A case of metastatic renal tumor originating from a malignant mixed tumor of the submandibular gland]

A rare case of metastatic renal tumor originating from a malignant mixed tumor of the submandibular gland is reported. The patient was a 45-year-old woman with hard masses palpated in the right upper arm and the right upper gluteal region. She had a history of surgical resection of a right submandibular tumor followed by radiotherapy in 1977. Biopsy findings of the gluteal mass suggested a malignant clear cell tumor. A chest X-ray, excretory urogram, CT scan, MRI and renal angiogram were highly suggestive of a right renal cell carcinoma with metastases to the right lung (S1 & S10), the left 4th and 5th ribs, the right upper arm muscle and the right upper gluteal muscle. Right nephrectomy and resection of the right upper arm and right upper gluteal tumors were performed. Microscopic examination showed that all tumors were malignant mixed tumors. When compared to the previous surgical specimen, the tumors were believed to be identical. The tumors of the lung and ribs subsequently resected were malignant mixed tumors. The patient is well with no objective or subjective evidence of recurrent neoplastic disease 7 months post-operatively. To our knowledge only one report of metastatic renal tumor originating from a malignant mixed tumor of the salivary gland has been published in Japan. But metastatic renal tumor originating from the same tumor of the submandibular gland has not been reported previously in Japan.     

切除左肋弓软骨显露食管裂孔行胃上部癌肿切除的技巧

作者对３２例胃上部癌肿采用经腹正中切口合并切除剑突及左第７－９肋弓软骨入路,行近端胃或全胃切除术。结果：全组部例均未发生肋软骨炎及左侧胸膜损伤气胸,也无肺肺并发症及吻合口瘘的发生,但发生食管断端癌残留１例和肋软骨床积液１例。     

Glomangiopericytoma causing oncogenic osteomalacia

A 47-year-old woman suffered from gait disturbance due to back pain and muscle weakness. Laboratory data showed serum hypophosphatemia, elevated alkaline phosphatase, and a normal level of ionized calcium. Radiological examinations revealed multiple pathologic fractures in the ribs and pubic rami. She had had no episode of familial or any other notable disorder, and so she was initially treated with medication for adult-onset osteomalacia. However, 19 years later (when she was 66 years old), she noticed a soft-tissue tumor in her buttock. The tumor was excised. The histological features were those of glomangiopericytoma characterized by both glomus tumor-like and hemangiopericytoma-like structures. After removal of the tumor, her symptoms disappeared immediately. Laboratory data normalized 8 months later. To our knowledge, this is the first report of oncogenic osteomalacia caused by glomangiopericytoma. Received: 3 May 1999     

Giant primary liposarcoma of the chest

Liposarcomas are the most common soft tissue sarcomas in adults, although liposarcomas of the chest are uncommon. We report two cases of giant liposarcoma in the mediastinum and chest wall, respectively. An 82-year-old man presented with a mass in the right upper mediastinum, as seen by computed tomography (CT). He had a past history of subcutaneous lipoma resection on his back (19 years previously). The patient underwent tumor resection with a right thoracotomy. A 58-year-old woman presented with an enlarging mass of the right lateral chest, involving the diaphragm and ribs, as seen by CT. She had a past history of subcutaneous lipoma resection of the right chest (18 years previously). The patient underwent an en bloc resection that included the tumor and a part of the right diaphragm and ribs. Histological examination of both patients’ tumors revealed a well-differentiated liposarcoma, with no pathological relation to the previous lipoma resected in either case.     

Newly designed approach to an aneurysm eroding the sternum and protruding over the sternum

A 54-year old man was admitted with a complaint of a pulsating tumor (7 x 6 x 2 cm) above the sternum accompanied by dysphagia. DSA showed the pulsating tumor was an aneurysm arising from the ascending aorta. CT gram of the sternum showed that the sternum was destroyed partially at the level of the 1st rib. We did the Y shaped skin incision. The clavicles, 1st and 2nd ribs were dissected out periosteally and perichondrially. We cut the clavicles and ribs, and dissected the mediastinum median to the internal mammary artery. Under the perfusion, F-F bypass and brain perfusion, the upper half of the sternum was dissected safely from the aneurysm. The aneurysm was false aneurysm and the perforating ostium was 3.5 cm in diameter. The margin of the perforating ostium had a deposit of calcium. Using an occlusion balloon catheter from the ostium, patch closure was done. The postoperative course was uneventful. We believe that this new approach is preferable to the severe erosion of the sternum by the aneurysm.     

