Emergency surgery for acute respiratory failure secondary to spontaneous thyroid hemorrhage

A 42-year-old woman was evaluated for an emergency at our surgical department for acute dyspnea associated with a spontaneous and rapidly enlarging mass of the neck. Clinical examination revealed a large, firm, nonfluctuant thyroid swelling on the right side of the neck. An urgent computerized tomography scan showed a hematoma within the right lobe of the thyroid and tracheal deviation with marked luminal narrowing. Because of the rapid progression of respiratory distress, endotracheal intubation by flexible laryngoscopy revealing normal vocal cords function and emergency total thyroidectomy were performed. During the operation, the thyroid gland showed a huge, edematous, nonfluctuant, rubbery, firm swelling with easy bleeding on touch, but the capsule appeared to be intact without rupture. Microscopic examination revealed a colloid multinodular goiter with massive parenchymal hemorrhage. Recovery was uneventful, and the patient was discharged 2 days after the operation.     

Case of a giant cervical carotid artery aneurysm with contralateral severe stenosis treated using a covered stent

We report a case of a cervical carotid artery pseudoaneurysm with contralateral severe stenosis, treated using a covered stent. A 79-year-old man admitted for a splenic artery aneurysm presented a pulsatile mass on the right side of his neck and lower cranial nerve palsy after misinsertion of a central venous line into the right carotid artery. MRI revealed a huge thrombosed aneurysm (30 mm×25 mm) in the right common carotid artery (CCA). We planned an aneurysmectomy and CCA interposition with a vascular graft. However the aneurysm continued to expand. We considered that it was difficult to expose the internal carotid artery (ICA) by a direct surgical technique, and therefore carried out placement of a covered stent over the orifice of the aneurysm using an endovascular surgical technique. Following placement of the covered stent, subsequent contrast-enhanced CT revealed leakage of contrast material into the aneurysm. An additional bare stent was placed into the proximal end of the covered stent at 15 days after the initial treatment. Angiography demonstrated no leakage of the contrast material. Following the second treatment, the pulsatile mass was reduced in size. Lower cranial nerve palsy remained but had slightly improved. We described the case of a huge cervical carotid pseudoaneurysm that was successfully treated using a covered stent.     

First case of huge classic papillary thyroid cancer rupturing spontaneously leading to ischemic necrosis,perforation and inflammation of overlying skin: Case report and review of the literature

IntroductionPapillary thyroid cancer (PTC) is the commonest form of well-differentiated endocrine carcinoma. It is categorized into indolent and aggressive, where the indolent subtypes (classic, follicular) rarely demonstrate aggressive behavior. We present a classic PTC presenting with a rapidly growing huge anterior neck mass that subsequently spontaneously ruptured subcutaneously resulting in ischemia, necrosis, and perforation of overlying skin leading to inflammation.Presentation of caseA 37-year-old female with no comorbidities presented to our emergency department with a neck swelling of 2 years duration that rapidly enlarged one week prior to presentation. Though the mass initially appeared of inflammatory nature, the tumor was a PTC, and she underwent total thyroidectomy with selective right side neck dissection and debridement of necrotic skin. The gross specimen revealed a fragmented non-intact right thyroid lobe mass causing pressure ischemia, necrosis and perforation of the skin. Histopathology showed a 9 × 9 × 5 cm classic PTC staged as pT3b N1b. Postoperative course was uneventful, she was discharged by the eighth postoperative day, and then she received a high dose of radioactive iodine ablation (RAI).DiscussionClassic PTC is usually of a smaller size and a relatively benign course compared to other PTC subtypes and thyroid cancers. It is indolent with favorable prognosis. Although it is associated with increased risk of lymph node metastases at the time of diagnosis, it is slow growing with high survival rates approaching 95%.ConclusionDespite that classic PTC progresses slowly, it should still be suspected in neck swellings presenting with rapid and aggressive behavior. Prompt and systematic assessment is required with surgical intervention and radioactive iodine ablation therapy.     

