Mediastinal tumors and cysts

Robotic surgery for thymic cysts: clinical features, management, and results of a multicentric study

Thymic cysts are rare, radiological diagnosis is often incidental, and cysts seldom assume clinical relevance for symptoms of compression. Thymoma were occasionally found inside both complex and simple thymic cysts. Given the challenges in accurately clinical diagnosing and since the occasionally discovering of thymoma inside both complex and simple thymic cysts, the management of thymic cysts remains controversial. Advancements in surgical tools such as robotics, applied to thymic conditions, could potentially transform the approach to thymic cysts. We report one the largest multicentric series of thymic cysts surgically treated with robotic approach, focusing on preoperative findings and surgical results. Cases were gathered from three Italian thoracic surgery centers with homogeneous clinical practice, significant experience in thymic neoplasms, and thoracic robotic skilled. Surgical intervention was indicated for patients with radiological diagnosis of thymic cysts under the following circumstances: the presence of symptoms, concurrent myasthenia gravis, cysts growing in follow-up, and the complexity of the cyst with suspicion of neoplasm. Data were collected and matched according to postoperative and pathological features to identify potential prognostic factors. Population include 57 patients, 29/28 male/female ratio with mean age of 59.46 ± 11.67 years. The average size of the thymic cysts was 29.14 ± 24.53 ranged between 3 and 150 mm. All patients undergone CT scan and mean of values of density was 25.82 ± 11-82 Hounsfield. Surgical procedures were robotic approach in all case including total/extended thymectomy 35 (61.4%) and cyst resection/partial thymectomy 22 (38.6%). There were no mortality or recurrence. Major complications rate was 5.3%. No correlations were observed between preoperative features and complication. Pathological examination revealed microfoci of thymic tumor in four cases. Robot-assisted surgery for thymic cysts showed excellent early clinical outcomes with low rate of postoperative complications also in case of large lesion. Thymic cysts should not be underestimated due to the risk of coexistent thymic neoplasm.

Incidental Mediastinal Thyroid Cancer

Cystic mediastinal masses are most commonly benign congenital lesions. Rarely, a cystic mediastinal mass will prove to be malignant. The patient, a 50-year-old woman who initially presented with uveitis, was incidentally found to have a right paratracheal opacity on chest X-ray (CXR). Chest computed tomography (CT) demonstrated a 5cm right paratracheal hypodense cystic mass. The patient underwent a right robotic-assisted thoracoscopic resection of the mediastinal mass. Final pathology revealed a 4.5cm mass consistent with metastatic papillary thyroid carcinoma (similar histology in 2 excised lymph nodes). The patient subsequently had a total thyroidectomy with central and right neck dissections.

Erosive effects of a posterior mediastinal mass in a 18th to early 19th c. Spanish child mummy

During the 2011 restoration works in the central nave of the church of the Assumption of Our Lady, known as "The Piquete", in the village of Quinto (about 50 kms southwest of Zaragoza, Spain), the remains of 70 individuals were uncovered. Of these there were 32 mummified bodies, four of which have been investigated with CT scans. Here we report on the findings in one such individual, namely a child of between 7 and 8 years of age, whose sex is debatable but may well be female. The main pathological finding is the presence of pressure erosion and distortion of the upper thoracic spine, the cause of which is discussed with the conclusion that this may well represent a neurenteric duplication cyst. The possible consequences of such a lesion are considered.

Parathyroid cysts: A review of 359 patients reported in the international literature

BACKGROUND

Parathyroid cysts are lesions that represent 1-5% of neck masses. They are subdivided into two categories: functioning and non-functioning.The aim of the present review is to give a detailed account of all reported cases of parathyroid cysts in the literature and to analyze statistically the available data.

METHODS

A bibliographic research was performed from 1905 until 2016. A database with the patients' characteristics was made and analyzed statistically.

RESULTS

A total of 218 articles were found, reporting 359 cases of cysts. Mean age of patients was 49.24 y/o and the male/female ratio was 1:1.85. The most common locations were left thyroid lobe (113/358 patients, 31.6%), and superior mediastinum (69/358 patients, 19.3%), while the most common symptoms were neck mass (148/355 patients, 41.7%), compressive symptoms (73/355 patients, 206%) and hyperparathyroidism (62/355 patients, 17.5%). Non-functioning cysts were more frequent (220/357 patients, 61.6%). Regarding dimensions, mean diameter was 4.88 cm. Ultrasound and FNA are used for their diagnosis, while cystic fluid analysis may help the differential diagnosis. Recurrences were mentioned in 27/97 patients (27.8%) with available data. No deaths due to parathyroid cysts were mentioned in the literature.

