Necrosis pulmonar masiva por micosis / Massive pulmonary necrosis due to mycosis

Introducción: La aspergilosis es una infección micótica oportunista que se presenta fundamentalmente en pacientes inmunodeprimidos y su principal fuente de transmisión lo constituyen las esporas presentes en el aire de salones de operaciones y unidades de cuidados intensivos. Objetivo: Presentar un caso de una micosis pulmonar masiva por una variante angioinvasiva de Aspergillus. Caso clínico: Se presenta un paciente con aspergilosis pulmonar grave, diagnosticada después de la resección de un tumor mediastinal. Se describen las características de la primera intervención, la evolución postoperatoria que condujo a la segunda, se muestran las imágenes tomográficas, quirúrgicas, microbiológicas y anátomo-patológicas que permitieron definir el diagnóstico. Conclusiones: La posibilidad de una micosis pulmonar debe tenerse en cuenta, aun cuando sea una afección rara y de manejo difícil, en pacientes inmunodeprimidos, con condensación pulmonar rebelde al tratamiento(AU)

Introduction: Aspergillosis is an opportunistic fungal infection that occurs mainly in immunosuppressed patients and its main source of transmission is the spores present in the air of operating rooms and intensive care units. Objective: To present a case of a massive pulmonary mycosis due to an angioinvasive variant of Aspergillus. Clinical case: A patient with severe pulmonary aspergillosis, diagnosed after resection of a mediastinal tumor, is presented. The characteristics of the first intervention are described, the postoperative evolution that led to the second one, the tomographic, surgical, microbiological and anatomo-pathological images that allowed to define the diagnosis are shown. Conclusions: The possibility of a pulmonary mycosis should be taken into account, even when it is a rare and difficult-to-handle condition, in immunocompromised patients, with pulmonary condensation that is rebellious to treatment. Aspergillosis is an opportunistic fungal infection that occurs mainly in immunosuppressed patients and its main source of transmission is the spores present in the air of operating rooms and intensive care units(AU)

Skull base surgery: Indian perspective.

Skull base tumors occur at an interface of multiple surgical specialties, which need to work in tandem to treat these cases. The number of estimated new cancer cases in India is approximately 1 million in a year, and skull base tumors are estimated to be 3500 a year. We present an overview of our experience of operating 550 patients with these tumors during a period of 15 years in a cross-section of society with varying economic background and with our limited resources. We have illustrated 5 patients who have been operated on by us. We have proposed how we could further our cause in treating these patients in our scenario.

Double flap technique for reconstruction of anterior skull base defects after craniofacial tumor resection: technical note.

BACKGROUND: Successful reconstruction of large anterior skull base (ASB) defects after craniofacial resection of malignant skull base tumors is paramount for preventing cerebrospinal fluid (CSF) fistulas. The vascularized pedicled pericranial flap (PCF) has been the gold standard for repairing ASB defects after transbasal transcranial approaches. However, flap necrosis and delayed CSF leaks can occur after adjuvant radiation therapy. We describe a "double flap" reconstruction technique in which the PCF is augmented inferiorly by a secondary vascularized pedicled nasoseptal flap (NSF) that is harvested and rotated using an endoscopic endonasal approach. METHODS: This technique is illustrated in 2 patients who underwent a combined cranionasal (transbasal and endoscopic endonasal) approach for large sinonasal malignancies with significant intracranial extension (1 esthesioneuroblastoma, 1 sinonasal teratocarcinosarcoma). After tumor removal via a combined cranionasal approach, primary repair of the ASB dural defect was performed with a free patch graft. The ASB defect was then repaired using the double flap technique with a vascularized PCF from above and augmented with a vascularized NSF from below. RESULTS: Postoperatively, there were no complications of CSF leakage, meningitis, or tension pneumocephalus in both patients. After subsequent radiation therapy, the double flap repair remained intact at 2 years postoperatively in both patients. CONCLUSION: The double flap skull base reconstruction technique provides an additional barrier of vascularized tissue to prevent CSF leakage, meningitis, tension pneumocephalus, and postradiation necrosis. This technique is a viable option if a combined transcranial and transnasal endoscopic tumor resection is performed and postoperative radiation is anticipated.

Late relapse in testicular germ cell tumors.

