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.     

Endobronchial metastasis from a primary uterine osteosarcoma in a patient with multiple myeloma: Report of a case

We present herein the case of a 75-year-old woman with multiple myeloma who underwent a left lower lobectomy for endobronchial metastasis from an uterine osteosarcoma. She had initially been admitted to our hospital for chemotherapy more than 1 year earlier, soon after which a primary uterine osteosarcoma was discovered and a total abdominal hysterectomy and bilateral salpingo-oophorectomy performed. One year after the operation, the patient developed hemoptysis. A flexible bronchofiberscopy demonstrated a polypoid mass obstructing the left basal bronchus, and computed tomographic scans showed three pulmonary nodules. Surgery was performed to control the hemoptysis. At thoracotomy, two metastatic nodules were identified in the left lower lobe, and the endobronchial extension of the tumor was resected en bloc with the left lower lobe. The tumor was diagnosed as lung metastasis from the uterine osteosarcoma. Although further lung tumors have recently appeared, the patient has remained well for the 3 years since her last operation without any hemoptysis.     

Thymoma with synchronous pulmonary metastasis; report of a case

We report a resected case of thymoma with a solitary pulmonary metastasis. A 63-year-old woman had pointed out a solitary nodule in right lung field on chest X-ray. Computed tomography (CT) scan showed an anterior mediastinal tumor and a solitary lung nodule in the right lower lobe. Extended thymectomy and partial resection of right lung was performed. Pathological diagnosis showed an invasive thymoma (type B3) and a pulmonary metastasis. Post operative radiotherapy was administered and she is doing well 19 months following the resection. Thymoma with a solitary synclonous pulmonary metastasis is rare and is classified into Masaoka stage IVb. Generally, thymoma cases with distant metastasis are not indication for operation. But, if radical resection is possible, operation is recommended for good prognosis.     

Interesting pulmonary metastasis from spindle cell carcinoma of the breast

We experienced a case of interesting pulmonary metastasis from spindle cell carcinoma of the breast. A 68-year-old female who had undergone a radical mastectomy 32 months earlier was admitted to our hospital for the pulmonary tumor in the left S10 in January 2005. Pathological study of the breast tumor revealed mixture of carcinomatous portion and sarcomatoid portion with spindle cells. Because of the presence of transitional areas from one portion to the other, the tumor was diagnosed as spindle cell carcinoma of the breast. Partial resection of the left lower lobe was performed. Pathological examination of the pulmonary tumor revealed that the tumor was composed of the component similar to carcinomatous element of the breast cancer. In June 2005, She was admitted to our hospital again for the pulmonary tumor in the right S7. Partial resection of the right lower lobe was performed. The tumor was composed of both carcinomatous and sarcomatoid elements. After operation, as she complained of epigastralgia, a gastroscopic examination was performed. It showed 2 white polypi of the stomach. The biopsy specimen of the polypi were composed of the tumor similar to the sarcomatoid element of the breast cancer. She died of widespread metastasis 43 months after mastectomy.     

A case of pulmonary rupture with primary pulmonary leiomyosarcoma--management by emergency surgical intervention]

We report a case of 18-year-old boy who was admitted to our hospital for hemoptysis and hemothorax caused by rupture in the pulmonary tissue. A tumoral mass was found protruding from the inferior aspect of the left lower lobe towards the diaphragma. A large hematoma was seen in the vicinity of the tumoral mass. An emergency left lower lobectomy was performed and the hematoma was removed. The tumor was yellow in color, soft and 7 cm in diameter. The histological diagnosis was that of primary pulmonary leiomyosarcoma. The resected lobe had a liver-like hard consistency due to extended infiltration of blood resulting from hemorrhages within the tissue located in and around the tumoral mass. Microscopically, the tumor was composed of the spindle-shaped cells with multinucleation along with some clear cell patterns. Recurrence of the tumor appeared six months after the operation, and a second resection of the recurrent leiomyosarcomatous tissue was performed. The patient is still alive for 1 year and 6 months after the first operation.     

Splenic and Pulmonary Metastases from Renal Cell Carcinoma: Report of a Case

We report herein the case of a patient in whom pulmonary and splenic metastases from renal cell carcinoma (RCC) were successfully treated by surgical excision. A 69-year-old man who underwent left nephrectomy for RCC 17 months before was suspected to have a pulmonary metastasis based on computed tomography (CT) findings. Partial resection of the left lower lobe was performed with thoracoscopic assistance. However, 4 months later, a splenic tumor, 6 cm in diameter, was detected by CT and ultrasonography, and a splenectomy was performed. Histologically, both resected specimens were diagnosed as metastasis from RCC. A second pulmonary metastasis of the left upper lobe was resected 4 years 8 months later. The patient was in good health when last seen 11 months after his last operation. Malignant neoplasms rarely metastasize to the spleen and most cases are found at autopsy, or feature multiple distant metastases. Only four other cases of splenic metastases from RCC have been reported. The prognosis associated with splenic metastasis is favorable when only a solitary lesion exists. Received: February 4, 2000 / Accepted: November 20, 2000     

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.     

