An Aggressive Large Epithelioid Hemangioendothelioma of the Anterior Mediastinum in a Young Woman.

Hemangioendothelioma is a rare vascular tumor with involvement of the liver, brain, long bones, and lung. Among the 6 histological subtypes, epithelioid hemangioendothelioma (EHE) is the most aggressive. Its occurrence in the mediastinum is quite rare, and very few cases have been documented. The reported cases in the literature have described difficulties in the preoperative diagnosis due to the unusual histological appearance of the tumor. Immunohistochemistry remains the mainstay for a definitive diagnosis. Due to its low incidence, there is no standard treatment for mediastinal EHE, but curative resection is the preferred treatment option where possible, with chemotherapy used as an adjuvant treatment or in cases of widespread inoperable disease. The present case study describes an aggressive EHE occurring in an 18-year-old woman in the anterior mediastinum.

Robotic adrenalectomy for a large right adrenal tumour.

The robotic approach for adrenalectomy has revolutionized the field of minimal access surgery for benign adrenal tumours. Robotic adrenal surgery has the edge over conventional laparoscopic adrenal surgery as it provides 3D stereoscopic vision, a high degree of dexterity with the use of EndoWrist instruments, and an ergonomic position for the surgeon. Here, we present our experience with robotic adrenal surgery in a large right adrenal tumour.

Eleven-year experience in thoracoscopic excision of bronchogenic cyst.

OBJECTIVES: bronchogenic cysts are uncommon congenital cystic lesions. Most are incidentally detected and require surgical excision for histological diagnosis, symptom relief, and to prevent complications. Video-assisted thoracoscopic resection is preferable in suitable patients. In this study, we reviewed the clinical presentation, diagnosis, and thoracoscopic treatment of bronchogenic cysts. METHODS: from January 2001 to December 2011, 14 patients with bronchogenic cyst underwent thoracoscopic surgery for excision of the cyst. Their mean age was 24 years. Twelve patients were symptomatic (85.71%). RESULTS: the average maximum diameter of the cysts was 6.7 cm. The most common location of the cyst was the mediastinum (n = 10, 71.4%). All bronchogenic cysts were completely excised. In 7 cases, the procedure was converted to thoracotomy. The mean hospital stay following thoracoscopic surgery was 4 days. There was no recurrence on follow-up. CONCLUSIONS: thoracoscopic excision of a bronchogenic cyst should be considered the first-line therapeutic option. Proper preoperative case selection can prevent conversion to thoracotomy due to major pleural adhesions. There should be a low threshold for conversion to thoracotomy if complete excision of the cyst is not possible, because this is the main goal of treatment to prevent recurrence.

Primary mediastinal chondrosarcoma with Horner's syndrome.

Chondrosarcomas are uncommon tumors of the mediastinum. Cases reported in the literature are chondrosarcomas originating from osteocartilaginous structures; primary chondrosarcomas that have no anatomical relation with cartilaginous structures are rare. They present with myriad symptoms depending on compression of the adjacent structures; but Horner's syndrome, as a symptom, has not been described before. We report a rare case of a large primary mediastinal chondrosarcoma that presented with Horner's syndrome.

Primary pulmonary synovial cell sarcoma: radiological findings and management.

Primary pulmonary synovial cell sarcoma is a rare tumor without specific symptoms, signs, or radiological features. The role of functional imaging has not yet been evaluated, and diagnosis is usually made on histopathological examination. Positron-emission computed tomography findings and surgical resection in a 22-year-old man and a 40-year-old woman are described.

Evaluation of the role of [18F]FDG-PET/CT and [68Ga]DOTATOC-PET/CT in differentiating typical and atypical pulmonary carcinoids.

