Intrathoracic lymphangioma

A case of a transient phrenic nerve paralysis after resection of a giant lymphangioma evaluated by dynamic digital radiography

BACKGROUND

Lymphangioma is a relatively rare benign congenital malformation composed of dilated cystic lymphatic vessels; however, its occurrence in adults and manifestation as mediastinal lymphangioma are even rarer. In general, the incidence of mediastinal lymphangiomas has been reported to range from 0.01 to 4.5% of all mediastinal tumors. Mediastinal lymphangiomas tend to increase in size and can sometimes stretch the phrenic nerve that are present in the mediastinum, resulting in phrenic nerve palsy. Dynamic digital radiography (DDR) allows for quantitative evaluation over time and has recently been utilized in actual clinical practice. The distance between the apex of the lung and diaphragm can be measured, and the movement of the left and right lungs and diaphragm can be evaluated separately. In this report, we describe a case in which DDR demonstrated the improvement of phrenic nerve palsy.

CASE PRESENTATION

A 32-year-old woman with no medical history and no smoking history reported dyspnea on exertion, and abnormalities were noted on chest X-ray. Close examinations revealed thymic, pericardial, bronchogenic, and teratoid cysts, and since they appeared to be growing in size, the patient was referred for surgery. Because the giant cyst prevented visualization of the thoracic cavity, puncture was performed for aspiration. The stretched phrenic nerve was identified in the giant cyst wall and was dissected to avoid damaging it. The cyst wall was detachable and excised without obvious mediastinal invasion. The patient had a good postoperative course and was discharged on postoperative day 5. Dynamic digital radiography on postoperative days 3 and 17 showed movement of the left diaphragm, with improvement over time.

CONCLUSIONS

Mediastinal lymphangiomas tend to grow in size and can sometimes stretch the phrenic nerves that are present in the mediastinum, resulting in phrenic nerve palsy. Dynamic digital radiography (DDR) is a modality that can also be evaluated quantitatively and over time and can comprehensively determine improvement in transverse paralysis.

Primary cardiac and pericardial lymphangiomas: clinical, radiologic, and pathologic characterization derived from an institutional series and review of the literature

Lymphangiomas are comprised of aggregates of lymphatic vessels, considered to represent either aberrant embryogenic remnants or developing secondary to obstruction. Lymphangiomas primary to the heart and pericardial are exceedingly rare, and to date sparingly reported in individual case reports. In this study, the histopathologic, clinical, and radiologic features of 35 cases of cardiac/pericardial lymphangiomas described in the literature to date together with four cases from our own institution (39 cases in total) are examined to provide clinicopathologic characterization. Cardiac/pericardial lymphangiomas were identified in both children and adults, with two cases initially discovered in utero. If presenting with symptoms, patients most commonly exhibited respiratory distress/dyspnea. By X-ray, a widened cardiac silhouette could be noted, and echocardiogram generally showed an echogenic mass with cystic and septal components. On computed tomography (CT) and magnetic resonance imaging (MRI), cystic and septal components were again observed, with CT showing an absence of calcifications or macroscopic fat. Most lymphangiomas were pericardial (specifically visceral) based, and frequently situated in the right atrioventricular groove. A majority of cases proceeded to surgical resection, with no evidence of recurrence post-operatively. Grossly, lesions had a median size of 6 cm and in almost all cases were multicystic/multilocular. Microscopically, the lymphangiomas were composed of lymphatic spaces lined by endothelial cells that specifically express podoplanin (D2-40) with immunoperoxidase staining. Further investigation with a larger and more uniformly organized cohort is required to better characterize the clinicopathologic features of lymphangiomas of this unusual anatomic location.

