Anesthesia for children with anterior mediastinal masses

Children with an anterior mediastinal mass may have cardiopulmonary compromise that can be exacerbated under general anesthesia. Signs and symptoms such as cough, shortness of breath, stridor, orthopnea, accessory muscle use, a history of respiratory arrest, and the presence of a pleural effusion and upper body edema are predictive of perioperative complications. A larger mediastinal mass on imaging is predictive of perioperative complications. Risk stratification of patients, together with an individualized plan, will best guide operative management for patients with an anterior mediastinal mass. General anesthesia (GA) should be avoided if possible, but a spontaneous breathing technique is recommended if GA is required.     

A rapidly advancing mediastinal mass--overcoming tracheobronchial obstruction

We report the case of a 7-year-old boy who presented with rapidly advancing airway obstruction secondary to mediastinal T-cell non-Hodgkins lymphoma. His brisk deterioration required transfer to the pediatric intensive care unit and intubation of the trachea. Unforeseen unilateral bronchial involvement led to gas trapping and critical pulmonary hyperinflation. Endobronchial advancement of the tracheal tube beyond the bronchial obstruction relieved pulmonary hyperinflation but subsequent one lung ventilation was poorly tolerated. We report the manufacture of a proximal 'Murphy's eye' which allowed ventilation of the contralateral lung to proceed. To the best of our knowledge this is the first time that this technique has been described in a pediatric patient.     

Primary midline cranial vault lymphoma simulating a parasagittal meningioma: The role of angiography in preoperative diagnosis

Primary non-Hodgkin's lymphoma (NHL) of the skull with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. Up to date, only nine such cases have been reported in the literature and in none was the lesion located in the midline. The authors report a unique case of a primary NHL involving the midline of the cranium. The lesion presented as a slowly growing scalp swelling mimicking a parasagittal meningioma. The angiographic findings of mild vascularity in the periphery of the tumor and downward displacement of a patent superior sagittal sinus indicated that the lesion was unlikely to be a meningioma. Neurosurgeons must maintain a broad differential diagnosis in any patient with a scalp mass eroding through the skull and associated neurological symptoms or signs. An intraoperative frozen section is recommended since the identification of a lymphoma is likely to influence the neurosurgeon's decision about the extent of the surgical excision.     

Clinical and diagnostic imaging findings predict anesthetic complications in children presenting with malignant mediastinal masses

BACKGROUND: The presence of a mediastinal mass in a child poses significant anesthesia-related risks including death. To optimize outcome clinicians must be able to predict which patients are at highest risk of anesthetic complications. METHODS: We conducted a retrospective review of 118 pediatric patients who presented with mediastinal masses. We investigated their medical records for clinical symptoms and signs at presentation and reviewed their chest radiographs, computed tomography scans, and echocardiograms and electrocardiograms when available. We then conducted analyses to identify clinical and diagnostic imaging features associated with anesthesia-related complications. RESULTS: Eleven of 117 [9.4%, 95% confidence interval (CI) 4.1-14.7%] patients experienced an anesthesia-related complication. Four preoperative features were significantly associated with anesthetic complications: orthopnea (P = 0.033, odds ratio (OR) 5.31, 95% CI, 1.15-24.56), upper body edema (P = 0.035, OR 8.00, 95% CI, 1.16-55.07), great vessel compression (P = 0.037, OR 5.41, 95% CI, 1.11-26.49), and main-stem bronchus compression (P = 0.044, OR 5.11, 95% CI, 1.05-24.92). The presence of pleural effusion (P = 0.060, OR 4.53, 95% CI, 0.94-21.96) or tracheal compression (P = 0.061, OR 5.09, 95% CI, 0.93-27.81) also appeared to be risk factors. Although the rate of anesthesia-related complications detected in our cohort was comparable with that found in earlier studies, the events were less severe. CONCLUSIONS: Patients who present with orthopnea, upper body edema, great vessel compression and main stem bronchus compression are at risk of anesthesia-related complications. The low severity of complications in our series may reflect a combination of factors: use of the least invasive method such as interventional radiology to obtain tissue for diagnosis, completion of a thorough preoperative assessment and minimal anesthesia intervention.     