An emergent operation for metastatic cardiac tumor of malignant cystosarcoma phyllodes

A 47-year-old owman was transferred to our hospital under endotracheal intubation with severe hemodynamic deterioration. A left mastectomy had been performed 8 months earlier and histology of the specimen showed malignant cystosarcoma phyllodes. An angiography and echocardiography suggested massive mass of the right ventricle extending to the pulmonary artery. An emergent life-saving operation was required using cardiopulmonary bypass. A huge multilobular tumor was resected from the right ventricle through the pulmonary artery as much as possible and a tricuspid valvuloplasty was also performed. The patient was weaned from cardiopulmonary bypass, then satisfactorily recovered from hemodynamic disturbances. Nevertheless, she died 15 days later due to multiple organ failure. Microscopic examination of resected specimen showed the neoplastic stromal cells that increase mitotic activity and have sarcomatous characteristics, consistent with a metastatic cystosarcoma phyllodes. This is a second case of operation for cardiac metastasis of cystosarcoma phyllodes using cardiopulmonary bypass, so far presented in the literature of the world reviewed by the authors.     

Long-term survival of Askin tumor for 10 years with 2 relapses.

An abnormal shadow was noted on a chest X-ray of a 32-year-old female in a medical check-up in March 1995, 3 months after she had given birth. Thoracic CT detected a tumor in contact with the left thoracic wall, and tumorectomy was performed in May 1995. The tumor was diagnosed as a primitive neuroectodermal tumor (PNET). After surgery, the thoracic wall to which the tumor adhered was treated with irradiation at 50 Gy. Chemotherapy was considered, but the patient did not wish to undergo this treatment. Lung metastasis occurred 5 years after the first surgery, and the left lower lobe of the lung was partially resected. Four years later, lobectomy of the left lower lobe of the lung was performed, due to further lung metastasis. The patient remains healthy as of April 2005.     

Metastatic Osteosarcoma in the Jejunum with Intussusception: Report of a Case

We report a case of metastatic osteosarcoma in the jejunum causing intestinal intussusception. A 58-year-old woman underwent right femoral region amputation, lower lobectomy of the left lung and complete left pneumonectomy after four courses of chemotherapy for osteosarcoma of the right femur with left lung metastases. She was referred to our department 13 months later with progressive abdominal pain and vomiting. Abdominal radiography showed a small-bowel obstruction. She underwent emergency laparotomy, which revealed jejunal intussusception. The lead point was found to be an intraluminal tumor. We resected the jejunum containing the tumor and histological examination confirmed that the tumor was osteosarcoma metastasis.     

Treatment of severe pulmonary hemorrhage after cardiopulmonary bypass by selective, temporary balloon occlusion

Severe pulmonary bleeding causes frequent mortality, particularly if this event occurs during separation from extracorporeal circulation during cardiac surgery. We present a new approach to treat this life-threatening complication: temporary balloon occlusion of the pulmonary artery feeding the involved lobe. On attempting to wean a 71-yr-old female patient from cardiopulmonary bypass after aortic valve replacement, she lost more than 2 L of blood through her trachea over approximately 15 min and severe gas embolism into the left atrium was visualized on transesophageal echocardiography. As the bleeding was too vigorous to be localized by fiberoptic bronchoscopy, an interventional cardiologist was consulted. After localizing the affected lobe using fluoroscopy, he inflated a balloon dilating catheter in the lower lobe artery. This effectively stopped the bleeding. Separation from extracorporeal circulation was uneventful using one-lung ventilation to prevent further gas embolism. Sixteen hours after the end of surgery the catheter could be deflated and removed without any further intervention. The patient made an excellent recovery.     

Pericardial reconstruction using a pedicle flap of the diaphragmatic central tendon

A 46-year-old woman was referred to our hospital for further evaluation of an abnormal shadow on a chest X-ray. Chest computed tomography and magnetic resonance imaging revealed a lobulated tumor arising from the left lower lobe. At operation, the tumor tissue was found to have invaded the lingula and pericardium, involving the left phrenic nerve. Resection of the left lower lobe, lingula and pericar-dium including the phrenic nerve was performed for extended pulmonary malignancy. A pedicle flap of the diaphragmatic central tendon was used as a pericardial patch for pericardial reconstruction with satisfactory results. The patient’s postoperative course was uneventful. The postoperative histological diagnosis was pulmonary adenocarcinoma with sarcomatous elements [pT3N2M0]. At present, 43 months after the operation, the patient is receiving chemotherapy after having undergone cyberknife radiotherapy for brain metastasis of the tumor. The use of a pedicle diaphragmatic flap was effective in repairing a pericardial defect after extensive resection of pulmonary malignancy.     

