Pericardial synovial sarcoma of the heart; is it always worth operating?

Synovial sarcoma is a rare malignant soft-tissue tumor that most commonly occurs in the extremities of young adults. Primary pericardial synovial sarcoma is extremely rare. We report the case of a 37 year old male patient who presented with intermittent fever, nocturnal sweating and asthenia. Chest X-ray revealed an enlarged cardiac silhouette. Echocardiography identified pericardial effusion and a mass compressing the right ventricle. After percutaneous drainage of the effusion, the mass was not visible and deemed to have been septations of the effusion. Chest computed tomography (CT) did not show the mass visible on the X-ray. At one month follow-up, the pericardial mass was again visible on echocardiography and confirmed by magnetic resonance imaging (MRI). CT-guided biopsy showed malignant mesenchymal cells. Complete resection was attempted, but not possible due to diffuse infiltration of the epicardium. Histological examination of the resected tissue revealed an undifferentiated primary pericardial synovial sarcoma. The patient refused adjuvant treatment and died 15 days later. Surgical resection is considered the cornerstone of treatment of this rare type of malignant tumor of the young; our patient presented with a diffusely infiltrating tumor which could not be resected and required reoperation for tamponade and left pericardectomy. We question whether the choice to attempt resection was beneficial.

Anomalous inferior vena cava complicating abdominal aortic aneurysmectomy.

Variations in the site and course of the inferior vena cava (IVC), although relatively infrequent, can have important surgical implications, especially during surgery for abdominal aortic aneurysm. We report two cases of left-sided IVC encountered during aneurysmectomy. In both cases, the anomaly was not detected during preoperative ultrasound examination, but was identified by CT scan in one case. Careful mobilization of the IVC and left iliac vein allow retraction of the IVC to the right, after which the aneurysm can be approached in the usual manner.

Palliation of malignant gastric outlet obstruction with self-expanding metal stents.

BACKGROUND AND STUDY AIMS: Self-expanding metal stents have long been used in the management of patients with malignant esophageal and malignant biliary obstruction. The aim of the present study was to report on the palliation of malignant gastric outlet obstruction using self-expanding endoprostheses. PATIENTS AND METHODS: Between March 1993 and December 1994, 12 patients (eight women, four men, mean age 64 years) suffering from malignant gastric outlet obstruction due to recurrent gastric carcinoma (seven patients) and pancreatic head carcinoma (five patients) presented with an inability to eat and intractable vomiting. The patients were managed with peroral insertion of self-expanding metal stents. RESULTS: Peroral introduction of the stent with the aid of a stabilizing overtube was successful in all patients, with the stent being supported as it was being advanced through the stenosis. Proper release of the stent into the stenotic area was achieved in all cases, relieving the intractable vomiting. The procedure was accomplished without any complications. All patients were able to eat semisolid food four days after the stent insertion. Apart from an asymptomatic partial stent occlusion in one patient, no other complications were seen during the short-term follow-up one, two, and three months after discharge. CONCLUSIONS: These preliminary results suggest that self-expanding stents can effectively relieve malignant gastric outlet obstruction.