后腹腔镜下右侧巨大肾上腺肿瘤切除的手术技巧

目的:探讨后腹腔镜下切除右侧巨大肾上腺肿瘤(最大径≥6cm)的可行性及手术技巧。方法:采用后腹腔镜下右侧巨大肾上腺肿瘤切除术治疗右侧巨大肾上腺肿瘤患者18例,肿瘤最大径为6~19(8.4±0.69)cm。术中按3个相对无血管平面分离,在腹侧平面游离时尽量将腔静脉与瘤体分开,并显露肾上腺中央静脉,在背侧平面分离时尽量向内侧中线分离,形成基于腔静脉与腰大肌之间的倒三角形肿瘤基底部。抬起瘤体,逐步向上离断汇入基底部的动脉血供,切除肿瘤。结果:除1例患者因粘连转为开放手术外,17例均顺利完成腹腔镜下肿瘤切除,手术时间80~210(147.9±7.6)min。术后病理检查报告为髓质脂肪瘤8例,嗜铬细胞瘤4例,节细胞神经纤维瘤3例,性索间质瘤1例,肾上腺囊肿伴囊壁钙化囊内出血1例。17例腹腔镜肿瘤切除手术均无术中术后输血。结论:后腹腔可以获得巨大的手术空间,术中妥善处理富含动脉血供的肿瘤基底部可以安全切除体积巨大的肿瘤。     

Suboccipital meningocele presenting as a huge retropharyngeal mass in a patient with neurofibromatosis Type 1. Case report.

The authors report an extremely rare case of neurofibromatosis Type 1 (NF1) with a suboccipital meningocele presenting as a huge retropharyngeal mass. A 73-year-old woman with typical cutaneous manifestations of NF1 presented with nasal obstruction and dysphagia due to a retropharyngeal mass. Magnetic resonance imaging revealed a huge mass lesion extending from the right occipital bone defect to the retropharynx through the right paravertebral region. Computerized tomography scanning after intrathecal administration of contrast material confirmed that the mass was a meningocele protruding through a right occipital bone defect. The authors attempted to ligate this meningocele, most of which was excised via a suboccipital approach, but a second transcervical operation was required. Finally, the meningocele resolved and the patient was discharged without symptoms.     

Cutaneous Metastasis From Adenoid Cystic Carcinoma of the Parotid Gland

BACKGROUND: Cutaneous metastasis from adenoid cystic carcinoma of the salivary gland is very rare. OBJECTIVE: To present an unusual case of cutaneous metastasis from adenoid cystic carcinoma of the right parotid gland. METHODS: A 63-year-old woman with multiple subcutaneous nodules on the abdomen and a gradually enlarged mass over the right parotid area was examined. A skin biopsy was taken from one of the abdominal nodules. RESULT: Skin biopsy demonstrated the characteristic histopathologic features of metastatic adenoid cystic carcinoma. A subsequent computerized tomography of the head and neck revealed a huge soft tissue mass involving the right parotid gland. Computerized tomography of the chest revealed extensive nodular pleural thickening, and pleural biopsy also showed typical histopathologic features of metastatic adenoid cystic carcinoma. All of these results are consistent with the diagnosis of an adenoid cystic carcinoma of the right parotid gland with disseminated metastases. CONCLUSION: We report a rare case of cutaneous metastasis from adenoid cystic carcinoma of the right parotid gland. The presentation of cutaneous metastasis is often nonspecific and may mimic benign lesions. Subcutaneous nodules that are rapidly developing or eruptive, are rapidly growing and have stony hardness in nature, have pain or tenderness, and have nonhealing ulceration remind us of the possibility of cutaneous metastases. Dermatologists and dermatologic surgeons should keep the diagnosis of cutaneous metastasis in mind and always perform skin biopsy when encountering these lesions.     

Liposarcoma associated with multiple intramuscular lipomas. A case report

A 71-year-old slender, previously healthy man was admitted to the authors' institution because of a huge painless mass in his left scapular area. Physical examination revealed a second soft tissue mass in his right scapular region and a third soft tissue mass in the anterior side of his right shoulder. Surgical treatment including marginal resection of the second and third small masses followed by wide local resection of the huge tumor was performed. Histologic examination showed that the first mass was a well differentiated lipomalike liposarcoma, whereas the second and third lesions were identified as intramuscular lipomas. A review of the literature showed two cases of retroperitoneal liposarcoma associated with multiple subcutaneous lipomas and two cases of liposarcoma involving an extremity associated with multiple subcutaneous lipomas. There is no previous report in which intramuscular liposarcoma was associated with multiple intramuscular lipomas.     

Multiple thyroid ectopics in a single patient: a rare presentation

A rare case of multiple thyroid ectopics has been presented. A 16 years old girl presented with swelling on the right side of neck and sense of lump in the throat. Oral examination confirmed presence of lingual thyroid. Examination of neck confirmed a 4 cm rounded soft mass on upper right side of patient's neck. Thyroid scan with I131 showed uptake of radio-iodine at the tongue base and also on right side of neck. Biopsy of mass from tongue dorsum and FNA from neck mass confirmed presence of thyroid tissue at both sites. Hormonal assay showed high TSH and low T3 and T4 level. Treatment with thyroxin for 3 months caused regression of thyroid tissue from both sites and improvement of patient's symptoms. Thyroid hormonal profile improved with thyroxin therapy and patient soon became euthyroid. The patient remained on long-term hormonal replacement with no recurrence of symptoms.     

