Mediastinal lymph-node carcinoma with no apparent primary lesion; report of a case

A 57-year-old woman was admitted to our department because of a chest X-ray showing a mass shadow about 40 mm in diameter in the right side of the middle of the mediastinum. A chest computed tomography(CT) scan demonstrated a large tumor, adherent to the superior vena cava and right pulmonary artery. No other metastases and no primary tumor were found. The tumor was resected through median sternotomy. Intraoperative frozen section analysis showed that the mediastinal tumor was a metastatic lymph-node carcinoma. Postoperative examination, too, did not detect the primary lesion. Radiotherapy was given after the operation. This case was thought to be a very rare case of T0N2M0 lung cancer or primary mediastinal lymph-node carcinoma (yolk sac tumor).     

Malignant fibrous histiocytoma of the rib: a case report of repetitive extensive resections and reconstruction of the chest wall

A forty-seven-year-old woman visited our hospital in March 1987 suffering from the local recurrence of the tumor. Her right 7th and 8th rib had been resected 2 years and 11 months before because of the malignant fibrous histiocytoma (MFH) originated from the right 7th rib. In May 1987, wide resection of the right lateral chest wall and partial resection of the right diaphragm were done. Dacron meshed silicon plate (Silastic) and musculocutaneous flap of the right latissimus dorsi were used to reconstruct the chest wall. Seven months after the second operation, local recurrence occurred again on the anterior chest wall, involving the right diaphragm and right lower lobe of the lung. In March 1988, extensive resection of the anterior chest wall with partial resection of the right diaphragm and the right lower lobe was followed by reconstruction of the chest wall by Silastic. The patient recovered uneventfully without any respiratory disturbances after both operations which included wide resection of the chest wall. Multiple pulmonary metastases were found 4 months after the operation, and she died of respiratory failure 7 months after the final operation. Although MFH was one of the most common sarcomas of the soft tissues, only one case of the MFH originated from the rib had been reported previously in this country. Silastic was proved to be a useful prosthesis for the reconstruction of widely resected chest wall.     

Pleural dissemination of esophageal gastrointestinal stromal tumors after an eight-year interval following the primary surgery

A 71-year-old man who had undergone surgical resection of esophageal gastrointestinal stromal tumors (GISTs) through a right posterolateral thoracotomy 8 years earlier was referred for treatment of an anterior mediastinal mass discovered on a follow-up chest radiograph in October 2007. Computed tomography findings revealed a tumor, 82 × 49 mm, with calcification, in the anterior mediastinum. When we radically resected the tumor via a median sternectomy, we found that it was actually located in the pleural cavity, and there was a small nodule near the main tumor on other pleura. Microscopically, the tumor was comprised of uniform spindle cells with fibrillary eosinophilic cytoplasm. In addition, immunostaining showed that the tumor was positive for CD117 (c-kit). The diagnosis was pleural dissemination of esophageal GISTs 8 years after primary surgery, making this the first report of pleural dissemination of esophageal GISTs after such a prolonged postsurgical interval.     

Primary hemangiopericytoma of the chest wall--a case report]

An extremely rare case of a primary hemangiopericytoma of the chest wall was reported. A 40-year-old female without any complaints was detected to have an abnormal shadow in the right chest wall on a chest X-ray film. The tumor was 2.6 x 2.2 x 2.0 cm in size and was resected together with the 8th rib which adhered to the tumor. Postoperative pathohistological examination led to the diagnosis of hemangiopericytoma. Postoperative course was uneventful, and the patient is now doing well and has had no recurrence for 11 months since the operation. A brief review was made on 9 cases collected from the literature.     

A surgical case of giant mediastinal neurilemmoma]

A 45-year-old male was admitted to Nagoya University Hospital with dyspnea. He was examined by chest X-ray, CT, MRI, and bronchofiberscope. The chest X-ray showed a large abnormal shadow in the right lung field. A large tumor mass pressing the right lung occupied a half of thoracic cavity on a chest CT and MRI. Bronchofiberscopic findings showed a stenosis of the right intermediate bronchus. The clinical diagnosis was posterior mediastinal tumor. He underwent a posterolateral thoracotomy and the tumor was removed smoothly. The size of resected specimen was 15 x 13 x 11 cm. Histopathological examination of the specimen revealed a mediastinal neurilemmoma. He has been well for 4 months postoperatively.     

