Ganglioneuroma Of The Right Cervicothoracic Transition.

A 26 year old male, submitted to resection of a ganglioneuroma of the right pulmonary apex through a right Grunenwald approach. The mass insinuated through the innominate vessels, extending posteriorly to the subclavian artery, which it encircled for over 180 degrees, and the right thyrocervical arterial trunk, which was ligated.

Percutaneous Pericardial Drain: A Deadly Embrace Of The Heart.

Pericardial effusions have multiple causes and when significant percutaneous drainage is standard. Usually removal is a simple and quick procedure with reduced risks. Still, the authors present a case were the drain surrounded the heart and great vessels, causing severe pain, bradycardia and hypotension when pulled, forcing a surgical removal of the same.

Post thyroidectomy gossypiboma.

Gossypiboma is an unfrequent surgical complication wich consists in the presence of a mass of textile origin surrounded by a foreign body reaction. The authors present a clinical case of a left paratracheal gossypiboma, diagnosed during the follow-up of a patient submitted to a total thyroidectomy two years before for a papilary carcinoma.

Not always a miracle - The case of the missing metastasis.

Spontaneous regression of malignant neoplasms is extremely rare, but renal cell carcinomas (RCC) are most often associated with this phenomenon. We report a case of a patient with personal history of RCC, who underwent nephrectomy and no other oncological treatment. One year after nephrectomy, a lung metastasis was detected and kept under follow-up for 3 years. Its size increased over time until a needle biopsy was performed, and its metastatic nature confirmed. Wedge resection of the lung nodule was performed, and no neoplastic cells were found, suggesting its spontaneous regression after biopsy. Different theories have been proposed to explain this phenomenon and, in most cases, the mechanism seems to involve the activation of the immune system. This case supports the importance of reducing tumor burden and the impact of the disturbance of the tumor microenvironment caused by instrumentation, in improving immune system activation and its essential role in neoplasm regression.

Solitary Diaphragmatic Metastasis of a Previously Excised Chest Wall Chondrosarcoma.

Chest wall chondrosarcomas are relatively infrequent tumours. Diaphragmatic metastasis are rarer still, and are generally associated with disseminated disease, usually involving the liver and the lungs. The authors present the case of a 65 year old man with a prior history of a chest wall chondrosarcoma, which on a routine chest CT was identified a single diaphragmatic metastasis. A redo thoracotomy was performed, with partial resection and reconstruction of the diaphragm. The post-resection histopathological examination revealed a conventional chondrosarcoma metastasis, centred in the diaphragmatic muscle, not reaching the pleura or the peritoneum.

Not Always a Thymoma - About a Mediastinal Cavernous Hemangioma.

A mediastinal cavernous hemangioma is difficult to distinguish from other types of mediastinal tumours. They are usually asymptomatic and incidentally discovered in an imaging study but can present with compressive symptoms or by infiltration of adjacent structures. A 64-year-old woman with a prior history of triple negative invasive carcinoma of the breast, under surveillance was referred after a Chest CT-scan showed a soft tissue 40x20 mm mediastinal mass, suggestive of a thymoma, and as such no tissue biopsy was obtained. A right-side uniportal VATS was performed, the anterior mediastinum dissected and the mass was exposed, and several anomalous veins were identified. Histopathology showed 36x31x15 mm mass, compatible with a cavernous hemangioma of the anterior mediastinum. This case, whilst not questioning the NCCN statement suggesting not doing a tissue biopsy, points to the fact that rare differential diagnosis, like a Cavernous Hemangioma do exist, and a careful and sound judgement is needed at all times.

GIANT THORACIC MASS - THE STORY OF A SOLITARY FIBROUS TUMOUR.

The tumours of the pleura are a vast and diverse field. One of the lesser known and less common tumour is the solitary fibrous tumour of the pleura, representing about 5% of these types of tumours. The authors present the case of a woman admitted to the emergency department with symptoms of dizziness and vomits. Imaging studies showed a giant thoracic mass on the left hemithorax, with a biopsy indicating a solitary fibrous tumour. The patient was referred for surgery, which was performed via thoracotomy. In the postoperative period she developed an acute pulmonary oedema secondary to lung reexpansion and fluid overload, with a good response to fluid restriction and intravenous diuretics.

Pneumomediastinum: A Brief Review Of Literature Apropos Of A Case Report.