Pericardial lymphangioma: a rare benign albeit variably symptomatic tumefactive lesion

Primary pericardial-based tumefactive lesions include pericardial cysts, mature teratomas, and lymphangiomas, and while benign they may result in clinical symptomatology that leads to their radiologic detection. We present the case of a 5-year-old boy with a heart murmur who was otherwise healthy and without significant medical history. Transthoracic echocardiogram, computed tomography, and magnetic resonance imaging studies revealed a pericardial multicystic mass imparting compression upon the right atrium and ventricle. The case proceeded to surgery in which complete resection of the mass was performed without complication, and the patient was discharged three days after. Pathology examination of the lesion determined it to be a pericardial lymphangioma with characteristic histologic features of sequestered vascular channels lined by endothelium that specifically expressed lymphatic-specific podoplanin (also known as D2-40), and with associated adipose tissue, smooth muscle bundles, and reactive lymphoid aggregates. Although a rare underlying etiology for mediastinal and specifically pericardial tumors, lymphangiomas should be considered in the differential of tumefactive lesions in this anatomic location.

Benign lesions of the mediastinum: A review with emphasis on cytology and small biopsy specimens

This review focuses on the diagnosis of select benign processes, ranging from reactive entities to heterotopic tissues to neoplasms, which may occur in the mediastinum. Currently, the mediastinum can be evaluated and biopsied with endoscopic procedures. Therefore, cytopathology specimens, fine needle aspirations, and small biopsies play an important role in the diagnosis of these lesions. In this review, an emphasis is given to relevant clinical presentations, histologic and cytologic findings, differential diagnoses, ancillary testing, and interpretation. Pitfalls are reviewed and discussed in each section. It is important for both surgical pathologists and cytopathologists to be familiar with these entities and their cytologic and histologic features that may be helpful in reaching a diagnosis.

American Thoracic Society 2019 Pediatric Core Curriculum

The American Thoracic Society Pediatric Core Curriculum updates clinicians annually in pediatric pulmonary disease in a 3 to 4 year recurring cycle of topics. The 2019 course was presented in May during the Annual International Conference. An American Board of Pediatrics Maintenance of Certification module and a continuing medical education exercise covering the contents of the Core Curriculum can be accessed online at www.thoracic.org.

Propranolol Alleviating the Challenging Clinical Course of Birth Onset Generalized Lymphangiomatosis. A Case Report

Background: Cystic hygromas, interchangeably named Lymphangiomas, are rare, congenital, benign lesions due to an abnormal lymphatic system development that tend to occur mostly in the head, neck, and oral cavity. Case Presentation: This is a case of 18 year old male patient Syrian, smoker, with a history of multiple cystic hygromas since birth along with a generous surgical history of multiple laparotomies for intrabadominal cystic excisions, splenectomy herniorrhaphies (bilateral inguinal hernias and 2 incisional hernias due to laparotomies) left orchieopexy then testiculectomy, scrotal skin graft , multiple abdominal radioguided cystic drainage and sclerotherapy; presented to our care center for fever, dry cough, pleuretic chest pain, and mild abdominal pain with watery diarrhea. Conclusion: Cystic Hygroma is still being considered as a rare entity and can virtually occur in the whole body sites mostly at head and neck regions as explained above. Challenges in this disease is by finding cases where the presence of such cystic lesions is in extremely rare and unusual sites as well as different treatment modalities and prognostics depending on the site and size of the detected cystic formations.

Application of endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal lymphangioma

Background

Mediastinal lymphangioma is a rare lymphatic malformation, and the standard treatment strategy is surgical dissection. Endobronchial ultrasound-guided transbronchial needle aspiration has good diagnostic abilities for paratracheal, mediastinal, and hilar lymph node lesions. Endoscopic ultrasound is a new technique which can be used for the treatment of mediastinal lymphangioma to reduce the incidence of surgical-related complications. This study was designed to investigate the value of endobronchial ultrasound-guided transbronchial needle aspiration in the treatment of mediastinal lymphangioma.

Methods

Retrospective analysis was carried out on nine patients with mediastinal lymphangioma who underwent endoscopic ultrasound-guided fine-needle aspiration from 2010 to 2018 in Shanghai Chest Hospital.

Results

No patients suffered serious complication. The amount of fluid aspirated was 50-205 mL. The disease was stable over a period of 9 months to 2 years.

