Reconstruction of the chest wall after resection of malignant peripheral nerve sheath tumor: A case report

BACKGROUNDMalignant peripheral nerve sheath tumors (MPNSTs) are a group of rare and aggressive sarcomas that often arise from major peripheral nerves and represent a notable challenge to efficacious treatment. MPNSTs can occur in any body surface and visceral organs with nerve fiber distribution. The treatment options for MPNSTs include surgery, chemotherapy, and adjuvant radiotherapy. CASE SUMMARYA 26-year-old female cellist presented with chest pain on her left side when she squatted to lift the cello. One week later, a chest X-ray was performed and revealed fracture of the fourth rib on the left side. Three months later, the patient inadvertently touched a mass on the left side of the chest wall. Chest computed tomography (CT) three-dimensional reconstruction of the ribs revealed bone destruction of the fourth rib on the left side with a soft tissue mass shadow measuring 5.7 cm × 3.7 cm. CT-guided puncture biopsy of the tumor showed that heterotypic cells (spindle cells) tended to be nonepithelial tumor lesions. PET-CT demonstrated bone destruction and a soft tissue mass with avid 18F-fluorodeoxyglucose activity (SUV_max7.5) in the left fourth rib. The tumor of the left chest wall was resected under general anesthesia, and reconstruction of the chest wall was performed. The postoperative pathological report exhibited an MPNST.CONCLUSIONMPNSTs are relatively chemo-insensitive tumors. The mainstay of treatment for MPNSTs remains resection with tumor-free margins.     

Pheochromocytoma in a 49-year-old woman presenting with acute myocardial infarction: A case report

BACKGROUNDPheochromocytoma is a rare endocrine tumor arising from chromaffin cells and having extensive and profound effects on the cardiovascular system by continuously or intermittently releasing catecholamines. The clinical manifestations of pheochromocytoma are diverse, and the typical triad, including episodic headache, palpitations, and sweating, only occurs in 24% of pheochromocytoma patients, which often misleads clinicians into making an incorrect diagnosis. We herein report the case of a patient with intermittent chest pain and elevated myocardial enzymes for 2 years who was diagnosed with pheochromocytoma.CASE SUMMARYA 49-year-old woman presented with intermittent chest pain for 2 years. Two years ago, the patient experienced chest pain and was diagnosed with acute myocardial infarction, with 25% stenosis in the left circumflex. The patient still had intermittent chest pain after discharge. Two hours before admission to our hospital, the patient experienced chest pain with nausea and vomiting, lasting for 20 min. Troponin I and urinary norepinephrine and catecholamine levels were elevated. An electrocardiogram indicated QT prolongation and ST-segment depression in leads II, III, aVF, and V3-V6. A coronary computed tomography angiogram revealed no evidence of coronary artery disease. Echocardiography showed left ventricular enlargement and a decreased posterior inferior wall motion amplitude. Contrast-enhanced computed tomography demonstrated an inhomogeneous right adrenal mass. The patient successfully underwent laparoscopic right adrenalectomy, and histopathology confirmed adrenal pheochromocytoma. During the first-year follow-up visits, the patient was asymptomatic. The abnormal changes on echocardiography and electrocardiogram disappeared. CONCLUSIONClinicians should be aware of pheochromocytoma. A timely and accurate diagnosis of pheochromocytoma is essential for alleviating serious cardiac complications.     

超声心动图诊断双心房占位

目的探讨双心房占位病变的临床表现及超声心动图特征。方法回顾性分析双心房占位患者8例,分析其临床资料及超声心动图表现,并与术后病理相对照。结果双心房占位的8例患者中,双心房血栓5例,肿瘤3例,其中良性1例,恶性2例。6例表现为活动后胸闷憋气,2例为下肢水肿,1例为右胸痛。双心房血栓占位主要表现为基底部较宽,无蒂,较易附着于心房顶部、心房侧壁心耳开口处及心耳内血流缓慢处。良性肿瘤主要为黏液瘤,表现为多发,瘤体松散,活动度大,有较窄的蒂与心房壁或房间隔相连。恶性肿瘤占位主要表现为向心房壁或间隔壁浸润性生长,位置固定,宽基底并伴中-大量心包积液。结论应用超声心动图可探查双心房占位的原发病变,可为临床治疗方案提供依据。     

