右心腔一例报道

子宫平滑肌瘤是女性生殖器官中最常见的良性肿瘤,进入静脉或淋巴管内称为脉管内平滑肌瘤病,局限于子宫可出现月经量增多、经期延长,肿瘤过大压迫可导致下肢肿胀、下腹部不适,累及髂静脉可引起腹痛,肿瘤向上生长累及下腔静脉、右心房、右心室、肺动脉等可出现呼吸困难、心悸、胸痛、胸闷、晕厥等,甚至可出现突发性大出血及休克。报道1例49岁女性患者因子宫平滑肌瘤长入右心腔导致下肢水肿3年,胸闷、胸痛2个月的病例,入院完善检查后予经腹全子宫+双侧附件+盆腔包块切除术,开胸行下腔静脉、右心房、右心室、肺动脉肿物清除术及房间隔缺损修补术,结合术中及病理结果,确诊为子宫平滑肌瘤、血管内平滑肌瘤。好转出院,随访8个月,肿瘤未复发。子宫平滑肌瘤侵入血管长入右心室达肺动脉者极少,病情严重,早发现、早诊断、早治疗尤为重要。     

Nodular malignant lymphoma presenting as bilateral adnexal masses

A case of nodular malignant lymphoma, small cleaved cell in both ovaries, tubes and peritubal tissue is reported in a 55-year-old nulliparous woman with primary clinical symptoms of dyspnea and chest pain. The disease was first diagnosed at laparotomy. The patient was treated by bilateral adnexectomy and chemotherapy. This is the third case of adnexal small cleaved cell nodular lymphoma reported in the literature. Clinical and pathological aspects of this relatively rare pathological entity are reviewed.     

Endometriosis of the Diaphragm: Four Cases Treated with a Combination of Laparoscopy and Thoracoscopy

Study ObjectiveWe aim to describe the clinical characteristics and the principles of combined laparoscopic and thoracoscopic management of women with diaphragmatic endometriosis at our institution.DesignCase series (Canadian Task Force Classification II2).SettingTertiary care referral center.PatientsFour women with diaphragmatic endometriosis.InterventionsLaparoscopy and thoracoscopy.MeasurementsWe retrospectively reviewed the charts of 4 consecutive women with diaphragmatic endometriosis who underwent laparoscopy and thoracoscopy from June 2008 through September 2008.Main ResultsFour patients underwent a combination of laparoscopy for treatment of abdominopelvic endometriosis and thoracoscopy for treatment of diaphragmatic endometriosis. All patients had a history of chest pain. Three had a history of pelvic pain. Two had a history of catamenial hemothorax or pneumothorax. Two had been previously diagnosed with endometriosis, and three had a history of hormonal pharmacotherapy. All underwent laparoscopy and thoracoscopy without complications. All had uneventful recoveries. At nine-month follow-up, all patients were free of chest pain, and one patient had recurring pelvic pain.ConclusionsTo the best of our knowledge, this constitutes the only reported series of patients with endometriosis who underwent a procedure systematically combining both laparoscopy and thoracoscopy for treatment of abdominopelvic and thoracic disease. It confirms that combined laparoscopic and thoracoscopic diagnosis and management of diaphragmatic endometriosis is reasonable. The inferior aspect of the diaphragm should be evaluated in all patients undergoing laparoscopy for endometriosis. Concomitant thoracoscopy should be considered for all patients with history of catamenial hemopneumothorax, cyclic chest or shoulder pain, or cyclic dyspnea. The aim of treatment should be to remove endometriotic lesions, to provide symptomatic relief, and to avoid recurrence. The use of these minimally invasive techniques may reduce the need for laparotomy or thoracotomy in affected patients.     

Role of three hour roentgenogram of the chest in penetrating and nonpenetrating injuries of the chest.