Conclusions

Endobronchial ultrasound-guided transbronchial needle aspiration could be an effective method for the treatment of mediastinal lymphangioma with a little trauma compared with surgical dissection, which may have significant therapeutic effects.

Left Functional Pneumonectomy Caused by a Very Rare Giant Intrathoracic Cystic Lesion in a Patient with Gorham-Stout Syndrome: Case Report and Review of the Literature

Gorham-Stout syndrome is an uncommon entity, with few cases reported in bibliography. It consists of osteolytic manifestations affecting various bones and replacing them with lymphangiomatous tissue. With pathophysiology unknown, Gorham-Stout disease affects also cardiorespiratory system usually causing lytic lesions to the bones of the thoracic cage or directly invading the thoracic duct. This is a case report of a unique respiratory manifestation of the disease and a review of its cardiorespiratory complications.

Cystic Lymphangioma of the Chest Wall in a 5-Year-Old Male Patient: A Rare and Atypical Localization-A Case Report and Comprehensive Review of the Literature

Lymphangioma is a benign congenital malformation. The extremely rare and atypical localization of a lymphangioma in the chest wall was the real motive for the present case study. A 5-year-old boy was admitted to the Emergency Department of the 1st Department of Pediatric Surgery, Aristotle University of Thessaloniki, due to the presence of a mildly painful swelling in the left lateral chest wall, which was first noticed three months ago, after a blunt injury during sport. Physical examination revealed the presence of a palpable, spherical, painful, nut-sized subcutaneous lesion in the left lateral chest wall, respectively, with the anterior axillary line, at the height of the 6th to 7th intercostal space. Presence of ecchymosis on the overlying skin was also noticed. During palpation, we did not notice fluctuation, while transillumination was not feasible. Performance of ultrasonography, including Doppler color flow imaging, followed, depicting a subcutaneous cystic lesion, 2.1⁎3.2 cm in dimensions, without extension to the thoracic cavity. Scheduled surgical excision of the lesion was decided. Histopathological examination documented the diagnosis of cystic lymphangioma. Patient is still followed up on a 6-month basis. He remains asymptomatic, after 2 years, without indication of relapse.

Thoracoscopic resection of a huge mediastinal cystic lymphangioma

Mediastinal cystic lymphangioma is an extremely uncommon benign tumor. The patients with mediastinal cystic lymphangioma are often misdiagnosed because of no specific symptoms. The cysts usually are incidentally found and preoperative diagnosis is difficult due to their atypical appearance on imaging studies. Most cases are diagnosed during or after the operation. Moreover, the standard surgical approach for resection has not yet been well established. We report a case of an adult patient with a giant mediastinal cystic lymphangioma that was successfully resected by video-assisted thoracoscopic surgery (VATS). This case report shows that resection by VATS is feasible when mediastinal cystic tumor is suspected, even if they are huge, and that VATS may be an alternative to open thoracotomy to treat mediastinal cystic lymphangioma.

Young patient with generalized lymphangiomatosis: Differentiating the differential

We present the case of a 19-year-old man who was extensively evaluated in multiple centres for long-standing cough, dyspnea, and hemoptysis without a definitive diagnosis. His chest radiograph at presentation showed mediastinal widening, bilateral pleural effusions, and Kerley B lines. Computed tomography of the thorax showed a confluent, fluid-density mediastinal lesion enveloping the mediastinal viscera without any mass effect. There were bilateral pleural effusions, prominent peribronchovascular interstitial thickening, interlobular septal thickening and lobular areas of ground glass density with relative sparing of apices. There were a few dilated retroperitoneal lymphatics and well-defined lytic lesions in the bones. In this case report, we aim to systematically discuss the relevant differentials and arrive at a diagnosis. We also briefly discuss the treatment options and prognosis along with our patient's course in the hospital and final outcome.

