Successful treatment of sclerosing cervicitis and fibrosing mediastinitis with tamoxifen

Venous retrograde approach for endovascular angioplasty in chronic total pulmonary vein occlusion -a case report

INTRODUCTION

Fibrosing mediastinitis (FM) is a rare disease characterized by excessive proliferation of fibrous tissue in the mediastinum and can cause bronchial stenosis, superior vena cava obstruction, pulmonary artery and vein stenosis, etc. CASE PRESENTATION: An aging patient with intermittent chest tightness and shortness of breath was diagnosed with FM associated pulmonary hypertension (FM-PH) by echocardiography and enhanced CT of the chest, and CT pulmonary artery (PA)/ pulmonary vein (PV) imaging revealed PA and PV stenosis. Selective angiography revealed complete occlusion of the right upper PV, and we performed endovascular intervention of the total occluded PV. After failure of the antegrade approach, the angiogram revealed well-developed collaterals of the occluded RSPV-V2b, so we chose to proceed via the retrograde approach. We successfully opened the occluded right upper PV and implanted a stent.

CONCLUSIONS

This report may provide new management ideas for the interventional treatment of PV occlusion.

Ptosis and Miosis Associated with Fibrosing Mediastinitis

BACKGROUND Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation of fibrosing mediastinitis that, to our knowledge, has never been seen before. CASE REPORT A 30-year-old female Colombian flight attendant presented with a right eyelid droop. Examination revealed partial right-sided ptosis and miosis but no anhidrosis. An ill-defined firm swelling was palpable at the root of the neck. Chest radiography revealed a widened mediastinum, and computerized tomography (CT) showed a right paratracheal mass without calcification extending to the thoracic inlet, encasing multiple blood vessels. All basic blood tests, magnetic resonance imaging of the head, and ultrasound Doppler of the neck vessels were normal. History and work up for infections including fungal diseases, granulomatous diseases, vasculitis, and autoimmune diseases were negative. Positron emission tomography (PET) showed significant FDG uptake in the mediastinum. Mediastinal biopsy was histologically consistent with fibrosing mediastinitis. All relevant immunohistochemistry and microbiological studies were negative. Subsequently, the patient developed signs of superior vena cava compression; this was managed by balloon angioplasty, which resulted in improvement of symptoms. However, over time, her symptoms worsened progressively, resulting in a left-sided ptosis and radiological progression of the mass on CT. She received treatment with rituximab and concomitant steroids, which yielded excellent results: the treatment led to both resolution of her symptoms and regression of the mass and its metabolic activity on PET scan. CONCLUSIONS Fibrosing mediastinitis can present with an incomplete Horner's syndrome. Treatment with rituximab and steroids shows promising results in select cases of metabolically active idiopathic fibrosing mediastinitis.

A review of endovascular stenting for superior vena cava syndrome in fibrosing mediastinitis

Fibrosing mediastinitis (FM) is a rare disorder of inflammation and fibrosis involving the mediastinum. The formation of fibroinflammatory mass in the mediastinum can lead to obstruction of mediastinal structures and cause severe debilitating and life-threatening symptoms. Superior vena cava syndrome (SVCS) is a dreaded complication of FM with no medical therapy proven to be efficacious. Spiral vein grafting has long been utilized as first-line therapy for SVC syndrome due to FM. Endovascular repair with stents and angioplasty for malignant causes of SVC syndrome is well established. However, there are limited data on their utility in SVC syndrome due to FM. We present two cases of SVC syndrome due to FM treated with endovascular stenting and a detailed review of current literature on its utility in SVCS due to benign causes.