猪源人工骨进行胸壁缺损修复重建的疗效观察

目的探讨用猪源生物材料骨进行骨性胸壁缺损修复重建的方法及疗效。方法对2008年12月至2011年9月我院胸外科收治的21例胸壁缺损患者用猪源生物材料骨进行重建。其中男16例,女5例,平均年龄45.8岁(10～72岁),17例为胸壁肿瘤或肺肿瘤侵犯胸壁手术切除后造成胸壁缺损,用猪源生物材料骨进行肋骨重建,外被自身软组织;4例为纵隔或胸骨肿瘤切除后造成胸骨或胸骨合并前胸壁缺损患者,用猪源生物材料骨替代胸骨与两侧前肋及锁骨固定。结果 21例患者均胸廓成形满意,术后无反常呼吸运动、浮动胸骨、血气胸、感染及材料相关并发症,术后X线及CT检查见生物材料骨与自体肋骨连接部有骨痂形成。随访6个月至3年3个月,全部病例胸廓成形满意,无材料松动、脱落、变形及折断。结论用猪源生物材料骨进行胸壁缺损修复重建疗效满意,术后见连接部有骨痂形成。     

Malignant pleural mesothelioma with scalp, cerebellar, and finger metastases: a rare case

Malignant pleural mesothelioma (MPM) is a rare and asbestosis-associated tumor. MPM commonly invades locally, mostly in the lung, heart, pericardium, chest wall, and vertebrae. Distant metastasis of MPM is very rare. Here we report a patient with MPM who presented with multiple unusual distant metastases. The patient's thorax tomography demonstrated right-sided, irregularly-thickened pleura with nodular masses and invasion of the chest wall into the subcutaneous area. The patient underwent biopsy for a subcutaneous mass in the right anterior chest wall. Pathologic examination revealed a malignant mesenchymal tumor. During follow-up, he suffered from a painful nodule on the scalp and nodules on the fingers, as well as weakness in his right arm. Cranial magnetic resonance imaging illustrated a 1 cm nodule in the left cerebellar hemisphere. Histopathologic examination of the biopsy from the nodule on the scalp revealed a typical mixed type of MPM, with calretinin, vimentin and creatine 5/6 positivity. Distant metastases can be seen in MPM and a biopsy of metastatic regions can yield the diagnosis.     

Surgical therapy for hemangioma of the azygos vein arch under thoracoscopy: A case report

BACKGROUNDAzygos vein aneurysms are extremely rare, and their pathogenesis is not clear. The overwhelming majority of patients have no obvious clinical symptoms and are found to have the disease by physical examination or by chance. There are few reports on the diagnosis of and treatment strategy for this disease. Moreover, the choice of therapeutic schedule and the treatment window are controversial.CASE SUMMARYWe report a case of azygos vein arch aneurysm in a 53-year-old woman. The patient had symptoms of back pain, chest tightness, and choking. Enhanced chest computed tomography showed a soft-tissue mass in the right posterior mediastinum, which was connected to the superior vena cava. The enhancement degree in the venous phase was the same as that of the superior vena cava. The patient received video-assisted thoracoscopic surgery. After the operation, her back pain disappeared, and her dysphagia and chest tightness were also significantly relieved. The postoperative pathology confirmed hemangioma. The patient was discharged on the seventh day after surgery without any comp-lications.CONCLUSIONSome patients with hemangioma of the azygos vein arch may experience dysphagia and chest tightness caused by the tumor compressing the esophagus and trachea. Enhanced computed tomography scanning is vital for the diagnosis of azygos vein aneurysms. In addition, despite the difficulty and risk of surgery, thoracoscopic surgery for azygos vein aneurysms is completely feasible.     

Malignant pheochromocytoma presenting as incapacitating bony pain

Among adrenal incidentalomas, pheochromocytomas are rare. Malignant pheochromocytoma is even less common, and it typically presents with classic hormonal symptoms, such as palpitations, labile blood pressures, and headaches. Bony metastasis usually occurs late in disease, but we report an unusual case of incapacitating bony pain as the initial presentation of malignant pheochromocytoma. Our patient is a 70-year-old woman with neurofibromatosis type 1 and a history of primary hyperparathyroidism, who tested negative for the ret mutation. She came to medical attention with chest pain and palpitations and was incidentally found to have an adrenal mass. Serum and urine testing was consistent with pheochromocytoma. Her blood pressure was easily controlled as she awaited elective adrenalectomy; however, she quickly developed severe, diffuse bony pain. She represented with hypercalcemia, spontaneous fractures, and incapacitating pain that required such high doses of pain medications that she had to be intubated. Further imaging and bone marrow biopsy confirmed metastatic neuroendocrine tumor. She received one round of chemotherapy with no change in her bony pain, which was her primary complaint. Unfortunately, her treatment options were limited by the heavy sedation required for comfort, and in the end, it was her bony pain rather than hormonal symptoms that made her disease untreatable.     