Thoracic Cystic Lymphangioma (Cystic Hygroma): A Chest Pain Syndrome

Vascular malformations of the mediastinum including mediastinal lymphangioma are exceedingly rare in adults. A resected case of mediastinal cystic lymphangioma (cystic hygroma) that presented with acute onset of retrosternal chest pain is reported in a 45-year-old man. Cystic hygromas are benign cysts frequently discovered incidentally on chest radiograph. Although computed tomography scan provides helpful information about the size, density, and site of the cysts, it cannot establish a precise diagnosis concerning its nature. Complete removal of the cyst is the treatment of choice and allows precise diagnosis on histologic examination. However, surgical excision is sometimes difficult, owing to the size and extension of the cysts, infiltrating mediastinal planes, enveloping great vessels, and displacing mediastinal organs without invasion. The difficulty of completely eradicating certain cysts explains cases of insidious progression with compressive recurrence. The subject is succinctly reviewed.

Asymptomatic Solitary Mediastinal Cystic Lymphangioma: A Rare Entity

Solitary mediastinal cystic lymphangioma is an extremely rare tumor-like abnormality of the lymphatic system, of congenital origin. From 1996 to 2003, 4 cases of solitary mediastinal cystic lymphangioma were managed in our department. The clinicopathologic characteristics were recorded and analyzed. The incidence proved to be 1.2% among all cases of mediastinal masses admitted to our department. All patients were asymptomatic, they shared common radiologic features, and all were managed by radical surgical excision. No recurrence or mortality were noted during follow-up ranging from 2 to 7 years. Complete excision of this benign entity has an excellent prognosis.

Simple lymphangioma to generalized lymphatic anomaly: role of imaging in disclosure of a rare and morbid disease

Generalized lymphatic anomaly is a rare multisystem congenital disorder in which multiple organs are involved. Imaging features often overlap with other complex lymphatic anomalies and diagnosis is difficult. Treatment options are limited, not remedial and prognosis is poor. We report a 12-year-old male who presented with axillary and chest wall lymphangioma but was subsequently diagnosed as having diffuse lymphangiomatosis affecting lungs, liver, spleen, and bones on computerized tomography scan. We suggest complete radiological evaluation of susceptible adolescent children with lymphangioma to avoid diagnostic delay in this morbid condition. We also discuss radiological features of other similar complex lymphatic anomalies and crucial role of imaging in diagnosis.

Mediastinal cystic lymphangioma in a patient with situs inversus totalis

We present a case of cystic lymphangioma of the mediastinum complicated with situs inversus totalis. The 70-year-old man underwent thoracoscopic resection of a mediastinal cystic tumor, which was diagnosed as cystic lymphangioma. Cystic lymphangiomas are congenital cystic abnormalities of the lymphatic system. The head and neck area is often involved while the mediastinum is rarely affected. The rarity of this case is further attributed to the coexistence of situs inversus totalis.

Gorham's Disease With Chest Wall Involvement: A Case Report and a Review of the Literature

Introduction:

Gorham's disease is a rare disorder characterized by osteolysis and abnormal vascular growth within bones. Diagnosis of Gorham's disease is often delayed and for accurate and early diagnosis high clinical suspicion is crucial. No specific treatment is available. Management options include surgery, radiation therapy and medical therapy. We aimed to present the first case of Gorham’s disease with chest wall involvement in Iran. By review of the literature we discussed important issues of this rare disease including clinical findings, diagnosis and treatment options.

Case Presentation:

We present a 48-year-old man with a history of dyspnea following a blunt chest trauma who was admitted to our clinic several times due to reaccumulation of pleural fluid and chylothorax. Gorham's disease was finally established according to clinical manifestations and radiological findings including massive osteolysis in his left ribs and also histological examination.

Discussion:

According to review of the literature and considering all treatment modalities the patients was successfully treated with a combination of radiotherapy, pamidronate and thalidomide. We suggest that this disease should be considered among differential diagnoses of patients with chest pain, pleural effusion and/or chylothorax with an unknown reason and more importantly history of chest trauma. In suspected cases, it is essential to examine biopsy specimens of the bone adjacent to the inflammated tissues in order to confirm diagnosis.