AIMS AND BACKGROUND: Analysis of patients with late relapse of testicular germ cell tumors (GCTs) with reports on clinicopathological features and outcomes. METHODS: We identified all patients diagnosed with testicular GCTs at our Institute between 1988 and 2004 who developed relapse > or = 24 months after completion of primary therapy. A retrospective case-note review was performed to extract clinical, pathological, treatment and outcome data. RESULTS: Six patients (1.25%) developed late relapse. All patients presented with stage I disease and were classified as "good risk" according to the International Germ Cell Consensus Classification. Mean time to late relapse was 48 months. Markers at late relapse were normal in all patients. Relapse was confined to retroperitoneal sites in five patients and located in the mediastinum in one patient. Five patients were managed by chemotherapy alone while one underwent combined treatment with surgery followed by chemotherapy. All patients obtained a complete response and all remained free from recurrence with a mean follow-up of 115 months. CONCLUSIONS: The incidence of late relapse in this small series is low. Chemonaive patients with late relapse were successfully salvaged with chemotherapy alone or surgical excision followed by cisplatin-based chemotherapy. The optimal duration of follow-up in patients with testicular GCTs is not known and practice varies widely. At our Institute we advise lifelong follow-up of all patients with malignant GCTs of the testis.

[Sinonasal teratocarcinosarcoma: a clinical, radiologic and pathologic study of 5 cases].

OBJECTIVE: To study the clinical, radiologic and pathologic features, as well as differential diagnosis of teratocarcinosarcoma in nasal cavity and paranasal sinuses. METHODS: Light microscopic examination and immunohistochemical study was performed in 5 cases of sinonasal teratocarcinosarcoma. The clinical, radiologic and pathologic features were analyzed and the literature was reviewed. RESULTS: All 5 patients were males and their age ranged from 34 to 43 years (mean age = 39 years). The clinical presentation was nasal obstruction, epistaxis and headache. Physical examination often revealed a polypoid mass with contact bleeding. Computed tomography showed a homogeneous nasal mass with obturation of sinuses. Cystic changes, calcification or ossification was not observed. Histologically, the tumor showed a heterogeneous admixture of components from the 3 germ cell layers, exhibiting various degrees of maturation. Squamous epithelium, smooth muscle cells, chondro-osseous tissue, intestinal or respiratory type epithelium, "fetal-type" clear cells and immature neuroepithelium were commonly seen. Immunohistochemical study demonstrated that the epithelial component expressed cytokeratin and epithelial membrane antigen, while the mesenchymal component variably expressed vimentin, smooth muscle actin and S-100 protein. On the other hand, the neuroepithelial component expressed neuron-specific enolase, synaptophysin and chromogranin, and the primitive component expressed CD99. The initial biopsy diagnosis included capillary hemangioma, olfactory neuroblastoma, craniopharyngioma and malignant mixed tumor. Follow-up information was available in all patients. Two of which had local recurrence and 1 had cervical lymph node metastasis. CONCLUSIONS: Sinonasal teratocarcinosarcoma is a rare and highly malignant tumor occurring in sinonasal tract. It manifests mainly in adult males and is characterized by a complex admixture of teratomatous and carcinosarcomatous components. "Fetal-type" clear cells, squamous epithelium and immature neuroepithelium represent important histologic characteristics useful in diagnosis.

Salivary gland malignancy with divergent differentiation: is it a teratocarcinosarcoma?

Four poorly differentiated malignant lesions occurred in a 60-year-old Chinese male in the nasal cavity, submandibular gland, a lymph node in the neck, and the mandible. These malignant lesions developed within an 8-year period and each showed distinctive histological features. Among these malignant lesions, the neoplasm in the submandibular gland presented variegated histological and immunohistochemical (IHC) features and posed a diagnostic challenge in interpretation. Based on microscopic and IHC findings, we believe the diagnosis of teratocarcinosarcoma is justified for the submandibular neoplasm and the metastasis in the lymph node. The pathological features and diagnoses of these malignant lesions are discussed.

Sinonasal teratocarcinosarcoma.

Sinonasal teratocarcinosarcoma (SNTCS) is a distinctly rare tumor characterized by a variegated histologic architecture of epithelial and mesenchymal components. By reported accounts, SNTCS is a highly malignant tumor displaying rapid, aggressive growth. Prognosis is poor: less than 45% of all patients survive past 5 years. Combination surgery and radiotherapy currently appear to be the most effective treatment. This report presents a 76-year-old African American man with a SNTCS in the right nasal cavity and paranasal sinuses. The patient was treated with combination surgical excision and postoperative radiation therapy. The clinical and pathologic features and clinical course will be discussed.

[Paraneoplastic hyperthyroidism in a patient with metastasizing teratocarcinoma and excessively high HCG]. / Paraneoplastische Hyperthyreose bei metastasiertem Teratokarzinom mit exzessiver HCG-Erhöhung.