The authors present a case of a 72-year-old man diagnosed with pneumomediastinum in a positron emission tomography scan (18F-FDG PET-CT) to assess the tumor response to palliative chemotherapy. The patient was asymptomatic and had no special findings in physical examination. Conservative approach was decided by the multidisciplinary team. The patient had an uneventful recovery.

PLEURAL METASTASIS OF A PEDIATRIC OSTEOSARCOMA.

INTRODUCTION: Osteosarcoma is the most common primary bone tumor in children and young adults. Although osteosarcoma is a tumor with a great metastatic potential, mainly to the lung; pleural metastasis in patients with osteosarcoma are rarely reported. We present a case of 16 years-old male with a pleural metastasis of a tibial osteosarcoma diagnosed 4years earlier. He was submitted to a left thoracotomy and intra-operatively a pleural mass and a left upper lobe lesion was identified. Video-assisted resection of the extra-pulmonary mass and a wedge resection of the left upper lobe lesion was performed. The surgery was uneventful. The patient is clinically well, asymptomatic, maintains active surveillance.

Mediastinal Teratoma In Children - Case Report.

Mediastinal teratomas presenting in the pediatric age are extremely rare. We report three cases of mediastinal teratomas in children aged 15 months to 9 years. Patients were submitted to complete tumor resection, with an uneventful postoperative course and follow-up. Our report emphasizes the importance of a detailed patient examination and careful interpretation of routinely performed image studies.

BRONCHOPLASTY FOR A TYPICAL CARCINOID: AN UNUSUAL CHOICE FOR AN UNUSUAL PATIENT.

Primary carcinoid tumours of the lung are rare tumours and when typical are associated with a benign behaviour and should be classified as low-grade neuroendocrine tumour/carcinoma. A 67-year old HIV-positive female was admitted due to a typical carcinoid tumour on the distal third of the main left bronchus, occupying two thirds of the lumen. Given she was HIV positive, had a moderately compromised lung function and in order to minimize surgical events, postoperative complications and to maximize postoperative lung function, the authors opted for a bronchoplasty using a patch. The surgery was uneventful and as the resected area of the bronchus was small, patency was assured and the distortion was minimal. During extubation, resistance was felt upon trying to the remove the bronchial blocker. After performing bronchoscopy it was seen that the loop at the end of the bronchial blocker was caught in the patch suture. Fortunately it was possible to cut the loop, freeing the blocker and avoiding a redo surgery. There were several possible options, ranging from left pneumonectomy, superior left lobe sleeve lobectomy, resection of the left main bronchus with a Y bronchial reconstruction or a bronchoplasty using a patch. The chosen technique has several advantages: From an oncological standpoint a typical carcinoid is indolent and needs only a clear resection margin. From a functional standpoint lung tissue resection was prevented. From a surgical standpoint it is less challenging, easy to perform and less prone to surgical events, essential considering the particular case of an AIDS patient.

GIANT THORACIC MASS - THE STORY OF A SOLITARY FIBROUS TUMOUR.

The tumours of the pleura are a vast and diverse field. One of the lesser known and less common tumour is the solitary fibrous tumour of the pleura, representing about 5% of these types of tumours. The authors present the case of a woman admitted in the emergency department with symptoms of dizziness and vomits. Imaging studies show a giant thoracic mass on the left hemithorax, with a biopsy indicating a solitary fibrous tumour. The patient was referred for surgery, which was performed via thoracotomy. In the postoperative period she developed an acute pulmonary oedema secondary to lung reexpansion and fluid overload, with a good response to fluid restriction and intravenous diuretics.

Giant chondrosarcoma of the chest wall: a rare surgical challenge.

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning-sparing key reconstructive options without compromising the tumor resection-allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Giant chondrosarcoma of the chest wall: a rare surgical challenge

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning—sparing key reconstructive options without compromising the tumor resection—allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Aortic valve surgery in patients who had undergone surgical myocardial revascularization previously.

