Simultaneous resection of metastatic melanoma in the esophagus and primary cutaneous melanoma showing partial regression: report of a case

We herein describe a case of melanoma that metastasized to the esophagus from a primary melanoma of the abdominal skin in a 40-year-old female. Esophagography and endoscopy demonstrated a 30-mm protruding mass in the proximal third of the esophagus, and this was diagnosed as malignant melanoma by mucosal biopsy. The patient also had a pigmented lesion on her abdominal skin, which was diagnosed immunohistochemically as a primary malignant melanoma from the resected specimen. The esophageal tumor was resected by transthoracic esophagectomy. Histopathologically, the radial growth phase of the tumor cells was not present in the esophageal lesion, which was diagnosed as melanoma metastatic to the esophagus. Postoperatively, the patient received 5 courses of DAV-Feron chemotherapy. Eight months after the chemotherapy, multiple metastases developed, including to the subcutis, bronchus, liver, adrenal gland and mediastinum. Chemotherapy was not effective at this stage. The patient died of multiple organ failure 21 months after initial esophagectomy.     

Resection of malignant fibrous histiocytoma through a combined thoracic and abdominal wall approach

We report a case of resection of malignant fibrous histiocytoma (MFH) via combined thoracic and abdominal wall incision reconstructed using GORE DUALMESH. A 60-year-old woman underwent resection of a left lower chest wall tumor. Since the tumor infiltrated into the diaphragm, a part of the left diaphragm and left upper abdominal wall were resected together. The left chest was closed by suturing the diaphragm to the ribs. The resected area of the thoracic and abdominal wall was 12×12 cm and was reconstructed with GORE DUALMESH. She received adjuvant radiotherapy as the tumor cells were detected in the surgical margin of the diaphragm. The patient has remained well without signs of recurrence for 10 months after the operation.     

超声引导下经皮微波消融治疗恶性胸、腹壁肿瘤

目的 观察超声引导下经皮微波消融（MWA）治疗恶性胸、腹壁肿瘤的效果。方法 对11例恶性胸、腹壁肿瘤患者行超声引导下经皮MWA治疗,共治疗14个病灶,腹壁6个,胸壁8个;术后随访,观察治疗效果及不良反应。结果 11例超声引导下MWA治疗均成功,技术成功率100%。术后1个月8例治疗有效,3例肿瘤残存。2例术后出现局部疼痛,经对症治疗后缓解;1例局部脂肪液化,予局部消毒换药1个月后痊愈。未见气胸、肠道损伤、皮肤烧伤等严重并发症。4例术前合并病灶周围神经痛,术后疼痛得到有效控制。术后随访4~28个月,中位随访时间8个月;期间2例失访、2例死亡;至随访终点7例疗效较好,未见复发及转移。结论 超声引导下经皮MWA治疗恶性胸、腹壁肿瘤安全、有效。     

Primary small cell carcinoma of the bladder in which the bladder preservation was achieved by chemotherapy and transurethral resection

A 78-year-old man was referred to our hospital for asymptomatic gross hematuria on April 16, 2007. Cystoscopy and abdominal computed tomography revealed a nonpapillary tumor at the upper area of the bladder. Abdominal and thoracic computed tomography showed no lymph nodes and no metastasis to other organs. Transurethral resection of bladder tumor (TURBT) was performed, and a pathological diagnosis of small cell carcinoma of the bladder at stage pT2N0M0 was made. Considering the patient's age and the location of the tumor, we administered chemotherapy using carboplatin and etoposide after resection of the tumor. After 2 courses of chemotherapy, a second-look TURBT was performed, and pathological examination showed no viable tumor cells. Cystoscopy performed after 3 months revealed recurrence of a nonpapillary tumor at a different area of the bladder. We performed TURBT and made a pathological diagnosis of small cell carcinoma of the bladder at stage pT1N0M0. The patient was free from disease in January 2011.     

Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma.

Curative resection is impossible in most patients with carcinoma of the esophagus or malignant tracheoesophageal fistulas, because of local tumor invasion or distant metastases. Optimal palliative therapy in these patients should relieve dysphagia and aspiration and restore the ability to swallow comfortably. This report describes a technique for palliation of carcinoma of the esophagus with a substernal gastric bypass after exclusion of the thoracic exophagus with the GIA surgical stapler. The results of this procedure in 10 patients with advanced malignant disease are discussed. Although postoperative morbidity and mortality rates were high, the quality of life achieved with this method of palliation was gratifying. Substernal gastric bypass of the excluded thoracic esophagus is an effective alternative to feeding tubes, prolonged radiation therapy, esophagogastrectomy, or colon bypass in patients with incurable, malignant esophageal disease.     