Estrogens Counteract the Profibrotic Effects of TGF-β and their Inhibition Exacerbates Experimental Dermal Fibrosis

Systemic sclerosis primarily affects women. This sex bias raises the question on the role female hormones could play in the development of fibrosis, which is largely unknown. Our aim was to evaluate the effects of estrogens in the development of experimental dermal fibrosis, in the mouse models of bleomycin-induced dermal fibrosis and tight skin (Tsk-1) mice, and on the activation of dermal fibroblasts by transforming growth factor-β (TGF-β). Estrogen inhibition, obtained through gene inactivation for the estrogen receptor-αknockout or treatment with tamoxifen, exacerbated skin fibrosis in the bleomycin model and in the Tsk-1 mice. In the dermal fibroblasts, treatment with 17-β-estradiol significantly decreased the stimulatory effects of TGF-β on collagen synthesis and myofibroblast differentiation, decreased the activation of canonical TGF-β signaling, and markedly reduced the expression of the TGF-β target genes. Tamoxifen reversed the inhibitory effects of estrogens by restoring Smad2/3 phosphorylation and TGF-β-induced collagen synthesis. Our results demonstrate a beneficial effect of estrogens in dermal fibrosis. Estrogens reduce the TGF-β-dependent activation of dermal fibroblasts, and estrogen inhibition leads to a more severe experimental dermal fibrosis. These findings are consistent with the prominent development of systemic sclerosis in postmenopausal women and the greater severity of the disease in men.

Multimodality Imaging of Focal and Diffuse Fibrosing Mediastinitis

Fibrosing mediastinitis is a rare benign but potentially life-threatening process that occurs because of proliferation of fibrotic tissue in the mediastinum. The focal subtype is more common and typically is associated with an abnormal immunologic response to Histoplasma capsulatum infection. Affected patients are typically young at presentation, but a wide age range has been reported, without a predilection for either sex. The diffuse form may be idiopathic or associated with autoimmunity, usually affects middle-aged and/or elderly patients, and is more common in men. For both subtypes, patients present with signs and symptoms related to obstruction or compression of vital mediastinal structures. The most common presenting signs and symptoms are cough, dyspnea, recurrent pneumonia, hemoptysis, and pleuritic chest pain. Patients with the diffuse subtype may have additional extrathoracic symptoms depending on the other organ systems involved. Because symptom severity is variable, treatment should be individualized with therapies tailored to alleviate compression of the affected mediastinal structures. Characteristic imaging features of fibrosing mediastinitis include infiltrative mediastinal soft tissue (with or without calcification) with compression or obstruction of mediastinal vascular structures and/or the aerodigestive tract. When identified in the appropriate clinical setting, these characteristic features allow the radiologist to suggest the diagnosis of fibrosing mediastinitis. Careful assessment is crucial at initial and follow-up imaging for exclusion of underlying malignancy, assessment of disease progression, identification of complications, and evaluation of treatment response. Online supplemental material is available for this article. ^©RSNA, 2019.

Sclerosing Mediastinitis Causing Unilateral Pulmonary Edema Due to Left Atrial and Pulmonary Venous Compression. A Case Report and Literature Review

Sclerosing mediastinitis (SM), previously named chronic fibrosing mediastinitis, is an inflammatory process that in its end-stage results to sclerosis around the mediastinal structures. SM is quite rare and has been correlated with inflammatory and autoimmune diseases, as well as malignancy. SM may either present in a mild form, with minor symptoms and a benign course or in a more aggressive form with severe pulmonary hypertension and subsequent higher morbidity and mortality. The diagnosis of SM may be difficult and quite challenging, as symptoms depend on the mediastinal structure that is mainly involved; quite often the superior vena cava. However, practically any mediastinal structure may be involved by the fibrotic process, such as the central airways, as well as the pulmonary arteries and veins, leading to obstruction or total occlusion. The latter may be impossible to undergo proper surgical excision of the lesion, and is considered to be a real challenge to the surgeon. We herein report a case of SM that presented with arterial and venous compression. The imaging appearance was that of unilateral pulmonary edema, associated with lung collapse. The case is supplemented by a non-systematic review of the relevant literature.

