Rosai-Dorfman disease is a rare disorder which seems to involve not only the lymph nodes but most other organs of the body. The case history is presented of a woman who was thought to have atypical carcinoma of the lung but in whom a diagnosis of Rosai-Dorfman disease was eventually made following a range of investigations including CT scans, positron emission tomography (PET) and histological analysis of open lung biopsy specimens. She remains well with no further progression of the disease without treatment. Rosai-Dorfman disease can mimic lung carcinoma and shows increased activity on PET scanning, so histological confirmation should be sought in all cases.
Nontraumatic liver herniation through diaphragm is a rare condition. We present a case of a 54-year-old female presenting with nontraumatic liver herniation mimicking a right lower lobe mass. Patient was noted to have growth of two right lower lobe lung nodules from 1.5 cm × 2.8 cm and 0.9 cm × 1.3 in August 2009 to 2.8 cm × 4.1 cm and 1.1 cm × 1.4 cm in March 2019 on computerized tomography (CT) scan. PET scan as well as the growth pattern was consistent with low-grade malignancy likely carcinoid tumor. CT-guided biopsy was not feasible because of location of the mass. We performed robotic thoracoscopy with plan for wedge resection, however gross inspection of the thoracic cavity revealed two masses on the dome of the diaphragm with appearance like liver and correlating with nodules seen on CT scan. A core needle biopsy showed that it was benign liver tissue.
Background Recurrent laryngeal nerve injury is a feared complication of thyroid surgery, carrying significant morbidity including hoarseness, dysphagia, and respiratory distress. Direct visualization of the nerve during surgery is the standard of care for preventing injury. Intra-operative nerve monitoring (IONM) is an adjunct utilized to decrease the risk of nerve injury, with rising popularity over the past two decades. At present, its exact role is controversial. Some studies advocate routine use, while others suggest that it only adds benefit to select complex cases. The present study is a single-center, retrospective analysis to determine whether the use of IONM significantly prevents injury to the recurrent laryngeal nerve during first-time thyroid surgery, as compared to the current practice of direct nerve visualization. Methods All patients undergoing thyroid surgery at Wellspan York Hospital and its affiliated outpatient surgical center from July 2018 until March 2021 were included in the study. For nine months of the study, IONM was routinely used for first-time thyroid surgery. For the remaining period, direct visualization alone was used for first-time surgery, and IONM was used only selectively for ipsilateral re-operative thyroid surgery. All data was acquired from The Collaborative Endocrine Surgery Quality Improvement Program, a national endocrine surgical database. We compared nerve injury rates across the three groups of patients. Results 377 patients who had thyroid surgery were identified with a total of 591 nerves at risk for injury. Six patients suffered inadvertent nerve injury, for an injury rate of 1.02%. In the group undergoing first-time thyroid surgery with direct visualization alone, four nerves out of 450 (0.89%) were injured. In the group with IONM routinely used for first-time surgery, there was one nerve injury out of 120 (0.83%). For patients with history of previous ipsilateral endocrine surgery with selective nerve monitoring, one injury occurred in a total of 13 at-risk nerves (7.69%). Conclusions The use of IONM as compared to direct identification and photo documentation of the recurrent laryngeal nerve offered no significant advantage in preventing injury. Additionally, re-operative cases have higher incidence of nerve injury, and IONM may be helpful in improving safety in these cases.
INTRODUCTION: Spontaneous diaphragmatic herniation is a rare type of acquired diaphragmatic hernia without any history of trauma. (1) We describe a case where a non-traumatic liver herniation through diaphragm was observed mimicking a lower lobe lung mass. CASE PRESENTATION:A 54-year-old female without prior thoraco-abdominal trauma was seen in the clinic because of growth of 2 right lower lobe lung nodules. These nodules were initially noted incidentally on CT scan in August 2009 and measured 1.5 cm x 2.8 cm and 0.9 cm x 1.3. They remained stable on CT scan and PET performed in 2010. Patient was lost follow-up after that until she had a CT scan in March 2019 because of concern of pneumonia and it was noted that the lung nodules have increased in size to 2.8 cm x 4.1 cm and 1.1 cm x 1.4 cm. The patient was otherwise asymptomatic. A PET scan was obtained which showed hypermetabolic nodules with maximum SUV of 3.29 and 1.4 for the larger and smaller nodule respectively. Radiographic appearance as well as the growth pattern was consistent with low-grade malignancy like carcinoid tumor. We performed robotic thoracoscopy with plan for wedge resection and possible completion lobectomy. Gross inspection of the thoracic cavity revealed abnormal mass on the dome of the diaphragm with appearance like liver. It was noted to be lying in the oblique fissure and corelated with the position of larger nodule seen on CT scan. There was a second area of thinned-out area of the diaphragm where a small nodule was noted pushing on the diaphragm with appearance like liver consistent with location of smaller lesion on CT scan. A Tru-Cut needle biopsy showed that it was benign liver tissue. The decision was made not to proceed with any diaphragmatic repair or reinforcement with mesh as this was an asymptomatic herniation through diaphragm and the liver was fibrosed to the diaphragm protecting from any intestinal herniation.DISCUSSION: A review of literature revealed that there are 28 reported cases spontaneous diaphragmatic rupture (SDH) and of those only 10% had liver herniation. SDH is caused by events that increase intra-abdominal pressure like complicated labor, intense physical exercise, psychiatric illness, and cough secondary to pertussis. Another predisposing factor for SDH is congenital diaphragmatic defect which creates an area of weakness and increases the likelihood of herniation secondary to increased intra-abdominal pressure. SDH has also been described in association with other conditions like Ehler-Danlos Syndrome (EDS) and endometriosis because of weakness of diaphragmatic tissue. CONCLUSIONS: Our case was unique because the patient had asymptomatic SDH presenting as a lung mass without any history of etiologies leading to increased intra-abdominal pressure or weakness of diaphragm. Liver herniation through diaphragm can be managed without surgical repair if liver if fibrosed to diaphragm.
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