Pulmonary carcinoids are histologically classified into typical and atypical. It is important to identify these preoperatively for treatment planning and prognosis. Structural imaging cannot conclusively differentiate between them. The aim of this study was to assess the possibility of differentiating the 2 variants using [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) and [68Ga]1,4,7,10-tetraazacyclododecane-N(I-IIII)-tetraacetic acid-(D)-Phe1-Thy3-octreotide (DOTATOC)-PET/CT. The imaging results of 20 patients with pulmonary carcinoids (13 typical, 7 atypical) on [18F]FDG-PET/CT and [68Ga]DOTATOC-PET/CT were assessed retrospectively. Six typical carcinoids failed to reveal significant uptake on [18F]FDG-PET/CT. All the atypical carcinoids revealed significant uptake on the [18F]FDG-PET/CT that was higher than that in typical carcinoids (standardized uptake value (SUV)max, 2.9-8.4, P = 0.001). The SUVmax in typical carcinoids on [68Ga]DOTATOC-PET/CT was significantly higher (SUVmax, 8.8-66) compared with atypical carcinoids (SUVmax, 1.1-18.5, P = 0.002). Ratios of SUVmax on [68Ga]DOTATOC-PET/CT to that on [18F]FDG-PET/CT were significantly higher (P < 0.001) in typical carcinoids compared with atypical carcinoids. The different uptake patterns on [18F]FDG and [68Ga]DOTATOC-PET/CT. and the ratio of SUVmax may be helpful in differentiating between typical and atypical carcinoids.

Evaluation of mediastinal lymph nodes using F-FDG PET-CT scan and its histopathologic correlation.

AIMS AND OBJECTIVES: To determine the efficacy of integrated (18)F-fluorodeoxy glucose positron emission tomography-computed tomography ((18)F-FDG PET-CT) in the evaluation and characterization of mediastinal lymph nodes into benign and malignant pathology. METHODS: Thirty-five patients with mediastinal lymphadenopathies without primary neoplastic or infective lung pathologies were included in the study. The lymph nodes were detected on contrast-enhanced CT scan of the chest. All patients underwent (18)F-FDG PET-CT scan for evaluation of mediastinal lymph nodes. Results of PET-CT were compared with histopathology of the lymph nodes and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. STATISTICAL ANALYSIS: The data were collected prospectively and analyzed using (SPSS Inc., Chicago, IL) 11.5 software. RESULTS: Histopathology results in 35 patients revealed tuberculosis in 12, sarcoidosis in 8, and lymphoma in 15. Maximum standardized uptake value (SUVmax) of the benign lymph nodes ranged from 2.3 to 11.8 with a mean±standard deviation (SD) of 5.02±3.26. SUVmax of the malignant lymph nodes ranged from 2.4 to 34 with a mean±SD of 10.8±8.12. There was a statistically significant difference between benign and malignant pathology (P<0.0059). (18)F-FDG PET-CT has sensitivity of 93% and specificity of 40% with SUVmax 2.5 as the cutoff. We found the optimal SUVmax cutoff to be 6.2 as determined by the receiver-operator characteristic curve. With 6.2 as cutoff, the sensitivity, specificity, and accuracy were 87%, 70%, and 77%, respectively. CONCLUSION: In countries where tuberculosis and other granulomatous diseases are endemic, SUVmax cutoff value of 2.5 has low specificity. Increasing the cutoff value can improve the specificity, while maintaining an acceptable sensitivity.

Surgically treated aggressive mediastinal sarcoma: a tumor of possible thymic origin.

True sarcoma of thymus has no epithelial component. This tumor behaves aggressively with invasion of adjacent structures. Only a few anecdotal case reports of this tumor are found in the English-language literature, and they describe a poor outcome. This case report describes a rapidly growing thymic sarcoma diagnosed at an advanced stage with a compressive effect on the heart. The tumor was resected en bloc with adjacent invaded structures.

Emergency video-assisted thoracoscopic foreign body removal and decortication of lung after chest trauma.

Video-assisted thoracoscopy can be a useful tool in selected chest trauma patients for diagnostic and therapeutic purposes. A metallic foreign body, embedded in peripheral lung parenchyma, was removed successfully with blood clot evacuation and limited decortication of lung in a hemodynamically stable 10-year-old patient using a video-assisted thoracoscopic technique.

Role of positron emission tomography-computed tomography in bronchial mucoepidermoid carcinomas: a case series and review of the literature.

