Ectopic epipericardial fat necrosis: a case report

BACKGROUND

Epipericardial fat necrosis (EFN) is a rare disease in which local inflammation and necrosis occur in the adipose tissue surrounding the heart, particularly epicardial fat. Few cases of EFN in which surgical resection was performed have been reported. We report a case of EFN after surgical resection of a right extrapulmonary tumor, in which a malignant disease could not be excluded.

CASE PRESENTATION

A 75-year-old male patient presented with fever and chest pain. A contrast-enhanced computed tomography scan of the chest revealed a lesion, 53 × 48 mm in size, with mixed fatty density spanning the middle and lower lobes of the right lung. Thoracic magnetic resonance imaging (MRI) revealed a mass with mixed fat and soft tissue density in the same area; the lesion was contiguous with pericardial fatty tissue. The tumor was diagnosed as a liposarcoma or teratocarcinoma based on imaging results; however, the possibility of lung cancer could not be excluded. Finally, EFN was diagnosed based on the postoperative histopathological examination. The patient underwent surgical resection of the suspected right extrapulmonary tumor. The intraoperative findings revealed a mediastinal mass contiguous with pericardial fat located between the middle and lower lobes. Intraoperative pathological examination of the lesion was performed using a needle biopsy; however, no definitive diagnosis was made. The tumor may have invaded the middle lobe of the right lung, and partial resection of the right lower lobe was performed in addition to resection of the middle lobe of the right lung. The patient was followed up every 3 months without adjuvant therapy. No recurrence was reported at 1 year after surgery.

CONCLUSION

EFN should be considered in the differential diagnosis of an extrapulmonary tumor when continuity with the pericardial space is observed on MRI or other imaging studies. Surgical resection is useful in the diagnosis and treatment of EFNs. Preoperative three-dimensional reconstructive imaging and MRI should be used to identify vascular structures and confirm the continuity of the lesion with the surrounding tissues to ensure safe and rapid tumor removal.

Surgical Resection of a Pneumothorax in an Adult Patient With a History of Wilson-Mikity Syndrome Diagnosed in Childhood

Wilson-Mikity syndrome (WMS) is a rare condition characterized by various respiratory and pulmonary abnormalities in neonates and infants. However, the diagnosis is based on the findings of physiological tests, such as respiratory function tests. Reports describing the histopathological features of WMS are limited. The patient was a 22-year-old woman with a history of WMS. She had been on a ventilator for the first three months of life due to pulmonary hypertension after early delivery at 24 weeks of gestation and required oxygen therapy until three years of age. One month before presenting at our clinic, the patient experienced chest pain and respiratory distress, and a left spontaneous pneumothorax was diagnosed based on a chest X-ray examination. The pneumothorax improved after the insertion of a thoracic drain but recurred soon thereafter. A histopathological examination revealed emphysematous changes associated with WMS in the background lungs, consistent with brevity. No postoperative complications were observed. The thoracic drain was removed on the second day, and the patient was discharged on the eighth postoperative day. Postoperatively, the patient was started on inhaled medication and was carefully monitored every three months. The present case suggests that childhood interviews are very important for adult patients who develop pneumothorax and that early surgical treatment may be selected based on a detailed interview. Moreover, postoperative follow-up should be carefully performed in collaboration with respiratory medicine in patients with pneumothorax originating from chronic obstructive pulmonary diseases such as WMS.

Primary Chondrosarcoma of the Right Fourth Rib Resected at the Marginal Margin: A Case Report

Primary chondrosarcoma of the ribs is relatively rare, and its basic treatment is surgical resection. In cases with positive resection margins, additional resection is considered, but its indications are unclear. However, reported cases with positive resection margins have been limited. We report a 71-year-old man whose medical checkup revealed an abnormal shadow in the chest. The findings from chest computed tomography, axial T2-weighted magnetic resonance imaging (MRI), and contrast-enhanced MRI led to a diagnosis of chondrosarcoma of the right fourth rib, and surgical resection was performed. The chest wall defect was reconstructed with a Marlex mesh. Postoperative histopathologic diagnosis was grade 2 chondrosarcoma. Gross resection margins, which were marginal, were negative, and the resection margin was grade 1. The patient was followed up without adjuvant therapy and did not undergo additional surgery. For chondrosarcomas with negative gross margins but a marginal margin, additional resection should be considered depending on the histologic grade of the margins. In cases with extensive resection of the chest wall, it is useful to reconstruct the chest wall while paying careful attention to infection control.

