Mediastinal masses in childhood: a review from a paediatric pathologist's point of view

A giant lobular thoracic ganglioneuroma cause skeletal erosion: A case report and literature review

RATIONALE

Ganglioneuroma (GN) is a rare tumor that originates from neural crest cells and can manifest in any location along the sympathetic chain. It typically exhibits a circular or oval shape and does not invade the surrounding tissue destructively and the enormous lobular appearance and erosion of adjacent skeletal tissues are extremely infrequent among GN.

PATIENT CONCERNS

A 15-year-old girl presented to our thoracic surgery clinic with a large intrathoracic mass that was incidentally discovered on a chest X-ray. Further imaging with computed tomography and magnetic resonance imaging revealed a lobular profile and an aggressive growth pattern of the tumor, which destroyed the vertebral and rib bones. A tissue sample obtained by needle biopsy was subjected to histopathological analysis, which confirmed the diagnosis of a GN.

DIAGNOSIS

Thoracic (posterior mediastinal) GN and Hashimoto's thyroiditis.

INTERVENTIONS

After thoracoscopic exploration, a thoracotomy was performed to excise the mass.

OUTCOMES

The patient recovered well after surgery, had no major complications, and was discharged without any issues. Further follow-up is necessary to clarify the medium to long-term outcome.

LESSONS

Based on existing reports, thoracic GN rarely erodes adjacent bone tissue. By examining previously reported cases, we speculate that the lobular morphology of the tumor may be linked to the more aggressive biological behavior of GN. We also discovered that female patients may be more susceptible to bone erosion. However, further research and additional cases are required to confirm these potential associations.

Association of anesthetic and surgical risk factors with outcomes of initial diagnostic biopsies in a current cohort of children with anterior mediastinal masses

Background

Diagnostic biopsies of pediatric anterior mediastinal masses (AMMs) are high-risk procedures in which general anesthesia (GA) is traditionally avoided. However, awareness of historically recognized risk factors and corresponding perioperative management have improved over time and may now no longer strictly preclude the use of GA. Therefore, in this study, we examined the association of anesthetic and surgical risk factors and modalities with resulting procedural and survival outcomes in a current patient cohort.

Methods

We retrospectively reviewed charts of 35 children with AMMs who underwent initial diagnostic biopsies between January 2001 and August 2019, and determined tracheal compression and deviation from archival CT scans and procedural and disease outcomes.

Results

Twenty-three (65%) patients underwent GA while 12 (35%) received sedation. Among patients with available CT measurements, 13 of 25 (52%) had >50% anteroposterior tracheal diameter reduction. Patients with >50% anteroposterior tracheal compression received sedation more frequently (p=0.047) and were positioned upright (p=0.015) compared with patients with ≤50% compression, although 4 of 13 and 9 of 12, respectively, still received GA. Intraoperative adverse events (AEs) occurred in four (11.4%) patients: three received GA, and all were positioned supine or lateral. AEs were not associated with radiographic airway risk factors but were significantly associated with morphine and sevoflurane use (p<0.001) and with thoracoscopic biopsies (p=0.035). There were no on-table mortalities, but four delayed deaths occurred (three related to disease and one from late procedural complications).

Conclusions

In a current cohort of pediatric AMM biopsies, patients with >50% anteroposterior tracheal compression were more frequently managed with a conservative perioperative management strategy, though not completely excluding GA. The corresponding reduction in frequency of procedural AEs in this traditionally high-risk group suggests that increased awareness of procedural risk factors and appropriate risk-guided perioperative management choices may obviate the procedural mortality historically associated with pediatric AMM biopsies.

The Hematological Differential Diagnosis of Mediastinal Masses

Mediastinal masses commonly present in children and may pose diagnostic challenges, particularly with limited sampling. This article aids the pathologist by reviewing the hematologic differential diagnosis of a pediatric mediastinal mass, along with ancillary testing useful for rendering the correct diagnosis. A review of the more common lymphomas is presented, including classic Hodgkin lymphoma, T-lymphoblastic leukemia/lymphoma, and primary mediastinal (thymic) large B-cell lymphoma, along with brief mentions of less common entities such as gray zone lymphoma and thymoma as well as non-neoplastic conditions such as benign cysts and infections.