OBJECTIVES: A very high percentage of patients submitted to coronary artery bypass grafting (CABG) develop symptomatic aortic disease requiring surgery upon ageing. The surgical risk of the redo procedure is controversial. We describe our recent experience with patients submitted to this surgery under such conditions. METHODS: From July 1999 to July 2010, 51 patients (mean age, 70.3 ± 7.0 years, 86.3% male) submitted to CABG previously required aortic valve surgery (AVS). The mean interval between the surgeries was 7.1 ± 3.9 years. Twenty-one patients (41.2%) had also undergone AVS during the first surgery [12 patients (57.7%) had valve replacement and 9 patients (42.8%) had valvuloplasty]. At presentation, 51.0% were in New York Heart Association Class III/IV and the standard and logistic EuroSCOREs were 10.1 ± 2.5 and 20.9 ± 16.5%, respectively. RESULTS: Aortic valve replacement was performed in 48 patients (94.1%). Two patients had undergone a surgery for the closure of a peri-prosthetic leak and one patient a valvuloplasty. Thirteen patients (25.5%) needed to undergo additional cardiac procedures, including root enlargement (three patients, 5.9%). Valve surgery was performed with non-dissection of the internal thoracic artery graft, when patented, and antegrade cardioplegic arrest of other territories. Hospital and 30-day mortality rate was 2% (n = 1). The mean duration of hospital stay was 13.0 ± 11.1 days. The most frequent complication was arrhythmias - in 25.5% of the patients, and mostly due to atrial fibrillation (19.6%). Permanent pacemaker for A-V block was required in 5.9% of the cases, stroke was documented in two cases (3.9%) and early re-intervention was observed in two cases. CONCLUSIONS: Redo AVS performed in patients submitted to CABG previously results in mortality and morbidity rates that are much lower than what is expected, bringing clear benefits to the patients.

Aortic root enlargement does not increase the surgical risk and short-term patient outcome?

OBJECTIVE: To analyze the short-term outcome of aortic root enlargement (ARE) using death and adverse events as end points. METHODS: From January 1999 through December 2009, 3339 patients were subjected to aortic valve replacement (AVR). A total of 678 were considered to have small aortic roots (SARs) in which an aortic prosthesis size 21 mm or smaller was implanted. ARE using a bovine pericardial patch was performed in another 218 patients, who constitute the study population. This comprised 174 females (79.8%); the mean age was 69.4 ± 13.4 years (8-87, median 74 years), the body surface area (BSA) was 1.59 ± 0.15m² and the body mass index (BMI) 25.77 ± 3.16 k gm⁻², and 192 (88.5%) were in New York Heart Association (NYHA) II-III. Preoperative echocardiography revealed significant left ventricular (LV) dysfunction in 17 patients (8%), a mean aortic valve area of 0.57 ± 0.27 cm², and a mean gradient of 62.51 ± 21.25 mm Hg. A septal myectomy was performed in 129 subjects (59.2%), and other associated procedures, mostly coronary artery bypass grafting (CABG), in 60 (27.5%). Bioprostheses were implanted in 161 patients (73.9%). The mean valve size was 21.9 ± 1.0 (21-25). The mean extracorporeal circulation (ECC) and aortic clamping times were 82.8 ± 19.8 min and 56.8 ± 12.5 min, respectively. RESULTS: Hospital mortality was 0.9% (n=2) for ARE as compared with 0.6% (n=4) for the SAR group (p=0.8). Inotropic support was required in only 13 (5.9%) patients and the first 24-h chest drainage was 336.2 ± 202 ml. Other complications included pacemaker implantation (7.8%), acute renal failure (10.6%), respiratory (4.1%), and CVA/transient ischemic attack (CVA/TIA) (3.2%). Postoperative echocardiographic evaluation showed a significant decrease in peak and mean aortic gradients (23.7 ± 9.5 and 14 ± 6.2 mm Hg, respectively, p<0.0001). The mean indexed effective orifice area (iEOA) was 0.92 ± 0.01 cm² m⁻² (vs 0.84±0.07 cm² m⁻², in SAR, p<0.0001). Only 11% of patients (n=24) with ARE exhibited moderate patient-prosthesis mismatch (PPM) and none had severe PPM. Mean hospital stay was 9.7 ± 9.29 days (median 7 days). CONCLUSIONS: With the growing number of patients with degenerative aortic valve pathology, mainly an older population, sometimes with calcified and fragile aortic wall, the issue of dealing with an SAR poses the dilemma of whether to implant a smaller prosthesis and admit some degree of PPM, or to enlarge the aortic root. This study demonstrates that the latter can be done in a safe and reproducible manner.