The Add-On Effect of Fluorouracil, Epirubicin, and Cyclophosphamide Regimens for Neoadjuvant Chemotherapy in Human Epidermal Receptor 2 (HER2)-Positive Breast Cancer: A Single-Center Retrospective Study

BACKGROUND

The addition of pertuzumab to trastuzumab in neoadjuvant chemotherapy (NAC) for anti-human epidermal receptor 2 (HER2) positive breast cancer has shown a significant improvement in the pathologic complete response (pCR) rate. However, the add-on effect of an anthracycline-based regimen (standard-of-care regimen) remains unclear. In this retrospective, observational study, participants received pertuzumab combination therapy as NAC for HER2-positive primary breast cancer.

METHODS

This study was conducted from January 1, 2020, to December 31, 2022. Patients who had not received at least three courses of pertuzumab owing to adverse events or those who had received preoperative radiotherapy were excluded.

RESULTS

The pCR rate was 35.3% (12/34 patients). The pCR group had a significantly higher percentage of histopathologic grade III (1/11 patients, p=0.030) and a significantly higher percentage of hormone receptor-negative patients (7/12 patients, p=0.015) than the non-pCR group. The non-pCR group had a significantly higher incidence of vascular invasion than the pCR group (7/22 patients, p=0.036). Menopausal status, stage, and ki-67 values were not significantly different between the two groups.

CONCLUSIONS

This study suggests an unlikely add-on effect of an anthracycline-based regimen for NAC in HER2-positive breast cancer. Moreover, our results support that the pCR rate is high in patients with hormone receptor-negative, HER2-positive breast cancer.

Radiation-Associated Breast Angiosarcoma

Radiation-associated breast angiosarcomas are rare following breast-conserving surgery. These angiosarcomas are considered adverse events associated with radiation therapy and are characterized by a high risk of both local and distant recurrence, even after complete resection. Despite this, there is currently no established standard treatment for them. The patient was a 70-year-old woman who had breast-conserving surgery for right breast cancer 10 years before presentation. She was followed up for 10 years after receiving 50 Gy of residual breast irradiation and an aromatase inhibitor for 5 years. During follow-up, a painless purplish area with induration, measuring 10 cm by 5.4 cm, was noted on the right nipple. A skin biopsy confirmed hemangiosarcoma. Treatment included surgery with a 2.0 cm margin from the area, followed by skin excision and total mastectomy. A final diagnosis of radiation-associated breast angiosarcoma was made. Radiation-associated breast angiosarcoma is a rare disease with a poor prognosis that lacks standard treatment. An aggressive skin biopsy should be considered when skin findings such as purpura are seen after breast cancer radiotherapy, as in this case.

Surgical Treatment of Secondary Pneumothorax-Complicated Interstitial Lung Disease

INTRODUCTION

To investigate the feasibility of early surgical treatment and perioperative steroid use in patients with interstitial lung disease (ILD) complicated by pneumothorax.

METHODS

We retrospectively examined data, including patient characteristics, laboratory findings, surgical treatment details, postoperative complications, and deaths, of nine patients with ILD complicated by secondary pneumothorax. The patients had been treated at our hospital during the past 10 years.

RESULTS

All nine patients were male (median age, 69.0 years). A total of nine patients had a histopathologic diagnosis of ILD after surgery. Of these, five were clinically diagnosed with ILD before surgery. Collagen disease was diagnosed in one case, drug-induced in one case, and idiopathic ILD (IILD) in three cases. All nine patients were diagnosed with postoperative ILD, including one case of collagen disease, one case of drug-induced, three cases of idiopathic pulmonary fibrosis (IPF)/cryptogenic fibrosing alveolitis, one case of nonspecific interstitial pneumonia (NSIP), and three cases of cryptogenic organizing pneumonia (COP). Regarding preoperative clinical characteristics, the performance status (PS) was 0 or 1 in all patients. Overall, three patients received oxygen (0-3 L/min), whereas steroids were administered to five patients. The mean drainage period was 23.5 days, and this was consistent with the time taken from pneumothorax occurrence to surgery. Video-assisted thoracic surgery (VATS) and thoracoscopic-assisted surgery were performed in seven and two patients, respectively. No postoperative recurrence or surgery-related deaths occurred.