Mediastinal lesions across the age spectrum: a clinicopathological comparison between pediatric and adult patients

The objective of this study was to identify the differences in histopathological distribution and clinical features of mediastinal lesions (MLs) across the age spectrum in Chinese series of patients and to compare with the available literature. A total of 409 cases of MLs, including 137 pediatric and 272 adult patients from a single institution, was reviewed and categorized into groups according to age. Among the 409 cases, the age showed a bimodal distribution with an increased incidence of MLs among (< 10 year) and (60–< 70 year) age groups. Thymic lesions, neurogenic tumors, and cysts made up 57% of MLs among the 409 cases. A significantly higher frequency was found for neurogenic tumors, germ cell tumors, mesenchymal tumors, and lymphatic lesions, (p < 0.01) for all, in pediatric population compared to adults. On the contrary, frequencies of thymic lesions and metastatic carcinomas were significantly higher in adults compared to pediatric category, (p < 0.01) for both. Overall, 41.6% were asymptomatic, however, pediatric patients showed a significantly higher incidence of cough and fever, (p < 0.01) for both, and dyspnea (p = 0.02), than adults. Whereas adult subset showed a significantly higher incidence of chest pain (p = 0.02), or oppression (p < 0.01), than pediatric counterpart. In conclusion, the age spectrum was the factor that influenced the histopathological distribution and the clinical presentation of MLs in Chinese series of patients. Such differences might be considered in the differential diagnosis and therapeutic approach for adult as well as pediatric patients with MLs. Furthermore, our study was comparable to the literature in terms of MLs frequencies.

Scoliosis secondary to ganglioneuroma: a case report and up to date literature review

Idiopathic scoliosis is the most common form of spinal deformity in children. However, secondary causes of scoliosis, such as ganglioneuroma, should be always considered to avoid wrong diagnosis, and further investigations are required when there are atypical signs. We report a case of ganglioneuroma misdiagnosed as idiopathic scoliosis and review the literature to identify the red flags useful for physicians during the evaluation of a child with scoliosis. On the basis of both clinical and radiographic criteria that emerged from this study, we propose an algorithm that could help in the differential diagnosis, suggesting when to perform an MRI.

Mediastinal masses in children: experience with 120 cases

Primary mediastinal malignancies are rare tumors and can originate from any mediastinal organ or tissue such as thymic, neurogenic, lymphatic, germinal, or mesenchymal. The authors reviewed all cases of primary pediatric mediastinal masses diagnosed over a 25-year period to determine the pattern of presentation, the histology, and the outcome of the surgical treatment. In this study, 120 primary pediatric mediastinal mass cases diagnosed between 1985 and 2011 are retrospectively evaluated according to their age, sex, symptoms, anatomical location, surgical treatment, and histopathological evaluation. The median age of the patients was 5.8 years. There were 34 benign and 86 malign tumors. Thirty patients were asymptomatic. Common symptoms in the patients were cough, dyspnea, fatigue, fever, abdomen pain, back pain, and neurological symptoms. According to their origins, they were presented as neurogenic tumors (38.3%), lymphomas (18.3%), undifferentiated sarcomas (15%), germ cell tumors (7.5%), and the other tumors (22%) thymic pathologies, lymphangiomas, rhabdomyosarcomas, lipomas, hemangiomas, and Wilms' tumor. Complete resection of the tumor was performed in 86 patients, partial resection of the tumor was the intervention in 11 patients. In 23 patients, biopsy was undertaken. Because of the high incidence of asymptomatic or nonspecific presentation such as the upper airway disease, the presentation of a mediastinal mass in children may be challenging. Neurogenic tumors or lymphomas are indicating surgery, if possible complete resection, for both benign and malignant conditions. Although surgery is the mainstay of therapy for most mediastinal tumors, an experienced multidisciplinary approach is necessary.

Bronchogenic and Esophageal Cyst With Laryngeal Malformations in a Thoroughbred Foal

This report documents an unusual case of congenital foregut cyst with dysphagia and stridor in a Thoroughbred foal. Histologically, the bilocular cyst, near the junction of larynx and trachea, had an epithelial lining of bronchogenic and esophageal origin. Concomitant malformation of the laryngeal muscles and cartilage resulted in a combination of anomalies that have not been reported in the human or veterinary literature.