Mediastinal lymphangioma treated using endobronchial ultrasound-guided transbronchial needle aspiration

Lymphangiomas are localized malformations of the lymphatic system that most commonly occur in the head and neck. However, less than 1% of all lymphangiomas are confined to the mediastinum. The standard treatment has been surgical excision, but the involvement of vital structures in the area local to the lymphangioma makes total excision virtually impossible in most cases. To our knowledge, there has been no report of mediastinal lymphangioma treated with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). We report here the first case of safe, effective treatment of a very large mediastinal lymphangioma using EBUS-TBNA in a 29-year-old man.

Generalised lymphangiomatosis in an 8-year-old girl who presented with cardiomegaly

Generalised lymphangiomatosis is a rare disease that is characterized by widespread bony and soft tissue involvement of lymphangioma. Radiological evaluation is crucial because the site and extent of the lymphangioma are important prognostic factors. The computed tomography, ultrasonography and magnetic resonance images showed sharply defined, non-enhanced cystic lesions involving the mediastinum, bones, spleen, lung, and lower neck. We report here a case that was referred to us for investigation of marked cardiomegaly.

Successful excision of an isolated mediastinal cystic lymphangioma with bilateral thoracoscopic surgery

Lymphangioma is a well-known benign tumor and its cystic abnormalities of the lymph vessels are predominantly congenital. Cystic lymphangioma usually occurs in the neck, axillary region, and rarely in the mediastinum, which frequently occurs in children and young adults. A 20-year-old woman had symptoms of palpitation, cough, and dyspnea during the recent 1 month. Both chest comuted tomography and magnetic resonance imaging of the chest revealed a well-defined, 13 × 10-cm cystic lesion in the anterior mediastinum. The patient underwent bilateral video-assisted thoracoscopic excision of the cyst and lymphangioma was confirmed based on histopathologic examination. Here, we report a rare case of isolated mediastinal cystic lymphangioma that was successfully excised using a minimally invasive technique.

Pulmonary lymphangioma in a 14-month-old

Intrapulmonary lymphangiomas are very rare. We report a case of a 14-month-old child found to have a pulmonary lymphangioma on routine chest radiograph in the emergency department and discuss the possible implications and appropriate management of this condition by the emergency physician.

A case of mediastinal lymphangioma: endosonographic appearance

Mediastinal lymphangioma is a rare, benign disease characterized by an abnormal proliferation of lymphatic vessels. Although a definitive diagnosis can be best made by surgical resection, computed tomography (CT) and magnetic resonance imaging (MRI) can be used as radiological methods to diagnose a pulmonary lymphangioma preoperatively. Endoscopic ultrasonography is a new method for visualizing pathological changes in the mediastum and may be used for preoperative diagnosis of a pulmonary lymphangioma, which is a rare example of a mediastinal disease.

Serious complications of pulmonary biopsy in a boy with chylopericardium and suspected pulmonary lymphangiomatosis

Lymphangiomatosis is a rare disorder. It is commonly localised in the skeletal system and called Gorham's disease, and in thoracic or abdominal organs. Involvement of the pericardium is rare and has been described in less than 20 patients worldwide. The case of a 14-year-old boy presenting with asymptomatic chylopericardium and interstitial lung disease is presented. After lung biopsy, performed to confirm the diagnosis of pulmonary lymphangiomatosis, he developed chylothorax and massive loss of chyle via chest drains. Thoracic duct ligation did not result in clinical improvement. Treatment with interferon α2b was given and because of clinical deterioration radiotherapy was added to the treatment. This resulted in a rapid decrease of chyle production in the patient.