CONCLUSIONS

Early surgery for secondary pneumothorax complicated by ILD may be a viable option for patients in good preoperative condition. For patients who are preoperatively treated with steroids, continued use of steroids should be carefully considered.

Synchronous multiple lung cancers with hilar lymph node metastasis of small cell carcinoma: A case report

BACKGROUND

Synchronous multiple lung cancers are rare and refer to the simultaneous presence of two or more primary lung tumors, which present significant challenges in terms of diagnosis and treatment.

CASE SUMMARY

We report a case of multiple synchronous lung cancers with hilar lymph node metastasis of small cell carcinoma of unknown origin in a 73-year-old man. Transbronchial lung biopsy revealed squamous cell carcinoma. Although enlargement of lymph node 12u was detected, no distant metastases were observed. The patient was preoperatively diagnosed with T1cN0M0 and underwent thoracoscopic right upper lobectomy with nodal dissection (ND2a). Based on histopathological findings, the primary lesion was squamous cell carcinoma. A microinvasive adenocarcinoma was also observed on the cranial side of the primary lesion. Tumors were detected in two resected lymph nodes (#12u and #11s). Both tumors were pathologically diagnosed as small cell carcinomas. The primary lesion of the small cell carcinoma could not be identified even by whole-body imaging; however, chemotherapy was initiated for hilar lymph node metastasis of the small cell carcinoma of unknown origin.

CONCLUSION

Multiple synchronous lung cancers can be accompanied by hilar lymph node metastasis of small cell carcinomas of unknown origin.

Granulomatous Mastitis Occurring during Pregnancy: A Case Report

Background and Objectives: Granulomatous mastitis is a benign disease with a clinical presentation similar to that of breast cancer, and is most commonly observed in women of childbearing age. Although it has been suggested that autoimmune diseases are involved in its pathogenesis, no specific treatments have been established. The occurrence of this disease during pregnancy has rarely been reported. We presented the case of a 37-year-old woman who complained of left breast induration at 24 weeks' gestation. Materials and Methods: She was pregnant and manifested a dichorionic, diamniotic placenta. At 24 weeks of gestation, the patient experienced a sensation of hardness in her left breast. Mastitis was suspected, and she was treated with cephem antibiotics. Simultaneously, she was diagnosed with erythema nodosum in the extremities. As her symptoms did not improve, an incisional drainage was performed. Bacterial cultures were obtained at 31 weeks of gestation, and Corynebacterium kroppenstedtii was detected. Results: An elective cesarean section was performed at 37 weeks of gestation, and the baby was delivered safely. After delivery, a needle biopsy was performed, and the patient was diagnosed with granulomatous mastitis. She was completely cured with prednisolone after weaning. In this case, the patient's condition was maintained through incision and drainage, as well as antibiotic, anti-inflammatory, and analgesic drugs during pregnancy. This approach was chosen, taking into consideration the potential side effects of steroids. Conclusions: This case suggests that incisional drainage and antibiotic therapy, as well as steroids and surgery, may be considered in the treatment of granulomatous mastitis occurring during pregnancy. This may also be true for management during delivery. After delivery, breastfeeding and steroidal therapy proved to be effective in treating the condition.