CONCLUSION

Parathyroid cysts should be taken into consideration in case of parathyroid dysfunction or asymptomatic neck mass. The surgeon's careful manipulations on the cyst are crucial for a definitive treatment.

Epidermoid cyst-a rare mediastinal mass

A 39-year-old male was referred to our service for treatment of an asymptomatic mediastinal mass. The mass was detected on a routine pre-employment chest X-ray. CT scan showed a well-defined soft tissue mass measuring 7.5 × 5.5 × 5.3 cm in close relation to the right border of the heart. A CT-guided biopsy proved to be inconclusive as necrotic tissue was obtained. At exploratory thoracotomy, a well-defined cyst was found attached to the right side of the pericardium. The cyst was totally excised and sent for histopathological examination which came back with a surprise diagnosis of epidermoid cyst.

Mediastinal schwannoma diagnosed preoperatively as a cyst

Mediastinal schwannomas are sometimes diagnosed as pericardial or bronchogenic cysts, if cystic degeneration is extensive. When mediastinal schwannomas are not diagnosed as primary cardiac tumors, the use of cardiopulmonary bypass in their resection appears to be infrequent. We report the case of a 48-year-old woman who presented with symptoms from a suspected intrapericardial cyst. Multiple diagnostic images revealed a large mass, potentially a proteinaceous or hemorrhagic cyst, in the transverse sinus behind the ascending aorta and against the left main trunk. After complete resection with the use of cardiopulmonary bypass, the mass was identified as a benign extracardiac schwannoma. More than 3 years postoperatively, the patient had no relevant symptoms. We discuss the preoperative diagnosis, the method of resection, and our broad strategy for dealing with such a case.

Imaging of Cystic and Cyst-like Lesions of the Mediastinum with Pathologic Correlation

Cystic masses of the mediastinum are a heterogenous group of asymptomatic or symptomatic, congenital, infectious, or neoplastic lesions. For early and correct diagnosis, evaluation, and optimal patient management of cystic mediastinal masses in infants, children, or adults imaging plays an important role. A non-invasive and sensitive imaging modality is an efficient and cost-effective tool. Multidetector computed tomography (MDTC) with volumetric acquisition provides fast acquisition of high resolution images and multiplanar reconstruction. Both 2D and 3D imaging in mediastinal imaging help in surgical planning and assessing resectability of mediastinal lesions. MR imaging has many advantages over other modalities for detecting and identifying cystic, or fluid-filled mediastinal masses, because of its intrinsic high soft tissue contrast and direct multiplanar imaging capabilities. However, histological tissue analysis may be required to differentiate a cystic lesion from other cyst-like or low-attenuation lesions.

Imaging of cystic masses of the mediastinum

Cystic masses of the mediastinum are well-marginated round lesions that contain fluid and are lined with epithelium. Major cystic masses include congenital benign cysts (ie, bronchogenic, esophageal duplication, neurenteric, pericardial, and thymic cysts), meningocele, mature cystic teratoma, and lymphangioma. Many tumors (eg, thymomas, Hodgkin disease, germ cell tumors, mediastinal carcinomas, metastases to lymph nodes, nerve root tumors) can undergo cystic degeneration-especially after radiation therapy or chemotherapy-and demonstrate mixed solid and cystic elements at computed tomography (CT) or magnetic resonance (MR) imaging. If degeneration is extensive, such tumors may be virtually indistinguishable from congenital cysts. A mediastinal abscess or pancreatic pseudocyst also appears as a fluid-containing mediastinal cystic mass. However, clinical history and manifestations, anatomic position, and certain details seen at CT or MR imaging allow correct diagnosis in many cases. Familiarity with the radiologic features of mediastinal cystic masses facilitates accurate diagnosis, differentiation from other cystlike lesions, and, thus, optimal patient treatment.

