A rare case of empyema caused by septic arthritis of the sternoclavicular joint, successfully treated with surgical drainage.

Septic arthritis of the sternoclavicular joint is a rare joint infection, and it sometimes leads to a chest wall abscess or mediastinitis. We report a case of a 70-year-old man who was diagnosed with empyema caused by an anterior chest wall abscess extended from septic arthritis of the sternoclavicular joint. It is very rare that arthritis causes empyema combined with an anterior chest wall abscess, and this is the first report of such a case. The patient was successfully treated with surgical drainage.

Rapid progressive spontaneous hemothorax caused by carcinoma of unknown primary: A very rare case.

We present a very rare case of spontaneous hemothorax which was caused by carcinoma of unknown primary. To the best of our knowledge, there are no other such cases reported worldwide. The patient was 72-year-old male who was referred to our department for massive hemothorax. We undertook surgical treatment for haemostasis, and found multiple tumours which led to the diagnosis of carcinoma of unknown primary as the cause of haemorrhage. The tumours increased and grew rapidly after surgery and hemothorax progressed despite our treatment. The patient died from disseminated intravascular coagulation caused by continuous bleeding on postoperative day 19.

Intraoperative control of air leak using a sutureless free pericardial fat pad covering method in lung cancer resection.

Here, we introduce a new method for intraoperative control of air leak using a free pericardial fat pad covering to lung damage with sutureless fixation. We covered the damaged lung tissue with a free pericardial fat pad with a polyglycol acid sheet and fibrin glue fixation. This method provides a good air leak controlling effect with the use of a free pericardial fat pad and relatively short operative time with sutureless fixation.

Positive outcome of diaphragm covering and total pleural covering techniques for catamenial pneumothorax.

Catamenial pneumothorax (CP) is reported to be caused by the endometriosis of diaphragm, lung and parietal pleura. Therefore, the resection of endometriotic lesion in these organs is reported as effective surgical treatment. Overlooking of endometrial tissues during the operation is believed to be the cause of recurrence after surgical treatment. To address this problem, we underwent total diaphragm covering (TDC) and total pleural covering with sheets of oxidized regenerated cellulose mesh. This report described two CP cases that underwent total diaphragm covering (TDC) and total pleural covering. Both patients were followed up for 1 year without recurrence.

Intrathoracic lipoma of chest wall misdiagnosed as liposarcoma with malignant features based on radiological image and intraoperative findings.

Lipomas are common benign tumors, which are usually located in the subcutaneous tissue. It is relatively rare for lipoma to occur in the intrathoracic cavity, and it is clinically difficult to distinguish it from liposarcoma. We present the case of a 72-year-old man with a chest wall tumor preoperatively diagnosed as liposarcoma, with tumor enlargement with radiological image change to heterogenous and 18F-fluorodeoxyglucose positron emission tomography uptake. The tumor was resected along the chest wall, lung and diaphragm because of dense adhesions. The tumor was diagnosed as lipoma with fat necrosis and inflammatory changes.

Thoracoscopic resection of pulmonary sequestration with carbon dioxide insufflation and indocyanine green.

We encountered a rare case of pulmonary sequestration supplied from the right renal artery, which was resected by video-assisted thoracic surgery with carbon dioxide insufflation and indocyanine green-guided technique. A 41-year-old woman with intralobar pulmonary sequestration supplied from the right renal artery was referred to our department. At the time of surgery, we used carbon dioxide insufflation to improve the manoeuvrable workspace for shutting off aberrant arteries and indocyanine green fluorescence guidance to differentiate the boundary of the sequestered lung from the normal lung. These procedures helped in the efficient resection of the lesion.

Preoperative prediction of the localization of a solitary fibrous tumor using four-dimensional computed tomography: a case report.

Solitary fibrous tumors of the pleura (SFTP) are relatively rare primary pleural tumors. Four-dimensional computed tomography (4D-CT) is reportedly useful in assessing parietal pleural invasion and adhesion in patients with lung cancer. We report a case in which 4D-CT was performed to evaluate SFTP localization and parietal pleural invasion and adhesions. A 62-year-old female presented with an abnormality on a chest radiograph. Chest CT revealed a well-demarcated solid nodule in the left lower lobe adjacent to the pleura. We considered that the tumor was intrapulmonary or arose from the visceral pleura, without adhesion or invasion to the chest wall based on 4D-CT. Primary lung cancer was suspected, and the tumor was resected. Pathological diagnosis revealed an SFTP. This case suggests that 4D-CT is useful in predicting the localization of SFTP and other thoracic tumors, assessing chest wall adhesion and invasion, and making surgical strategies.

Primary posterior mediastinal angiolipoma: a case report.