Two Cases of Breast Cancer With Gastric Metastasis

Gastric metastases from breast cancer are difficult to distinguish from primary gastric cancer. We report two cases of gastric metastasis of breast cancer with a review of the literature. In the first case, a 77-year-old woman was diagnosed with adenocarcinoma after upper gastrointestinal endoscopy, which revealed an erosive lesion in the gastric corpus. She was treated with an aromatase inhibitor and a CDK4/6 inhibitor, but five years later, she developed multiple bone metastases and gastric lesions, and she is currently receiving weekly paclitaxel (PTX) and bev. In the second case, a 63-year-old woman underwent total mastectomy and axillary lymphadenectomy [invasive lobular carcinoma (ILC)]. Eleven years after the surgery, the patient complained of pharyngeal tightness, and upper gastrointestinal endoscopy revealed a type 4 gastric tumor in the gastric body and posterior wall. In conclusion, when a patient with ILC or advanced breast cancer presents with gastric symptoms and anemia, it is important to examine and treat the patient based on the possibility of gastric metastasis.

Solitary fibrous tumor resembling pulmonary fractionation disease: A case report

RATIONALE

Preoperative differentiation between pulmonary fractionation and solitary fibrous tumors (SFTs) is challenging. Diaphragmatic primary tumors are relatively rare among SFTs, with limited reports of abnormal vascularity.

PATIENT CONCERNS

A 28-year-old male patient was referred to our department for surgical resection of a tumor near the right diaphragm, Thoracoabdominal contrast-enhanced computed tomography (CT) scan revealed a 10 × 8 cm mass lesion at the base of the right lung. The inflow artery to the mass was an anomalous vessel in which the left gastric artery bifurcated from the abdominal aorta, and its origin was the common trunk and right inferior transverse artery.

DIAGNOSIS

The tumor was diagnosed as right pulmonary fractionation disease based on the clinical findings. The postoperative pathological examination determined a diagnosis of SFT.

INTERVENTIONS

The pulmonary vein was used to irrigate the mass. The patient was diagnosed with pulmonary fractionation and underwent surgical resection. Intraoperative findings revealed a stalked, web-like venous hyperplasia anterior to the diaphragm, contiguous with the lesion. An inflow artery was found at the same site. The patient was subsequently treated using a double ligation technique. The mass was partially contiguous with S10 in the right lower lung and stalked. An outflow vein was identified at the same site, and the mass was removed using an automatic suture machine.

OUTCOMES

The patient received follow-up examinations that involved a chest CT scan every 6 months, and no tumor recurrence was reported during 1 year of postoperative follow-up.

LESSONS

Differentiating between SFT and pulmonary fractionation disease may be challenging during preoperative diagnosis; therefore, aggressive surgical resection should be considered as SFTs may be malignant. Identification of abnormal vessels using contrast-enhanced CT scans may be effective in reducing surgical time and improving the safety of the surgical procedure.

Surgical resection of a large invasive mucinous adenocarcinoma: A case report

Invasive mucinous adenocarcinoma often presents with pneumonia-like findings on imaging, which complicates its diagnosis. This case demonstrates that aggressive bronchoscopy is useful for examining infiltrating shadows in the lung field and large tumors occupying the entire lung lobe should be treated cautiously when lung parenchyma develops.

Subareolar Breast Abscess in a Male: A Case Report

A subareolar breast abscess (SBA) is caused by the formation of an inflammatory abscess around the milk duct. SBAs usually occur in females, and reports of SBAs in males are very rare. This study reports the case of a 62-year-old male patient who presented with a subcutaneous nodule and diffuse erythema around the left nipple. Ultrasonography revealed a mixed lesion measuring 2.5 x 1.5 cm, mostly cystic. A computed tomography scan of the chest showed an irregular, nodular structure in the same area. Magnetic resonance imaging with contrast enhancement suggested an abscess. A needle biopsy was performed on the lesion, and results showed moderate inflammatory cell infiltration, including lymphocytes, plasma cells, neutrophils, and abscess formation, thus leading to the diagnosis of SBA. The patient did not strongly desire a surgical procedure. He was treated with the cephem antibiotic cefaclor and antipyretic analgesics. During the six-month healing period, cefaclor was administered for a total of six weeks. Once he improved, recurrence was observed two years after the onset of the disease; however, the symptoms improved with conservative treatment, such as warm compresses. Preventive measures should be considered as SBAs are prone to recurrence.