Mediastinal tumors in children: a single institution experience

Mediastinal masses in children are a heterogeneous group of asymptomatic or potentially life-threatening congenital, infectious, or neoplastic lesions that present complex diagnostic and therapeutic dilemmas. Some patients are asymptomatic; in others, the mass may compress mediastinal structures and cause sudden asphyxia. In these cases, close cooperation is needed among pediatric surgeons, anesthesiologists, intensivists, oncologists, and radiologists. The files of 45 children with mediastinal masses admitted between 1986 and 1999 to the Pediatric Intensive Care Unit (PICU) of Schneider Children's Medical Center of Israel were reviewed. Twenty-one were admitted for perioperative care, and 21 for emergency care, including 19 with respiratory distress. Five of the emergency care group had asphyxia and 10 needed assisted ventilation. Two children were admitted for evaluation and 1 for leukopheresis. The children admitted on an emergency basis had more clinical findings than the postoperative group: almost 80% had dyspnea and more than 45% had oxygen desaturation; 33% had cough and noisy breathing, and 25%, superior vena cava syndrome or hepatosplenomegaly. Eight patients (17.8%) had benign disease and 37 (82.2%) malignant disease. The patients with a benign mass were significantly younger than the patients with a malignant mass (p<0.005); in 5 cases (12.5%), a congenital anomaly presented as a mediastinal mass. Most of the malignant masses were of hematologic origin (40.5%), followed by neurogenic tumors (27%). Twenty-seven patients underwent surgery, including 6 emergency procedures (3 partial resections, 2 biopsies, 1 lymph node biopsy). There were no intraoperative or postoperative deaths. The present series emphasizes the complex care children with a mediastinal mass require. They should be treated in a tertiary center with a multidisciplinary approach.

Current use of imaging in the evaluation of primary mediastinal masses

A wide variety of lesions occur in the mediastinum in patients of every age. Twenty five to 50 percent of these primary mediastinal masses may be malignant, making early diagnosis and therapy crucial. Since most arise from normal structures in the region, localization of lesions to compartments of the mediastinum may assist in diagnosis. This article reviews imaging techniques for lesions originating in the mediastinum.

Mediastinal tumours. A report of 129 cases

Primary mediastinal tumour or cyst was surgically treated in 129 patients (including 19 younger than 12 years) during a 16-year period. All histologic specimens and smears from fine-needle aspiration biopsy were reviewed. Intrathoracic goitre, neurogenic lesions and thymomas comprised 62% of all the tumours. Fifty lesions (39%) were found at routine radiographic examination and were asymptomatic. Eight of these 50 lesions were malignant. Chest pain, fatigue, weight loss and fever were significantly more common in malignant than in benign disease. Despite extensive investigations, the diagnosis was not established preoperatively in 32% of the cases. Chest radiography, CT-scanning and fine-needle aspiration biopsy usually provide satisfactory diagnostic information, thereby substantially reducing the need for other preoperative procedures. Early operative intervention is mandatory in these cases.

Diagnostic imaging techniques in mediastinal malignancies

Mediastinal masses occur in both men and women of every age, and close to half of affected patients are asymptomatic. Screening of asymptomatic persons is not economically feasible. Symptomatic patients should be evaluated initially with posteroanterior and lateral chest radiographs. Additional imaging techniques may be required in patients suspected of having a mediastinal mass, when there is a questionable abnormality seen on chest radiographs or when local or systemic symptoms suggest a mediastinal mass. These techniques include oblique views, over-penetrated radiographs, and fluoroscopy of the chest. Computerized tomography of the chest is the imaging modality of choice for further assessment of a mediastinal mass. It can also be an important adjunct in radiotherapy portal planning. The use of other imaging modalities depends on the location of the tumor, the equipment available, and the expertise of local radiologists. In following up treated patients for disease recurrence, periodic chest radiographs are usually sufficient. Computerized tomography scans, because of their expense, should only be obtained as a baseline after completion of therapy or in patients with a suspected relapse.

Primary malignant non-seminomatous germ cell tumour of the mediastinum treated by surgery and chemotherapy

Primary malignant germ cell tumours of the mediastinum are rare and are associated with poor survival when treated with surgery alone or with surgery when chemotherapy has failed. Recent improvements in combination chemotherapy have given some prospect of cure. A patient treated with primary surgical excision and postoperative chemotherapy, who remains free of disease 24 months after completion of treatment is reported here.

Primary anterior mediastinal tumors in children and adults

This review details pertinent anatomical, radiological, pathological, and clinical information regarding primary anterior mediastinal tumors. Although the majority of these lesions are included in one of several subgroups, for example, thymic tumors, teratomas, or thyroid abnormalities, other less common entities will occasionally be encountered by the practicing surgeon. Likewise, there are variations in the frequency distribution of anterior mediastinal lesions in children as opposed to adults. Management of these individual lesions is outlined.