Extraneural metastasis of malignant glioma through a ventriculo-peritoneal shunt: growth in peritoneal cavity as ascitic form

This is the first report of extraneural metastasis of malignant glioma through V-P shunt tube and growth in peritoneal cavity as ascitic form. The patient was a 43-year-old man who was admitted to our hospital with occipital headache. CT scan showed enhanced cystic tumor mass at left temporal lobe. Craniotomy and partial excision of the tumor was done and the histology of tumor tissue showed a malignant astrocytoma. Following this treatment, the patient received the adjuvant therapies of radiation, chemotherapy and immunotherapy with interferon, and also recraniotomy three times. In the mean time, a ventriculo-peritoneal shunt was set up for internal hydrocephalus. One month later, abdominal bulging appeared and yellowish ascites could be obtained with peritoneal tap. In the ascite, tumor cells with glial fibrillary acidic protein were observed at the concentration of 5-10 x 10(4) cells/ml. The patient died three months after extraneural metastasis to the abdominal cavity as ascitic form. At autopsy, solid metastatic mass lesion was not found in extraneural region include abdomen.     

Experimental study of lymph node metastasis in thoracic esophageal carcinoma--regarding lymph node metastasis and changes in lymphatic flow by ultrafine charcoal in rabbit esophageal carcinoma model]

Esophageal carcinoma models were created by transplanting VX2 cells to rabbit esophagus endoscopically. By injecting finely divided activated charcoal into normal rabbit esophagus and tumor sites of esophageal carcinoma model, lymph flow was observed directly. Existence of lymph node metastasis was studied in detailed pathology. In 30 rabbits with upper esophageal carcinoma, lymph node metastasis was seen in 77%. Metastasis to bilateral intrathoracic paratracheal lymph node was seen in 50%, and also concentration of lymphatic flows from tumor site was seen. However, there were no metastasis and no lymph flow to abdominal lymph nodes. While, metastasis to cervical lymph nodes showed around 13%. Esophageal lymphatic flows were also seen reaching the cervical area along the esophagus. In 40 models with mid lower esophageal carcinoma, lymph node metastasis were seen in 88%. Metastasis to right and left thoracic paratracheal lymph nodes was 75% and 53%, respectively, and 25% of metastasis went to cardia lymph nodes. The lymph flows were going up and down around these lymph nodes, and reaching to lymph nodes at upper highest mediastinum or left gastric artery. The metastatic rate to the cervical lymph nodes was about 5%. There were no significant differences in lymphatic metastasis between right and left mediastinum. These findings suggest the necessity of radical dissection for both sides of the mediastinum.     

Primary B cell lymphoma of the penis: successful treatment with organ preservation

Malignant lymphoma uncommonly manifests in the genitourinary tract. Primary penile lymphoma is extremely rare. A 77-year-old male presented with primary malignant B-cell lymphoma of the penis with the chief complaint of a painless and itching nodule on the penile glans for more than 2 months. The pathologic examination with immunohistochemical stain of penile biopsy revealed malignant B cell lymphoma, mixed cellular type. The physical examination and the computed tomography scan of chest, abdomen, and pelvis showed no evidence of superficial, thoracic, abdominal, or pelvic lymphadenopathy. This case was treated with local excision and systemic chemotherapy with good cosmetic and functional results. There was absence of recurrence 16 months after therapy.     

Massive pneumoperitoneum after esophagectomy

A 79-year-old man presented for routine follow-up computed tomography after esophagectomy (reconstruction had been done by intrathoracic esophagogastrostomy) had been performed 18 months earlier for thoracic esophageal cancer (pT2, pN1, M0, stage IIB according to International Union Against Cancer classification). Although he had no symptoms, plain abdominal radiography and computed tomography revealed massive pneumoperitoneum and a small right pneumothorax. On the day after admission, upper gastrointestinal endoscopy showed no ulcers or strictures of the remnant esophagus, gastric tube, and duodenum. Air was released by spontaneous rupture of blebs in the right lung, after which it passed through the esophageal hiatus, which had been opened at the time of esophagectomy, and accumulated in the abdominal cavity. The origin of the gas can be understood from the postoperative anatomic changes, as can the mechanism of air retention in the abdominal cavity. When a patient has a history of operation, accurate understanding of operative procedure and postoperative anatomic change may provide a clue to appropriate diagnosis.     