Carcinosarcoma of the gallbladder: A case report and review of the literature

A rare case of a huge carcinosarcoma of the gallbladder is presented. Despite a tumor thrombus in the portal vein, this tumor was resected successfully by extended right hepatic lobectomy with right caudate lobectomy and gastroduodenectomy. However, hepatic metastases developed rapidly, and the patient died only 3 months after surgery. Macroscopically, a whitish tumor filled the body and neck of the gallbladder and involved the right lobe and left medial segment of the liver, stomach, and duodenum. Microscopically, the neoplasm consisted of both carcinomatous and sarcomatous components. The former contained adenocarcinoma and squamous cell carcinoma, which were observed in the wall of the gallbladder. The latter comprised the bulk of the mass and contained malignant cartilage and osteoid. Immunohistochemically, the sarcomatous cells reacted to antibodies for epithelial membrane antigen and cytokeratin, but were negative for vimentin antibody, Although stromal differentiation into osteoid and cartilage was noted, the sarcomatous component was felt to be derived from mesenchymal metaplasia of the carcinomatous cells. Only 14 cases of carcinosarcoma of the gallbladder have been reported in the English language literature since 1967.     

Dermoid cyst of the floor of mouth

A case report of a 30-year-old male with a huge suprahyoid neck swelling and causing respiratory as well as oral function difficulties is reported. The mass was enucleated through oral route, following which normal oral functions as well as respiratory ease were restored. The gross appearance was consistent with dermoid form of congenital cyst of the mouth floor.     

巨大右侧肾上腺血管瘤的手术切除

目的 总结巨大右侧肾上腺血管瘤的诊断及治疗。方法 回顾性分析我院1例巨大右侧肾上腺血管瘤的特点及治疗，结合献讨论该疾病的诊断、治疗。结果 本病呈良性经过，临床症状以压迫周围器官为主，少数病例可合并高血压等表现，切除可治愈。结论 本病罕见，须与右肝肿瘤鉴别，切除治疗预后良好。     

Successful resection of the right atrial myxoma with excessive tumor vascularity in a elderly patient

A 72-year-old female underwent successful resection of a giant right atrial myxoma. The patient had slight cough with abnormal cardiac silhouette and elevated ESR. The diagnosis of right atrial myxoma was established by echocardiography and angiography. Venacavography revealed huge mass which occupied in the entire right atrium. This tumor was perfused by well developed feeding arteries arising from both right and circumflex coronary arteries, and showed rich tumor vascularity. This tumor was resected with the interatrial septum and the free wall of the right atrium which were attached with tumor. Interatrial septal defect was closed with a Teflon fabric patch and the defect of right atrial free wall was approximated by direct closure with Z-plasty. Postoperative course was uneventful. Pathological examination showed myxoma without invasion into the resected septum and atrial wall. It is important to prevent tumor embolization to the pulmonary artery or strangulation into the right ventricle during surgery on this type of huge right atrial myxoma.     

Hyperparathyroidism presenting as a large bone tumour. A case report

A 59-year-old man, who presented to hospital with a large expansile bone tumour over the left elbow and a mass in the right side of the neck, was eventually found to have parathyroid adenoma manifesting clinically as severe hypercalcaemia. Histological examination of a section of the neck mass showed parathyroid adenoma and the bone biopsy specimen revealed a 'brown tumour', consistent with hyperparathyroid bone disease.     

Vertebral aneurysm of the neck

We recently encountered a case of a huge vertebral aneurysm involving the entire right neck, extending from the clavicle to the mandibular area. The patient had undergone laminectomy of the cervical spine at age 45 for neuritis or spinal caries. This operative procedure apparently caused a small vertebral laceration and produced the giant aneurysm. The aneurysm was resected under hypothermia in order to protect the brain. One vertebral artery was ligated, but cerebral damage did not occur. Only a few cases of huge aneurysms extending from the clavicle to the mandible have been reported in the literature.     

Giant pseudoaneurysm of the extracranial vertebral artery successfully treated using intraoperative balloon catheters.