Tamoxifen attenuates dialysate-induced peritoneal fibrosis by inhibiting GSK-3β/β-catenin axis activation

Peritoneal fibrosis is a severe complication arising from long-term peritoneal dialysis (PD). Tamoxifen (Tamo) has been clinically proven effective in a series of fibrotic diseases, such as PD-associated encapsulating peritoneal sclerosis (EPS), but the mechanisms underlying Tamoxifen’s protective effects are yet to be defined. In the present study, C57BL/6 mice received intraperitoneal injections of either saline, 4.25% high glucose (HG) PD fluid (PDF) or PDF plus Tamoxifen each day for 30 days. Tamoxifen attenuated thickening of the peritoneum, and reversed PDF-induced peritoneal expression of E-cadherin, Vimentin, matrix metalloproteinase 9 (MMP9), Snail, and β-catenin. Mouse peritoneal mesothelial cells (mPMCs) were cultured in 4.25% glucose or 4.25% glucose plus Tamoxifen for 48 h. Tamoxifen inhibited epithelial-to-mesenchymal transition (EMT) as well as phosphorylation of glycogen synthase kinase-3β (GSK-3β), nuclear β-catenin, and Snail induced by exposure to HG. TWS119 reversed the effects of Tamoxifen on β-catenin and Snail expression. In conclusion, Tamoxifen significantly attenuated EMT during peritoneal epithelial fibrosis, in part by inhibiting GSK-3β/β-catenin activation.

Effect of tamoxifen on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs

End-to-end anastomosis in the treatment for bile duct injury during laparoscopic cholecystectomy has been associated with stricture formation. The aim of this study was to experimentally investigate the effect of oral tamoxifen (tmx) treatment on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs. Twenty-six pigs were divided into three groups [sham (n = 8), control (n = 9) and tmx (n = 9)]. The common bile ducts were transected and anastomosed in the control and tmx groups. Tmx (40 mg/day) was administered orally to the tmx group, and the animals were euthanized after 60 days. Fibrosis was analysed by Masson's trichrome staining. Picrosirius red was used to quantify the total collagen content and collagen type I/III ratio. mRNA expression of transforming growth factor (TGF)-β1, -β2 and -β3 was quantified using real-time polymerase chain reaction (qRT-PCR). The control and study groups exhibited higher fibrosis than the sham group, and the study group showed lower fibrosis than the control group (P = 0.011). The control and tmx groups had higher total collagen content than the sham group (P = 0.003). The collagen type I/III ratio was higher in the control group than in the sham and tmx groups (P = 0.015). There were no significant differences in the mRNA expression of TGF-β1, -β2 and -β3 among the groups (P > 0.05). Tmx decreased fibrosis and prevented the change in collagen type I/III ratio caused by the procedure.

Post-tuberculous fibrosing mediastinitis: a review of the literature

Fibrosing mediastinitis (FM) is a rare disease where there is thickening of the fibrous tissue in the mediastinum. While histoplasmosis is the the most common recognised cause, the link with tuberculosis (TB) has been rarely documented. We review the link between TB and FM, and describe a case of probable TB-related FM.Our case is of a 74-year-old man who presented with breathlessness 3 years after fully treated TB. Scans revealed a calcified soft tissue mass within the mediastinum, and a diagnosis of fibrosing mediastinitis resulting in pulmonary hypertension was made. Tests for histoplasmosis and IgG4 staining were negative. Surgical intervention was not felt to be beneficial, and he was treated with prednisolone and mycophenolate mofetil.In the review, we highlight the two forms of mediastinitis—granulomatous versus fibrous, and how these two entities may be on a spectrum of disease progression. We also explore the prevalence, clinical presentation, pathogenesis, imaging techniques and treatment options of TB-related FM.

[Treatment of chronic mediastinitis]

BACKGROUND

Chronic mediastinitis is a rare disorder characterized by the proliferation of fibrous tissue within the mediastinum resulting in compression of mediastinal structures.

OBJECTIVE

This article gives an overview of the treatment options for chronic mediastinitis.