Life-threatening airway obstruction as a complication to the management of mediastinal masses in children

Life-threatening airway obstruction from large mediastinal masses in children poses a difficult diagnostic and therapeutic dilemma, requiring the close coordination of a pediatric surgeon, anesthesiologist, radiologist, and oncologist. To focus on this problem, the anesthetic and surgical management of 50 consecutive children with mediastinal masses treated between 1978 and 1984 were reviewed. Thirty children presented with respiratory symptoms; nine had life-threatening respiratory compromise with dyspnea, orthopnea, and stridor. Thirteen of these symptomatic children had marked compression of the trachea and/or mainstem bronchi on radiographic studies. The tracheal cross-sectional area which was measured by computed tomography was decreased by 35% to 93% of the normal tracheal dimensions in these children. Nonresectable malignant neoplasms including lymphoma, Hodgkin's disease, rhabdomyosarcoma, and neuroblastoma were the eventual diagnoses in 10 of these patients. The other 3 patients were less than 4 years old and had benign lesions. General anesthesia was judged to be prohibitively risky in 5 of 13 patients. The diagnosis was established by node or needle biopsy under local anesthesia, and general anesthesia was deferred until the compromised airway was alleviated by radiation and chemotherapy. General anesthesia with endotracheal intubation was administered to 8 patients, 5 of whom developed total airway obstruction. Using a variety of maneuvers, ventilation was reestablished in all 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary malignant mediastinal tumors

Thirty-eight patients with primary malignant mediastinal tumors of all cell types are the basis for this review. Eleven of these patients had germ cell tumors. Five germ cell tumors were seminomas, two were malignant teratomas, and two were endodermal sinus tumors. Mean survival for all patients with germ cell tumors was 3.3 years. Eight children had surgical excision of mediastinal neuroblastomas, and all but 1 are alive for a mean survival of 6.7 years. Seven patients had lymphoproliferative disorders; 6 of these patients had nodular sclerosing Hodgkin's disease, and 1 had lymphoblastic (thymic) lymphoma. Mean survival was 5.1 years. There were five carcinomas of various cell types and one angiopericytoma. None of the patients with these lesions survived more than 2 years. Four patients had thymoma with an average survival of 3.7 years. Two patients had carcinoid tumors of thymic origin; neither survived more than 1 year. In 1972, we reported 5-year disease-free survival of 26% in a series of patients with primary mediastinal tumors. Our experience since 1970 shows current survival of 47.3% and 5-year disease-free survival of 34.2%. We use combined methods of therapy, including aggressive surgical resection, combination chemotherapy, and often mediastinal irradiation for most types of mediastinal tumors. Primary mediastinal malignancies should be treated aggressively using a multidisciplinary approach, since many of these tumors are curable.

Cystic duplications of the esophagus and neurenteric cysts

This paper reviews the past 25 years of experience with these lesions at The Hospital for Sick Children, Toronto, during which 19 infants and children were treated. There were 8 females and 11 males. Nine of these patients were under 1 year of age at presentation, 5 were between the ages of 1 and 10 years, 5 were older than 10 years. Eleven presented with symptoms referrable to the chest, and six with predominantly neurological symptoms. Two asymptomatic children were referred because of chest masses found incidentally on chest x-rays. Fifteen chest masses were noted; the other four had neurological symptoms only. Fourteen of these 19 lesions had associated vertebral anomalies. Nine patients underwent myelograms and 8 abnormalities were demonstrated, 2 of which were neurologically asymptomatic. Four patients had both myelographic abnormalities and mediastinal masses. Two out of three technetium scans were positive. Fourteen thoracotomies and six laminectomies were carried out. Nine of the 15 chest masses contained gastric mucosa including 2 which had perforated. None of the intraspinal masses contained gastric mucosa. The long-term survival was 95%. In this series, intraspinal anomalies co-existed with mediastinal masses in almost 25% of patients and were often initially asymptomatic. It is recommended that myelography be carried out in all patients with cystic duplications of the esophagus who have vertebral anomalies. Technetium scans may be useful if the diagnosis is obscure.

Misleading density of mediastinal cysts on computerized tomography

Five patients seen with roentgenographic evidence of smooth, rounded mediastinal masses were evaluated by computerized tomographic (CT) scanning. Density readings from the lesion were interpreted in all patients as being equivalent to solid tissue. With these findings, thoracotomy seemed necessary for definitive diagnosis. All 5 lesions were found to be thin-walled cystic structures containing thick viscid fluid. Contrary to views expressed in the radiology literature, we conclude that computerized tomography does not differentiate reliably between solid and cystic mediastinal masses.