INTRODUCTION: Mucoepidermoid carcinoma of the tracheobronchial tree is rare. Such tumors usually present with signs and symptoms of bronchial obstruction. Histologically, they can be classified as high-grade or low-grade tumors. Experience of imaging these tumors with 18fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) is limited. We present three cases of this rare tumor, describe the functional imaging results, and review the available literature. CASE PRESENTATION: Three Caucasian patients, two men (21 and 24 years of age) and one woman (14 years of age), with bronchial masses were evaluated by us. All three patients were symptomatic, and underwent a thorough clinical examination, bronchoscopy and biopsy, plain computed tomography, 18F-FDG PET-CT and 68Gallium 1,4,7,10-Tetraazacyclododecane-NI,NII,NIII,NIIII,- tetra acetic acid (D) - Phel1-Tyr3-octreotide positron emission tomography-computed tomography (68Ga-DOTATOC PET-CT). 18F-FDG PET-CT revealed mild uptake in all three patients, whereas 68Ga-DOTATOC PET-CT revealed no significant uptake in any patient, making carcinoid tumor unlikely. Results of histopathological examination were consistent with low-grade mucoepidermoid carcinoma in all patients. CONCLUSION: Our study reveals that functional imaging may be helpful in the initial investigation of patients with mucoepidermoid carcinoma. 18F-FDG PET-CT may have a prognostic relevance by predicting the histopathologic differentiation of the tumor.

Role of (68)Ga-DOTATOC PET/CT in the evaluation of primary pulmonary carcinoids.

BACKGROUND/AIMS: Although carcinoid tumors usually have good prognosis, early and specific diagnosis is important. Computed tomography and magnetic resonance imaging do not provide findings that are specific for carcinoids, and somatostatin receptor scintigraphy suffers from low spatial resolution. 18-Fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) has limited sensitivity for carcinoids due to low uptake of the marker. A PET/CT system that uses the somatostatin receptor-based PET tracer 1,4,7,10-tetraazacyclododecane-N(I),N(II),N(III),N(IIII)-tetraacetic acid (D)-Phe(1)-thy(3)-octreotide ((68)Ga-DOTATOC) has also been used in the evaluation of carcinoids, although information regarding its use for the detection of primary pulmonary carcinoids is limited. Thus, we investigated the value of (68)Ga-DOTATOC PET/CT for the diagnosis of primary pulmonary carcinoid tumors. METHODS: This was a retrospective analysis of patients with primary pulmonary tumors who underwent (68)Ga-DOTATOC PET/CT. All the patients had a histopathologic diagnosis of carcinoid. The rate of detection of primary pulmonary carcinoid tumors using (68)Ga-DOTATOC PET/CT was assessed. RESULTS: Twenty patients were diagnosed as having carcinoid, and 19 tumors showed significant uptake on (68)Ga-DOTATOC (detection rate, 95%). The maximal standardized uptake value (SUV(max)) ranged from 1.1 to 66, with a median value of 21.6. In one patient, (68)Ga-DOTATOC PET/CT revealed additional lesions. CONCLUSIONS: Our results demonstrate that (68)Ga-DOTATOC PET/CT is useful in the evaluation of primary pulmonary carcinoids and should be included in the diagnostic work-up of these patients.

Endobronchial fibroleiomyomatous hamartoma: a diagnostic pitfall.

A 46 year-old man was found to have a polypoidal growth in the lumen of the right main bronchus. Fiberoptic bronchoscope-guided biopsy of the mass on two occasions showed acute-on-chronic inflammation. The origin of the polyp was the right upper lobe bronchus; and upper lobectomy with adequate resection margin was done. Histopathology examination of the polyp showed features compatible with benign fibroleiomyomatous hamartoma. True fibroleiomyomatous hamartoma arising primarily in the lung is rare and presents as a pulmonary parenchymal lesion. the endobronchial variant of this tumor is extremely uncommon and not well documented in the literature. A preoperative diagnosis is difficult, and a high index of suspicion is required for diagnosing this benign neoplasm.

Thymic neuroendocrine tumour (carcinoid): clinicopathological features of four patients with different presentation.