Endobronchial ultrasound in pediatric pulmonology

Endobronchial ultrasound (EBUS) is a recently introduced technique that has significantly advanced bronchoscopic techniques in adult medicine. Use of ultrasound allows far more accurate localization and sampling of both peripheral pulmonary, as well as mediastinal and hilar lesions. This has led to greater diagnostic success, with a reduced rate of complications. Its performance characteristics in adult populations are equivalent to surgical procedures previously considered gold standard, but it has dramatically reduced morbidity and mortality among patients requiring invasive diagnostic procedures, when compared to surgical approaches. We describe the types of EBUS in clinical use, the method of use, the clinical indications for each procedure, and the potential role for EBUS in pediatric pulmonology. Radial probe EBUS is used in the investigation of peripheral lung lesions and could be adopted in children to achieve accurate biopsy of such lesions. Linear probe EBUS allows minimally invasive biopsy of mediastinal and hilar lesions. It has potentially greater performance characteristics than current biopsy techniques, with no significant complications reported to date. It may be useful in the diagnosis of lymphoma, or neurogenic tumors, as well as many other diseases resulting in mediastinal or hilar lymphadenopathy. EBUS is a minimally invasive technique that allows tissue sampling of peripheral lung lesions, or mediastinal/hilar masses, with a high diagnostic accuracy, and a significantly lower morbidity and mortality than alternative approaches. The indications for and the use of EBUS in pediatric patients is certain to increase in the future.

Management of children and adolescents with a critical airway due to compression by an anterior mediastinal mass

This study used retrospective review of patients with critical airway due to compression by an anterior mediastinal mass treated at a single pediatric teaching institution. Diagnostic workup is reviewed with a focus on diagnostic biopsy. Algorithm for streamlining the choice of biopsy technique and minimizing invasive procedures is suggested.

An unusual cause of a superior mediastinal mass in an infant

Tuberculosis has not been reported to be a cause of mediastinal masses in previous case series of mediastinal masses in children. We report the case of a 7-month-old infant with a superior mediastinal mass extending into the right chest, who was referred to the paediatric surgical team for biopsy and further management. Clinical and radiological findings were suggestive of a malignancy. However, thoracoscopic biopsy revealed the presence of a tuberculous mass.

Foregut cyst of the oesophageal wall in a cynomolgus monkey (Macaca fascicularis)

Congenital oesophageal cysts of foregut origin are rare in animals and human beings. This report describes a case in a 4-year-old cynomolgus monkey with no clinical symptoms. The cyst, which was located within the oesophageal submucosal tissue near the mid-point of the oesophagus, was lined with pseudostratified ciliated epithelium and had a thin layer of submucosal tissue. The cyst was surrounded by a smooth muscle layer which was partly intermingled with the circular muscle layer of the oesophagus. The muscularis mucosae of the oesophagus was not shared with the cyst wall. Simple tubular glands were present, opening into the cyst lumen. No communication between the cyst lumen and the oesophagus was observed. Cartilaginous tissue, which is a diagnostic feature of bronchogenic cysts, was not identified in the cyst wall. On the basis of the histopathological features, a foregut cyst of the oesophagus was diagnosed.

Multiple endocrine neoplasia type I in a cat

A 13-year-old 4.6-kg (10.2-lb) neutered male domestic long hair cat was evaluated because of a history of lethargy, exercise intolerance, and ventroflexion of the cervical portion of the vertebral column. After extensive assessment at the Veterinary Teaching Hospital at Michigan State University, the clinical signs were attributed to an aldosterone-secreting tumor of the adrenal gland. Subsequently, an insulin-secreting tumor of the pancreas as well as a functional parathyroid gland adenoma were diagnosed. All 3 masses were surgically removed, and the cat made a full recovery with complete resolution of clinical signs. The syndrome of multiple endocrine neoplasia is well described in humans, and the heritability of the condition has been confirmed. In cats and other species with 1 or more endocrine neoplasms, it is important to perform thorough clinical assessments of patients to identify other endocrine organs that may also be affected concurrently with neoplastic disease.

Clinical spectrum of primary mediastinal tumors: a comparison of adult and pediatric populations at a single Japanese institution

BACKGROUND AND OBJECTIVES

The purpose of this study was to review our Japanese institutional experience of mediastinal tumors and to compare differences in the clinical spectrum between adults and children.

METHODS

We retrospectively reviewed the records of 806 patients (676 adults and 130 children) between 1951 and 2000 at our institution.

RESULTS

There were 244 thymomas (36%), 106 germ cell tumors (16%), 95 congenital cysts (14%), 82 lymphomas (12%), 76 neurogenic tumors (11%), and 24 thyroid tumors (4%) in adult patients. There were 60 neurogenic tumors (46%), 24 germ cell tumor (19%), 17 lymphoma (13%), 10 congenital cysts (8%), and 5 thymomas (4%) in the pediatric patients. There was a significant higher incidence of neurogenic tumors and a lower incidence of thymomas and thyroid tumors in children than adults. The most common location was the anterior compartment (68%) in adults and the posterior compartment in children (52%). The prevalence of malignancy in pediatric patients was lower than adults (37% vs. 47%; P < 0.05). Symptoms due to compression or direct invasion into adjacent structures may have caused the higher incidence of dyspnea or respiratory distress in the pediatric group compared to the adults (15.4% vs. 4.0%; P < 0.001). There were fewer incidences of facial edema in children compared to adults (2.6% vs. 10.7%; P < 0.02). Emergent operations were required more often in the pediatric group than the adult group.

