A unique case of a typical carcinoid of the middle mediastinum: en bloc surgical resection on cardiopulmonary bypass

We report a unique case of a 67-year-old man with a typical carcinoid of the middle mediastinum that adhered tightly to the pericardium, the posterior part of the ascending aorta and the pulmonary trunk, that was radically resected with the patient on cardiopulmonary bypass by clamping, sectioning and suturing the ascending aorta.     

Thymic carcinoid in association with MEN syndromes.

Although carcinoid tumors in association with multiple endocrine neoplasia syndrome (MEN) has been well described, thymic carcinoid in association with MEN is extremely rare (only 23 cases in the world literature). A patient with thymic carcinoid and MEN-I was treated with surgical resection and postoperative radiation therapy, which was later followed by subtotal parathyroidectomy for hyperparathyroidism. Four years later, a symptomatic recurrence of his thymic carcinoid was resected from below his right clavicle. Six years after his original operation, the patient came to the hospital with pancreatitis, and a 5 cm, distal, pancreatic metastasis was resected. He now has symptomatic paraspinal and pleural metastases and is receiving somatostatin. Review of the world's literature shows that the majority of patients with thymic carcinoid and MEN-I are men with an average age of 37 years. Their clinical course is indolent, and surgery represents the only means of cure. Adjuvant chemotherapy and radiation therapy confer no survival advantage. The surgical decision making involved in treating a patient with thymic carcinoid and hyperparathyroidism associated with MEN is also discussed.     

Recurrent thymic carcinoid tumor--report of a case

A previously operated 62-year-old male with recurrent thymic carcinoid tumor was reported. This patient underwent resection of the thymic carcinoid tumor through left thoracotomy 7 years ago. Although the postoperative clinical course was uneventful, an anterior mediastinal tumor on the patient's chest was discovered after an X-ray examination due to a traffic accident in July, 1989. With the diagnosis of recurrent thymic carcinoid tumor, he underwent an excision of the anterior mediastinal tumor and residual thymus. He also underwent partial resection of the pericardium, mediastinal pleura, and left upper lobe of the lung. 42 cases with thymic carcinoid tumor that have been reported in the Japanese literature were reviewed. A perusal in the relevant literature suggested that total thymectomy was advisable because partial thymectomy was associated with a high risk of local recurrence and metastases.     

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.     

Recurrent thymic carcinoid tumor--report of a case and review of the literature]

A case is presented of a 48-year-old male patient with thymic carcinoid tumor who was operated on twice and followed for 12 years. The original tumor was removed in 1979, and a recurrent tumor was removed 4 years later. Multiple metastases to the lungs, pleura and lymph nodes of the neck were found in 1988; chemotherapy (BAPP) and radiation therapy were not effective, and there was subsequent subcutaneous invasion of the anterior chest. We also discuss the 153 cases of thymic carcinoid tumor reported in the Japanese literature in the Niigata Carcinoid Registry.     

Thymic carcinoid—A case report and review of the literature

We report herein a case of a patient with thymic carcinoid who was operated on twice and has been followed for 9 years. In 1979, the original tumor was removed through an emergency left thoracotomy incision done for a hemothorax caused by an anterior mediastinal biopsy. Tumor recurrence was found 6 years later and removal carried out through a median sternotomy. The patient has been working and enjoying life following radiation and chemotherapy for a total of 9 years after his first operation. Recurrent thymic carcinoid has been thought to carry a poor prognosis, but this successfully treated case has been followed up for a long time after the removal of his recurrent tumor. We present this case and discuss other such cases reported in the Japanese literature.     

A case of tricuspid valvular myxoma in a child]

A six-year old boy had hospitalization because of cardiac murmur and syncope attack. Laboratory data including immunoglobulin and erythrocyte sedimentation rate were normal, but echocardiography and cardioangiography indicated tricuspid valvular myxoma in the right atrium. The tumor was successfully removed with the septal tricuspid valve using the cardiopulmonary bypass. The tumor was 18 x 20 x 12 mm in size and pathological findings showed a myxoma originated from tricuspid valve. Now he shows normal cardiac function and no recurrent sign of tumor. There has been reported a few cases of valvular myxoma in Japan. However, this is the first case which was successfully resected by surgery.     

Carcinoid tumor of the thymus: a clinicopathologic report of two cases with a review of the literature

Thymic carcinoid, a tumor with neuroendocrine-derived cells, is extremely rare. Its clinical and pathological features are distinct from other thymic tumors or carcinoids in other organs. The prognosis is poorer compared with other thymic tumors. Herein, we describe two cases with thymic carcinoids that were completely resected and underwent radiotherapy after surgery. The postoperative follow-up periods were 7 years and 7 months. These rare cases are discussed in light of the clinico-pathological picture of thymic carcinoid reported in the literature.     

Thymic carcinoid tumor--report of 3 operative cases]

Three cases of thymic carcinoid were surgically treated in our hospital. All 3 cases belonged to stage IVb (Masaoka's classification) because of anterior lymph nodes metastasis. A 44-year-old male patient died of multiple metastasis of bone and liver in 94 months after the operation. A 45-year-old female patient who had undergone operation 4 years ago, was re-operated on for recurrent carcinoid tumor but complete resection of the tumor could not be performed because of the tumorous invasion to superior vena cava, pericardium and costal bone. After the operation she has been treated by radiotherapy and any re-growth of the tumor has never been detected for 1 year. Another 50-year-old male patient who had been operated and treated by chemo-radiotherapy for thymic carcinoid before 50 months was diagnosed as recurrent tumor at left interpectoral lymph node. Radiotherapy is now preparing for this patient. 160 cases of thymic carcinoid reports in Japan were reviewed. 37 cases were stage IVb and 36 cases had supraclavicular or mediastinal lymph nodes metastasis. Those cases which had been underwent complete resection followed by radiotherapy seemed to have better prognosis. We conclude that patients of thymic carcinoid should be treated with complete resection including supraclavicular and mediastinal lymph nodes dissection, followed by radiotherapy.     