Bilateral loculated pleural effusion as a manifestation of acute parenteral organophosphate intoxication: a case report

BackgroundAcute organophosphate (OP) toxicity causes a wide range of clinical effects on the respiratory system, including pulmonary bronchoconstriction and bronchorrhea. Morbidity and mortality from acute OP toxicity correlate best with pulmonary secretions.ObjectiveIn this article, we report bilateral loculated pleural effusion as a rare pulmonary effect in a patient with acute parenteral OP toxicity.Case ReportA 25-year-old, previously healthy woman was transferred to our Poison Department 3 days after suicidal injection of malathion. At the time of presentation her vital signs were normal, except that her respiratory rate was 24 breaths/min. She complained of pleuritic chest pain and had a cough productive of yellow sputum. She had generalized chest wall tenderness, and breath sounds were decreased in the base of both lung fields. Standard therapy for OP toxicity, including atropine, pralidoxime, and diazepam, was initiated. Due to persistent pleuritic chest pain, a computed tomography (CT) scan was performed that showed bilateral loculated pleural effusions. Shortly after hospital admission, the patient developed respiratory distress, for which she was intubated and transferred to the Intensive Care Unit. She received continued medical therapy and was extubated on hospital day 3. A CT scan of the chest on hospital day 9, after completion of the treatment, documented resolution of the effusions.ConclusionParenteral OP toxicity occurs rarely, and in this case it was associated with bilateral loculated pleural effusions. In this regard, it should be considered in a patient with acute parenteral OP toxicity and persistent chest wall pain.     

盆壁肿瘤的多层螺旋CT诊断

目的 通过对盆壁肿瘤的多层螺旋CT表现的分析,提高对其CT诊断的认识.方法 回顾性分析20例盆壁肿瘤的多层螺旋CT表现,其中转移瘤10例,神经源性肿瘤5例(其中神经鞘瘤2例,神经纤维瘤1例,神经纤维瘤病2例),软骨肉瘤2例,脊索瘤1例,骨巨细胞瘤1例,骨软骨瘤1例.结果 盆壁肿瘤的主要征象包括骨质破坏、软组织肿块,转移...     

胸壁肿瘤的外科治疗(附77例报告)

目的：探讨胸壁肿瘤的诊断及外科治疗,方法：回顾分析我科１９８３年～１９９８年７７例胸壁肿瘤外科手术治疗的临床资料。结果：经手术治疗的胸壁肿瘤７７例,原发性胸肿瘤６２例（良性４３例,恶性１９例）。转移性胸壁肿瘤１５例,本组病例皆取手术治疗,其中对１２例较大骨性胸壁缺损病人采用重建材料修复,结论：胸壁肿瘤临床表现以疼痛及肿块为主,多采用手术治疗。较大的骨性胸壁缺损需有重建材料修复,比较各种胸壁重建材料,硅橡胶绦纶丝网颅骨成型片（颅骨替代品）用于胸壁修补重建,优点鲜明且全面,可以作为一种理想的胸壁修复材料。     

Thoracic pyogenic infectious spondylitis presented as pneumothorax: A case report

BACKGROUNDPyogenic infectious spondylitis (PIS) is a rare condition, with an incidence between 0.2 and 2 cases per 100000 per annum. It’s most common symptom—back or neck pain—occurs in more than 90% of cases. Herein, we reported a case of thoracic PIS accompanied by pneumothorax in a 65-year-old male patient.CASE SUMMARYA 65-year-old man presented with right chest pain and dyspnea. The initial erect posteroanterior chest radiography revealed pneumothorax, which was further evaluated by chest computed tomography, revealing pleural effusion in the right lung and a paravertebral abscess with bony destruction of vertebral body. Based on magnetic resonance imaging, the patient was diagnosed with thoracic infectious spondylitis with an anterior paravertebral abscess. He was prescribed antibiotics and underwent neurosurgery due to aggravated symptoms and neurologic deficit. Tissue examination revealed that the cause of pleural effusion and pneumothorax was Staphylococcus aureus infection contiguously spread to lung pleura. After several surgical treatments with intravenous antibiotic therapy for two months and transition to oral antibiotics (rifampin 600 mg qd and ciprofloxacin 500 mg bid), the patient received physical therapy to recover balance. One month after discharge, the patient had no chest pain or dyspnea, and exhibited no elevation in inflammatory markers or new thoracic lesions.CONCLUSIONTo our knowledge, this is the very first report of a case of thoracic PIS with pneumothorax.     

Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique

Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.     

Sternum insufficiency fracture presenting as acute chest pain: a case report and review of the literature.

The spine, pelvic bones and long bones of the lower extremities are common sites for insufficiency fractures. Cases of sternum insufficiency fractures have been rarely reported in an elderly patient. Insufficiency fracture tends to occur in bones with decreased mechanical strength. It tends to occur in elderly patients, especially in postmenopausal women, with underlying diseases. We describe a case of sternum insufficiency fracture in a patient with rheumatoid arthritis and systemic lupus erythematosus on long-term corticosteroid therapy diagnosed in an emergency setting. Sternum insufficiency fracture is a rare cause of chest pain. This case serves to remind the emergency physician to remain vigilant for other noncardiac and nontraumatic causes of chest pain. If diagnosed accurately, these patients can be discharged and treated as outpatients.     

Chest wall ectopic synovial bursa cyst

We report an unusual case of chest wall tumor in a 27-year-old patient. A complete resection was accomplished, and the patient had an excellent postoperative course. Histologically, the mass was confirmed to be an ectopic synovial bursa cyst. Although rare, synovial cysts should be considered in any case of a fluctuating chest wall mass. We also discuss the etiology and diagnostic approach of cystic masses of the chest wall.     

Sternal tuberculosis presenting as multiple cutaneous sinuses

Isolated involvement of the sternum with tuberculosis is rare. Only a few cases of sternal tuberculosis have been reported in literature. Tubercular sternal osteomyelitis presenting as multiple cutaneous sinuses over the anterior chest wall is extremely rare. We present a patient with sternal tuberculosis presenting as multiple cutaneous sinuses over the anterior chest wall. Standard antitubercular chemotherapy resulted in complete recovery.     

Incidental finding of congenital thoracic malformations in adult population

OBJECTIVE: Evaluation of abnormal adult chest computed tomography (CT) scans. STUDY DESIGN: Retrospective series of 3 cases. SETTING: Two University-based hospitals. INTERVENTION: Three adult patients (age range 56 to 61) underwent chest CT scans. Two were trauma patients and one complained of chest pain with a negative cardiac workup. One CT scan revealed a lung mass that was highly suspicious for malignancy and the other two CT scans were suspicious for diaphragmatic hernia. Two patients underwent elective surgery and the third underwent emergent surgery. RESULTS: The CT scan of patient 1 was suspicious for malignancy; however, the pathology of the lung mass revealed only inflammation consistent with an intralobular bronchopulmonary sequestration. Patient 2 had a congenital Morgagni hernia with omentum and colon in the mediastinum, and patient 3 had a diaphragmatic defect combined with a bifid sternum and defective pericardium, fulfilling three criteria of pentalogy of Cantrell. CONCLUSION: Thoracic congenital malformations may go unnoticed and unsuspected until adulthood. They should be kept in mind when reviewing unusual CT scans of the chest in adults. Their surgical management, however, is similar to their counterparts in infancy.     

Nonhypertensive male with multiple paragangliomas of the heart and neck: A case report

BACKGROUNDParaganglioma is a rare disease that can be lethal if undiagnosed. Thus, quick recognition is very important. Cardiac paragangliomas are found in patients who have hypertension. The classic symptoms are the triad of headaches, palpitations, and profuse sweating. We describe a very rare case of multiple paragangliomas of the heart and bilateral carotid artery without hypertension and outline the management strategies for this disease.CASE SUMMARYA 46-year-old man presented with the chief complaint of recently recurrent chest pain with a history of hemangioma of the bilateral carotid artery that had been surgically removed. He was found to have an intracardiac mass in the right atrioventricular groove and underwent successful excision. The final pathology demonstrated that the intracardiac mass was a cardiac paraganglioma, and the patient had an increased level of normetanephrine in the blood. The pathology and immunohistochemistry results showed that the bilateral carotid masses were also paragangliomas. During the 3 mo follow-up period, the patient did not experience recurrence of chest pain.CONCLUSIONTo our knowledge, this is the first case of multiple paragangliomas of the heart and neck without hypertension. This rare disease can be lethal if left undiagnosed. Thus, quick recognition is very important. The key to the diagnosis of cardiac paraganglioma is the presence of typical symptoms, including headaches, palpitations, profuse sweating, hypertension, and chest pain. Radiology can demonstrate the intracardiac mass. It is important to determine the levels of normetanephrine in the blood. The detection of genetic mutations is also recommended. Surgical resection is necessary to treat the disease and obtain pathological evidence.     