Thymic carcinoids are aggressive and present at an advanced stage. This article describes the utility of (68)Gallium-1,4,7,10-traazacyclododecane-NI, NII, NIII, NIIII-tetra acetic acid-(D)-Phel1-Tyr3-octreotide positron emission tomography ((68)Ga DOTATOC PET-CT-scan) and clinicopathological features of four thymic carcinoid tumours. Two typical, one atypical, and one large cell neuroendocrine carcinoma (LCNEC) were analysed. There were three males and one female with a mean age of 33 years. Three patients had a stage III and one had a stage II tumour. Preoperative (68)Ga DOTATOC PET-CT-scan of three patients did not show uptake of radiotracer in the tumour. Three patients were disease free at 19-27 months follow-up. The patient with LCNEC developed recurrence in the lumbar vertebrae. There is no locoregional recurrence of tumour in any of our patients. Complete surgical resection of the tumour with invaded adjacent structures, postoperative radiotherapy to the tumour bed helps in obtaining disease free survival.

Functional imaging in differentiating bronchial masses: an initial experience with a combination of (18)F-FDG PET-CT scan and (68)Ga DOTA-TOC PET-CT scan.

OBJECTIVE: To evaluate the role of combination of (18)F-FDG PET-CT scan and (68)Ga DOTA-TOC PET-CT scan in differentiating bronchial tumors observed in contrast enhanced computed tomography scan of chest. STUDY DESIGN: Prospective observational study. Place of study: All India Institute of Medical Sciences, New Delhi, India. METHODS: 7 patients with bronchial mass detected in computed tomography scan of the chest were included in this study. All patients underwent (18)F-FDG PET-CT scan, (68)Ga DOTA-TOC PET-CT scan and fiberoptic bronchoscope guided biopsy followed by definitive surgical excision. The results of functional imaging studies were analyzed and the results are correlated with the final histopathology of the tumor. RESULTS: Histopathological examination of 7 bronchial masses revealed carcinoid tumors (2 typical, 1 atypical), inflammatory myofibroblastic tumor (1), mucoepidermoid carcinoma (1), hamartoma (1), and synovial cell sarcoma (1). The typical carcinoids had mild (18)F-FDG uptake and high (68)Ga DOTA-TOC uptake. Atypical carcinoid had moderate uptake of (18)F-FDG and high (68)Ga DOTA-TOC uptake. Inflammatory myofibroblastic tumor showed high uptake of (18)F-FDG and no uptake of (68)Ga DOTA-TOC. Mucoepidermoid carcinoma showed mild (18)F-FDG uptake and no (68)Ga DOTA-TOC uptake. Hamartoma showed no uptake on either scans. Synovial cell sarcoma showed moderate (18)F-FDG uptake and mild focal (68)Ga DOTA-TOC uptake. CONCLUSION: This initial experience with the combined use of (18)F-FDG and (68)Ga DOTA-TOC PET-CT scan reveals different uptake patterns in various bronchial tumors. Bronchoscopic biopsy will continue to be the gold standard; however, the interesting observations made in this study merits further evaluation of the utility of the combination of (18)F-FDG PET-CT scan and (68)Ga DOTA-TOC PET-CT scan in larger number of patients with bronchial masses.

Concurrent benign schwannoma of oesophagus and posterior mediastinum.

A 52-year-old female with recent onset dysphagia and haematemesis was found to have an intramural tumour of the oesophagus. A separate tumour in the posterior mediastinum was also detected. Both the tumours were immunohistochemically and histomorphologically compatible with benign schwannoma. Oesophageal schwannoma is extremely rare and its association with a concurrent schwannoma in posterior mediastinum is not reported earlier in the literature.

Neuroendocrine carcinoma of the thymus gland with sternal invasion.

Large-cell neuroendocrine carcinoma of the thymus is a rare cancer that is more aggressive than other thymic epithelial tumors with poorer prognosis. We report one such case in a 44-year-old male patient with invasion into the upper 2/3rd of the sternum but no endocrinopathy. Complete enbloc resection of the tumor with adherent pericardium, upper 2/3rd of the sternum and mediastinal lymphadenectomy was performed. The chest wall was reconstructed with polypropylene mesh and bilateral pectoralis major muscle advancement flap cover. A search of PubMed database with user query words 'neuroendocrine carcinoma, thymus gland, sternal invasion' revealed no case report in the literature of thymic neuroendocrine carcinoma with invasion of the sternum.