CONCLUSIONS

We demonstrated definite differences in histologic distribution, location, and symptomatology in mediastinal tumors between adult and pediatric populations, which should be considered in the evaluation and planning of a therapeutic modality for mediastinal tumors.

Unusual primary lung tumors: a radiologic-pathologic overview

Although the great majority of lung carcinomas are histologically characterized as adenocarcinoma, squamous cell carcinoma, large cell undifferentiated carcinoma, or small cell carcinoma, a variety of rare benign and malignant lung tumors may sporadically affect the lung. Several nonneoplastic tumorlike lesions are seen infrequently but are also part of the differential diagnosis for lung masses. Conventional radiographic findings, although of limited value in the diagnosis of these entities, should be examined carefully when lung tumors are suspected. Computed tomography (CT) is well suited for making a definitive diagnosis of some disease processes. CT helps determine the location and features of the lesions and depicts associated findings to help document the extent of disease. The differential diagnosis can be narrowed when there are typical CT features (eg, the presence of fat in lipoid pneumonia). Although unusual primary lung tumors are difficult to diagnose on the basis of imaging findings alone because such findings are nonspecific in the majority of cases, cross-sectional imaging can play an important role in the diagnostic work-up of these unusual tumors by delineating their extent and directing the radiologist or bronchoscopist to the appropriate biopsy site.

Thoracic lymphangioma

Thoracic lymphangioma is a benign congenital condition that may involve any organ within the chest. Here, a case of intra thoracic isolated extramediastinal lymphangioma is reported. The child had respiratory distress from neonatal period. Surgery completely cured the patient. However, it is only the 3rd reported case in English literature.

Primary mediastinal malignancies in children: report of 22 patients and comparison to 197 adults

PURPOSE

Examine a contemporary series of patients with primary pediatric malignant mediastinal tumors and determine epidemiology, histology, treatment, and survival. Patients and Methods. All malignancies diagnosed between January 1, 1973 and December 31, 1995 were analyzed.

RESULTS

Twenty-two patients, age 18 years or less, with pediatric primary mediastinal malignancies were identified from a database of 110,284 patients with primary malignancies. During the same period, 197 adult patients with primary mediastinal malignancies were identified. Fifty-nine percent of the pediatric patients were male. Median age was 11 years. Lymphoma was present in 55%, neurogenic malignancies in 23%, malignant germ cell tumors in 18%, and sarcoma in 5%. Neurogenic tumors presented in infants and lymphomas and germ cell tumors presented in teens (p = 0.005). In treated children, surgery was used more often in neurogenic tumors and germ cell tumors than in lymphomas (p = 0.002). Five-year survival was 74% for lymphomas, 67% for neurogenic tumors, 25% for germ cell tumors, and 61% overall (p = 0.23). Compared to adults, children had more neurogenic tumors (p < 0.001) and fewer thymomas (p = 0.0499). There were no significant differences in staging or survival between children and adults.

CONCLUSIONS

Pediatric mediastinal malignancies occurred with a frequency of 1/5,013 patients with malignant tumors. Lymphoma, neurogenic tumors, and germ cell tumors predominated. Compared to adults, children had more neurogenic tumors and fewer thymomas. Within the pediatric group, differences were found in age of presentation between histologic groups. These differences between adults and children, and between infants and teens, should be considered when evaluating a patient suspected of having mediastinal malignancy.

Lymphomas of the anterior mediastinum

Lymphomas are the most common cause of masses in the pediatric mediastinum. More than 50% of children with lymphoblastic lymphoma present with an anterior mediastinal mass, and more than one third of all patients with non-Hodgkin's lymphoma have their primary sites in the mediastinum. Hodgkin's disease also frequently involves this anatomic compartment with approximately two thirds of all pediatric cases manifesting mediastinal adenopathy. Although surgical resection generally is not involved in the primary treatment of these diseases, surgeons often play a key role in obtaining adequate tissue for proper diagnostic analysis. Surgical access to the mediastinum often is required in the acquisition of a specimen.