胃上部癌的经腹外科治疗

目的 提高胃上部癌外科治疗水平。方法 对94例胃上部癌采用了经腹正中切口或合并切除剑突及左第7～9肋弓软骨入路，行近端胃或全胃切除术。结果 全组病例发生吻合口瘘1例，食管断端癌残留3例和肺部感染8例，无肋软骨炎及胸膜损伤所致血气胸发生。结论 胃上部癌经腹入路暴露良好，创伤小，痛苦少，适用于食管无浸润或浸润小于1cm的胃上部癌的患者。     

Fetus in fetu removal in a 47-year-old man.

A case of removal of a fetus in fetu in a 47-year-old man is reported. The patient had an upper abdominal mass since birth that had never caused any subjective symptoms. A preoperative computed tomographic scan was useful to confirm the diagnosis. The operative specimen consisted of a cystic mass about 20 cm in diameter, situated in the upper retroperitoneal space. The cyst was full of a yellowish fluid and hairs. A bony structure, about 10 cm in diameter, contained a vertebral axis connected to the ribs and was adherent to the cystic wall. To our knowledge this is the first reported case of fetus in fetu described in an adult man. The tumor, present for 47 years, did not grow or cause any complications and did not show any sign of malignancy.     

A case of the successful surgical treatment of mediastinal giant neurogenic tumor, and the chest wall reconstruction by the autologous ribs

A mediastinal tumor, particularly a neurogenic tumor, sometimes develops into a giant tumor; this large tumor mass then puts pressure on the heart and lungs, and may cause severe complications. In our department, 164 mediastinal tumors were experienced, the largest one was an intrathoracic fibromyoma which weighed 3,760 g. This report deals with our recent experience in which we found a neurogenic tumor weighed out 4,500 g. This tumor was excised in an emergency operation, after which the patient's life was saved by twenty-two days of artificial respiration. Since this tumor was so large, four entire right ribs had to be removed in order to create enough space to excise it. In order to reconstruct the chest wall, three of the removed ribs were retransplanted in their original sites. An extremely good prognosis resulted.     

Clinicopathological study of upper urinary tract tumors associated with bladder tumors

Among 535 cases of urothelial tumors (upper urinary tract and bladder tumors) from 1970 to 1988, 40 had upper urinary tract tumor associated with bladder tumor. Of 40 cases, 18 (45%) were synchronous, 17 (43%) were metachronous with primary upper urinary tract tumor followed by subsequent bladder tumor 18.5 +/- 14.1 (means +/- SD) months later and 5 (12%) were metachronous with primary bladder tumor followed by subsequent upper urinary tract tumor 40.2 +/- 13.6 months later. The incidence (17/52 = 0.32) of bladder tumor occurrence subsequent to primary upper urinary tract tumor was much higher than that (5/465 = 0.01) of upper urinary tract tumor subsequent to primary bladder tumor. The histologic grades of upper urinary tract tumor and associated bladder tumor were consistent in 73%. Except in 1 case, multiple occurrence of upper urinary tract tumor was always observed unilaterally on the side involved. The current results not only support the theory of multicentricity but raise the possibility that tumor cell implantation may play some role at least in the development of bladder tumor subsequent to upper urinary tract tumor.     

Primitive chest wall neuroectodermal tumor in a pediatric patient

A 13-year-old boy with a primitive neuroectodermal tumor of the chest wall is presented. After four cycles of chemotherapy, a computed tomography scan of his chest showed a larger mass invading the left upper lobe of the lung. He underwent resection of the left chest wall from the left fourth to sixth ribs, including the tumor, combined with left upper lobectomy and lymph node dissection. A diagnosis of primitive neuroectodermal tumor was confirmed histopathologically and immunohistochemically. After surgery, four cycles of chemotherapy with ifosfamide and etoposide were given. One year after treatment, the patient is currently doing well without evidence of recurrence.     

Superior sulcus lung cancer invading the ribs and brachial plexus successfully resected by modified trap-door thoracotomy after induction chemoradiotherapy

We report on a 49-year-old male patient presented with right superior sulcus lung adenocarcinoma, which had invaded the first and second ribs and brachial plexus. He underwent concurrent chemoradiotherapy, which resulted in a partial response. The tumor was resected along with the first and second ribs without difficulty via a modified trapdoor thoracotomy. The brachial plexus was preserved, and the surgical margin was microscopically negative for cancer due to the effect of the neoadjuvant chemoradiotherapy which degenerated most of the tumor into scar tissue. We conclude that modified trapdoor thoracotomy is a good approach for resection of superior sulcus lung cancer invasive to the first and second ribs and brachial plexus. Neoadjuvant chemoradiotherapy is also necessary to achieve a negative surgical margin.     

