Thoracic duct cysts: a rare differential diagnosis

Cervical thoracic duct cyst: a conservative resolution

A woman in her 70s presented with an enlarging, asymptomatic palpable mass in the left supraclavicular fossa. The clinical impression was of a lipoma. Imaging showed a cystic lesion with continuity of a tubular structure leading to the carotid sheath. Cytology was consistent with thoracic duct sampling. A diagnosis of the rare entity of a thoracic duct cyst with supraclavicular extension was made. This was managed conservatively via repeated aspirations which reduced the size of the mass.

Recurrent thoracic duct cyst of the left supraclavicular fossa: A retrospective study of 6 observational case series and literature review

ABSTRACT

The transient occlusion of the terminal thoracic duct is a rare disease responsible for renitent supraclavicular cysts. The aim of this study was to describe the clinical characteristics, evolution, and treatment.A retrospective multicenter study and literature review was carried out. The literature search (PubMed) was conducted including data up to 31 December 2020 and PRISMA guidelines were respected.This study identified 6 observational cases between September 2010 and December 2020. The search results indicated a total of 24 articles of which 19 were excluded due to the lack of recurrent swelling or the unavailability of full texts (n = 5). Fourteen patients (8 from literature) mostly reported a noninflammatory, painless renitent mass in the supraclavicular fossa which appeared rapidly over a few hours and disappeared spontaneously over an average of 8 days (range: from about 2 hours to 10 days). Anamnesis indicated a high-fat intake during the preceding days in all cases and 7 from literature found in the Medline databases. Recurrences were noted in 10 patients. Thoracic duct imaging was performed in all cases to detect abnormalities or extrinsic compression as well as to eliminate differential diagnoses.A painless, fluctuating, noninflammatory, and recurrent swelling of the left supraclavicular fossa in patients evoking an intermittent obstruction of the terminal portion of the thoracic duct was identified. A low-fat diet was found as safe and effective treatment.

Variations in the Management of Cervical Thoracic Duct Cyst

We present an uncomplicated case report of a cervical thoracic duct cyst (CTDC) in a 61-year-old woman treated with surgical excision. We reviewed 47 similar cases since it was first described in 1964 and evaluated the different diagnostic and management approaches. Previously believed to be the gold standard tool for evaluation, lymphangiography is now less popular due to advent of high-resolution imaging combined with aspiration techniques. CTDC treatment includes observation, low-fat diet, repeated aspirations, external pressure, sclerotherapy, embolisation, and surgical intervention. The preferred management of choice to date is surgical excision.

To Be or Not To Be: A Case of Recurrent Swelling Syndrome of Thoracic Duct

Thoracic duct aneurysm is a rare entity presenting as a stable, asymptomatic, left supraclavicular swelling. We report an unusual case of a thoracic duct aneurysm in a 71-year-old woman presenting as a recurrent swelling syndrome of the left supraclavicular area associated with sporadic episodes of sharp left subcostal pain. (Level of Difficulty: Intermediate.)

Spontaneous retropharyngeal and mediastinal thoracic duct cyst in an infant with respiratory distress

Thoracic duct cysts (TDC) within the retropharyngeal space and mediastinum are exceedingly rare lesions, with the majority related to trauma or neoplasm. We describe a case of an otherwise healthy 8-month-old boy who presented with severe respiratory distress, which was found to be caused by a large, spontaneous TDC occupying most the retropharyngeal and mediastinal space. To our knowledge, this is the youngest patient to date presenting with TDC. Ultimately, his TDC was completely resolved with sclerotherapy, however the patient's age and size presented unique challenges to his medical management, which we describe below.

[Cervical thoracic duct cyst: An uncommon entity]

BACKGROUND

Cervical thoracic duct cysts are a rare anomaly.

OBJECTIVE

To report a case of cervical thoracic duct cyst, and perform a literature review.

CLINICAL CASE

A 78-year-old female, with a one-year history of a left-sided asymptomatic supraclavicular cystic mass. Computerized tomography revealed a cystic mass 42mm in diameter. We performed a fine needle aspiration puncture, obtaining a thick, milky, whitish liquid. The patient underwent surgery; finding a left-sided supraclavicular cystic mass, with some lymph vessels heading towards the jugulo subclavian venous junction. We performed a ligation of these lymph vessels and resection of the mass. The histopathologic study confirmed the diagnosis of thoracic duct cyst.

CONCLUSION

Diagnosis of cervical thoracic duct cyst should be suspected with a cystic lesion in the left supraclavicular region, which when perforated exudes a very distinctive thick milky, whitish liquid with a high content of lymphocytes and triglycerides. Treatment should be complete removal with ligation of the lymphatic afferent vessels.

A Giant Thoracic Duct Cyst as the Cause of Abdomen Pain: A Case Report and Review of the Literature

Thoracic duct cysts, which may be of congenital or degenerative origin, are very rare lesions. Most patients are asymptomatic, but when symptoms are present they include cough, dyspnea, dysphagia and chest pain. However, in this case report a 35-year-old male patient presented to us with intermittent abdomen pain. Clinical symptoms and radiographic findings helped to identify a giant thoracic duct cyst in this patient. Surgical resection of the cyst resolved the abdominal symptoms. This was the first case reported in the literature of a thoracic duct cyst with the symptoms of abdominal pain.