MATERIAL AND METHODS

A literature search was carried out regarding treatment options for chronic mediastinitis

RESULTS AND CONCLUSION

Little is known about the pathogenesis of chronic mediastinitis, which has hampered the development of novel therapeutic approaches. There is no convincing evidence for the success of medicinal (antifungal or conventional anti-inflammatory) therapy and it is not recommended. In cases of clinical symptoms procedures for decompression, such as endovascular or endobronchial stents or surgical procedures, such as decompression interventions or extra-anatomic bypasses should be considered. The prognosis for unilateral involvement is better than for bilateral involvement if performed in specialized centers.

Tamoxifen ameliorates renal tubulointerstitial fibrosis by modulation of estrogen receptor α-mediated transforming growth factor-β1/Smad signaling pathway

BACKGROUND

After insult to the kidney, a renal fibrotic process is initiated with sustained inflammation, fibroblast activation and accumulation of extracellular matrix (ECM). Tamoxifen has been used as an anti-estrogen for the prevention and treatment of breast cancer. In this study, we investigated the protective effects of tamoxifen on unilateral ureteral obstruction (UUO)-induced renal tubulointerstitial fibrosis and its molecular mechanism.

METHODS

Renal fibrosis was induced by UUO in 7-week-old C57BL/6 mice. Tamoxifen (50 mg/kg) was given by oral gavage for 5 days before induction of renal fibrosis. Tamoxifen treatment was continued for 14 days after UUO operation. Histologic changes were examined by periodic acid-Schiff stain and Masson's trichrome stain. Expression of α-smooth muscle actin, vimentin, type I collagen, fibronectin and cell adhesion molecules were evaluated by immunohistochemistry and western blot analysis. We also evaluated the effect of tamoxifen on estrogen receptor (ER)-α-mediated transforming growth factor (TGF)-β1/Smad signaling pathway in vitro.

RESULTS

Renal tubular injury and fibrosis were increased after UUO. Tamoxifen treatment significantly decreased UUO-induced renal tubular injury and fibrosis. Renal fibroblast activation, ECM deposition and inflammation were significantly increased after ureteral ligation. However, tamoxifen treatment significantly decreased UUO-induced renal fibroblast activation, ECM deposition and inflammation by suppression of TGF-β1/Smad signaling pathway in vivo. Tamoxifen decreased TGF-β1-induced fibroblast proliferation and cell migration by modulating ERα-mediated TGF-β1/Smad signaling pathway in vitro.

CONCLUSION

These findings indicate that tamoxifen has a beneficial effect on UUO-induced tubulointerstitial fibrosis by suppression of renal fibroblast activation via modulation of ERα-mediated renal TGF-β1/Smad signaling pathway.

Fibrosing mediastinitis: an unusual cause of pulmonary symptoms

Fibrosing mediastinitis (FM), also known as granulomatous or sclerosing mediastinitis, is an uncommon but serious cause of chest symptoms. Due to an infectious or inflammatory challenge, production of collagen occurs in the confined space of the mediastinum. Collagen formation leads to compression of vital structures, resulting in cough, chest pain and dyspnea. The majority of cases of FM occur as a result of prior exposure to Histoplasma capsulatum. The following is a case of a previously healthy young woman who presented with a 3-month history of cough, chest pain and trouble breathing, and was subsequently found to have fibrosing mediastinitis. Fibrosing mediastinitis should be considered in the differential diagnosis of cough, chest pain and dyspnea, primarily when findings such as increased venous pressure are present on physical exam and hilar abnormalities are seen on chest radiograph. Clinical presentation, diagnosis and management of fibrosing mediastinitis are discussed.

Tamoxifen decreases the myofibroblast count in the healing bile duct tissue of pigs

OBJECTIVE

The aim of this study was to evaluate the effect of oral tamoxifen treatment on the number of myofibroblasts present during the healing process after experimental bile duct injury.

