Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm

Primary diaphragmatic undifferentiated pleomorphic sarcoma in a cat

Case summary

A 5-year-old neutered female domestic shorthair cat was referred for acute onset of dyspnoea. Thoracic radiographs performed by the referring veterinarian revealed the presence of pleural effusion. Upon presentation, the cat was dyspnoeic, and cardiopulmonary auscultation revealed muffled heart sounds and bilaterally increased bronchovesicular sounds. Radiographic study of the thorax revealed bilateral pleural effusion and a soft tissue opacity in the dorsocaudal region of the left hemithorax. A whole-body contrast-enhanced CT scan identified a soft tissue mass arising from the left diaphragmatic crus. Transthoracic ultrasound-guided fine-needle aspiration (FNA) of the mass was performed and the result was consistent with a malignant mesenchymal neoplasia, showing giant cells. Cytoreductive surgery was performed and the histopathology diagnosis of undifferentiated pleomorphic sarcoma was made. Adjuvant chemotherapy was then offered. Ten days after surgery pleural effusion recurred. Thoracic echography revealed the presence of a diaphragmatic thickening in the area of surgical resection. FNA of the thickening was consistent with mesenchymal neoplasia. Even when chemotherapy and supportive treatment with pain relief was instituted, the clinical condition of the cat worsened within a few days and it was euthanased 1 month after surgery.

Relevance and novel information

Primary diaphragmatic tumours (PDTs) have been rarely reported in human and in veterinary medicine, where only three cases have been described in the dog. To our knowledge, this is the first report to describe a PDT, specifically an undifferentiated pleomorphic sarcoma, in a cat.

Trans-diaphragmatic Pathologies: Anatomical Background and Spread of Disease on Cross-sectional Imaging

The diaphragm is not only a sheet of muscle separating the abdominal and thoracic cavities: it plays an essential role in ventilation and can act as a gateway for the spread of different disease processes between the abdominal and the thoracic cavity. Careful attention to the appearance of the diaphragm on various imaging modalities is essential to ensure the accurate diagnosis of diaphragmatic disorders, which may be secondary to functional or anatomical derangements.

Rare diaphragmatic tumor mimicking liver mass

Primary tumors of the diaphragm are quite rare. About 150 cases have been reported in the literature. Fibrosarcomas are the commonest malignant neoplasms of the diaphragm; however, only a few (less than 20) cases have been reported to date. We present the case of an extremely rare tumor of the diaphragm mimicking a liver mass. The patient, a young 28-year-old woman, presented with an 8-month-history of mildly progressive upper abdominal pain and early fullness after meals. Computed tomography scan of the abdomen revealed a mass located in the region of the left lobe of the liver with non visualized left lobe and partial vascular supply of the mass from the left hepatic artery. The tumor was also seen to draw its vascularity from bilateral internal mammary arteries. Surgical excision and hepatectomy was planned, keeping in mind the diagnosis of an atypical left hepatic mass. Laparotomy revealed a left diaphragmatic tumor growing caudally into the upper abdomen, compressing and splaying the liver along the left medial surface where the tumor was virtually adherent to it. Successful excision of the mass and subsequent histopathological and immunochemistry examination of the specimen revealed low grade fibromyxoid sarcoma of the diaphragm. This case highlights the unusual presentation of a diaphragmatic mesenchymal tumor and how it can be mistaken as an atypical liver mass. It also emphasizes the tumoral vascular supply as an indicator of its organ of origin.

Primary rhabdomyosarcoma of the diaphragm: case report and review of the literature

BACKGROUND

Diaphragmatic sarcomas are extremely rare and mostly described in children. We present the case of an adult with rhabdomyosarcoma of the diaphragm.

METHODS

We performed a literature review, highlighted possible diagnostic pitfalls, and discussed multidisciplinary treatment options.

Schwannoma of the diaphragm--a pediatric case report and review of the literature

Diaphragmatic tumors are uncommon and difficult to diagnose in the pediatric population. Schwannoma is a benign, slow-growing peripheral nerve sheath tumor that is most commonly associated with the extremities in childhood. We herein report a schwannoma of the diaphragm in a pediatric patient and review the pediatric literature.

White hemithorax in children

The aim of this pictorial review is to introduce the radiologist to the differential diagnosis of a white hemithorax in children, to provide significant information on the diagnostic work-up, and to promote radiation-free techniques whenever possible. There are many causes of white hemithorax in children and it can be due to a variety of chest disorders. In most cases, plain chest radiographs and ultrasound will suffice. However, additional information provided by, e.g., CT or MRI is sometimes required.

Multimodality imaging of the pediatric diaphragm: anatomy and pathologic conditions

Apart from serving as an important landmark for description and staging of pathologic conditions, the diaphragm is also affected by various types of pathologic conditions in children. Congenital abnormalities affecting the diaphragm include aplasia or hypoplasia, accessory diaphragm, eventration, and hernias. Congenital diaphragmatic hernias (CDHs) include Bochdalek, Morgagni, and hiatal hernias. Although survival rates are improving with the advent of new therapies, there is still significant morbidity and mortality associated with CDH. The morbidity and mortality depend on the associated congenital anomalies, the size of the hernia, and the degree of lung hypoplasia. Newer surgical repair techniques for the diaphragm have resulted in new postoperative complications and imaging appearances. Ultrasonography has become the modality of choice for evaluation of diaphragmatic paralysis. The diaphragm is uncommonly affected by trauma in children; when diaphragmatic injury is present, it usually indicates high-impact trauma associated with other severe injuries. Primary diaphragmatic tumors are very rare in children, with rhabdomyosarcoma being the most common. The diaphragm may also be secondarily involved by invasion of an adjacent tumor. Radiologists should have an understanding of the embryology, anatomy, and anatomic variations of the diaphragm and should be aware of the imaging appearances of pathologic conditions affecting the diaphragm in children.

Tumors of the diaphragm

Primary tumors of the diaphragm are rare. The most common benign cystic lesions of the diaphragm are bronchogenic or mesothelial cysts, while the most common benign solid lesion is a lipoma. Benign tumors of the diaphragm are resected if they are symptomatic or if there is a doubt about the diagnosis. The most common primary malignant lesion is rhabdomyosarcoma. Malignant tumors are treated based on histology and often with chemotherapy and/or radiation along with surgical resection if feasible. Endometriosis, a benign process that metastasizes to the diaphragm, is typically treated medically; surgical ablation or resection is considered only after failed conservative treatment. Surgical resection of metastatic malignant tumors, such as ovarian cancer and thymoma, as well as malignancies affecting the diaphragm by direct extension, such as mesothelioma, lung, and esophageal cancer, may provide some survival advantage.

Lipoma of the Diaphragm: A Rare Presentation

Lipoma of the diaphragm is an extremely rare entity. A 67-year-old asymptomatic man who had a tumor located in the posterior region of the left hemi-diaphragm is presented. The tumor was removed through a left mini-thoracotomy. The diaphragm was reconstructed primarily by using nonabsorbable suture material. The final pathologic examination revealed a mature lipoma. The patient remains without evidence of recurrence 60 months after the operation.