The current study examined whether a three hour roentgenogram of the chest was as reliable as the six hour roentgenogram of the chest in detecting delayed complications (that is, pneumothorax and hemothorax) of penetrating and nonpenetrating trauma to the chest. The 285 patients in the study were placed into three groups: those stabbed in either the chest or back; those sustaining multiple fractures of the ribs, and those with gunshot wounds to the chest or back. All the patients selected for study by three and six hour films of the chest were asymptomatic on admission and no pneumothorax or hemothorax was seen on initial anteroposterior and lateral roentgenograms of the chest. None of the patients included in the study required immediate operation. Twelve patients (4 percent) had delayed pneumothoraces on the three hour roentgenogram of the chest. Nine of these 12 (75 percent) required thoracostomy tube drainage, while the remaining three patients were managed with needle aspiration. No additional patients had complications on the six hour roentgenogram of the chest. Computed tomographic (CT) scan discovered five additional patients (2 percent) with pneumothoraces not visualized by the three or six hour films. Seventeen patients (6 percent) had delayed pneumothoraces despite negative admission roentgenograms of the chest and lack of symptoms. Twelve of the 17 (71 percent) were discovered on three hour roentgenogram of the chest, while an additional five of 17 (29 percent) were only seen by CT scan. Three hour roentgenograms of the chest are as reliable as six hour roentgenograms of the chest in visualizing the development of delayed complications of penetrating and nonpenetrating thoracic trauma. The CT scan is more effective than the roentgenogram of the chest in visualizing small pneumothoraces, but its use as a screening tool for detection of delayed complications of trauma to the chest pneumothoraces is probably cost-prohibitive.     

Pneumomediastinum as a cause of acute chest pain postpartum.

Pneumomediastinum can easily be mistaken for a pulmonary embolus or myocardial infarction. We describe herein a case of pneumomediastinum postpartum. A primigravida complained five-hours postpartum of acute chest pain and mild dyspnea. The initial (working) diagnosis was pulmonary embolus and the patient was treated with antithrombotic therapy. A CT scan revealed the real cause of the chest pain: pneumomediastinum. The patient was given adequate analgesia and two days later was able to leave the hospital in good clinical condition. We suggest that in the case of acute chest pain during or shortly following labor, pneumomediastinum should be considered.     

Acute coronary syndrome associated with oral administration of ritodrine hydrochloride during pregnancy: a case report.

We report a case of acute coronary syndrome associated with the oral administration of ritodrine hydrochloride. Ten days following the administration of ritodrine hydrochloride, the patient complained of chest pain, and an electrocardiogram showed ST elevation and ST depression. Intensive care was initiated. She recovered without chest pain.     

Pleural plaque related to asbestos mining in Taiwan

A 78-year-old woman complained of twisting-like pain in her left lower chest. During physical examination, friction rubbing was noted in both lungs. Chest radiography showed extensive bilateral pleural calcification. High-resolution computed tomography confirmed the presence of bilateral calcified pleural plaques. The patient had worked at a Japanese asbestos factory in Taiwan for 1 year when she was 16 years old. Her job involved picking out asbestos fibers from crushed asbestos minerals, but no protective equipment was used at that time. This is believed to be the first reported case of asbestos-related disease in Taiwan that resulted from asbestos mining. We also summarize the history of domestic asbestos mining, importation of asbestos, and trends in asbestos use in Taiwan.     

A case of congenital jejunal atresia associated with bilateral athelia and choanal atresia: new syndrome spectrum

We present a case of bilateral choanal atresia, cleft of the posterior palate. Cardiac, respiratory and central nervous system examinations were normal. An examination of the chest revealed aplasia of the bilateral absence of the bilateral nipple-areola complex. Skin, soft tissue and bilateral pectoral muscles of the chest wall were normal. The patient did not have scalp nodules or abnormal ears. Four hours after birth, an X-ray examination showed the distended intestinal loops, suggesting small bowel obstruction. Exploration was performed and congenital jejunal atresia was surgically identified. A primary anastomosis was performed. At 3 years of age, the patient had mild mental and growth retardation. Chromosome analysis was normal (46,XX). Magnetic resonance imaging showed no abnormal finding in the spinal cord; however, mild atrophy of the left cerebrum was pointed out. An abdominal echo examination showed no abnormal findings in the kidney. These associations may represent a previously undescribed syndrome spectrum.     