An angiolipoma is a benign tumor, and a primary mediastinal angiolipoma is extremely rare. Herein, we describe the presentation and management of a posterior mediastinal angiolipoma in a woman with loss of consciousness. Chest computed tomography (CT) revealed a contrast-enhancing mass in the right posterior mediastinum, with intercostal arterial blood supply identified on three-dimensional reconstruction CT (3D-CT). Magnetic resonance imaging revealed a fatty component. Pre-operative embolization of the supplying intercostal artery was performed to reduce intraoperative bleeding. Mass resection was performed using video-assisted thoracic surgery. Histopathology confirmed angiolipoma diagnosis. Although rare, a posterior mediastinum angiolipoma should be considered a possibility; 3D-CT and pre-operative embolization may be useful in the surgical treatment of hypervascular mediastinal tumors, such as angiolipomas.

Pulmonary metastasis with coexisting pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma 20 years after endometrioid adenocarcinoma surgery: A case report.

Late pulmonary metastasis from endometrioid adenocarcinoma (EA) is rare, and occurrence after >20 years is extremely rare. Here, we report a case of pulmonary metastasis with coexisting pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma that occurred 20 years after surgery for EA. A 60-year-old Japanese woman had previously undergone surgery for primary EA, and 20 years later presented with an abnormality that was detected on chest radiography. Chest computed tomography (CT) revealed two nodules in the right lower lung lobe, which were suspected to be primary lung cancer. Wedge resection was performed, and the intraoperative pathological diagnosis was that of adenocarcinoma with MALT lymphoma; this prompted additional right lower lobectomy. The final pathological diagnosis was pulmonary metastasis from EA with coexisting MALT lymphoma. This is probably the first report on late pulmonary metastasis coexisting with MALT lymphoma 20 years after surgery for EA. Surgeons should be aware of the possibility of late pulmonary recurrence of EA after more than 20 years and should consider aggressive resection. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Although extremely rare, pulmonary metastasis can occur more than 20 years after surgery for endometrioid adenocarcinoma. Furthermore, pulmonary metastasis from endometrioid adenocarcinoma may coexist with mucosa-associated lymphoid tissue lymphoma. WHAT THIS STUDY ADDS: Endometrioid adenocarcinoma requires long-term postoperative follow-up to detect recurrence, even in early-stage cases. Video-assisted thoracoscopic surgery (VATS) is useful for resecting pulmonary metastasis from endometrioid adenocarcinoma.

Expanding the Phenotypic Spectrum of Mesenchymal Tumors Harboring the EWSR1-CREM Fusion.

ATF1, CREB1, and CREM constitute the CREB family of transcription factors. The genes encoding these factors are involved in gene fusion events in human tumors. EWSR1-ATF1 and EWSR1-CREB1 are the 2 most characterized fusions, whereas EWSR1-CREM has been less studied. To better understand the phenotypic spectrum of mesenchymal tumors associated with the EWSR1-CREM fusion, we investigated archival cases using fluorescence in situ hybridization and/or RNA sequencing. Among 33 clear cell sarcomas of soft tissue tested, we found 1 specimen, a hand tumor bearing the rearrangements of EWSR1 and CREM, with classic histology and immunophenotype. None of 6 clear cell sarcoma-like tumors of the gastrointestinal tract tested harbored the EWSR1-CREM fusion. Among 11 angiomatoid fibrous histiocytomas, we found that 3 tumors of myxoid variant harbored the rearrangements of EWSR1 and CREM. All 3 tumors occurred in middle-aged men and involved the distal extremities (N=2) and the lung (N=1). Prominent lymphoid cuff, fibrous pseudocapsule, and amianthoid fiber were present in 3, 2, and 2 tumors, respectively, whereas none showed pseudoangiomatoid spaces. All 3 tumors were immunohistochemically positive for epithelial membrane antigen and desmin. These cases suggested a closer relationship between angiomatoid fibrous histiocytoma and a recently proposed novel group of myxoid tumors with CREB family fusions. Our cohort also included 2 unclassifiable sarcomas positive for EWSR1-CREM. One of these was an aggressive pediatric tumor of the abdominal cavity characterized by proliferation of swirling spindle cells immunopositive for cytokeratin and CD34. The other tumor derived from the chest wall of an adult and exhibited a MUC4-positive sclerosing epithelioid fibrosarcoma-like histology. Our study demonstrates that a wider phenotypic spectrum is associated with the EWSR1-CREM fusion than previously reported.

A case of simultaneous bilateral spontaneous pneumothorax after the Nuss procedure.

We present a case of simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication formed from Nuss procedure for pectus excavatum. A 17-year-old man with a history of Nuss operation complained chest pain and dyspnea. A chest roentgenogram demonstrated a tiny bilateral pneumothorax and two metallic bars inserted at the Nuss procedure. Computed tomography revealed furthermore a bulla in the apex of the left lung. The bilateral pneumothorax critically deteriorated after 4 days from onset and urgent bilateral chest drainages were performed. Nevertheless the drainages the full expansion of both lungs was not obtained and air leakage only from left side was continued. A video-assisted left bullectomy was performed 9 days after the tube insertion. The two bars penetrating anterior mediastinal pleura were thought to be a cause of the simultaneous bilateral spontaneous pneumothorax.