A resected case of thymolipoma]

We reported a resected case of thymolipoma, which has been hardly experienced. The patient was 21-year-old female and consulted a doctor for general fatigue. Chest roentgenogram revealed a mass-like shadow at the right lower mediastinum, which was suspected mediastinal tumor. The mass of right anteroinferior mediastinum, which was clearly shown by chest CT scan and MRI, was continued to the right lobe of the thymus. Under a diagnosis of anterior mediastinal tumor, operation was carried out. The tumor, which was 10 x 8 x 7 cm in diameter and 160 g in weight, was removed together with right lobe of the thymus. Histological diagnosis of thymolipoma was obtained from the resected specimen.     

Aneurysmal bone cyst arising in the rib; report of a case

We experienced with a relatively rare case of an aneurysmal bone cyst (ABC) arising in the left rib. A 34-year-old female, had experienced chest discomfort on the left anterior side and pain for 1 year. A chest X-ray suggested a left chest wall tumor involving the ribs. Computed tomography (CT), magnetic resonance imaging (MRI) and a bone scintigram revealed an expansive tumor of the anterior portion of the left 4th rib involving the 3rd and 5th rib with "blow out appearance" and "fluid-fluid level". Wide excision of the tumor and adjacent muscle tissue was performed with an antero-axillary incision. Chest wall reconstruction was performed with prolene mesh (140 x 90 mm). The resected specimen showed an encapsulated bony mass (75 x 60 x 35 mm) with multiple blood-filled spaces. Histopathological diagnosis was an ABC originating in the left 4th rib. She has been doing well with no evidence of recurrence 12 months postoperatively.     

A case of primary leiomyosarcoma of the chest wall successfully resected under the video-assisted thoracoscopic approach.

We report a case of a 62-year-old woman with primary leiomyosarcoma of the chest wall which was successfully resected under the video-assisted thoracoscopic approach. The disease was found during the treatment for a malignant melanoma of the left heel. On the preoperative CT images, the lesion was suspected to be a metastasis of the malignant melanoma. The thoracoscopic surgery revealed that the tumor originated from the parietal pleura, and it was resected with a 5-mm margin of normal pleura. Histopathologically, the tumor was diagnosed as low-grade leiomyosarcoma. Since no residual tumor cells were proven in the resected margins histologically, further resection was not performed. At present, she is alive and well with no sign of recurrence of leiomyosarcoma two years and one month after operation. Thoracoscopic surgery is worth trying for accurate diagnosis of and effective treatment for a chest lesion without apparent invasion of the chest wall on the preoperative CT images.     

Multiple glomus tumors in chest wall and buttocks

We report a case of a 50-year-old man with multiple glomus tumors of the chest wall and buttocks. He was admitted to our hospital because of right chest pain for 10 years. The chest pain was lancinating and gradually increasing. A computed tomography (CT) showed a mass in the right 3rd intercostal space and a mass in the right buttocks. The chest tumor was enhanced with contrast medium on chest CT. Two tumors were resected completely including the 4th rib. Histological examination showed numerous vascular space lined with sheets of epithelial cells (glomus cells), so they were diagnosed as glomus tumor. The postoperative course was well, and the pain disappeared after resection. The glomus tumor of chest wall could be diagnosed as malignant tumor, based on the criteria of the size more than 2 cm and deep location. The glomus tumors which occurred in the chest wall and buttocks were very rare. We presented the case with reference to the literature.     

A resected case of multiple lung cancers

A 78-year-old man was admitted to our hospital because of abnormal shadows on chest film. A 20 x 25 mm tumor shadow was found in the right lower lung field (S10) and a 5 x 10 mm tumor shadow in the right upper lung field (S2). Bronchoscopic curettage revealed squamous cell carcinoma from the specimen on the S10 and did not revealed malignant cells from the specimen on the S2. He was performed operation, squamous cell carcinoma in the S10 was removed by right lower lobectomy and nodule in the S2 was also removed by partial resection. Histological examination confirmed well-differentiated squamous cell carcinoma from the S10 and well-differentiated adenocarcinoma from the S2. He is healthy three year after operation.     