Metástasis pulmonares de un adenocarcinoma de endometrio. Tratamiento hormonal

We present a case of endometrial endometrioid adenocarcinoma that was initially treated by presurgical external radiotherapy plus total abdominal hysterectomy and bilateral annexectomy plus postsurgical brachytherapy. Three years later the patient presented bilateral lung metastases. The suspected diagnosis of lung metastases was made in routine screening with abdomino-pelvic computed tomography (CT) with subsequent chest CT. The diagnosis was confirmed by fine-needle aspiration of the major pulmonary lesion. Treatment consisted of high-dose gestagens: medroxyprogesterone acetate (MAP) 200 mg/day for an indefinite period. The patient continues in complete remission after 5 years of treatment.     

Apical hypertrophic cardiomyopathy: clinical, echocardiographic and angiographic features in 3 Chinese patients

We present 3 cases of apical hypertrophic cardiomyopathy. The presenting symptoms were dyspnea on exertion in 2 of 3 patients, typical anginal pain in 1 patient, atypical chest pain in 1 patient, and fatigue in 1 patient. One patient was asymptomatic with an abnormal electrocardiogram. Sustained apical impulse was noted in all patients, Grade 1/6 systolic murmur was audible in 2 patients. Electrocardiogram showed T wave inversion in the left precordial leads in all patients with amplitudes of 1.4, 0.8 and 2.0 mV, respectively. Isolated apical hypertrophy was noted in all patients. Two-dimensional echocardiogram and the left ventriculogram revealed a "spade-shaped" configuration of the left ventricular cavity at endo-diastole in only one patient. Left ventricular end diastolic pressures were elevated and coronary angiograms were normal in all 3 cases. We conclude that this disease entity should be considered in patients whose electrocardiogram shows a large inverted T wave in the left precordial leads, either accompanied by symptoms such as dyspnea on exertion or chest pain, or even when asymptomatic. Echocardiogram is the most useful screening tool in the diagnosis of apical hypertrophic cardiomyopathy.     

Pulmonary sequestration.

Pulmonary sequestration is an uncommon congenital abnormality in which nonfunctioning lung tissue is supplied by an anomalous systemic artery. Both the extralobar and intralobar forms probably develop from an accessory lung bud from the primitive foregut. Both forms are situated on the left side in about two-thirds of patients. The anomalous arterial supply usually originates from the descending thoracic aorta, and there may be a large left-to-left or left-to-right shunt through the sequestration. The sequestration may have a fistulous communication with the upper gastrointestinal tract. Congenital anomalies, particularly diaphragmatic hernia, are frequently associated with the extralobar form. Intralobar sequestration occasionally is an incidental finding on roentgenograms of the chest in an asymptomatic patient; however, the disorder is usually symptomatic and the most common presentation is recurrent pulmonary infection. Presentation may be characterized by gastrointestinal symptoms, congestive heart failure, hemoptysis or hemothorax. Extralobar sequestration is usually an incidental finding on routine roentgenograms of the chest or during the management of some other congenital anomaly. Infrequently, extralobar sequestration presents with symptoms similar to those seen with the intralobar form. Roentgenograms of the chest, upper gastrointestinal series and arteriography are the most helpful diagnostic aids. The usual treatment is resection of the sequestration by removal of only the sequestration in patients with the extralobar form and by lobectomy or segmental resection in patients with the intralobar form. The reported results of operation have generally been excellent.     

A case report of spontaneous pneumoperitoneum after sexual intercourse following a total laparoscopic hysterectomy,bilateral saplingo-oophorectomy and infra-colic omentectomy