Clinically manifest hyperthyroidism is a rare paraneoplastic syndrome in patients with excessive HCG production due to testicular cancer. A 40-year-old patient with right testicular cancer (teratoma, embryonal cell carcinoma), diffuse pulmonary metastases and high serum HCG levels presented with symptomatic hyperthyroidism. The patient received immediately thyrostatic therapy and 4 cycles of PEI chemotherapy (Cisplatin, Etoposide, Ifosfamide). Thyroid function had returned to normal by the beginning of the second course of chemotherapy. After right orchiectomy and resection of residual pulmonary masses which revealed vital tumor cells, two additional courses of chemotherapy were performed. The patient is well and without evidence of disease 11 months after therapy. All patients with testicular cancer and excessive HCG production should be evaluated for biochemical and clinical signs of hyperthyroidism and treated accordingly with antithyroidal medication and immediate cytoreductive chemotherapy.

Pneumonectomy for lung metastases: report of ten cases.

Today, pulmonary resection for lung metastases is a widely accepted treatment if complete resection can be achieved. However, 5-year survival is only 40 %. Many patients develop recurrences, but some reports have demonstrated that salvage operations can result in a long-term survival. A resection of a complete lung or a resection of more than a lung is still controversial since procedure-related morbidity or mortality does not outweigh the survival benefit. We report on a series of 10 consecutive patients who underwent a primary pneumonectomy or an operation on the residual lung after pneumonectomy with curative intent for pulmonary metastases. 5 year survival rates for the 10 patients after pneumonectomy alone or with additional resection was 45 %, which was not significantly different from those who underwent a more minor resection with a 5-year survival of 39 % (p = 0.40). Since there is currently no alternative proven therapy for patients with isolated pulmonary metastases, a primary or completion pneumonectomy may be offered to selected patients as long as sufficient pulmonary reserve is present, and a complete resection can be achieved.

Fungating scrotal mass. Rare clinical presentation of testicular tumor.

We present a case of large fungating scrotal mass in a 18-year-old male. Investigations revealed non-seminomatous germ cell tumor with retroperitoneal nodes. Systemic chemotherapy was followed by excision of the mass. This rare presentation is reported here.

[Surgical treatment of intrathoracic compression of respiratory ways caused by mediastinal teratocarcinoma in children]. / Khirurgicheskoe lechenie vnutrigrudnoi kompressii dykhatel'nykh putei, obuslovlennoi teratodermoidnoi opukhol'iu sredosteniia, u detei.

Twelve children with mediastinal teratodermoid tumor, causing intrathoracic compression of respiratory ways (ITCRW) in 8 of them, were treated in clinic. In 75% of children with ITCRW the conduction of special preoperative preparation was necessary. All the patients were operated on. Tumor was removed en bloc or using the fragmentation method. In secondary tracheomalacia the anterior aortopexy for the tracheal lumen preservation was done simultaneously.

Case report: Sinonasal teratocarcinosarcoma.

Sinonasal teratocarcinosarcoma (SNTCS) is a rare, teratoma-like lesion of the nasal cavity and paranasal sinus. To the best of our knowledge, SNTCS is highly malignant. We report a case of SNTCS arising in the nasal cavity of a 71-year-old male who complained of nasal obstruction and epistaxis. In spite of intensive treatment, the tumor recurred three times and the patient died from a local extension into the anterior cranial fossa 7 years after initial onset. The resected tumors consisted of variegated components, such as epithelial elements, including cystic, ductal and glandular structures occasionally associated with squamous differentiation, neuroectodermal ones exhibiting neural rosette formation, and mesenchymal ones with prominent rhabdomyoblastic differentiation. Immunohistochemical and ultrastructural studies clearly demonstrated characteristic cellular differentiation of each component. These three principal elements were often topographically related and showed morphological transition with each other. These findings suggest the derivation of divergent components from common progenitor cells. Although the cellular atypia of the primary lesion was inconspicuous, the recurrent tumors became anaplastic and mitotically active. Histologic anaplasia may be somewhat related with aggressiveness of recurrent lesions. Appropriate sampling of specimens, and awareness of this rare teratoid tumor are important to make the correct diagnosis.

Teratocarcinosarcoma of the nasal cavity. Report of a case showing favorable prognosis.