Well-differentiated papillary mesothelioma of the female peritoneum: a clinicopathologic study of 26 cases

Well-differentiated papillary mesothelioma (WDPM) is an uncommon mesothelial tumor that occurs in the peritoneum of women over a wide age range. Although considered a tumor of uncertain malignant potential, information about its biological behavior is still limited. In this study, we present the clinicopathologic features of 26 cases of WDPM of the female peritoneum seen in our institution over a 20-year period (1990 to 2010). Clinical information and pathology material were reviewed in all cases. Patients ranged in age from 23 to 75 years (median, 47 y; mean, 48.6 y). There was no history of asbestos exposure in any of our cases. Ten patients had undergone surgery previously, and 6 had a history of endometriosis. In 24 patients, the WDPM was an incidental finding during surgery for a benign or malignant lesion. Only 2 patients presented with symptoms: 1 with an acute abdomen and the other with chronic pelvic pain. The former had developed a small hemoperitoneum because of bleeding of 1 of the lesions of WDPM, whereas the latter had a 2-cm WDPM involving the distal fallopian tube. The lesions were single or multiple (13 cases each) and ranged in size from 0.1 cm to 2 cm. The following sites were involved: abdominal or pelvic peritoneum not otherwise specified (10 cases), omentum (7 cases), cul-de-sac (6 cases), colonic serosa (4 cases), small bowel mesentery (2 cases), uterine serosa (2 cases), stomach serosa (1 case), large bowel mesentery (1 case), fallopian tube (1 case), ovary (1 case), and inguinal hernia (1 case). In all cases the lesions were excised. Microscopically, all of our cases had the typical features described for WDPM (ie, a papillary architecture that may be accompanied by glandular/tubular patterns, nests of cells and individual cells, bland mesothelial cells, absent or rare mitotic figures). The initial diagnosis in our cases was variable, including WDPM, mesothelial hyperplasia, malignant mesothelioma, serous tumor of low malignant potential of the peritoneum, papillary endosalpingiosis, and chronic xanthogranulomatous salpingiosis. Follow-up was obtained for 25 patients, and it ranged from 4 to 192 months (mean, 47.5 mo; median, 32 mo); 22 patients are alive with no evidence of WDPM after a follow-up that ranged from 5 to 144 months. One of these patients experienced recurrence of WDPM 46.5 months after initial diagnosis. In this patient, WDPM was an incidental finding during a total abdominal hysterectomy and bilateral salpingo-oophorectomy for serous cystadenofibroma. The recurrence was also an incidental finding during a colectomy for colonic adenocarcinoma. This patient is alive with no other recurrences 73 months after initial diagnosis and 36 months after diagnosis of the recurrence. Three patients died of other causes: pancreatic cancer at 4 months and 12 months and leukemia at 192 months. Recognition of the histologic features of WDPM and proper clinical correlation allow for the correct diagnosis of this entity. If necessary, immunohistochemical studies such as calretinin and keratin 5/6 facilitate the recognition of the mesothelial nature of this neoplasm. Although no patient died of disease in this series, follow-up of patients with this diagnosis is warranted on the basis of possible recurrences or misdiagnosis of an undersampled malignant mesothelioma.     

Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Gastric stromal tumors. Our experience in 21 cases surgically managed

BACKGROUND: A retrospective review on 21 patients with gastric stromal tumors who underwent surgical treatment in the period 1974-2001, is presented. METHODS: The patients were 8 males and 13 females, with an average age of 62.6 years. Histological examination showed 15 smooth muscle tumors (9 benign and 6 malignant), 5 neural tumours (3 benign and 2 malignant) and 1 undifferentiated tumor. Main symptoms were abdominal pain and palpable abdominal mass and the most sensible diagnostic techniques were endoscopy and abdominal CT-scan. Surgical procedures performed were: local resection (15 cases), partial gastric resection (3 cases), subtotal gastrectomy (2 cases) and total gastrectomy (1 case). RESULTS: There were no operative mortality and morbidity. Among 12 patients with benign GSTs, 1 died for causes not related to the disease, while 11 patients are still alive and in good health after a mean follow-up of 148.5 months (range 6-262). Among patients with malignant muscular GSTs, 3 were lost to follow-up and 3 are alive and free from disease after a median follow-up of 58 months (range 3-108). The 2 patients with malignant neural GSTs are still alive and in good health 140 and 24 months after surgical procedure, while the patient with undifferentiated GST died for liver metastases 43 months after total gastrectomy. CONCLUSIONS: The authors conclude that the most frequent symptoms are abdominal pain and a palpable mass, but no specific signs have been detected. Endoscopy plays a very important diagnostic role and CT-scan is the most sensible technique in the evaluation of location, size, invasion of adjacent organs and metastasis. The aim of treatment must be the complete resection of the tumor and the prognostic prediction on the basis of histologic findings is quite difficult.     