Primary immunoblastic B-cell lymphoma of the cranial vault

Summary We present the first reported patient with primary immunoblastic non-Hodgkin’s lymphoma of the cranial vault, with a fatal outcome in spite of complete surgical removal. Present address: Juan A. Barcia, Servicio de Neurocirugía, Hospital Clínico San Carlos, c/ Prof. Martín Lagos s/n, 28040 Madrid, Spain Correspondence: Juan A. Barcia, Servicios de Neurocirugía y Anatomía Patológica, Consorcio Hospital General Universitario de Valencia, Av Tres Cruces, s/n, 46014 Valencia, Spain     

Histoplasmosis as a possible cause of retroperitoneal fibrosis and median arcuate ligament syndrome: A case report

INTRODUCTION

Median arcuate ligament syndrome (MALS), a condition of poorly understood etiology, is caused by compression of the celiac artery by fibers of the median arcuate ligament.

PRESENTATION OF CASE

A 46-year-old man with chronic abdominal pain and weight loss was diagnosed with MALS and admitted for surgery. During surgery, extensive retroperitoneal fibrosis around the celiac artery and adjacent aorta was noted. Large necrotizing granulomas and budding yeast, both indicators of histoplasmosis, were found on pathologic evaluation of retroperitoneal tissue removed during surgery.

DISCUSSION

Histoplasma capsulatum may cause pulmonary fibrosis and fibrosing mediastinitis, and the organism may disseminate to reach various internal organs in the immunocompromised individual. Retroperitoneal histoplasmosis has been demonstrated in immunocompromised individuals in the past without retroperitoneal fibrosis. Our patient may have had chronic histoplasma infection of his retroperitoneal lymph nodes, triggering fibrosis in the area surrounding the adjacent celiac artery and abdominal aorta, thus leading to symptomatic MALS.

CONCLUSION

Histoplasma capsulatum, an organism that has demonstrated its capability to cause fibrosis elsewhere in the body, may play a causative role in MALS in our patient, given the finding of retroperitoneal fibrosis in conjunction with retroperitoneal lymph node histoplasma.     

Head and Neck Histoplasmosis—A Nightmare for Clinicians and Pathologists! Experience at a Tertiary Referral Cancer Centre

Histoplasmosis is a rarely reported deep mycotic infection in the Indian context. Oral or oropharyngeal manifestation can occur as an isolated symptom or as part of a disseminated process associated with immunosuppression especially with HIV and diabetes. Five cases of head and neck histoplasmosis accrued over 6 years in a tertiary referral cancer institute were reviewed. All these patients presented clinically as cancer. In three patients, the marked pseudoepitheliomatous hyperplasia led to a mistaken biopsy diagnosis of malignancy following which definitive surgical treatment was performed. The subsequent excision revealed typical features of histoplasmosis. Isolated oral presentation of histoplasmosis can mimic malignancy both clinically as well as pathologically, leading to potentially disastrous consequences. A high index of suspicion in those with overt or hidden immunosuppression and a deep wedge biopsy to demonstrate the organisms in the subepithelial tissue is recommended. This work has been presented in the “Slide seminar on Infections and Infestations” in the IAP-ID pre conference CME in APCON 2006.     

Follicular large cell lymphoma localized to the testis in children

PURPOSE: Primary follicular lymphoma of the testis in childhood is rare with only 6 cases previously reported. We present 3 additional cases. MATERIALS AND METHODS: We extensively analyzed primary follicular lymphoma of the testis in 3 boys. Clinical data were obtained by reviewing patient charts. RESULTS: The patients were 4, 5 and 11 years old, respectively. Two patients presented with painless unilateral testicular enlargement and 1 presented with unilateral hydrocele. Laboratory findings were within normal limits in all patients. Radical orchiectomy was done in all cases. The excised testes were partially or completely replaced by tumor. In all cases the features were those of follicular, large cell-type malignant lymphoma. Tumor cells in all cases were CD20 and CDw75 positive, focally CD23 positive and bcl-2 negative, while in 2 they were CD10 positive and bcl-6 positive. Surface Ig was absent in the 2 cases studied. Karyotyping in 1 case showed a normal karyotype. Staging revealed no evidence of extratesticular disease. All patients underwent combination chemotherapy and were in complete remission 7 to 59 months after therapy. CONCLUSIONS: We present 3 cases of pediatric primary follicular lymphoma of the testis. Pathological findings and clinical features were similar to those in the 6 previously reported cases and suggest that primary pediatric testicular follicular lymphoma may represent unique subset of follicular lymphoma with a particularly good prognosis.     