The finding of pneumoperitoneum on a chest radiograph is most commonly associated with an underlying viscus perforation (Mularski et al. West J Med 170:41–46, 1999). Urgent surgical intervention, in particular emergency laparotomy, is often required in these cases. However, in 10 % of patients, a perforated viscus is not the precipitating cause of a pneumoperitoneum (referred to as a spontaneous or non-surgical pneumoperitoneum (SP). These cases are rarely associated with peritonitis and are usually managed conservatively (Mularski et al. West J Med 170:41–46, 1999; Pitiakoudis et al. J Med Case Rep 5:86, 2011). We present a case of a 28-year-old female presented to the Accident and Emergency department with a 6-h history of severe abdominal pain and bilateral shoulder tip pain. She reported that the pain developed 2 h following sexual intercourse. She had undergone a laparoscopic total hysterectomy, bilateral saplingo-oophorectomy and infra-colic omentectomy for borderline ovarian tumours 25 days previously. The most likely cause of this patient’s acute abdominal pain was a spontaneous pneumoperitoneum secondary to sexual activity. Clinicians should be aware with the potential non-surgical causes for the presence of a pneumoperitoneum, particularly in patients who are not presenting with the other characteristic clinical features of an acute gastrointestinal perforation such as peritonitis, fever and elevated white cell count. These particular patients can be largely managed conservatively.     

Adnexal torsion in a patient with hydrosalpinx who underwent tubal occlusion before in vitro fertilization

OBJECTIVE: To report a rare case of adnexal torsion in an infertile patient with bilateral hydrosalpinges who had proximal tubal occlusion performed before IVF-ET 5 years earlier. DESIGN: A case report and literature review. SETTING: Reproductive endocrine division in a community teaching hospital. PATIENT(S): A 43-year-old infertile woman with acute left-side pelvic pain. INTERVENTION(S): Laparoscopic bilateral salpingectomies. MAIN OUTCOME MEASURE(S): Diagnosis and etiology of pelvic pain with subsequent therapy to alleviate symptoms. RESULT(S): The patient experienced resolution of her pain and prophylactic prevention of further torsion status after bilateral salpingectomies. CONCLUSION(S): Although laparoscopic proximal tubal occlusion is an effective treatment of hydrosalpinges in patients undergoing IVF-ET, it carries the risk of torsion of the hydrosalpinx and the associated morbidities.     

Massive hemothorax due to diaphragmatic endometriosis after a laparoscopic cystectomy of an ovarian endometrioma in a patient without a history of thoracic endometriosis

Background

Severe hemothorax is a rare complication after laparoscopic surgery for endometriosis, and the causes and proper management are not well understood.

Case

We report here the extremely rare case with massive hemothorax after laparoscopic surgery for ovarian endometrioma. A 40-year-old woman, gravida 1, para 1, underwent laparoscopic cystectomy of ovarian endometrioma. On postoperative day 2, she had progressive anemia (Hb 5.3) as well as dyspnea. A chest X-ray and computed tomography showed massive fluid collection in the right thoracic cavity, suggestive of intrapleural bleeding.

Treatment

Thoracoscopic operation was performed and a total of 930?ml of blood retention in the right thoracic cavity was found. Scattered small endometriotic lesions were present on the pleural surface of the right diaphragm; pulsatile active bleeding was confirmed from one of these. Furthermore, two endometriotic lesions had perforated into the intraperitoneal cavity. The diaphragm containing bleeding spots was thoracoscopically resected and sutured. After thoracoscopic surgery, the dyspnea and anemia resolved. On postoperative day 5, the patient left the hospital.

Conclusion

The present report reminds us of the importance of paying special attention to postoperative-thoracic complications caused by diaphragmatic endometriosis if the patient shows respiratory symptoms.     

Thoracic endometriosis syndrome resembling pulmonary embolism

A 32-year-old infertility patient with a previous diagnosis of stage IV endometriosis experienced shortness of breath and chest pain. She was diagnosed with a pulmonary embolism by spiral volumetric computed tomography (SVCT) and anticoagulated during hospitalization, although no history of thrombosis was ever identified. She continued to have intermittent symptoms of chest pain, back pain, and shortness of breath for the next 1.5 months. Repeat SVCT revealed a large, right-sided pleural effusion with associated consolidation but no evidence of pulmonary embolism. To obtain a definitive diagnosis, a thoracoscopic pleural biopsy was performed and showed thoracic endometriosis involving the pleura. The patient desired to retain her fertility and opted for treatment with depot medroxyprogesterone. She has been asymptomatic for 2 years with this treatment. This case illustrates the importance of recognizing thoracic endometriosis syndrome and the difficulty diagnosing this condition considering its nonspecific features.