Mediastinal mature teratoma with rupture into pleural cavity due to blunt trauma.

We report a rare case of mediastinal mature teratoma with rupture due to blunt trauma. A 15-year-old boy had received a strong head-butt in the left upper chest wall and was admitted with the sudden onset of left-sided severe chest pain and dyspnea. Chest computed tomography (CT) scan on admission revealed a heterogeneous mass lesion in the anterior mediastinum. The contrast-enhanced CT scans obtained 2 days after admission showed not only mediastinal mass lesion but also left pleural effusion. On the radiologic finding at 5 months later, the lesion became larger and was thought to be a typical mediastinal mature teratoma. The patient underwent extirpation of the tumor. Microscopically, the tumor was typically composed of adult-type tissues and was confirmed to be mature teratoma.

Localized mucinous bronchioloalveolar carcinoma of the lung: thin-section computed tomography and fluorodeoxyglucose positron emission tomography findings.

PURPOSE: The aim of this study was to evaluate thinsection computed tomography (CT) and fluorodeoxyglucose positron emission tomography (FDG-PET) findings of localized pulmonary mucinous bronchioloalveolar carcinomas (BACs). METHODS AND MATERIALS: From February 2000 to February 2009, there were seven patients with pulmonary localized mucinous BACs that were pathologically confirmed in the surgical specimens. Their CT findings were assessed regarding location, extent (percent) of groundglass opacity (GGO), margin characteristics, and the presence of air-containing spaces and contractive changes. We evaluated the presence of the "angiogram sign" in the patients who underwent enhanced CT. The maximum standardized uptake value (SUVmax) on FDG-PET was measured in four cases. RESULTS: All tumors were located in the lower lobes. The percentages of GGOs ranged from 0% to 70% (average 20%). The tumor margins were well defined in five cases and ill-defined in two cases. Air-containing spaces were seen in all cases. Evidence of contractive change was seen in two of the seven cases. The angiogram sign was identified in one of five patients who underwent enhanced CT. The SUVmax on FDG-PET ranged from 0.93 to 1.97 (mean 1.53). CONCLUSION: The imaging features of localized mucinous BACs include solid or partly solid attenuation, the presence of air-containing spaces, lack of contractive changes, and lower lobe predominance. Additionally, the SUVmax is markedly low on FDG-PET.

Stromal tumor of the pancreas with expression of c-kit protein: report of a case.

We report on a case of a stromal tumor, similar to a gastrointestinal stromal tumor, originating from the pancreas. The patient was a 54-year-old woman, who was seen at the Kofu Municipal Hospital because of an abdominal tumor. On abdominal computed tomography and splenic arteriography, the tumor was detected in the pancreatic tail. The patient underwent distal pancreatectomy with splenectomy. Macroscopically, the cut surface of the tumor showed almost completely surrounded by the normal pancreatic tissue. Microscopically, the tumor composed of spindle-shaped cells that were immunoreactive for vimentin, CD34, and c-kit protein. Therefore, the tumor was diagnosed as a stromal tumor of the pancreas. The expression of c-kit protein suggests that this pancreatic stromal tumor may originate from primitive mesenchymal cells which can be a logical candidate for the origin of gastrointestinal stromal tumors and extra-gastrointestinal stromal tumors.

Air-containing space in lung adenocarcinoma: high-resolution computed tomography findings.

OBJECTIVE: To disclose imaging features of air-containing spaces other than air bronchograms in lung adenocarcinoma on high-resolution computed tomography (HRCT). MATERIALS AND METHODS: We retrospectively reviewed HRCT scans of 42 consecutive patients with surgically proved lung adenocarcinoma correlating with pathologic specimens. RESULTS: Air-containing spaces were seen in 17 (40%) of cases on HRCT. The air-containing spaces appeared as multiple air densities (16 cases [94%]) with variable shapes and had a relatively larger size than that of air bronchograms. Internal septi were often noted (11 cases [65%]). CONCLUSION: Our results demonstrate that multiplicity, larger diameter, and internal septi are the features of air-containing spaces. These findings could be a key to the definitive diagnosis of lung adenocarcinoma, distinguishing it from the mimics such as organizing pneumonia, tuberculoma, or malignant lymphoma.

[Refractory non-small-cell lung cancer responding to combination chemotherapy with gemcitabine and cisplatin].

The patient was a 60-year-old female with adenocarcinoma of the lung. An effective radiation therapy was performed for cervical lymph node metastases found 19 months after the operation. A right adrenal metastasis and abdominal paraaortic lymph node metastases were detected 11 months later, and chemotherapy with cisplatin (CDDP) was administered. Although a temporary partial response was obtained, the metastatic lesion was refractory to CDDP. The patient was treated with gemcitabine (GEM) and CDDP, which resulted in near complete response continued for 3 months. The combination therapy of GEM and CDDP may be effective for recurrent non-small-cell lung cancer refractory to other regimens.