Management of cervical thoracic duct cyst with cyst-venous anastomosis

INTRODUCTION

Cervical thoracic duct cyst (CTDC) is a rare cause of lateral neck mass. Surgical excision with ligation of the cervical thoracic duct is the current standard for definitive management with symptomatic patients. We report the first case of an alternative method of management performing a cyst venous anastomosis for decompression.

PRESENTATION OF CASE

A 77 year old female presented with a six month history of left arm pain, swelling and a left-sided cystic neck mass. She was treated with cyst-venous anastomosis between the cyst wall and the left internal jugular vein. At two year follow-up, she has had resolution of pain and no recurrence of the mass.

DISCUSSION

Many potential etiologies have been proposed for CTDC, though surgical management of this rare problem has consistently required cyst excision and thoracic duct ligation. Few innovative modes of therapy have been developed to address this problem in a less invasive manor. Maintaining a more natural thoracic duct anatomy decreases the likely of complications associated with duct ligation.

CONCLUSION

Cyst-venous anastomosis for the management of CTDC provides an effective, novel form of treatment which maintains the integrity of the thoracic duct and avoids potential complications associated with duct ligation.

Direct puncture sclerotherapy of a thoracic duct cyst presenting as an enlarging left supraclavicular mass

A 58-year-old woman presented with a palpable mass at the base of the left neck which she had first noticed 12 years previously, shortly after abdominal surgery. The mass had progressively enlarged, resulting in dysphagia, dyspnea and occasional pain. Imaging showed a septated but otherwise simple cystic mass extending into the mediastinum and containing lymphocytic fluid on aspiration. A diagnosis of the rare entity of a thoracic duct cyst with supraclavicular extension was made. The patient opted for percutaneous sclerotherapy of the lesion, which was performed using glacial acetic acid. This resulted in complete resolution of the mass with one treatment. After exclusion of other causes of cystic left supraclavicular masses including cystic neoplasms and pseudoaneurysms of the carotid or subclavian arteries, direct puncture sclerotherapy can be safe and effective.

Thoracic Duct Cyst in Mediastinum - A case report -

The thoracic duct cyst is an extremely rare cystic lesion in the mediastinum. Surgical treatment of the cyst is necessary to confirm histologic diagnosis and prevent potential complications such as spontaneous or traumatic rupture of the cyst and chylothorax.

A left-sided asymptomatic supraclavicular cystic mass in a 14-year-old girl

A 14-year-old girl was referred to our department with a 3-month history of an asymptomatic swelling in the left cervical triangle. The girl, an active ski jumper, was used to carrying her skis on the left shoulder. There was a history of many minor falls and contusions of her body. The left posterior cervical triangle was enlarged by an elastic, partially fluctuating and clearly delineated swelling with 4-6 cm in diameter. The trapezius was elevated and the overlaying skin was intact. It was clear that the mass was spreading infraclavicularly. Nevertheless, the distal boundaries of the mass were not quite clear (Fig. 1). The infraclavicular spreading was confirmed with an ultrasound examination which revealed a hypoechogenic echo-free mass of the size of 7-10 x 3.6 cm. The mass was sonocompressible, clearly outlined and there were no signs of any infiltrating growth. No internal perfusion was found by colour-coded Doppler investigation. The blood count or biochemical tests did not reveal any pathological findings.

Thoracic duct cyst: sclerotherapy as alternative for surgical treatment

BACKGROUND

Thoracic duct cysts of the cervical portion are rare benign lesions for which surgery is the treatment of choice.

METHODS

We present 2 cases of a thoracic duct cyst of the cervical portion. One patient was treated by surgery and the other patient by ethanol sclerotherapy.

RESULTS

After establishing diagnosis by radiologic assessment and chemical and cytological fine-needle aspirate of the cystic masses, both patients were treated successfully.

CONCLUSION

Ethanol sclerotherapy provides an alternative therapy for thoracic duct cyst when evaluation establishes a high likelihood of clinical diagnosis.

Cervical thoracic duct cyst: a differential diagnosis of left supraclavicular swelling

We report a 79-year-old woman with a left sided neck mass that appeared to be a thoracic duct cyst (TDC). A TDC is a rare condition. Generally, it may cause local symptoms, but most likely it presents as an asymptomatic swelling. The pathogenesis of TDC is not known, but different theories on the development, including weakness of the duct wall and obstruction of the lymphoid flow, have been suggested. Sonography with needle aspiration, examination of the cyst fluid, and CT scan/MRI may raise the suspicion of the TDC diagnosis. Surgery with total excision of the cyst, followed by histopathological examination confirms the diagnosis.

Spontaneous cervical lymphocele

BACKGROUND

Primary (spontaneous) cervical lymphoceles in adults are extremely rare. More frequently occurring acquired cervical lymphoceles have been described in the setting of a neck trauma or after a neck dissection. We report a case of a spontaneous left cervical lymphocele in a previously asymptomatic female.

METHODS AND RESULTS

A 44-year-old woman presented with a 2-month history of a left neck mass initially noted by her physician during a routine physical examination. She denied prior head and neck surgery or neck trauma. CT scan of the neck revealed a left cystic mass. Fine-needle aspiration of the cyst yielded chylous material and lymphocytes. The surgical specimen grossly and microscopically was consistent with a lymphocele. The diagnosis was confirmed using D2-40 antibody targeting lymphatic endothelial cells lining the cyst.

CONCLUSION

Primary cervical lymphocele should be included in the differential diagnosis of a solitary neck mass in an adult.