Mediastinal lipoma: Report of a case

We experienced a case of mediastinal lipoma, which is considered to be a relatively rare disease. A 3-year-old girl was referred to Gifu University hospital because of fever and an abnormal shadow on her chest X-ray. The chest X-ray clearly showed a well-delineated tumor shadow which seemed to oppress the diaphragm and the right atrium in the right lower lung area. A computed tomogram (CT) of the chest showed a homogeneous mass localized on the right diaphragm and adjoining the right anterior chest wall and heart. The mass showed a fat density measuring about-100 HU. Magnetic resonance imaging (MRI) showed a high-intensity mass which was almost the same level as the subcutaneous fat on both the T₁-weighted and T₂-weighted images. Thoracotomy was performed and a fatty tumor was found. It arose from the right side of the pericardium and adjoined the diaphragm, the anterior chest wall, and the thymus. There was no adhesion between the tumor and the surrounding organs. It was resected easily and its contents were yellowish and homogeneous. The patient made an uneventful recovery and was discharged 10 days after the operation. Light microscopy showed a lipoma consisting of mature adipose tissue and no malignancy was found.     

A case report of mediastinal cystic lymphangioma

Mediastinal lymphangioma is very rare in the literature. A resected case of mediastinal cystic lymphangioma was reported. A 41-year-old man admitted to our hospital complaining of sore throat. A chest X-ray examination showed a large mediastinal mass on the right. At the right thoracotomy, a large cystic mass filled the anterior mediastinum and extended from the thoracic inlet to the posterior costophrenic angle. The cyst contained about 600 ml yellowish brown fluid and was adherent to the surrounding tissue, especially to the aorta and the left main bronchus. The resected tumor was 20 x 12 x 10 cm in size and 620 g in weight. Histological diagnosis was cystic lymphangioma. The patient is alive and well 26 months later, and there is no sign of recurrence of the tumor.     

Mediastinal aberrant goiter; report of a case

A 54-year-old woman was admitted to our hospital because of an abnormal shadow on chest X-ray. Chest computed tomography (CT) scan and magnetic resonance imaging (MRI) demonstrated an anterior mediastinal tumor. The tumor was resected completely through a median sternotomy. The tumor was dissected successfully from the surrounding vessels in spite of the heavy adhesion to them. The blood supply of the tumor was from a branch of the brachiocephalic artery. The tumor was 9 x 8 x 3 cm in size, and was diagnosed as an aberrant mediastinal goiter since it showed no communication to the thyroid gland. An aberrant mediastinal goiter is a quite rare entity of diseases and its removal through the neck would result in uncontrolled blood loss because its blood supply usually derives from intrathoracic vessels.     

Efficacy of extended radical operation based on preoperative staging

From 1985 to 1988, we have resected 203 cases of the thoracic esophageal cancer with right thoracotomy. Those 203 cases were classified as R3 (bilateral cervical, thoracic and abdominal node dissection), R2 + alpha (left cervical, thoracic and abdominal nodes dissection) and R2 (thoracic and abdominal node dissection) based on preoperative staging. The background of R3 mainly contained Iu cases, advanced cases, positive cases of upper mediastinal metastasis, and that of R2 mostly contained high aged and risk cases, though this group showed low LN metastasis. The incidence of postoperative complications were higher R3 greater than R2 greater than R2 + alpha in order. Pneumonia had no relationship to neck dissection. Recurrent nerve palsy was recognized in R3 group about 16%. Operative mortality mostly belong to high aged group over 70 y.or., noncurative cases and R3 group. The survival rate of C greater than 0 resected cases with right thoracotomy after 1985 showed some improvement compared with the cases of standard R2 dissection by right thoracotomy from 1980-1984. It showed no difference of the curative survival curve among R3, R2 + alpha and R2 groups. Thus, it is effective to improve the survival rate of resected esophageal cancer with our indication based on preoperative staging.     