METHODS

The sample consisted of 16 pigs that were divided into two groups (the control and study groups). Incisions and suturing of the bile ducts were performed in the two groups. Tamoxifen (20 mg/day) was administered only to the study group. The animals were sacrificed after 30 days. Quantification of myofibroblasts in the biliary ducts was made through immunohistochemistry analysis using anti-alpha smooth muscle actin of the smooth muscle antibody. Immunohistochemical quantification was performed using a digital image system.

RESULTS

In the animals treated with tamoxifen (20 mg/day), there was a significant reduction in immunostaining for alpha smooth muscle actin compared with the control group (0.1155 vs. 0.2021, p = 0.046).

CONCLUSION

Tamoxifen reduced the expression of alpha smooth muscle actin in the healing tissue after bile duct injury, suggesting a decrease in myofibroblasts in the scarred area of the pig biliary tract. These data suggest that tamoxifen could be used in the prevention of biliary tract stenosis after bile duct surgeries.

[Acute pulmonary edema, new complication of sclerosing mediastinitis]

Sclerosing mediastinitis is a rare and benign disease, which can cause obstruction of mediastinal structures, this determines the clinical presentation and prognosis. The obstruction of pulmonary venous structures secondary to mediastinal fibrosis has been rarely reported, clinically it mimics mitral stenosis. We describe the clinical case of a young patient with idiopathic sclerosing mediastinitis. The radiologic exams found stenosis of the right pulmonary artery, the right bronchus and pulmonary veins. Through this observation, we discuss this rare entity that although benign, can also be deadly. We study the different etiologies, clinical and therapeutic possibilities.

Idiopathic mediastinal fibrosis with involvement of the pulmonary vessels and left main coronary artery

Idiopathic mediastinal fibrosis (IMF) is an uncommon clinical condition and the manifestations of this disease vary from a relatively benign disorder with minor symptoms to severe pulmonary vascular occlusion leading to mortality, commonly presenting a diagnostic and therapeutic challenge. Here, we present the case of a Taiwanese woman with obstruction of the left pulmonary veins and artery and stenosis of the left main coronary artery (LMCA) resulting from IMF. To our knowledge, this is the first reported case of IMF successfully treated with percutaneous balloon angioplasty with stent placement for the LMCA stenosis.

Antifibrotic effect of tamoxifen in a model of progressive renal disease

Tamoxifen, a selective estrogen receptor modulator, has antifibrotic properties; however, whether it can attenuate renal fibrosis is unknown. In this study, we tested the effects of tamoxifen in a model of hypertensive nephrosclerosis (chronic inhibition of nitric oxide synthesis with L-NAME). After 30 days, treated rats had significantly lower levels of albuminuria as well as lower histologic scores for glomerulosclerosis and interstitial fibrosis than untreated controls. Tamoxifen was renoprotective despite having no effect on the sustained, severe hypertension induced by L-NAME. Tamoxifen prevented the accumulation of extracellular matrix by decreasing the expression of collagen I, collagen III, and fibronectin mRNA and protein. These renoprotective effects associated with inhibition of TGF-β1 and plasminogen activator inhibitor-1, and with a significant reduction in α-smooth muscle actin-positive cells in the renal interstitium. Furthermore, tamoxifen abrogated IL-1β- and angiotensin-II-induced proliferation of fibroblasts from both kidney explants and from the NRK-49F cell line. Tamoxifen also inhibited the expression of extracellular matrix components and the production and release of TGF-β1 into the supernatant of these cells. In summary, tamoxifen exhibits antifibrotic effects in the L-NAME model of hypertensive nephrosclerosis, likely through the inhibition of TGF-β1, suggesting that it may have therapeutic use in CKD treatment.

Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response

Fibrosing mediastinitis (FM) is a rare disorder characterized by the invasive proliferation of fibrous tissue within the mediastinum. FM frequently results in the compression of vital mediastinal structures and has been associated with substantial morbidity and mortality. Its pathogenesis remains unknown. However, in North America most cases are thought to represent an immune-mediated hypersensitivity response to Histoplasma capsulatum infection. To characterize the clinical disease spectrum, natural disease progression, responses to therapy, and overall survival, we retrospectively analyzed all 80 consecutive patients with a diagnosis of FM evaluated at Mayo Clinic, Rochester, MN, from 1998 to 2007. Furthermore, we characterized the adaptive immune response in 15 representative patients by immunohistochemistry. The majority of patients presented with nonspecific respiratory symptoms due to the compression of mediastinal broncho-vascular structures. Chest radiographic imaging most frequently revealed localized, invasive, and frequently calcified right-sided mediastinal masses. Most patients had radiographic or serologic evidence of previous histoplasmosis. In contrast to earlier reports summarizing previously reported FM cases, the clinical course of our patients appeared to be more benign and less progressive. The overall survival was similar to that of age-matched controls. There were only 5 deaths, 2 of which were attributed to FM. These differences may reflect publication bias associated with the preferential reporting of more severely affected FM patients in the medical literature, as well as the more inclusive case definition used in our consecutive case series. Surgical and nonsurgical interventions effectively relieved symptoms caused by the compression of mediastinal vascular structures in these carefully selected patients. In contrast, antifungal and antiinflammatory agents appeared ineffective. Histologic examination and immunostaining revealed mixed inflammatory infiltrates consistent with a fibroinflammatory tissue response in these histoplasmosis-associated FM cases. The immune cell infiltrates included large numbers of CD20-positive B lymphocytes. As B lymphocytes may contribute to the pathogenesis of the disease, therapeutic B-cell depletion should be investigated as a therapeutic strategy for FM.

An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients

With increasing numbers of immune-compromised patients with malignancy, hematologic disease, and HIV, as well as those receiving immunosupressive drug regimens for the management of organ transplantation or autoimmune inflammatory conditions, the incidence of fungal infections has dramatically increased over recent years. Definitive diagnosis of pulmonary fungal infections has also been substantially assisted by the development of newer diagnostic methods and techniques, including the use of antigen detection, polymerase chain reaction, serologies, computed tomography and positron emission tomography scans, bronchoscopy, mediastinoscopy, and video-assisted thorascopic biopsy. At the same time, the introduction of new treatment modalities has significantly broadened options available to physicians who treat these conditions. While traditionally antifungal therapy was limited to the use of amphotericin B, flucytosine, and a handful of clinically available azole agents, current pharmacologic treatment options include potent new azole compounds with extended antifungal activity, lipid forms of amphotericin B, and newer antifungal drugs, including the echinocandins. In view of the changing treatment of pulmonary fungal infections, the American Thoracic Society convened a working group of experts in fungal infections to develop a concise clinical statement of current therapeutic options for those fungal infections of particular relevance to pulmonary and critical care practice. This document focuses on three primary areas of concern: the endemic mycoses, including histoplasmosis, sporotrichosis, blastomycosis, and coccidioidomycosis; fungal infections of special concern for immune-compromised and critically ill patients, including cryptococcosis, aspergillosis, candidiasis, and Pneumocystis pneumonia; and rare and emerging fungal infections.

Successful treatment of sclerosing mediastinitis with a high serum IgG4 level

Sclerosing mediastinitis is not a common condition in the thoracic cavity and is difficult to cure. Several medications have been used; however, most of the cases do not achieve satisfactory results, and the most successful treatment is operative resection. We report the first case of IgG4-related sclerosing mediastinitis that showed IgG4-positive plasma cells infiltrated into the fibrous tissue and a high serum IgG4 level. The patient clearly showed remission of the symptoms after steroid therapy. Our findings suggest that the serum IgG4 level is a good selection indicator for steroid therapy in sclerosing mediastinitis.