Concurrent Granulomatous Mastitis and Ductal Carcinoma In Situ

Granulomatous mastitis (GM) is a benign inflammatory breast disease that often poses diagnostic challenges due to its similar clinical and radiographic features to breast cancer. We report the case of a 34-year-old female with concurrent GM and ductal carcinoma in situ (DCIS). Initially, breast cancer was suspected based on imaging; however, a needle biopsy confirmed GM. Corticosteroid treatment led to a reduction in tumor size, but subsequent imaging continued to suggest the presence of breast cancer. Surgical excision ultimately revealed the coexistence of GM and DCIS. It is essential to consider the possibility of concurrent breast cancer in cases of GM with discordant imaging and pathology findings.

A Case of Pneumothorax Ex Vacuo Associated with COVID-19

Pneumothorax is a known complication of coronavirus disease 2019 (COVID-19). The concept of pneumothorax ex vacuo has also been proposed to describe pneumothorax that occurs after malignant pleural effusion drainage. Herein, we present the case of a 67-year-old woman who had abdominal distension for 2 months. A detailed examination led to the suspicion of an ovarian tumor and revealed an accumulation of pleural effusion and ascitic fluid. Thoracentesis was performed, raising the suspicion of metastasis of high-grade serous carcinoma arising from the ovary. An ovarian biopsy was scheduled to select subsequent pharmacotherapy, and a drain was inserted preoperatively into the left thoracic cavity. Thereafter, a polymerase chain reaction analysis revealed that the patient was positive for COVID-19. Thus, the surgery was postponed. After the thoracic cavity drain was removed, pneumothorax occurred, and mediastinal and subcutaneous emphysema was observed. Thoracic cavity drains were then placed again. The patient’s condition was conservatively relieved without surgery. This patient may have developed pneumothorax ex vacuo during the course of a COVID-19 infection. Since chronic inflammation in the thoracic cavity is involved in the onset of pneumothorax ex vacuo, careful consideration is required for the thoracic cavity drainage of malignant pleural effusion and other fluid retention.

[Thymic Neuroendocrine Tumor Associated with Multiple Endocrine Neoplasia Type 1]

Multiple endocrine neoplasia (MEN) type 1 is a hereditary syndrome characterized by hyperplasia and adenoma of the parathyroid gland, pancreatic tumor, and pituitary tumor. We report a rare case of thymic neuroendocrine tumor diagnosed after removal of a thymic tumor following pancreatic and parathyroid surgery. A 35-year-old man was diagnosed with MEN type 1 by hypercalcemia and gastrinemia with a ureteral tone. Two well defined nodules in the anterior mediastinum on computed tomography (CT), and a high degree of accumulation on positron emission tomography (PET) was noted. Surgery was performed through a median sternotomy with anterior mediastinal tumor resection. Pathology showed thymic neuroendocrine tumor (NET). Immunostaining results were different from pancreatic NET and duodenal NET, and a diagnosis of primary thymic NET was made. Postoperative radiation therapy was completed as adjuvant therapy, and the patient is alive without reccurrence.

Primary Dedifferentiated Liposarcoma of the Posterior Mediastinum With a Positive Surgical Margin

Liposarcoma often occurs in the extremities and retroperitoneum. Primary mediastinal liposarcoma is uncommon, and there is no settled opinion regarding adjuvant therapy after surgery. We have recently experienced a relatively rare case of primary dedifferentiated liposarcoma of the posterior mediastinum. The patient was a 76-year-old woman. An abnormal shadow was noted in the posterior mediastinum. Esophageal submucosal tumor and gastrointestinal stromal tumor were suspected; endoscopic ultrasound-guided fine needle aspiration was performed, but a definitive diagnosis could not be obtained. As the tumor tended to slowly grow, surgical resection was performed. Based on histopathological findings, the patient was diagnosed with primary dedifferentiated liposarcoma of the posterior mediastinum. Owing to the presence of a positive surgical margin, postoperative radiotherapy (60 Gy/24 fr/6 w) was administered. No recurrence was observed after three and a half years of follow-up. The prognosis of primary dedifferentiated liposarcoma of the posterior mediastinum with a positive surgical margin is poor, but postoperative radiotherapy may be useful.