A resected case of malignant fibrous histiocytoma of the chest wall

We report a 74-year-old woman with malignant fibrous histiocytoma (MFH), treated successfully by radiation and followed with chest wall resection and reconstruction. The patient suffered from right back pain and her chest X-ray showed a clear round shadow in the middle field of the right lung. Chest computed tomography (CT) showed a 5 x 5 cm tumor in diameter, involving the right 8 rib with destructive changes. After radiation therapy of total 30 Gy to the tumor to obtain the safety surgical margin, we widely resected 10 x 9 cm chest wall with 3 ribs in area under thoracoscopy and performed reconstruction using GORE-TEX Soft Tissue Patch. The pathological and immuno-histochemical diagnosis showed pleomorphic type of MFH. Final result of the tumor negative in surgical margin manifested that our technique of chest wall resection and reconstruction using thoracoscope after the irradiation to the tumor was very safe and useful.     

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.     

Two cases of supposed metastasizing leiomyosarcoma of the uterus

Case 1. A 57-year-old female had hysterectomy 10 years ago because of leiomyoma uteri. She was recently found to have a clear-cut round mass shadow in the right middle lung field on her chest X-ray film 3. The mass was resected and microscopically diagnosed as metastatic leiomyosarcoma. Re-examination of the pathological specimen of the uterine tumor resected 10 years ago revealed 5-9 mitosis per 10 high-powered fields (/10 HPF). Case 2. A 54-year-old female who had undergone hysterectomy for myoma uteri 9 years previously was found to have a well-defined oval shadow in the left lower lung field which was resected and pathologically diagnosed as metastatic leiomyosarcoma. Her uterus lesion microscopically revealed 1-2 mitosis/10 HPF. The relationship between metastatic leiomyosarcoma of the lung and mitotic activity of leiomyoma uteri was discussed.     

A case report of resected double primary lung cancers in the same one segment

A 68-year-old man with hypertension was admitted to the Shiga Kenritsu Seijinbyo Center for further examinations, because abnormal opacity in the right upper lung field was accidentally revealed by chest X-ray. Chest CT demonstrated two separate mass shadows, one 31 X 27 mm, the other 10 X 10 mm in size, both of which were located in the posterior segment of right lung. Specimens from transbronchial biopsy of the larger mass was histologically diagnosed as adenocarcinoma. He underwent right upper lobectomy with hilar and mediastinal lymph nodes resections. Postoperative patho-histological study showed the larger mass to be poorly differentiated adenocarcinoma, the smaller one, small cell carcinoma respectively, and no continuity between the two masses. Lymph nodes metastasis were negative. Any malignancy was not detected by brain CT, abdominal CT and any other gastro-intestinal examinations, and he was diagnosed to have double primary lung cancers in the same one segment. In this report, we discussed the diagnosis and treatment of double primary lung cancers, and reviewed the literatures.     

Mediastinal liposarcoma appearing as a tumor arising in the esophageal wall

We report a case of mediastinal liposarcoma, a relatively uncommon neoplasm, in which the mass also appeared as a tumor arising in the esophageal wall. A 76-year-old man diagnosed with a posterior mediastinal mass had the tumor extirpated in local esophageal myectomy due to its unclear margin on the esophageal wall. The resected specimen was diagnosed as well-differentiated liposarcoma. Preoperative angiography showed the tumor received its blood supply from a branch of the left gastric artery, suggesting it arose in the lower esophageal segment close to the hiatus and extended to the mediastinum. Since this tumor's growth pattern differed completely from esophageal liposarcoma described in previous case reports, we concluded that it was mediastinal liposarcoma.     

Anterior mediastinal paraganglioma mimicking thymoma

A 54-year-old man was referred to our institution with hemoptysis and hoarseness of 1 year's duration. A computed tomography (CT) scan showed an anterior mediastinal mass (2.5 cm x 1.0 cm), which was diagnosed as thymoma. The tumor was resected under a sternotomy. The tumor had invaded the anterior wall of the ascending aorta. With the patient under cardiopulmonary bypass, the aortic wall invaded by the mass was resected, and arterial reconstruction was performed with patch material. The tumor was revealed to be a tumor of neuronal origin. The patient's postoperative course was uneventful. The patient was discharged on postoperative day 9. One year after the operation, a follow-up chest CT evaluation showed no specific complications or recurrence.