Traumatic pseudoaneurysms of the extracranial vertebral artery rarely occur, because of its deeply protected anatomical location. Because the direct surgical approach has resulted in high morbidity and mortality rates, ligation of the vertebral artery has been adopted, but this can cause an ischemia in the vertebrobasilar system. We report the case of a 73-year-old woman with a huge pseudoaneurysm of the right vertebral artery that occurred after attempted placement of a cardiac pacemaker. The aneurysm was 7 x 7 x 5 cm in size and its neck was situated just distal to the right subclavian artery. Direct surgical repair of the injured vessel and removal of the aneurysm were successfully performed using balloon catheters placed intraoperatively in both the innominate artery and the right vertebral artery.     

Papillary carcinoma arising from thyroglossal duct cyst with thyroid and lateral neck metastasis

INTRODUCTIONThyroglossal duct carcinomas (TGDC) are rare, with approximately 274 reported cases since the first report in 1915. The prevalence of carcinomas in surgically removed thyroglossal duct cyst (TGD) is less than 1%. The usual recommended treatment for this condition is the Sistrunk operation, but controversies remain regarding the need for total or partial thyroidectomy.PRESENTATION OF CASEA 28-year-old woman was admitted to our hospital with the symptoms of painless midline neck swelling and growing mass. A preoperative computed tomography (CT) showed a 4 cm sized heterogeneous mass at the infrahyoid anterior neck. Ultrasonography of the neck additionally showed suspicious metastatic lymph node at right level VI, both level VI. The patient underwent a Sistrunk operation. The frozen section revealed papillary carcinoma arising from TGDC and also revealed metastatic papillary carcinoma in the right thyroid, at right level III and level VI. Total thyroidectomy, right modified radical neck dissection and central neck dissection were performed. The thyroid gland and TGD were confirmed papillary carcinoma. The dissected neck lymph nodes revealed metastatic papillary carcinoma.DISCUSSIONThe usual recommended treatment for TGD is the Sistrunk procedure. There is controversy regarding whether total or partial thyroidectomy should be performed.CONCLUSIONPhysicians should be aware of extended operation, including thyroidectomy and/or neck node dissection for TGDC with metastatic lesion of thyroid and neck node.     

The giant cavernous hemangioma of the neck]

A 67-year-old female who had complains of dyspnea and giant mass in the right neck. The plain CT scan and selective angiography showed an giant mass in the neck and extended into antero-superior mediastinum which pressed intrathoracic trachea. The tumor was resected completely by oblique neck incision and partial median sternotomy. It was 15 x 9 x 5 cm in size. The histological diagnosis was cavernous hemangioma. The giant cavernous hemangioma in neck extended into mediastinum is rare.     

A case of left pelvic kidney with non-functioning hydronephrosis

A 19-year-old male was admitted with left lower abdominal pain and dysuria. Excretory urograms showed only a right kidney. V.C.G. showed a cystic mass lesion over the bladder. Computerized tomography revealed a huge retroperitoneal cystic mass located near the bladder. It seemed to be a huge bladder diverticulum, but the diagnosis was not clearly confirmed before operation. Through a lower abdominal midline incision, the cystic mass structure was removed. The specimen was a left ectopic pelvic kidney with non-functioning hydronephrosis. The removed mass was 91 X 85 X 78 mm in size, and 120 g in weight. The intrarenal fluid was 350 ml. A brief discussion and review are made. To our knowledge, only 3 such case have been described in the Japanese literature.     

Right ventricular mass: a histopathological surprise

A 33-year-old woman in the postpartum period presented with a mass in the right ventricular outflow tract. She underwent excision of the mass under standard cardiopulmonary bypass. Histopathologic examination of the mass revealed a metastatic lesion from the thyroid, which was follicular carcinoma of the thyroid. Later she underwent total thyroidectomy with lymph node dissection of the neck and radioactive ¹³¹I ablation for the residual tumor in the neck. At 1-year follow-up, the patient has no evidence of residual lesion in the heart, neck, or anywhere else in the body. A detailed preoperative workup could have changed the order of interventions and probably avoided a heart operation.     

Ear Deformity Due to Neurofibromatosis Type 1

Neurofibromatosis is an autosomal dominant neurogenetic disorder. It is associated with significant morbidity and results in substantial loss of function as well as significant cosmetic problems. Elephantiasis neurofibromatosa is the most impressive manifestation of the disease because of its size. In this setting, the lesion leads to massive overgrowth of both the skin and the associated soft tissue, causing disturbing deformities. The reported patient had huge plexiform neurofibromas involving both the external right ear and neck regions. Deformed external ear and neck regions were restored surgically with satisfactory cosmetic results.