An incidental finding of thymic carcinoid during urgent CABG operation

We present a case report of a 60-year-old Malay man who was undergoing an urgent coronary artery bypass graft (CABG) operation when a well encapsulated thymoma-like tumor was found incidentally. Total thymectomy was performed together with the CABG. Histopathological report of the tumor, however, confirmed a rare thymic carcinoid. The clinical features, management, and outcome of surgery are discussed.     

Recurrent thymic carcinoid tumor in the pleural cavity

Thymic carcinoid is a rare malignant tumor having a high incidence of local recurrence and distant metastasis. To date, few reports have described the reoperative management of recurrent thymic carcinoid appearing as a pleural tumor. Here we report 2 such cases in long-term survivors. Long-term follow-up is recommended for patients with thymic carcinoid even after curative surgery. Aggressive treatment including surgical resection may prolong survival in these patients.     

A case of thymoma protruding into the superior vena cava through the thymic vein

We describe an unusual case of an invasive thymoma protruding into the superior vena cava and left brachiocephalic vein through the thymic veins in a 64-year-old patient. The tumor was resected with a bypass of the right brachiocephalic vein and right atrium. Although this type of growth form is rare for an invasive thymoma, this case suggests that in surgical procedures for thymomas, meticulous examination of the thymic veins is necessary to avoid leaving residual tumor.     

Extrapleural pneumonectomy with venous confluence resection for stage IVA thymic tumors

We report 4 patients with stage IVA thymic tumors who underwent extrapleural pneumonectomy and thymectomy with venous confluence resection using a temporary percutaneous venous jugular-femoral bypass technique. The superior vena cava was replaced in 2 patients, and the innominate vein was resected in 2 patients. Complete tumor resection was obtained in all patients. There was no 90-day postoperative mortality. One patient died at 6 months postoperatively of an unrelated cause, without recurrent disease, and 3 are alive and disease-free with a follow-up ranging from 19 to 80 months. Extrapleural pneumonectomy can be combined with thymectomy and venous confluence resection for stage IVA thymic tumors.     

A case report of ruptured thymic carcinoid

A scarce case of a rupture of thymic carcinoid followed by hemothorax and mediastinal enlargement was reported. And the mechanism of rupture of thymic carcinoid was discussed comparing to 38 thymic carcinoid cases reported in Japan. A 61-year-old male who had been pointed out mediastinal tumor by chance in a chest X-ray developed a sudden onset of chest pain and dyspnea during an aortography in a hospital transferred to our center because the rupture of the tumor was suspected. Emergency median sternotomy revealed a rupture of a solid tumor with a lot of clot which originally located in the anterior mediastinum but perforated into the right pleural space. This may be the first report of the ruptured thymic carcinoid, so far as we know in Japan. Reviewing the reported cases, the tumor of carcinoid is generally large in size and poorly differentiated in histological study. In more than half of the cases, it is reported that intraparenchymal necrosis or hemorrhage is found. Therefore, it is considered that a thymic carcinoid is a tumor which may result in the rupture, and it should be emphasized that the rupture of the thymic carcinoid which require an emergency treatment is one of the severe complications of the tumor.     

Bronchial carcinoid of an accessory tracheal bronchus

We present a rare case of bronchial carcinoid tumor arising in an accessory right tracheal bronchus and involving the associated tracheal lobe in a 48-year-old man, who presented with a history of recurrent respiratory infections and recent onset of hemoptysis. Diagnosis was established on preoperative bronchoscopy and biopsy. The tumor was completely removed by right upper lobectomy with the tracheal bronchus resected flush to its origin from the right lower tracheal wall. Final histology revealed a typical carcinoid tumor.     

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.     

Apical suction device facilitating off-pump bypass for recurrent coarctation: case report

Apical suction devices to perform complete surgical revascularization without cardiopulmonary bypass have been recently introduced in cardiac surgical practice. We have increasingly explored the possibility of using these devices to perform other procedures on a beating heart that have previously necessitated the need for cardiopulmonary bypass. We present a case of recurrent coarctation in which an ascending-to-abdominal aorta bypass graft was successfully facilitated by the use of an apical suction device. The surgical technique and advantages and disadvantages of this method are highlighted.     

Traumatic aneurysm of the aortic arch. Report of an unusual location

A case is presented of chronic traumatic aneurysm of the aortic arch between the innominate and left common carotid artery. The aneurysm was resected successfully with the patient on cardiopulmonary bypass.     

Papillary fibroelastoma of the aortic valve with atypical chest pain: late presentation with acute myocardial infarction and cardiac arrest

We report a case of a 54-year-old female with papillary fibroelastoma of the aortic valve who presented with ST-elevation myocardial infarction and cardiac arrest. Though her initial symptom was only atypical chest pain, life-threatening complications such as acute myocardial infarction and cardiac arrest developed. After cardiopulmonary resuscitation, we promptly resected the fibroelastoma on cardiopulmonary bypass, and the patient was discharged without any other complications.     

Hypotension following valve replacement surgery in carcinoid heart disease

We report the use of adrenaline in a 62-year-old woman with carcinoid heart disease who underwent double valve replacement. She was given an intravenous infusion of octreotide throughout the peri-operative period. Following the termination of cardiopulmonary bypass she developed profound hypotension which proved to be refractory to various therapies but responded to adrenaline. Adrenaline is said to be contraindicated in carcinoid syndrome, but we would suggest the consideration of its use in such cases where the hypotension may result from myocardial depression rather than from a carcinoid crisis.