A Glomus Tumor With Recurrence and Malignant Transformation in the Chest Wall: A Cautionary Tale of Seeding?

Glomus tumors are rare tumors most often occurring in the extremities of the limbs. We report a unique case of a glomus tumor, originally arising in the paraspinal region, which was excised and subsequently recurred in the chest wall with malignant transformation. The recurrence is likely to have been caused by wound seeding. To the best of our knowledge, this is the first report in the English literature of a glomus tumor recurrence secondary to the notion of wound seeding.

Mediastinal paraganglioma: time to panic?

Paragangliomas (extra-adrenal phaeochromocytomas) are tumours arising from extra-adrenal chromaffin tissue. The authors describe a case of a 54-year-old woman presenting with shortness of breath and chest pain. CT pulmonary angiogram demonstrated a mediastinal mass. Further history taking revealed spontaneous attacks of headaches and palpitations. Subsequent imaging and biochemical testing confirmed the presence of a rare posterior mediastinal paraganglioma. The patient was prepared for surgery. A left thoracolaparotomy was performed and the mass was excised in its entirety. Postoperatively, 24-h urine collections showed normal normetanephrine and metanephrine levels. Since then, yearly catecholamine levels remain within the normal range.

Positron emission tomography may underestimate the extent of thoracic disease in lung cancer patients.

OBJECTIVE: Although widely utilised in the staging of lung cancer various studies have questioned whether the accuracy of this staging modality is sufficient to replace conventional invasive staging techniques. We have therefore reviewed our experience in order to assess the accuracy of PET CT as an intrathoracic staging tool for non-small cell lung cancer (NSCLC). METHODS: Two hundred patients referred for surgery between June 2006 and January 2008 underwent PET CT followed by staging mediastinoscopy and, if appropriate, resection. Results of scans and histopathology were correlated and analysed. RESULTS: Overall, PET CT correctly staged 99 out of 200 patients (49.5%), under-staged 59 (29.5%), and over-staged 42 (21%). Superior mediastinal nodes were incorrectly staged by PET CT in 35 (19%) of 186 patients undergoing mediastinoscopy: in 15 (8%) mediastinoscopy revealed metastatic disease not detected on PET CT and 20 (11%) had negative histology despite a positive scan. Five (2.5%) resections were benign despite avid FDG uptake, and 6 (3%) were malignant despite a negative scan. PET CT had false positive result of 6.5%, 5.5%, 4.5% and 3.5%, respectively for hilar, station 2, 7 and 5 node groups. The false negative result was 12.5%, 10.5% and 8%, respectively for hilar, intrapulmonary and station 4 nodes. Twelve (6%) of patients were under-staged regarding chest wall and mediastinal invasion, and 10 (5%) patients had metastatic nodules in the lung (T4) not detected by PET CT. Stage I or II disease was identified by PET CT in 141 patients of whom 26 (18.4%) had IIIa or higher stage disease. The false positive and negative predictive values for PET CT with respect to N2 or greater status were 17.2% (11.8-24.2) and 48.6% (32.2-65.3), respectively. CONCLUSIONS: Our experience would suggest that PET CT alone is not sufficiently accurate to replace mediastinoscopy and other conventional biopsy techniques in the evaluation of NSCLC cases. It may better be viewed as a valuable additional tool with which to inform decision making and to screen for disseminated disease.

Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma.

OBJECTIVES: Despite advantages regarding pain and muscle function, video-assisted thoracic surgery (VATS) lobectomy is infrequently performed and is particularly controversial in bronchogenic carcinoma. We have, therefore, reviewed our experience with VATS lobectomy for non-small cell lung cancer (NSCLC) in an attempt to define the long-term results of VATS lobectomy in this setting. METHODS: Patients were selected for surgery on the basis of clinical Stage I or II disease with routine use of thoracic/upper abdominal CT scanning and cervical mediastinoscopy. VATS resection was performed using the endoscopic hilar dissection technique. All related hilar nodes were cleared and supportative sampling of mediastinal stations beyond the reach of mediastinoscopy was undertaken. Perioperative data were collected prospectively and oncologic outcomes were assessed by 6 monthly census. RESULTS: One hundred and fifty eight patients (mean age 66 years) underwent 159 VATS lobectomies for NSCLC between May 1992 and December 2001. One patient underwent staged bilateral resections. Twenty further procedures were uneventfully converted to open thoracotomy (rate=11.2%). The median operation time was 130 min and median operative blood loss was 60 ml. The median postoperative stay was 6 days. One patient (0.6%) died following VATS resection from acute respiratory distress syndrome (ARDS). Two VATS resection patients died following discharge but within 30 days of surgery. Combined, inpatient and 30-day outpatient mortality was, therefore, 1.8%. The stage distribution for resected lesions was: Stage I, 117; II, 33 and III, 8. Mean follow-up was 38 months (range: 1-107). Tumour recurred in 36 patients presenting as local recurrence in the hilum or mediastinum in nine (25%), metastatic disease in 23 (63.9%) and unknown pattern in four (11.1%). Kaplan-Meier calculated probabilities of freedom from cancer related or associated death at 60 months were Stage I, 77.9%; II, 51.4% and III, 28.6%. CONCLUSION: VATS lobectomy is a safe procedure which is associated with a low probability for conversion to open thoracotomy. The patterns of cancer recurrence do not suggest inadequate local clearance while the long-term survival data for Stage I NSLC cases is encouraging. We believe that this technique should become the operation of choice for early stage NSCLC.