Diagnosis of mediastinal masses in pediatric patients using mediastinoscopy and the Chamberlain procedure

BACKGROUND/PURPOSE

Mediastinal masses commonly are referred to the pediatric surgeon and can be difficult diagnostic problems. Various techniques have been used to perform biopsy in the mediastinum, but there are few reports of mediastinoscopy or Chamberlain procedure in children in the literature. The authors reviewed their experience with these techniques in a pediatric oncology population.

METHODS

The medical records of all patients on the pediatric surgical service between 1987 and 1997, inclusive, who underwent mediastinoscopy or Chamberlain procedure were reviewed. Demographic data, diagnostic accuracy, complications, operating time, and blood loss were recorded.

RESULTS

Sixteen consecutive patients underwent 13 Chamberlain procedures and six mediastinoscopies over the above period. Diagnostic accuracy was found to be 95% overall (100% for Chamberlain procedure, 83% for mediastinoscopy). Five complications occurred in the Chamberlain group and none in the mediastinoscopy group. No complication required thoracotomy or sternotomy. Among patients whose sole reason for admission was diagnosis of a mediastinal mass, the mean hospital stay was 1.7+/-0.8 days (n = 7) for those who underwent Chamberlain procedure and 1.4+/-0.9 days (n = 4) for those who underwent mediastinoscopy. One mediastinoscopy was performed as an ambulatory procedure.

CONCLUSION

Mediastinoscopy and the Chamberlain procedure are effective and safe techniques for biopsy of mediastinal masses in this age group.

Mediastinal lipoma: report of a case

We experienced a case of mediastinal lipoma, which is considered to be relatively rare disease. A 3-year-old girl was referred to Gifu University hospital because of fever and an abnormal shadow on her chest X-ray. The chest X-ray clearly showed a well-delineated tumor shadow which seemed to oppress the diaphragm and the right atrium in the right lower lung area. A computed tomogram (CT) of the chest showed a homogeneous mass localized on the right diaphragm and adjoining the right anterior chest wall and heart. The mass showed a fat density measuring about -100 HU. Magnetic resonance imaging (MRI) showed a high-intensity mass which was almost the same level as the subcutaneous fat on both the T1-weighted and T2-weighted images. Thoracotomy was performed and a fatty tumor was found. It arose from the right side of the pericardium and adjoined the diaphragm, the anterior chest wall, and the thymus. There was no adhesion between the tumor and the surrounding organs. It was resected easily and its contents were yellowish and homogeneous. The patient made an uneventful recovery and was discharged 10 days after the operation. Light microscopy showed a lipoma consisting of mature adipose tissue and no malignancy was found.

Horner's syndrome and bilateral esophageal duplications

Bilateral esophageal duplications are exceptionally rare. A 3-month-old male presented with a left-sided Horner's syndrome. Upon further investigation, bilateral upper thoracic masses with an air-fluid level within the right-sided mass were found. Sequential thoracotomies at 1-week intervals confirmed the presence of bilateral esophageal duplications. At 1 year of age the patient is growing normally and is asymptomatic except for a persistent Horner's syndrome. We believe this to be the first case of bilateral esophageal duplication cysts presenting with Horner's syndrome.

Plasma cell granuloma of the lung in childhood: atypical radiologic findings and association with hypertrophic osteoarthropathy

Three cases of pulmonary plasma cell granuloma in the pediatric age group are presented. Although rare, it is the most frequent primary lung tumor in childhood. In two of the cases, there was a close adherence between the tumor and the surrounding mediastinal structures and diaphragm, a very uncommon feature in these tumors. In the other case, plasma cell granuloma of the lung was seen in association with a clinical-radiological picture of hypertrophic osteoarthropathy, which resolved after excision of the mass. Such an association has not, to date, been reported in the literature, and could constitute an additional finding useful in the differential diagnosis of primary lung tumors in childhood. The literature concerning this issue has been reviewed.

Primary mediastinal neoplasms (other than thymoma)

Primary mediastinal neoplasms encompass a long list of histologically diverse lesions that can arise from a wide variety of mediastinal structures. Recent advances in diagnostic techniques have considerably enhanced the evaluation of the mediastinum with use of noninvasive or minimally invasive procedures. In adults, most primary mediastinal neoplasms can be classified in one of four categories: thymus-derived neoplasms, neurogenic tumors, lymphomas, or germ cell neoplasms. In children, neurogenic tumors (especially neuroblastomas) and lymphomas are most frequently encountered. Because of the presence of many vital structures in the confined thoracic cavity, even benign mediastinal neoplasms can cause severe symptoms from the mass effect and therefore warrant a carefully planned management strategy. With modern therapeutic and surgical interventions, associated morbidity and mortality can often be substantially decreased.