1. Tumors of the Diaphragm

2. The diaphragm is commonly involved with malignant pleural disease or malignant peritoneal disease. Only rarely, however, is the diaphragm the source of either benign or malignant processes.

3. HISTORIC BACKGROUND Grancher described a primary diaphragmatic tumor, a benign fibroma in 1868. Clark described a diaphragmatic lipoma in 1886. The last report found a total of only 71 case reports.

4. PRESENTATION AND EVALUAION Tumors of the diaphragm are not associated with any characteristic symptom. 50% of patients were asymptomatic and were found incidentally. If any symptom is characteristic, it is that lower chest discomfort, heaviness and referred pain to the top of the shoulder.

5. PRESENTATION AND EVALUAION Large masses which compress the lung may cause dyspnea, hemoptysis or cough. Large masses which compress the heart may cause lower leg edema, if venous return is compromised. Differentiated diagnosis includes hematoma, infections( TB…), congenital abnormality, hiatal hernia or metastasis.

6. PRESENTATION AND EVALUAION Lobulations, localized eventration, slip or hypertrophic crus may simulate tumors of the diaphragm.

7. PRESENTATION AND EVALUAION Distinguishing the mass: 1. The lung mass is suggested with the presence of irregular margins with the nearby lung, acute angle between the mass and the diaphragm, focal lung volume loss, vessels and bronchi appearing curve into the lesion.

8. PRESENTATION AND EVALUAION 2. A pleural mass is suggested by the presence of obtuse angle between the mass and the diaphragm. 3. Herniated organs can be enhanced with the use of oral or IV contrasts. 4. Ultrasound or MRI can localized a liver mass.

9. PRIMARY BENIGN NEOPLASTIC LESIONS Table 53-1

10. PRIMARY BENIGN NEOPLASTIC LESIONS 1. Lipoma( most common benign tumor of the diaphragm ) (1) It appears a sharp-bordered, smooth, possibly lobulated mass on the radiogram. (2) It often has “ dumbbell “ or “ hourglass “ shape. (3) It is predominantly from the left and posterolateral area of the diaphragm.

11. PRIMARY BENIGN NEOPLASTIC LESIONS 2. The other 2 groups of predominating benign lesions are cystic formation and neurogenic tumors. 3. Half of neurogenic tumors of the diaphragm are associated with hypertrophic pulmonary osteoarthropathy or/and clubbing finger. 4. Treatment is surgical excision.

12. PRIMARY MALIGNANT NEOPLASTIC LESIONS OF THE DIAPHRAGM Most are mesenchyma origin. Leiomyosarcoma, malignant fibrous histiocytoma and fibrosarcoma were ever reported. Surgical resection with or without chemotherapy of radiotherapy was often performed. Primary closure of the diaphragm is usually not possible.

13. PRIMARY MALIGNANT NEOPLASTIC LESIONS OF THE DIAPHRAGM Mortality and morbidity after resection of the tumor is low. The prognosis appears grim. Long term survival is rare.