Remission induced by interferon alfa in a patient with massive osteolysis and extension of lymph-hemangiomatosis: a severe case of Gorham-Stout syndrome

The treatment of massive osteolysis with lymphangioma and/or hemangioma (Gorham-Stout syndrome) has been controversial. The authors report on a patient with multiple massive osteolyses and extensive lymph-hemangiomatosis whose lesions were reduced by interferon alfa therapy.A 2-year-old girl had complained of left chylothorax. Thoracoscopy showed an increase in small lymphatic vessels in the chest wall. The chylothorax was improved by coagulation of the lymphatic vessels. Later, multiple massive osteolyses appeared in the left 11th and 12th ribs, the TH10-L3 vertebrae, and the right femur. There were also hemangiomas in the liver and spleen, a tumor lesion in the left lower chest wall, and hemangiomatous change on the skin surface of the left back. The left lung had only a minimal air content. After OK-432 was injected into the femur and chest wall lesions, the femur lesion disappeared. Then, as right chylothorax appeared, OK-432 was injected into the right pulmonary cavity. The chylothorax disappeared, but pericardial effusion appeared. After steroid pulse therapy, pericardial effusion disappeared. During these treatments, the 7th to 10th ribs disappeared from the x-ray and scoliosis developed. One month later, a cloudy fluid collection in the right lung was found on computed tomography. Interferon alfa and steroid pulse therapy were started. Interferon alfa (1,500,000 units) was subcutaneously administered daily for 2 months and was gradually reduced and maintained at 1,500,000 unit/wk. Steroids were also reduced and maintained at 5 mg/d of predonine. Later, the progress of osteolysis and the extension of lymph-hemangiomatosis stopped. Ten months later, hemangioma in the back disappeared, and the 7th to 10th ribs, which had disappeared, reappeared. The interferon alfa therapy was stopped 14 months after it was administered. The patient's condition has been stable for 10 months since then. At this time, computed tomography shows regression of the hemangiomatous lesion in the back.The authors clinically diagnosed the patient as having Gorham-Stout syndrome with extension of lymph-hemangiomatosis. Interferon alfa with or without steroid therapy should be a choice for patients with extension lesions.     

Resection of thymic carcinoma in a patient with thoracic aortic aneurysm.

A 72-year-old man with a history of brain infarction presented with left sided anterior chest pain secondary to a thymic carcinoma. He received induction radiotherapy, 45 Gy. Preoperative computed tomography showed the tumor was adherent to a thoracic aortic aneurysm (TAA) which had extensive mural thrombus and calcification. To obtain adequate exposure without exerting tension on the fragile aneurysmal wall, ribs were resected to allow us to separate the tumor from the TAA, after which median sternotomy was performed uneventfully, creating generous exposure. The tumor had invaded the sternum, ribs, innominate vein, phrenic and recurrent laryngeal nerves, and lung. The tumor was removed en bloc, and the chest wall was reconstructed. Intra- and post-operative brain infarction and rupture of the TAA were avoided. The patient is alive and well without recurrence 10 months after surgery.     

Total vertebrectomy (Th2) and dissection of the subclavian artery for a superior sulcus tumor invading the spine: A case report

IntroductionSurgery for primary lung cancer invading the spine remains challenging. Here, we present a case of superior sulcus tumor (SST) with vertebral invasion, successfully resected with total vertebrectomy (Th2) and dissection of involved apical chest wall and the subclavian artery (SCA).Presentation of caseA 62-year-old man was referred with the diagnosis of lung squamous cell carcinoma originating from left upper lobe (clinical stage IIIA/T4N0M0) involving the thoracic vertebrae (Th2) as well as the apical chest wall including three ribs (1st, 2nd and 3rd) and SCA. After induction concurrent chemo-radiotherapy, we achieved complete resection by three-step surgical procedures as follows: first, the anterior portion of involved chest wall including SCA was dissected through the trans-manubrial approach (TMA); next, the posterior portion of involved chest wall including ribs was dissected and left upper lobectomy with nodal dissection was performed through posterolateral thoracotomy; finally, total vertebrectomy (Th2) was performed through posterior mid-line approach.DiscussionThis tumor was existence of anterior and posterior position in pulmonary apex region. So that, it is very important for complete resecting this complicated tumor to work out operation’s strategy.ConclusionSurgery may be indicated for SST invading the spine, when complete resection is expected.     

B-mode nephrosonography in renal masses. Its use and some limitations.

One hundred B-mode nephrosonograms were reviewed, and 41 percent of these had a diagnosis proved by either arteriography, cyst puncture or tissue examination. There were 8 proved normal sonograms with one error, an upper pole renal cell carcinoma in a kidney badly distorted by chronic pyelonephritis and ureteral obstruction. Overlying ribs and anatomic distortion contributed to the misinterpretation. Sonic diagnosis of solid tumor was correct in all proved cases. Cysts were diagnosed in 23 patients; six were in error. Four were called cysts less than 3 cm. in diameter. If the lower limit of sonographic resolution is considered 3 cm., the accuracy for diagnosed simple cysts becomes 90 per cent.     