Computed tomography and the idiopathic form of proliferative fibrosing mediastinitis

Fibrosing mediastinitis is characterized by abnormal proliferation of acellular collagen and fibrous tissue in the mediastinum. Although most cases in the United States are attributed to Histoplasma capsulatum, there is a different and important idiopathic subset, with potentially different treatment and prognosis implications. We reviewed 12 such cases encountered from 1995 to 2004. Computed tomography showed that the masses were large, averaging 5 x 9 cm, with none showing significant calcification. Five had extension into the neck, and all had some vascular or airway involvement. Mimics may include the precalcific form of postinflammatory mediastinal fibrosis, mediastinal granuloma, malignancy (esp. lymphoma), sarcoidosis, and Castleman disease.

A Potential Role for F-18 FDG PET/CT in Evaluation and Management of Fibrosing Mediastinitis

Fibrosing mediastinitis is an uncommon benign disorder, and its pathogenesis and management remain unclear. Conventional imaging techniques (chest radiographs, CT, MRI) may suggest its diagnosis but are frequently nonspecific, and it frequently mimics a malignant process by presenting as a mediastinal mass without calcifications, encasing, and infiltrating adjacent mediastinal structures, and showing an overall aggressive behavior. The value of FDG PET imaging in this entity remains largely unknown with only a few case reports in the literature, and often, biopsy is necessary for definitive diagnosis. We report a case of biopsy proven fibrosing mediastinitis highlighting the utility of PET in the evaluation and management of the disease.

Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients

BACKGROUND & AIMS

Sclerosing mesenteritis is a rare non-neoplastic disease that affects the small bowel mesentery with chronic fibrosing inflammation. There are few data on the natural history and therapeutic options for this condition.

METHODS

We performed a retrospective and prospective study to describe the clinical characteristics, therapy, and outcome of all cases of sclerosing mesenteritis diagnosed at the Mayo Clinic, Rochester, from 1982-2005.

RESULTS

Ninety-two cases were identified; 70% were male, with a median age of 65 years (interquartile range, 55-72). Common presenting symptoms included abdominal pain in 70%, diarrhea in 25%, and weight loss in 23%. Treatment included medical therapy alone in 26%, surgery alone in 13%, surgery followed by medical therapy in 9%, and 52% received no treatment. Ten percent responded to surgery alone, 20% responded to additional medical treatment after surgery, and 38% responded to medical therapy alone. Tamoxifen in combination with prednisone was used in 20 patients, and 60% improved. Non-tamoxifen-based regimens were used in 12 patients, and 8% improved. Eighteen deaths were noted during the study period, and 17% were attributed to complications of sclerosing mesenteritis or its treatment.

CONCLUSIONS

Although a relatively benign condition, sclerosing mesenteritis can have a prolonged debilitating course with a fatal outcome. Our results suggest that symptomatic patients might benefit from medical therapy, particularly tamoxifen and prednisone combination treatment. Long-term follow-up is needed to substantiate these results.

Successful Steroid Treatment for Fibrosing Mediastinitis and Sclerosing Cervicitis

The use of steroids to successfully treat a 75-year-old woman with fibrosing mediastinitis and sclerosing cervicitis causing a stricture of the left common carotid artery is reported. Biopsy specimens showed collagenous fibers and fibroblasts with moderate infiltration of lymphocytes. The mediastinal and neck lesions were significantly reduced, with almost complete resolution of arterial stricture, 3 months after initiating administration of prednisolone at 20 mg/d.

Breast cancer and scleroderma

INTRODUCTION

Epidemiologic studies have shown that patients with scleroderma have an increased risk of cancer.

METHODS

The authors report eight cases and retrospectively review the published data on the possible association between breast cancer and scleroderma of the cutaneous and systemic forms. The records of all patients with scleroderma and breast cancer who were hospitalized during 1980-2002 in the Chaim Sheba Medical Center were surveyed. A literature search for breast cancer and scleroderma was performed.