A case of mucosal esophageal carcinoma with a large intramural metastasis in the stomach

The prognosis of mucosal carcinoma of the esophagus is extremely good because of low frequency of lymphatic invasion compared with submucosal carcinoma. A 64-year-old male was admitted presented with dysphagia and weight loss. Roentgenogram and esophagoscopy revealed erosive lesions in the lower portion of the esophagus and a huge submucosal tumor that looked like the myosarcoma in the cardial portion. After total resection of thoracic esophagus and partial gastrectomy, esophagogastrostomy was done through the anterior thoracic route. During the operation, we found a few disseminative foci in the thoracic cavity (pl1) and direct invasion of cardial tumor to the celiac portion. Therefore, the operation was absolute by palliative. Histological examination of the resected specimen showed that the IIc-like lesion of the lower portion of the esophagus was a moderately differentiated squamous cell carcinoma invading the mucosa (mm), which was 2.0 x 1.6 cm in size, with marked lymphatic invasion, and intra-mural metastatic foci (7.0 x 5.0 cm) at the cardial portion. The patient died 3 months after the operation with mediastinal lymph node metastasis. In our 19 cases of resected mucosal carcinoma of the esophagus, lymphatic invasion was positive in 16%, and lymph node metastasis was positive in 16%, and intramural metastasis was in only one case. Frequency of intramural metastasis in esophageal carcinoma is about 10% in sm -a3 lesion, 5% in mm. In our experience, the prognosis of curatively resected mucosal carcinoma of the esophagus is generally good. We get long survivals, when curative operation is undergone, even if the lymphatic invasion is positive.     

The course of neurofibromatosis type 1 on immunosuppression after lung transplantation: report of 2 cases.

We describe 2 patients with neurofibromatosis type 1 (NF1) who underwent lung transplantation. Case 1 reports a patient with NF1 with no complications 5 years after bilateral lung transplantation. Case 2 details a patient with NF1 diagnosed with both post-transplant lymphoproliferative disorder (PTLD) and massive intra-abdominal sarcoma consistent with a malignant nerve sheath tumor 9 months after lung transplantation. There was no clinical evidence of sarcoma preceding or immediately following lung transplant as demonstrated by a normal abdominal sonogram 3 months post-transplantation. Although an increased risk for cancer has been documented in NF1, the rapid malignant degeneration of a neurofibroma following transplantation raises concern about immunosuppression and transplantation candidacy among individuals with NF1.     

腹膜后恶性蝾螈瘤2例报告

目的：总结恶性蝾螈瘤（malignant triton tumor,MTT）的临床及病理特点、诊治方法及预后。方法：回顾性分析2例腹膜后MTT患者的临床资料,均为女性,分别为8个月及44个月大婴幼儿。均因体检发现腹部肿物入院。下腹部均可触及质韧肿物,表面光滑,活动度可,无压痛。B超、CT、MRI等影像学检杏见中下腹或腹盆腔区有大小约14cm×12cm×9cm和15cm×13cm×10cm肿块,增强CT示肿物呈不均匀强化。2例患者均行肿瘤根治性切除术。结果：镜下见肿瘤由梭形细胞及多角形细胞组成,可见病理性核分裂,伴有横纹肌分化。免疫组织化学染色示NSE＋,Vimentin＋,Desmin＋,S-100＋。诊断为腹膜后MTT。1例患者随访3个月,术后2个月复发转移,近期肿物有所增长。另1例随访5个月,目前情况良好。结论：腹膜后MTT是一种罕见、高度恶性的肿瘤,确诊需依赖病理检查和免疫组织化学检测。本病以手术根治治疗为主,术后易复发和转移,预后差。     

Successful combined resection of carcinoma of the esophagus and adrenal metastasis: Report of a case

We report herein the case of a 56-year-old man who underwent successful combined resection of carcinoma of the esophagus and an adrenal metastasis. The patient presented with carcinoma of the thoracic esophagus, and an adrenal tumor was incidentally detected by computed tomography(CT). Complete removal of the carcinoma was accomplished along with a combined resection of the thoracic esophagus and left adrenal gland. Surgery was followed by the administration of anticancer chemotherapeutic agents. He is currently doing well with a grade 1 performance status and no signs of recurrence 22 months after his operation. To our knowledge, no previous report of the successful simultaneous resection of esophageal carcinoma and an adrenal metastasis has been documented in the literature.     