Primary malignant lymphoma of the cranial vault

Summary A 60-year-old woman presented with a subcutaneous mass on her scalp. Computed tomography (CT) showed a homogeneously enhanced mass of the parietal bone with both intra- and extra-calvarial extension and having destroyed the right parietal bone. The mass was hypointense on the T1-weighted magnetic resonance image, slightly hyperintense on the T2-weighted image and homogenously enhanced with Gd-DTPA. Bone scintigraphy showed prominent accumulation of radioisotopes in the scalp lesion. The tumour was removed, including the involved bone and dura mater. Histologic diagnosis was non-Hodgkin’s B-cell lymphoma, and tumour cells had infiltrated into the dura mater. The patient was treated with radiotherapy and chemotherapy. She returned to ordinary daily life and has been well without recurrence for 3 years. Although primary malignant lymphoma of the cranial vault is rare, it should be considered in the differential diagnosis when a mass is encountered in the cranial vault. We have found only fourteen such cases in the literature, and we review these cases.     

Mediastinal mass obscured by a large pericardial effusion in a child: a potential cause of serious anaesthetic morbidity

Anaesthesia in the presence of a mediastinal mass is known to be hazardous. We report a case of a 5-year-old boy with a presumed postviral pericardial effusion presenting for pericardiocentesis under general anaesthesia. Cardiorespiratory collapse following induction of anaesthesia occurred due to an undiagnosed mediastinal tumour. The reasons for misdiagnosis, mechanisms for perioperative complications and optimal management are discussed. Mediastinal masses and underlying malignancy should always be considered in patients with large pericardial effusions.     

Hodgkin lymphoma presenting with chest wall involvement: a case series

Chest wall tumors in the pediatric population can have a variety of etiologies, malignancy being the most worrisome. Hodgkin lymphoma (HL) rarely presents as a chest wall mass in the pediatric population. In this report, we describe 3 male pediatric patients, all of whom had chest wall masses present at the initial diagnosis of HL. We also discuss the literature on this topic. We conclude that malignancy and, more specifically, HL should always be considered when evaluating a pediatric patient who presents with a chest wall mass.     

Ectopic Primary B Cell Lymphoma of the Thyroid Presenting as an Anterior Mediastinal Mass. A Case Report

Ectopic thyroid tumours arising in the mediastinum without connection to the cervical thyroid gland are very rare. Follicular adenoma, papillary carcinoma and follicular carcinoma in the mediastinum has been reported, but primary ectopic thyroid B cell lymphoma has not been reported previously. We report mediastinal primary ectopic thyroid large B cell lymphoma in an 80-year-old man. Differential diagnosis from primary mediastinal large B cell lymphoma and clinicopathologic features are discussed.     

Ectopic mediastinal thyroid removed by U-VATS approach. A case report

IntroductionEctopic thyroid tissue is a rare entity, and accounts for approximately 1% of all mediastinal tumours. It is a differential diagnosis of the mediastinum tumors or metastatic deposits from an orthotopic gland, as well as other benign or malignant masses. Although most cases are asymptomatic and discovered incidently by imaging, symptoms related to tumor size and its compression of adjacent structures may also appear which necessites explorations and lead to diagnosis.Case presentationThis is a 59-year-old women, followed for glaucoma and operated for bilateral congenital cataract reffered to our structure by the service of pnemology for a right laterotracheal mediastinal mass. The patient presented respiratory symptoms over four months, and the physical examination found patient in good condition with PS 0 and normal vital signs, a poor oral health was noticed. The CT scann showed a left basal opacity and a right laterotracheal mediastinal mass at the upper right mediastinum, pushing forward the superior vena cava and compressing the trachea on the contralateral side, with well-defined borders and without signs of infiltration of adjacent structure. The brochoscopy was perfomed which showed the yellowish granulous aspect and the pathophysiology revealed a pulmonary actinomycosis. The patient was treated with antibiotic based on parenteral infusion of penicillin G at 20 million / day for 6 weeks relayed by oral administration of 3 g / day for 3 months with a good response and the left basal opacity disappeared on the CT control but the mediastinal mass persisted. After multidisciplinary concertation, the mediastinoscopy was perfomed and has revealed an ectopic thyroid which was removed by Uniportal Videoassisted Thoracoscopic Surgery (U-VATS) approach.DiscussionThe first case of ectopic thyroid gland was described by Hickman in 1869, since a few cases have been reported by the literature. Its prevalence is about 1 per 100 000–300 000 people, rising to 1 per 4000–8000 patients with thyroid disease. The main techniques indicated in the management of undetermined lesions of the anterior mediastinum, are midline exploratory sternotomy, anterior lateral thoracotomy and VATS. U-VATS has demonstrated its feasibility and safety compared to conventional techniques by several advantages.ConclusionEctopic mediastinal thyroid is an unusual presentation of thyroid pathology. Complete surgical resection remains a therapeutic and a key diagnosis. The aim of this study is to prouve the feasibility, efficiency and efficacity of U-VATS approach as minimally invasive thoracic surgery for mediastinal mass resection.     