RESULTS

The clinical data of 65 women patients with breast cancer and scleroderma, eight of whom were hospitalized in the Chaim Sheba Medical Center and 57 who were reported in the literature, are summarized. In 29 patients (44%), scleroderma appeared before or simultaneously with the diagnosis of breast cancer. While a higher frequency of systemic scleroderma was described in this group, a higher rate of cutaneous scleroderma appeared in the group where scleroderma followed breast cancer diagnosis (p<0.001).

CONCLUSIONS

Large-scale case-control studies are needed to substantiate the possible association between scleroderma-both cutaneous and systemic-and breast cancer.

Sclerosing cervicitis: report of a skull base lesion with literature review

BACKGROUND

Invasive fibrosclerotic lesions of the head and neck outside of the thyroid and orbit are extremely rare. To date 13 cases of sclerosing cervicitis have been described in the literature.

METHODS

We present a case of a sclerosing inflammatory lesion encountered at the skull base in a 49-year-old woman.

RESULTS

After surgical excision and pathologic examination, this lesion was identified as sclerosing cervicitis.

CONCLUSIONS

This case report contributes to an awareness of a rare lesion of the head and neck that presents clinical and treatment challenges for surgeons managing these patients.

Fibrosing Mediastinitis

Fibrosing mediastinitis is a rare benign disorder caused by proliferation of acellular collagen and fibrous tissue within the mediastinum. Although many cases are idiopathic, many (and perhaps most) cases in the United States are thought to be caused by an abnormal immunologic response to Histoplasma capsulatum infection. Affected patients are typically young and present with signs and symptoms of obstruction or compression of the superior vena cava, pulmonary veins or arteries, central airways, or esophagus. There may be two types of fibrosing mediastinitis: focal and diffuse. The focal type usually manifests on computed tomographic (CT) or magnetic resonance (MR) images as a localized, calcified mass in the paratracheal or subcarinal regions of the mediastinum or in the pulmonary hila. The diffuse type manifests on CT or MR images as a diffusely infiltrating, often noncalcified mass that affects multiple mediastinal compartments. CT and MR imaging play a vital role in the diagnosis and management of fibrosing mediastinitis.

[Chronic sclerosing mediastinitis: infrequent cause of unilateral diaphragmatic paralysis]

Chronic sclerosing mediastinitis (CSM) is a rare disease whose etiology varies and which usually develops through mediastinal compression syndromes, generally due to occlusion of the superior vena cava. We report a case of CSM diagnosed after a chance finding of unilateral diaphragm paralysis, a circumstance not previously reported in the literature. We review the clinical, radiological and histological features of CSM.

Laparoscopic treatment of retroperitoneal fibrosis: report of two cases and review of the literature

OBJECTIVES

We present the results of treatment by laparoscopy of two patients with retroperitoneal fibrosis and review the literature since 1992, when the first case of this disease that was treated using laparoscopy was published. We also discuss the contemporary alternatives of clinical treatment with corticosteroids and tamoxifen.

CASE REPORT

Two female patients, one with idiopathic retroperitoneal fibrosis, and other with retroperitoneal fibrosis associated with Riedel's thyroiditis, were treated using laparoscopic surgery. Both cases had bilateral pelvic ureteral obstruction and were treated using the same technique: transperitoneal laparoscopy, medial mobilization of both colons, liberation of both ureters from the fibrosis, and intraperitonealisation of the ureters. Double-J catheters were inserted before the operations and removed 3 weeks after the procedures. The first patient underwent intraperitonealisation of both ureters in a single procedure. The other had 2 different surgical procedures because of technical difficulties during the first operation. Both patients were followed for more than 1 year and recovered completely from the renal insufficiency. One of them still has occasional vague lumbar pain. There were no abnormalities in the intravenous pyelography in either case.

CONCLUSIONS

Surgical correction of retroperitoneal fibrosis, when indicated, should be attempted using laparoscopy. If possible, bilateral ureterolysis and intraperitonealisation of both ureters should be performed in the same operation.