Chest wall tumors. Experience with 100 consecutive patients

One hundred consecutive patients with chest wall tumors undergoing resection during the past 8 years were reviewed. There were 55 female and 45 male patients with ages ranging from 12 to 84 years (median 54.5 years). Fifty patients had primary malignant neoplasms, 32 had metastases, and 18 had benign tumors. The tumor was located in the ribs in 78 patients and in the sternum in 22. The number of ribs resected ranged from one to eight (median 3.4). Sternectomy was performed in 22 patients. Overlying soft tissue was resected en bloc in 47 patients. Reconstruction was with prosthetic material in 57 patients and autogenous ribs in 11. There were 100 muscle transpositions, including 45 pectoralis major, 33 latissimus dorsi, and 9 serratus anterior. Hospitalization ranged from 4 to 80 days (median 9.6 days). Complications occurred in nine patients. One patient required tracheostomy. There was one operative death. Median follow-up was 31.5 months. Recurrent tumor developed in seven patients. All patients with benign tumor and 95% of patients with primary tumor not previously treated were alive. However, only 41% of patients with metastatic tumor were alive. Metastases were responsible for 89% of late deaths. We conclude that aggressive resection for chest wall tumor with reliable reconstruction can be accomplished safely and that early wide resection is potentially curative treatment.     

Tumors of the diaphragm

Four cases of diaphragmatic tumor have been reported herein. In addition, reports of thirty apparently authentic cases were found in the literature. The clinical manifestations of such tumors were not very characteristic. Usually, more or less severe pain occurred in the lower part of the thorax, with costal extension and with accentuation on deep inspiration. Most patients had a cough and, in some instances, blood-streaked sputum was produced. In several cases the tumor was palpable as a bulging through the ribs; in a few, a mass that moved with respiration was noted in the upper part of the abdomen. The benign tumors often produced no symptoms whatever. Roentgenologic examination aided in establishing the diagnosis in some instances. Thoracoscopic examination, after artificial pneumothorax, sometimes was helpful. Also, in some cases pneumoperitoneum was an aid in establishing the diagnosis.     

Giant cell tumor expanded into the thoracic cavity with spinal involvement

This article describes a case of a giant cell tumor that expanded into the thoracic cavity and through the spinal canal into the vertebrae. A 36-year-old man presented with a 6-month history of back pain and dyspnea. Plain chest radiographs showed a huge mass accompanied by right pleural effusion. The mass involved the 12th thoracic spine, and the spinal cord was severely compressed. The tumor was resected with a 2-stage procedure. As a first stage to separate the tumor from the anterior vital structures under direct vision, thoracic surgeons performed a right thoracotomy with chest wall reconstruction from the 8th to 11th ribs. The right lung and inferior vena cava were gently retracted, and the tumor was carefully detached from these structures. We were not able to separate the tumor from the right diaphragm due to severe invasion; therefore, we performed partial resection of the right diaphragm with the tumor. After excision of the anterior part of the tumor, the thoracic wall was reconstructed with the right eighth rib and Marlex mesh. When the patient's general condition improved 2 weeks later, spondylectomy by posterior approach was performed. We achieved excision of a giant cell tumor that had expanded into the thoracic cavity and through the spinal canal into the vertebrae. The patient had achieved full rehabilitation with no neurological or respiratory abnormalities at 7 years postoperatively.     

Aneurysmal bone cyst in the first rib

Aneurysmal bone cyst is a benign tumor of the skeletal system that rarely occurs in ribs. We report two cases of aneurysmal bone cyst in the first rib. The first patient was a 21-year-old woman with an aneurysmal bone cyst in the left first rib that was resected with an L incision. The second patient was a 42-year-old man with an aneurysmal bone cyst in the right first rib that was resected with a posterolateral incision but recurred 1 year later. An en bloc resection was performed, without recurrence to date. We also review this disease with emphasis on the etiology, clinicopathology, and treatment approaches.     

Reconstruction of the upper extremity with a compound rib-latissimus dorsi osteomusculocutaneous flap.

The reliability and versatility of the pedicled latissimus dorsi muscle or osteomusculocutaneous flap make it our first choice in the management of upper arm injuries and we have treated three such patients in this way. They had severe skeletonising, crushing injuries of an upper extremity with humeral defects that were treated with latissimus dorsi musculocutaneous flaps and segments taken from the ribs. All the flaps survived completely with no injury of the pleura at the donor site. The reconstructed humerus was strong enough for the patients to participate in all activities of daily living. We think that this technique is suitable for the upper arm defects with humeral loss because of its simplicity and minimal morbidity.