A rare cause of dysphagia and simultaneous hoarseness of voice in the octogenarian: a Killian-Jamieson diverticulum, management, and review of literature.

An 82-year-old male presented with progressive dysphagia and simultaneous hoarseness of voice for the past 6 months. He had mitral valve repair and a permanent pacemaker for a heart block 5 years ago. A computed tomographic scan of the neck demonstrated a cervical esophageal diverticulum. Oral Gastrogrifin contrast study confirmed esophageal diverticulum in Killian-Jamieson space. Open surgical diverticulectomy was performed safely. Patient's dysphagia resolved immediately, and he regained his normal voice after 6 weeks. Introduction: Killian-Jamieson's esophageal diverticulum is a rare form of pulsion diverticulum which originate through a muscular gap in the anterolateral wall of the esophagus, inferior to the cricopharyngeus muscle and superior to the circular and longitudinal muscle of the esophagus. Killian-Jamieson defined this area where the recurrent laryngeal nerve enters the pharynx, called Killian-Jamieson triangle. Ekberg and Nylander, in 1983, described an esophageal diverticulum in Killian-Jamieson space. The most common clinical manifestations in such patients are dysphagia, cough, epigastric pain, recurrent respiratory tract infections, and rarely hoarseness of voice. In symptomatic patients, surgical or endoscopic resection of the diverticulum is mandatory. We report this case in line with SCARE (Surgical CAse REport) criteria. Case Report: An 82-year-old male presented to our outpatient clinic with a history of progressive dysphagia for solid food and hoarseness of voice for the last 6 months. He denied gastroesophageal reflux, cough, and shortness of breath. On examination of the neck, there was swelling on the left side but no tenderness or lymphadenopathy. Basic blood investigations, including complete blood count, liver, and renal panels, were normal. An echocardiogram showed mild impairment of left ventricle function and normally functioning mitral valve. Chest X-ray showed a pacemaker in position. Computed tomography scan of the neck showed esophageal diverticulum. Gastrogrifin contrast study showed esophageal Killian-Jamieson diverticulum (KJD). Discussion: The acquired esophageal diverticulum is categorized into three types based on its anatomical location. Zenker's and Killian-Jamieson (pulsion diverticulum) in the proximal part, traction diverticulum in the middle part, due to pulling from fibrous adhesions following the lymph node infection and epiphanic pulsion type in the distal esophagus. Although the KJD and Zenker's diverticulum (ZD) arise close to each other in the pharyngoesophageal area, they are anatomically distinct. Although ZD and KJD have the same demographic features, they are more commonly found in older men (60-80 years) and women, respectively. The incidence of ZD is 0.01-0.11%, and KJD is 0.025% of the population. Rubesin et al. reported radiographic findings in 16 KJD cases. They found the majority of them were on the left side (72%), followed by 20% on the right side and 8% bilateral. Conclusion: In conclusion, we report a rare case of dysphagia and simultaneous hoarseness of voice in an octogenarian due to KJD, who was treated with open diverticulectomy, and dysphagia resolved; he regained his voice back after 6 weeks. In our opinion, endoscopic surgery in such a patient with KJD can put recurrent laryngeal at risk of injury since an endoscopic approach operator cannot visualize and dissect away the recurrent laryngeal nerve, particularly when KJD already compresses it.

Mediastinal malignant triton tumor: A rare case series and review of literature.

INTRODUCTION: In 1938, the Malignant Triton Tumor (MTT) was first explained by Mason. CASE PRESENTATION: Case 1: A man aged 28 years presented with chest pain and difficulty in breathing since last five months, there was no history of cough fever or night sweats. Clinical examination was unremarkable. His routine hematological tests including tumor markers were within normal range, testicular ultrasound was normal. CT scan of thorax revealed a mass in the anterior mediastinum. CT guided biopsy revealed a malignant triton tumor. Case 2: A 30 years old man, nonsmoker presented with history of chest tightness and feeling pressure while kneeling down since last 3 months, otherwise fit and healthy. His routine hematological investigations including tumor markers were within normal range. A CT scan of thorax revealed a large mass in the right posterior mediastinum. CT guided biopsy showed malignant triton tumor. Case 3: A man aged 28 years presented with chest pain and difficulty in breathing since last five months, there was no history of cough fever or night sweats. Clinical examination was unremarkable. His routine hematological tests including tumor markers were within normal range, testicular ultrasound was normal. CT scan of thorax revealed a mass in the anterior mediastinum. CT guided biopsy revealed a malignant triton tumor. DISCUSSION: Malignant peripheral nerve sheath tumors (MPNST) are uncommon sarcomatous tumors that are believed to be derived from Schwann cell or neighboring cells with perineurial differentiation. MTT is rarely reported in mediastinum, lung and heart (<10%) To the best of our knowledge, only few cases of MTT in the mediastinum have been reported in English literature, including, four were reported in the anterior mediastinum, three in the posterior mediastinum, one in the middle mediastinum and one between the ascending aorta and the main pulmonary artery. Most of the patients were young adults. We report three cases of rare mediastinal malignant triton tumors. They have been treated with palliative surgery/radical surgery +/- adjuvant therapy. The prognosis varied from a 3 month overall survival time to being alive at a 53 month follow-up period. CONCLUSION: In conclusion we report three rare cases of mediastinal malignant triton tumor treated with radical surgical resection and post-operative radiotherapy, one patient developed lung metastasis, and two had late local recurrence. The malignant triton tumor is a lethal neoplasm which carries very poor prognosis particularly when they occur in the mediastinum because it's very difficult to obtain wider tumor free margin due to the nature of location site.

Radical chest wall resection and modified reconstruction technique for solitary internal mammary lymph node recurrence in breast cancer.

INTRODUCTION: Although the incidence of internal mammary lymph node recurrence rate in breast cancer is low but still it is the second most common drainage site after axilla. Patients with solitary internal mammary lymph node (IMLN) recurrence have overall better prognosis. The role of chemo and radiotherapy in internal mammary lymph node involvement with breast cancer is still controversial. Radical surgical resection and reconstruction remains mainstay for good prognosis. PRESENTATION OF CASE: Here in we present a case of a 32 year old female with breast cancer who had left mastectomy followed by adjuvant chemo radiotherapy treatment for adenocarcinoma of breast in 2008. She presented with upper left parasternal pain in 2009. Computed tomographic scan (CT) of her thorax showed internal mammary lymph node enlargement, likely metastasis. We performed modified surgical reconstruction after enbloc radical resection of part of manubrium; hemi sternum, chest wall and left parasternal IMLN. Patient remained disease free to date. DISCUSSION: There is no standard treatment after IMLN metastasis. Previous surgical studies reported no survival benefit with ERM, but is there any role of adjuvant locoregional radiotherapy or systemic therapy to prevent relapses in IMLN is a matter of debate. CONCLUSION: To the best of our knowledge this is first case ever managed with radical enbloc surgical resection and modified reconstruction of chest wall using such technique. Our reconstruction technique provides better chest wall stability with minimal risk of plate dislodgement or excursion and at the same time provides good cosmoses and better survival.