Insufficiency fracture of the sternum simulating myocardial infarction: case report and review of the literature

Insufficiency fracture is a type of stress fracture that occurs when stress is applied to the bone with less than the normal elastic resistance, as in osteoporosis. Insufficiency fracture of the sternum is rare among all kinds of fractures. We describe two cases with insufficiency fractures of the sternum secondary to osteoporosis and thoracic kyphotic deformity. Both of the present cases, a 76-year-old woman and a 65-year-old woman, presented with severe anterior chest pain simulating myocardial infarction. However, cardiopulmonary examinations including chest radiographs, electrocardiograms, and laboratory tests were normal. Lateral radiographs of the sternum in both patients showed insufficiency fractures of the sternum. Conservative treatment with rib bandaging/bracing and analgesics relieved their symptoms. Clinical behavior, type of sternal insufficiency fractures, and mechanism of the fracture are reviewed from perusal of the literature. We emphasize that sternal insufficiency fracture should be considered in the differential diagnosis of acute chest pain in the elderly along with myocardial infarction or pulmonary embolism.     

KSHV-associated extracavitary primary effusion lymphoma in an HIV seronegative patient: a case report and review of the literature

Primary effusion lymphoma (PEL) is a rare type of non-Hodgkin’s lymphoma presenting as a lymphomatous effusion and absence of a solid tumor mass. Extracavitary PEL (EC-PEL) is a subtype of PEL with the absence of an effusion but presence of solid tumor. PEL and EC-PEL share the same histopathologic and immunophenotypic features. Kaposi sarcoma-associated herpesvirus (KSHV) positivity is seen universally in these malignancies and is a requisite for diagnosis. Most cases are seen to occur in HIV positive individuals. We present a unique case of a 21-year-old male who presented with ongoing chest pain and right hip pain found to have an extensive lytic lesion of the right iliac bone, a paratracheal mass and a large pelvic mass. All the involved sites were FDG (F-18 fluorodeoxyglucose)-avid on PET-CT scan. The patient was seronegative for HIV with no risk factors for immunosuppression. A biopsy of the pelvic mass and bone marrow showed large atypical cells with irregular multi-lobulated nuclei, prominent nucleoli, and abundant amphophilic cytoplasm. The cells were positive for MUM1, in situ hybridization for EBV-encoded RNA (EBER), and KSHV, while negative for B-cell and T-cell markers. The patient was treated with six cycles of DA-EPOCH with a follow up PET scan showing a decrease in size of the masses and bone lesion and conversion to non-FDG-avid status. To the best of our knowledge, our case is the first in published English literature with bone involvement with EC-PEL regardless of HIV status. We review the reported cases of EC-PEL including their presentation, diagnostic features, treatment and outcomes.     

Extraosseous spinal epidural plasmocytoma associated with multiple myeloma: Two case reports

BACKGROUNDMultiple myeloma is a malignant hematological disease characterized by proliferation of monoclonal plasma cells mainly in the bone marrow. Extraosseous epidural plasmacytoma associated with myeloma arises from lymphoid tissue in the epidural space without focal vertebral involvement, and is rare.CASE SUMMARYA 52-year-old woman was diagnosed with kappa subtype nonsecretory multiple myeloma and presented with bilateral arm weakness 11 mo after completing multiple courses of chemotherapy. Spinal magnetic resonance imaging (MRI) showed a posterior C7–T3 epidural mass with spinal cord compression. After five courses of chemotherapy, follow-up MRI showed resolution of cord compression. A 54-year-old man presented with paraplegia 15 mo after a diagnosis of IgD kappa subtype multiple myeloma and completing multiple courses of chemotherapy. He underwent Th11 and L1 laminectomies for tumor resection because MRI showed an epidural mass causing cord compression. His-topathologic examination was consistent with IgD multiple myeloma. The patients have currently survived for 33 mo and 19 mo, respectively.CONCLUSIONIsolated extraosseous epidural plasmacytoma associated with multiple myeloma without bony involvement is difficult to diagnose by imaging. Definitive diagnosis requires pathological and immunohistochemical examination.