Right atrial myxoma complicated with pulmonary embolism

A 25-year-old woman was admitted to our hospital with chest pain and dyspnea, and was diagnosed as having a right atrial myxoma complicated with pulmonary embolism. An emergency operation was performed with cardiopulmonary bypass. A papillary pedunculated tumor was found having a narrow-based attachment to the free atrial wall. After the tumor was carefully removed together with the atrial wall around the attachment, pulmonary embolectomy was performed. Several fragments of the tumor were removed, and sufficient back-flow from the pulmonary artery was established. The postoperative course was uneventful. However, a non-perfused area was observed in the left lower lung on pulmonary hemodynamic scintigraphy at 3 months after the operation. Long-term observation is required due to the high risk for metastasis and recurrence, and further surgical treatment remains the most appropriate treatment option. A second operation may be needed to prevent progression in complications.     

Unusual extension of lung cancer into the left atrium via the pulmonary vein

Four operative cases of lung cancer with intra-atrial extension via the pulmonary vein were reviewed. Three of them had circulatory as well as respiratory symptoms, and their performance status (PS) was extremely poor. In two cases, after assessment of the cardiac involvement using two-dimensional echocardiography and/or CT-scan, we successfully removed the tumor en bloc through combined left atrial resection and radical left pneumonectomy with cardiopulmonary bypass. In both cases, the postoperative course was uneventful, and PS was improved. However, seven months later one patient died of widespread metastases, while the other is alive but has recurrence. The other two patients underwent ordinary lobectomy because there were no abnormal findings in the hilar examinations. However, the lumens of the resected pulmonary veins were filled with tumor tissue. One patient developed a massive embolism, never regained consciousness, and died on the second postoperative day. The last case was discharged without trouble, although the intra-atrial portion of the tumor dislodged intraoperatively into the circulation. As a result, he developed multiple brain metastases four months after the operation. There were no clear patterns in terms of the histological type or tumor location in these cases. On the other hand, all the tumors showed rapid growth and comprised a large mass in the lung parenchyma. Especially the cardiac and intravascular portions of each tumor were less differentiated and more necrotic than the primary focus in the lung. We conclude that radical surgery using a cardiopulmonary bypass for lung cancer patients with such intracardiac involvement is effective for improvement of PS and reduces the risk of sudden death due to cardiac failure or tumor emboli.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reimplantation of extracorporeal irradiated bone segments in musculoskeletal tumor surgery: clinical experience in eight patients and review of the literature

BACKGROUND: Two methods are available for extracorporeally devitalizing resected tumor-bearing bone specimens, the simpler of which, autoclaving, has substantial disadvantages. We present our experience with the alternative reconstruction technique of reimplantating extracorporeally irradiated specimens (IEIR) PATIENTS AND METHODS: Eight patients who had primary malignant bone tumors of the long bones were managed with wide en bloc resection and IEIR. The segments were fixed by either plate osteosynthesis, knee arthrodesis rod, or intramedullary nailing. All seven patients with high-grade tumors received chemotherapy. RESULTS: After a median follow-up of 66 months (40-76) five of eight patients were continuously free of disease. One man with a chondroblastic osteosarcoma developed pulmonary metastases which were resected. One woman with teleangiectatic osteosarcoma developed a local recurrence in the soft tissue without contact to the irradiated reimplant. At the latest follow-up, 58 months after resection of the pulmonary metastases and 28 months after resection of the locally recurrent tumor, there was no evidence of disease in either patient. Another woman 67 months after IEIR for an osteosarcoma of the distal femur developed a subcutaneous metastasis of the scalp and the thoracic wall and an ossifying pulmonary metastasis. At the time of writing she is receiving chemotherapy. After a median duration of 4.3 months (2.3-25.2) all graft-host junctions had healed. The functional result was good in four patients and excellent in the other four. CONCLUSIONS: Limb salvage using reimplantation of extracorporeally irradiated tumor-bearing bone segments for reconstruction offers an excellent reconstruction method in appropriately selected patients compared with other options of management.     

