Long-Term Outcomes of Simultaneous Skin and Bowel Flaps for Esophageal Reconstruction.

Esophageal reconstruction can be performed with skin or bowel flaps. The choice of flap remains controversial, as the long-term outcomes of skin flaps cannot always be assessed in patients with limited life expectancies due to advanced malignancy, unlike the pediatric and benign cases which have had esophageal reconstruction using bowel flaps. We report the long-term clinical and histopathological outcomes in a series of 45 cases repaired with combined skin and bowel flaps.Four patients developed symptomatic strictures after corrosive esophageal injuries were repaired with a combination of a tubed free radial forearm fasciocutaneous flap and a pedicled bowel flap. On average, 24 years had passed since uneventful initial esophageal reconstructions. Barium esophagograms were obtained in all cases and pathological examination was performed upon all surgical specimens.The cutaneous portions of the reconstructed esophagus exhibited a variety of findings on barium examination. Each of the 4 cases developed an esophagocutaneous fistula after revision; an average of 4 surgeries was required to close these fistulae. The inner surfaces of the portion of esophagus repaired with skin flaps showed extensive ulceration, polypoid lesions, and fibrosis. Pathology specimens from skin flaps showed extensive acute and chronic inflammation, microabscesses, fibrosis, and acanthosis, with depletion and degeneration of the pilosebaceous units. By contrast, adjacent parts of the esophagus repaired with bowel were widely patent with normal appearing mucosa.Our findings indicate that a bowel flap is durable with good tolerance to gastrointestinal content over long periods, whereas skin flaps often developed morphological changes and could not maintain long-term esophageal function without eventual stricture and dysphagia. We therefore recommend use of bowel flaps for esophageal reconstruction in patients with long life expectancy.

Intramural metastases of rectum from carcinosarcoma (malignant müllerian mixed tumor) of uterine cervix.

A 25-year-old woman had carcinosarcoma of uterine cervix after definitive treatment. One year later, local recurrent disease was found in the right posterior pelvis on FDG PET/CT. FDG PET/CT also disclosed an incidental intramural hypermetabolic lesion in the rectum, which seemed separate from the right pelvic lesion on contrast-enhanced CT. The rectal lesion was confirmed as metastatic carcinosarcoma from uterine cervix after endoscopic biopsy.

Parotid gland metastasis from squamous cell carcinoma of esophagus detected by FDG PET/CT.

A 55-year-old man was diagnosed with squamous cell carcinoma in the middle thoracic esophagus. The FDG PET/CT revealed an incidental strong FDG-avid finding (SUVmax, 11) in the right parotid gland, which was subsequently confirmed as metastasis from the squamous cell carcinoma of esophagus via surgery. The current case adds another differential diagnosis of parotid FDG-avid lesion to the existing literature.

Primary pulmonary epithelioid angiosarcoma presenting as a solitary pulmonary nodule on image.

Primary angiosarcoma of lung is a rare condition. Only about 20 cases have appeared in English published reports so far. Its rarity and consequent low index of suspicion makes clinical diagnosis difficult. Pathological diagnosis of the epithelioid variant of pulmonary angiosarcoma is particularly challenging. We report a case of primary pulmonary epithelioid angiosarcoma as a solitary pulmonary nodule in image study in a 41-year-old man with a brief review, to contribute it to the sparse literature on this disease.

Synchronous squamous cell carcinomas of the esophagus and renal pelvis.

A 55-year-old man was incidentally diagnosed with a superficial squamous cell carcinoma of esophagus. However, the systemic survey with FDG PET/CT revealed a picture of more advanced disease because of the regional lymph node metastases and a suspected distal metastasis in the left renal pelvis, which was somewhat strange for a small superficial esophageal cancer. Subsequently, the renal pelvic lesion was confirmed as squamous cell carcinoma. However, a primary tumor rather than metastasis in the renal pelvis was considered according to the histologic characteristics and radiologic findings.

Unexpected findings on gallium-67 scintigraphy: detection of undifferentiated endometrial stromal sarcoma.

We reported an extremely rare case of undifferentiated endometrial stromal sarcoma imaged with gallium-67 scintigraphy. This previously healthy 32-year-old woman presented with cough and dyspnea for days. Unexpectedly, the pathology of the opacity in the right pulmonary hilar region demonstrated metastatic high-grade epithelioid sarcoma. Gallium scintigraphy performed to detect possible origin showed abnormal uptake in the right supraclavicular region, chest region and pelvic region. Computed tomography-guided biopsy of the pelvic mass revealed undifferentiated endometrial stromal sarcoma. This case demonstrated the usefulness of gallium-67 scintigraphy in the detection of the primary disease and the evaluation of the metastatic disease.