A 20-year-old male with thoracic pain and a lower thoracic mass

Abstract

A 20-yr-old Caucasian male construction worker had a previous history of a road traffic accident 3 yrs before presentation. A computed tomography (CT) scan of the thoracic spine was carried out to exclude vertebral damage. No evidence of vertebral bone damage or other lesions was seen, and the patient recovered without sequelae.A week before presentation, he noticed a stabbing pain in his right hemithorax, without dyspnoea. The pain persisted, and the patient was referred, by his general practitioner, for a chest radiograph ( fig. 1). Based on these results, the patient was referred to a general hospital for further diagnostic tests. A CT scan of thorax and abdomen (not shown) revealed a large mass, which was interpreted to arise in the right upper abdomen, probably originating from the liver. A malignant tumour, or a metastatic lesion, was suspected and the patient was referred to University Medical Center Groningen (Groningen, The Netherlands).The patient did not suffer from dyspnoea, cough or haemoptysis and there was no history of fever, weight loss, fatigue or excessive sweating. There were no neurological or gastrointestinal complaints. The patient was a nonsmoker, and did not use any medication.On physical examination, a healthy appearing, haemodynamically stable young male, of normal posture was seen. On percussion, a dull sound was found in the right lower zone of the chest. Auscultation revealed normal cardiac sounds without murmurs, and normal breathing sounds on the left side and upper right side of the chest. Abdominal examination revealed no palpable masses or other abnormalities. No palpable lymph nodes were present. Additional physical examination revealed no other abnormalities.Laboratory tests only showed a slightly elevated serum alkaline phosphatase of 174 U?L -1 (normal value: 13-120 U?L -1 ). Serum lactate dehydrogenase, a-fetoprotein and b-human chorionic gonadotropin values were all normal; therefore, an extra-gonadal germ cell tumour was unlikely.On revision of the CT scan, there was doubt regarding the hepatic origin of the mass. Therefore, abdominal ultrasonography was performed. No focal lesions in the liver parenchyma were observed, and the liver blood flow appeared intact. In the right thoracic region, a mass was seen with variable echogenicity and rich vascularisation. Due to the high degree of vascularisation observed on the abdominal ultrasonography, no percutaneous biopsy was performed. A CT angiography was performed: first, to narrow the differential diagnosis, and, secondly, to provide the thoracic surgeon with more detailed information about vascularisation ( fig. 2). At bronchoscopy, no endobronchial abnormalities were seen. Cytological examination of the bronchial lavage showed no signs of malignancy. A bone scan was normal.Exploratory thoracotomy revealed a tumour originating from the right dorsal region, lateral from the vertebral column. A surgeon was able to remove the tumour (figs 3 and 4). Eur Respir J 2005; 26: 740-743

Largest recorded non-invasive true intrathoracic desmoid tumour

“…Numerous hypotheses regarding the cause of these tumours have been suggested, including abnormal scarring from previous trauma in up to 25% of cases, hormonal factors (oestrogen) and familial predisposition. [2] Most desmoid tumours with bony involvement are detectable on a chest radiograph. A CT scan usually further elucidates the size and location of the tumour.…”

“…If complete surgical resection is not possible, treatment options include neoadjuvant radiotherapy to reduce tumour size to permit resection or achieve a possible cure; [2] postoperative brachytherapy or intraoperative radiation therapy to kill remaining tumour cells; non-steroidal inflammatory drugs, antioestrogen therapy (tamoxifen) or a combination thereof; and chemotherapy or targeted drug therapy. [3,5] Radiotherapy alone and surgery combined with radiotherapy result in better local control than surgery alone.…”

“…Even in patients with positive margins following surgery, adjuvant radiotherapy resulted in a significant decrease in recurrence. [2] However, radiotherapy should be used judiciously to avoid the complications of tissue fibrosis and radiation-induced neoplasms, which are of particular concern in the young patient. [2,3] The recurrence rate varies from 29% to 54%, with a longer disease-free interval associated with negative resection margins.…”

“…[2] However, radiotherapy should be used judiciously to avoid the complications of tissue fibrosis and radiation-induced neoplasms, which are of particular concern in the young patient. [2,3] The recurrence rate varies from 29% to 54%, with a longer disease-free interval associated with negative resection margins. [1,2] Most of these tumours recur within 2 years after resection.…”

“…[2,3] The recurrence rate varies from 29% to 54%, with a longer disease-free interval associated with negative resection margins. [1,2] Most of these tumours recur within 2 years after resection. [2] Repeat resection or radiation after surgery achieves a control rate of up to 80%.…”