外科手术在胃淋巴瘤联合治疗中的作用（附52例报告）

本文总结了５２例原发性胃非何杰金淋巴瘤（ｐｇＮＨＬ）的治疗经验。全组病例平均随诊时间６８个月（１２～１２０个月）。根据肿瘤分期、组织学分类、肿瘤浸润深度、手术方式和肿瘤切除与否等可能的预后因素，分析外科手术在联合治疗ＰｇＮＨＬ中的作用。结果表明，单纯手术的疗效远不如手术加化疗等联合治疗，但肿瘤未切除者预后更差。因此我们认为，ｐｇＮＨＬ应以联合治疗为主，而外科手术是联合治疗中不可缺少的重要环节。     

Adrenal insufficiency in T-cell lymphoma

Primary adrenal lymphoma (PAL) is an extremely rare neoplasm of T-cell origin. Here we describe a 42-year-old woman who suffered from intermittent fevers and night sweats of 3 months duration. Laboratory results, imaging, pathology, and immunohistological examination led to a final diagnosis of primary adrenal T-cell lymphoma (PATL) with adrenal insufficiency. The patient received combination chemotherapy and prednisolone but expired 2 months after the treatment. Most reported PAL patients who have received only one therapeutic modality have unsatisfactory survival rates resulting from tumor recurrence and/or postchemotherapy infections. In contrast, one patient who received an adrenectomy followed by low-dose radiotherapy experienced long-term survival. A combination of therapeutic modalities may improve prognosis for patients with PATL, although the case numbers are too small to draw any conclusions.     

Anaesthetic management of an infant with anterior mediastinal mass

A substantial mediastinal mass in a small infant can create a dilemma regarding the safest mode of airway management. To ensure safety at all times, we adopted one lung ventilation for fear of compression of the carina and/or both main bronchi. Anaesthesia was maintained at a very light plane by the use of local nerve blocks to secure the airway and epidural analgesia for surgery until the tumour was mobilized.     

Basilar pneumonia simulating acute appendicitis in children.

Twelve children with acute abdominal pain, which was suspected of being acute appendicitis, were subsequently found to have lower lobe pneumonia. Diagnostic barium enema or operative exploration failed to demonstrate any appendiceal abnormality. The abdominal symptoms and the ileus subsided soon after the initiation of antibiotic therapy. Contrary to common belief, it was observed that left-sided pneumonia is capable of mimicking appendicitis almost as frequently as right-sided pneumonia. Since the likelihood of acute appendicitis accompanying pneumonia is small, operative intervention is rarely indicated and should be undertaken only after careful and intensive investigation.     

Idiopathic mediastinal fibrosis: Report of a case

(Received for publication on Nov. 14, 1996; accepted on May 12, 1997)     

Post-transplant lymphoma in a liver allograft

We describe the development of a lymphoma in a liver allograft shortly after orthotopic liver transplantation. Aspiration and core biopsies of the nodule were persistently negative so that a diagnosis could not be made until the patient underwent retransplantation, when examination of the liver resection specimen revealed a B-cell lymphoma. Using a rapid technique based on the polymerase chain reaction, we were able to demonstrate that the tumor was of donor origin.