ABSTRACr Leiomyomas account for about 2% of benign tumours of the lower respiratory tract. From the relatively few cases reported in the literature, it appears that these tumours most commonly occur in the fourth decade, although one third of patients are under the age of 20 years. The distribution of leiomyomas favours the distal part of the tracheobronchial tree and the most common site for tracheal lesions is the membranous portion of the lower third. Over 90% of pulmonary parenchymal leiomyomas, which themselves are more common in women, are incidental findings on chest radiographs whereas bronchial lesions are important causes of irreversible lung damage. Tracheal lesions may present as bronchial asthma. Accurate early diagnosis rests on a high index of clinical suspicion and histological examination of bronchoscopic biopsy specimens or frozen section material obtained at exploratory thoracotomy. Treatment could be conservative surgery, but 65% of reported cases have been managed by lobectomy or pneumonectomy as a result of advanced irreversible lung disease or unawareness of the benign nature of the lesion.

Three cases of iatrogenic diaphragmatic herniation are reported following thoracic and high abdominal surgery. Each case presented at least 6 months after the original surgery with symptoms of acute upper gastrointestinal obstruction. Diaphragmatic herniation was not considered in the initial differential diagnosis which lead to a delay in their referral. We emphasise the importance of checking the diaphragm following upper abdominal surgery and care when closing a defect.

Three patients with lung carcinoid related Cushing's syndrome (LCRCS) treated at Frenchay Hospital, Bristol between 1984 and 1994 are described. The first patient presented with hyperpigmentation 13 years after bilateral adrenalectomy. The second patient had no recurrence or metastases 14 years after removal of a typical carcinoid tumour. The last patient survived nine years after diagnosis of liver metastasis. The possibility of LCRCS should be considered in every patient proved to have Cushing's disease and bilateral adrenal enlargement on abdominal computed tomography. Biochemical sets of investigation (for example, adrenocorticotrophic hormone (ACTH) stimulation, dexamethasone suppression, and metyrapone response) could be misleading and should not be relied upon solely. Search for an ectopic ACTH source should be called oV only when ACTH has been demonstrated in the surgically removed specimen, and most importantly, when the serum ACTH concentration returns to normal after surgery. Lung carcinoid tumours are compatible with long survival, and liver metastasis could prove indolent and slowly growing. (Postgrad Med J 2001;77:464-467)

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Primary amyloidosis presenting as isolated mediastinal mass higure 2 Contrast enhanced computed tomographic scan of the chest showing bilateral hilar adenopathy, posterior mediastinal adenopathy, and bilateral pleural effusion. only when the patient is cooperative and has no bleeding diathesis. It is usually an easy, efficient and safe procedure. Mediastinal amyloidosis occurs infrequently and may be confused with other tumours more usually found in this region. The diagnosis should be considered in the evaluation of a large mediastinal mass. Percutaneous needle biopsy may be sufficient to provide a definitive diagnosis.

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