The lymphatics of the esophagus--evaluation of endoscopic RI-lymphoscintigraphy with SPECT

For the studies of the esophageal lymphatics, endoscopic RI-lymphoscintigraphy was performed in 23 cases of esophageal cancer, 3 cases of lung cancer and 5 cases of gastric cancer. 99mTc-Rhenium colloid was endoscopically injected into the submucosal layer of the esophagus near the tumor and the images of the lymph flow were obtained after about 3 hours. Single photon emission computerized tomography (SPECT) was used to acquire the three-dimensional images of the esophageal lymph flow on 19 patients. RI-uptake of all dissected lymph nodes was also counted after the operation. The results were shown as follows. 1. Whole neck, thoracic and abdominal lymph nodes could be imaged in any cases injected at any parts of the thoracic esophagus. But the lymph flow in the upper third of the esophagus tended to move mainly upward, and the lymph flow in the lower third tended to move mainly downward. 2. The block of intra-mural lymph vessels by the tumor had very important roles upon the esophageal lymph flow. 3. The removal of upper mediastinal lymph nodes and intraabdominal lymph nodes as well as paraesophageal lymph nodes seemed to be very important for curative resection of carcinoma of the esophagus.     

Infantile spinal cord tumor: diagnostic difficulties. A case report

We report an infant with a thoracic intradural extramedullary tumor to illustrate the presentation of an infantile spinal cord tumor and the difficulty in establishing a diagnosis. An infant presented with edema of the legs, motor loss in the lower extremities, and anuria at 3 months of age. Magnetic resonance imaging of the lumbar region did not reveal any abnormalities. At 1 year of age, the patient underwent surgery to correct urinary incontinence of unknown etiology. The patient developed gait disturbance and had abdominal pain at 17 months of age. Magnetic resonance imaging of the thoracic spine revealed an intradural extramedullary tumor at T2-T5. The spinal cord tumor was completely resected and pathologic findings indicated an endodermal cyst. All symptoms improved after the operation. Infants who present with weakness of the lower legs, urinary incontinence and unknown abdominal pain should be evaluated for a spinal cord tumor.     

Resection of pulmonary metastases following chemotherapy for high stage testicular tumors

BACKGROUND: Our objective was to analyze retrospectively our experience with 19 patients who had metastatic germ cell testicular tumor and had undergone resection of pulmonary metastases following chemotherapy. We wished to determine the necessity of thoracic surgery on these patients. METHODS: Of 103 patients in need of postchemotherapeutic surgery for metastatic germ cell testicular tumors, 19 patients (mean age 31) underwent surgery for thoracic masses following cis-platin based chemotherapy. Resection of pulmonary metastases was performed on patients with normal tumor markers after chemotherapy, who did not achieve complete radiological remission. Histopathological findings, correlation with the pathology of abdominal surgery and probable prognostic factors for disease-free and overall survivals were evaluated. RESULTS: Disease-free and overall survival rates were 14/19 (73%) and 16/19 (84%), respectively, within a median follow-up time of 30 months (15-212 months). Patients with and without viable tumor cells in their thoracic histopathological specimen had 40% and 85% disease-free survival rates, respectively (P < 0.05). Eight patients had both abdominal and thoracic postchemotherapy surgery. Only two (25%) of these patients had the same histopathological features at both sites. CONCLUSIONS: All patients with residual thoracic masses must be considered candidates for surgery, because there are no predictive factors to determine the thoracic pathology without surgery. With the resection of the pulmonary metastases only, surgery can be performed without significant morbidity and is essential to select patients for further chemotherapy, to remove all visible masses and to provide histopathological confirmation. Patients with viable tumor cells in the thoracic surgical specimen have a poor prognosis.     

Surgical treatment of esophago-pleural fistula caused by chemotherapy for lung cancer]

A 72-year-old woman was admitted for cough and dyspnea. Bronchofiberscopy examination revealed lung cancer at the right main bronchus. Plain chest X-ray and chest CT revealed that the tumor had invaded to the mediastinum and esophagography demonstrated stenosis of the thoracic esophagus without fistula. Because pulmonary resection was contraindicated, chemotherapy for lung cancer was initiated. Complete response was noted, but an esophago-pleural fistula developed as a consequence of chemotherapy. After intrathoracic tube drainage, a permanent endoesophageal tube was inserted through a small incision in the stomach under general anesthesia. However, it migrated into the thoracic empyema after 4-postoperative days. Because the lung cancer was well-controlled, a second operation to reconstruct the esophagus was performed without resection of the thoracic esophagus or fistula. After the operation, thoracic empyema was washed out with povidone iodine and pure alcohol. The chest tube was removed 3 months after the second operation. We conclude that in cases of esophago-pleural fistula caused by chemotherapy for lung cancer, if complete response to chemotherapy is noted, reconstruction of the esophagus should be considered.