Cystic thymoma simulating pulmonary stenosis

A 36-year-old man presented with chest pain, an anterior mediastinal mass and a loud pulmonary systolic murmur. At operation a large, tense, well encapsulated, cystic thymoma was found to be compressing the right ventricular outflow tract and the main pulmonary trunk, producing a systolic thrill over the artery. After excision of the cyst, the thrill and the murmur disappeared and there was complete symptomatic relief. Classification, pathology, clinical presentation, diagnosis and treatment of cysts of the thymus are discussed. The syndrome of pulmonary artery compression characterized by a triad of chest pain, dyspnoea and a loud pulmonary systolic murmur, which decreases in intensity during inspiration, is described. Pertinent literature on cysts of the thymus, and acquired pulmonary stenosis due to extrinsic compression is reviewed.

The use of computed tomography to evaluate suspected mediastinal tumors

Thirty patients with suspected mediastinal tumors were evaluated by computed tomography (CT) at UCLA Medical Center. Twenty patients with myasthenia gravis were examined for possible thymomas, benign and malignant; and 10 patients were studied for other mediastinal masses (including teratoma, seminoma, mediastinal lipomatosis, carcinoma, lymphoma, and paravertebral abscess). The CT scan was found useful in several respects: (1) yielding information not available by conventional radiographic techniques; (2) defining the anatomical location and extent of mediastinal tumors; (3) detecting pulmonary metastasis and involvement of mediastinal nodes in cases of malignancy; and (4) establishing the diagnosis of benign mediastinal fatty masses. On the basis of our early experience, we believe CT is a valuable adjunct in the preoperative assessment of patients with suspected mediastinal tumors.

Fibrosarcoma of the mediastinum

Fibrosarcoma is a rare primary malignant tumor of the mediastinum. Three cases are presented with different presenting symptoms and clinical manifestations. Thoracotomy with biopsy of the mass is the only method for arriving at a definitive histologic diagnosis.

Intrapericardial bronchogenic cysts

A rare case of large intrapericardial bronchogenic cyst with superior vena caval obstruction is reported. The cyst was successfully removed and the superior vena cava, which was narrowed by pressure fibrosis and thrombosis, was reconstructed satisfactorily and has maintained patency. In another case a large cyst of the same type without vena caval obstruction was successfully treated surgically. The features of these 2 cases are compared with those of 20 reported cases. The angiographic data in these cases appear to be sufficiently characteristic to suggest the nature of the lesion and the clinical finding of pericarditis early in the course of the disease may also suggest the diagnosis.

Primary malignant germinal tumors of the mediastinum. A study of 24 cases

The malignant germinal tumors found in the testis (seminoma, teratocarcinoma, embryonal carcinoma, choriocarcinoma, and mixtures of these) can originate in the anterior mediastinum. An occult testicular tumor must be sought, but primary mediastinal germinal tumors constitute a true entity. The details of 24 such patients treated at Walter Reed General Hospital are presented. Of 19 patients who died, 2 were women; postmortem examination of the testes of 13 men failed to reveal a primary tumor. Five patients are alive and well with no testicular abnormality. It is important to distinguish the histopathologic types. Seminomas are readily controlled with modest doses of irradiation. Embryonal carcinomas are also radiocurable with somewhat higher doses; 2 long-term disease-free survivors are reported. Teratocarcinomas are highly malignant and require higher doses for control. Choriocarcinomas progress so rapidly that chemotherapy is necessary.

Carcinoid tumour of the thymus gland: report of a case

CARCINOID OF THE THYMUS IS A RARE PROBLEM A case is reported to add to only 16 previously reported. None of these 17 patients had the carcinoid syndrome. Complete surgical excision, if possible, is the treatment of choice.

Primary malignant tumours of the mediastinum and their management

Primary malignant tumours of the mediastinum are difficult clinical problems in thoracic surgery from both diagnostic and therapeutic points of view. Three cases of malignant seminoma of the mediastinum have been documented, thus bringing the total number of cases reported in the literature to 78. A case of metastasis to the subcutaneous tissue in malignant thymoma has been documented. Because of the multiple-cell types of these tumours and their ill-defined extent due to involvement of adjacent structures, surgery is often difficult. Radiotherapy along with chemotherapy has a definit place in their management, either as a primary treatment in inoperable cases or as a supplement to surgery if the condition is operable.