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.

Radical resection and improvised surgical reconstruction for a rare malignant triton tumour of intercostal nerve in a patient with neurofibromatosis type 1.

A man aged 28 years, with neurofibromatosis type 1, presented with abdominal pain and visible right lower chest swelling. He had cutaneous neurofibromas and several café-au-lait spots. CT scan of the chest and abdomen revealed a giant mass most likely originating from the right 7th intercostal nerve, extending downwards into the abdomen causing massive hepatic compression. A Trucut biopsy showed malignant peripheral nerve sheath tumour. Radical surgical resection with wide margins was performed. The chest wall and diaphragm were reconstructed with improvised surgical technique with excellent results. Final histopathology report revealed a triton tumour of the intercostal nerve.

Hoarseness of voice, respiratory distress and dysphagia due to giant primary posterior mediastinal ectopic goitre: a rare clinical entity.

Primary posterior mediastinal ectopic goitre is an extremely rare entity; we report a case of a 28-year-old man who presented with dysphagia, respiratory distress and hoarseness of voice, gradually worsening over a period of 3 months. CT scan of the thorax revealed a giant posterior mediastinal ectopic goitre. The mass was removed through a right posterolateral thoracotomy. The patient's symptoms, respiratory distress and dysphagia disappeared immediately after surgery while his voice gradually returned to normal after 6 weeks.

Radical surgical resection for giant primary mediastinal endodermal sinus tumour with pulmonary metastasis after chemotherapy: can be curative.

Primary non-seminomatous germ cell tumours of anterior mediastinum are uncommon. Endodermal sinus tumour of the anterior mediastinum (yolk sac) is a rare but lethal neoplasm. We present a case of an 18-year-old man who presented with chest pain, cough and haemosputum with markedly raised serum α-fetoprotein (AFP) levels above 112,000 ng/mL. Chest roentgenogram and CT showed a giant anterior mediastinal mass. CT guided biopsy revealed a diagnosis of endodermal sinus tumour. After the completion of chemotherapy, extensive surgical resection was carried out along with the right lung metastastectomy. Five years postresection follow-up the patient is disease free with normal serum tumour markers. This is the longest survival ever reported of such tumours with highest AFP level (>112,000 ng/mL) and lung metastasis.

A rare cause of asymptomatic solitary pulmonary nodule: adult Schistosoma worm.

Solitary pulmonary nodule due to various pathologies has been reported in the medical literature. We report a case of solitary pulmonary nodule in an asymptomatic 60-year-old male smoker, who had a positive family history of pulmonary tuberculosis. His routine screening chest X-ray revealed a 2 × 1.5 cm nodule in the right lung upper zone. A CT scan of the thorax confirmed the finding. Bronchoscopy, lavage, biopsy and screening for tuberculosis were negative. Owing to its technical difficulty, a CT-guided biopsy was deferred by the radiologist, hence we decided to perform segmentectomy that showed granuloma harbouring an adult Schistosoma worm. This is the first case of asymptomatic solitary pulmonary nodule due to adult Schistosoma worm 26 years after the exposure.

Recurrent phyllodes sarcoma of breast with complete chest wall invasion; a multidisciplinary approach for radical resection.

Phyllodes tumour of the breast is a relatively uncommon condition, and rarely invades the chest wall. We report a case of young women who had recurrent large phyllodes tumour invading the chest wall, following mastectomy, chemotherapy and radiotherapy. A multidisciplinary approach was used for radical resection of the tumour, chest wall and reconstruction.