Bilateral heterochronic spontaneous hemothorax caused by pulmonary arteriovenous malformation in a gravid: A case report

Bilateral heterochronic spontaneous hemothorax as a result of pulmonary ateriovenous malformation is a very rarely happened disease. A 34-year-old woman presented major symptoms with right-sided chest pain and shortness of breath. The following contrast-enhanced computed tomographic scan of the chest showed a large amount of fluid in the right thorax with mediastinal shift, but without major vessel injury and 2 small dense opacities in the apical segment of the right lower lobe and in the posterior aspect of the left lower lobe. The patient underwent local resection of the right lower lobe. The pulmonary ateriovenous malformation was further identified by pathological examination. One month after she was discharged home, the symptoms described above recurred. A follow-up computed tomographic scan of the chest showed a large amount of fluid in the left thorax. During the emergency operation, we found a bullous lesion in the left lower lobe and a small blood vessel overlying the lesion that was actively bleeding. As stated above, local resection of the left lower lobe was performed once more. Pathological result was the same as observed previously. There were no postoperative complications and she was discharged from the hospital after two weeks. Two months later, she successfully delivered a healthy female infant. Up to now, regular follow-up observation has shown her to be perfectly asymptomatic.     

Peripheral arterial embolism arising from pulmonary adenocarcinoma

Bronchogenic carcinoma is a rare source of peripheral arterial embolism. We present the case of a 28-year-old female nonsmoker with an adenocarcinoma of the left main bronchus involving the pulmonary veins. While the patient was hospitalized awaiting operation, she presented embolization in her legs; embolectomy and fasciotomy were necessary to treat compartment syndrome. Echocardiography disclosed floating tumoral masses in the left atrium. Seven days later, an operation was performed with cardiopulmonary bypass to remove the tumor masses from the atrial lumen; pulmonary veins were sutured from within the atrium, and pneumonectomy was performed. Fulminant infection of the lower limbs developed that led to gangrene and multiple organ failure, and the patient died 8 days after the operation.     

Complete resection of thymic carcinoma supported by cardiopulmonary bypass

We would like to report on a case of thymic carcinoma that could be completely resected supported by extracorporeal circulation. A 53-year-old female complaining of severe coughing and hoarseness was admitted to our hospital. Her chest X-ray film revealed an abnormal shadow in the upper mediastinum and an elevation of the left diaphragm. Chest CT and MRI showed an anterior mediastinal mass that invaded the main pulmonary artery. The preoperative histological diagnosis of thymoma was made by mediastinoscopic specimen. After 50 Gy irradiation, surgery was performed. During the operation, after resection of the left brachiocephalic vein and a part of the upper lobe of the left lung, the tumor was detached from the wall of the aorta and resected with the invaded part of the pulmonary artery supported by cardiopulmonary bypass. Reconstruction of the pulmonary wall defect was accomplished with Xenomedica. The final pathological diagnosis was thymic adenosquamous carcinoma. The postoperative course has been uneventful 24 months after surgery. Extracorporeal circulation is a useful technique in operations involving malignant diseases when complete resection is able to be accomplished.     

A case of re-operation of pulmonary venous obstruction following surgical repair of total anomalous pulmonary venous return

A case of six-month old female with pulmonary venous obstruction (PVO) following surgical repair of total anomalous pulmonary venous return (TAPVR) is reported. A digital subtraction angiography (DSA) performed at 9 days after birth showed a supracardiac type of TAPVR (Darling Ia) with pulmonary venous stenosis and pulmonary hypertension. On the following day she underwent a corrective operation through posterior approach. The anastomosis between common pulmonary venous chamber and left atrium had released the pulmonary venous stenosis. Nevertheless, the pulmonary hypertension progressed after the operation. Five months later a cardiac catheterization data showed PVO. Six months after the first operation she underwent a corrective re-operation for release from the PVO using EPTFE (expanded polytetrafluoroethylene) patch. Postoperatively the symptoms caused by PVO and pulmonary hypertension were markedly improved.     

Recurrence and pulmonary metastasis of extradural paraganglioma in thoracic vertebral canal: report of a case]

A 70-year-old female was operated on for extradural spinal cord tumor in 1982. Microscopic examination revealed the tumor as paraganglioma. Tumor recurred at paravertebral twice in 1985 and 1989, and they were also resected. In 1995, her chest X-ray film showed round tumor in the right upper field. Exploratory open lung biopsy was performed in 1996, and right upper lobectomy was performed according to for malignant lung tumor because intra-operative microscopic findings showed carcinoid or lung metastasis of paraganglioma. Chest wall tumor at paravertebral was resected at the same time. Postoperative microscopic examination revealed the tumors were same as operated paraganglioma. The 2nd thoracotomy was done in 1999, and two chest wall tumors and a pulmonary nodule in right S8 segment were resected. They were recurrence and pulmonary metastasis of paraganglioma. Now 18 years after initial operation, she is out of hospital in tumor free.