We report a very rare case of teratocarcinosarcoma of the nasal cavity showing a favorable prognosis. The patient was a 66-year-old man with a mass completely obstructing the right nasal cavity. Subsequently, extirpation of the mass and Denker-Watsuji operation were performed, and the patient was treated with a combination of radiation therapy and chemotherapy. Neither recurrence nor distant metastasis was observed during follow-up lasting 30 months. Histologic examination of the resected mass revealed several tissue elements including columnar and squamous epithelia with atypia, smooth muscle cells with rare mitotic activity, and neuroectodermal tissue. The glandular epithelium and smooth muscle cells were reminiscent of a primitive intestinal organoid structure, suggestive of teratomatous tumorigenesis. Our case and a review of the literature indicate that the absence of invasiveness to the stroma or surrounding tissue is closely related to a favorable prognosis.

[Metastasizing malignant germ cell tumor of the testis with infiltration of the thoracic aorta--a case for metastasis surgery]. / Metastasierender maligner Keimzelltumor des Hodens mit Infiltration der Aorta thoracica--Kasuistik zur Metastasenchirurgie.

HISTORY AND FINDINGS: A 33-year-old man was admitted 7 years after a testicular teratomatous carcinoma had first been diagnosed, treated by a right orchiectomy and two-stage radical retroperitoneal lymphadenectomy. Five years later the first mediastinal metastases were treated with high-dosage chemotherapy and autologous germ-cell transplantation, and remaining paraaortic--mediastinal tumour tissue was resected. Two years later another tumour at that site was only partially resected. A curing treatment seemed impossible, because the aortic wall had been invaded. TREATMENT AND COURSE: Five months after re-thoracotomy the metastasis and the invaded aortic segment were resected, the latter replaced by a vascular prosthesis. Histology indicated metastasis of a malignant teratoma of intermediate type. There has been no evident recurrence in the last 20 months. CONCLUSION: Combined orchidectomy, lymphadenectomy, high-dosage chemotherapy with cisplatin and autologous germ-cell transplantation at present constitute the standard treatment of malignant testicular germ-cell tumour. In case of metastatic infiltration of vital structures, such as the aortic wall, special operative procedures can prolong the period of remission when the success of a standard treatment seems limited.

Sinonasal teratocarcinosarcoma: ultrastructural and immunohistochemical evidence of neuroectodermal origin.

The authors report a case of sinonasal teratocarcinosarcoma in a 37-year-old man, which was located in the anterior skull base and extended to the right nasal cavity and paranasal sinuses. The tumor was surgically resected twice, but it could not be removed completely. Microscopically, it was mainly composed of primitive cell nests within a moderately cellular stroma. The components of squamous cell epithelia with focal teratoid appearance and adenocarcinomatous differentiation were observed. There were many rhabdomyoblasts scattered in the nests and stroma. Ultrastructurally, the primitive cells had many neural processes with parallel microtubules, resembling olfactory neuroblastoma. Rhabdomyoblasts showed various degrees of skeletal muscle differentiation. Some of the stromal spindle cells had actin filaments with dense patches and dense core granules. Immunohistochemically, the primitive cells were positive for epithelial markers, neuron-specific enolase, synaptophysin, and myogenic regulatory proteins. The rhabdomyoblasts showed immunoreactivity for myoid markers, cytokeratin, epithelial membrane antigen, and synaptophysin. Most of the stromal spindle cells were positive for smooth muscle actin, neuron-specific enolase and synaptophysin. The immunohistochemical and ultrastructural findings suggest that primitive cells had the most primitive phenotype of placodes, and support the possibility that sinonasal teratocarcinosarcoma is essentially a neuroectodermal tumor with divergent differentiation.

A case report of sinonasal teratocarcinosarcoma.

A sinonasal teratocarcinosarcoma (SNTCS) is a rare and aggressive malignant neoplasm histologically characterized by the combination of one or more epithelial elements and mesenchymal components. We report a case of a 78-year-old man with SNTCS involving the nasal cavity and paranasal sinuses. He complained of epiphora and exophthalmos with weight loss. Physical and diagnostic images resulted T4N0M0. The tumor was completely and widely resected via a trans-facial approach to perform total maxillectomy with orbital exenteration. The clinical presentation, pathologic features, and clinical course are described with a review of the literature.

Bilateral pulmonary resection for lung metastases: report of two cases.

Resection of bilateral pulmonary metastases is exceptional. However, in carefully selected patients extensive resections might be successfully performed. We report two patients who underwent a pneumonectomy and excision of pulmonary metastases in the other lung, via a left wedge resection for patient 1 and left segmentectomy for patient 2. Resections were carried out for metastases of a malignant fibrous histyocytoma and for a teratocarcinoma. Both patients are still alive 9 months and 4 years after their last metastasectomy, respectively.