Cystic hygroma in an adult; a case report

Lymphangioma is a benign infiltrative malformation of the lymphatic channels. Cystic lymphangioma or cystic hygroma is a subtype of lymphangioma which exhibits large macroscopic cystic space histologically. The cause of cystic hygroma is believed to be developmental defect or primary Multilocular cystic malformation of dilated lymphatic channels. Cystic hygroma is a common and distinct entity that is not manifested in the oral cavity but occurs in the neck as a large, deep diffuse swelling. They are usually found in the posterior triangle of the neck. They often cross the midline, reaching axilla and mediastinum. Such localization verifies the complexity and extent of the lymphatic system in the cervical region when compared to other regions of the body. The five main locations where cystic hygroma can occur are, cervical (75-90%), axillary (20%), inguinal, retroperitoneal and thoracic. They usually appear as solitary lesions. They are usually infiltrative, often separating fascial planes and incorporating nerves, muscles, and blood vessels. They are fluctuant, freely mobile, compressible, painless and transilluminate well. The skin overlying the lesion is normal and usually there is no associated lymphadenopathy. Various treatment modalities have been tried. Surgery has been the main form of treatment, but total removal is not possible in all cases because of the extent of the lesion, which sometimes involves vital structures. We report a case of cystic hygroma in a young male patient.

Diffuse lymphangiomatosis with genital involvement--evaluation with magnetic resonance lymphangiography

OBJECTIVE

To assess, for the first time, the morphology of the lymphatic system in patients with diffuse lymphangiomatosis and genital involvement by magnetic resonance lymphangiography (MRL).

MATERIALS AND METHODS

Ten patients with diffuse lymphangiomatosis and genital involvement were examined by MRL. Three locations were examined: first, the lower leg and foot region; second, the upper leg and the knee region; and third, the pelvic with retroperitoneal region. MR imaging was performed with a 1.5-T system equipped with high-performance gradients. For MRL, a T1-weighted 3D-spoiled gradient-echo and a T2-weighted 3D-TSE sequence were used.

RESULTS

The size of the genital lymphangiomas, which were revealed in all patients, varied between 6 and 85 mm. In 60% of the patients, lymphangiomas were additionally detected at the level of the lower legs, and in 70% patients at the level of the upper leg. Furthermore, lymphangiomas were seen in the inguinal and retroperitoneal regions in 80%, and in the pelvic region and anterior abdominal wall in 90% of the patients examined. The genital lymphangiomas feeding lymphatic vessels were detected in 80% of the patients in the anterior abdominal wall and in 90% of the patients in the inguinal and pelvic regions; 90% of the patients suffered consecutively from a lymphedema of the lower extremities. All patients suffered from recurrent infections in the genital region; 80% of the patients repeatedly experienced genital lymphorrhea due to lympho-cutaneous fistulas and lymphcysts.

CONCLUSION

MRL is a safe and accurate minimal-invasive imaging modality for the evaluation of the lymphatic circulation in patients with diffuse lymphangiomatosis and genital involvement. Because the site and extent of the lymphangiomas with their feeding lymphatic vessels are important prognostic factors, performing radiologic evaluation with a high resolution is crucial for the therapeutic planning of patients.

MR imaging evaluation of disorders of the chest wall

Chest wall lesions constitute a diverse group of thoracic diseases, including those of soft tissue and osseous origin. MR imaging, with its superior tissue-resolving capability and multiplanar image acquisition, is an important tool for assessing chest wall lesions. In this article, the authors review common and uncommon diseases of the chest wall, with an emphasis on the MR imaging characteristics of these diseases. Among the diseases they discuss are diseases of the soft tissue including lipoma, hibernoma, liposarcoma, hemangioma, and lymphoma. They also examine diseases of the osseous thorax, including benign osseous tumors, fibrous dysplasia, and aneurysmal bone cyst. In addition, they discuss such malignant osseous tumors as osteosarcoma and Ewing's sarcoma.

Massive benign pericardial cyst presenting with simultaneous superior vena cava and middle lobe syndromes

A 66 year old woman presented in extremis with symptoms and clinical and radiological signs of simultaneous obstruction of superior vena cava and middle lobe of right lung secondary to compression by a massive benign anterior mediastinal cyst. Excision of the cyst at median sternotomy resulted in complete resolution of all symptoms. This report is unusual on account of a) the concomitant presence of superior vena cava and middle lobe syndromes caused by a benign cyst because of its sheer size producing obstruction of these structures and b) the complete resolution of all symptoms and signs after removal of the cyst. Benign anterior mediastinal cysts are unknown to cause either of the two syndromes. To our knowledge, it is the first report of a benign anterior mediastinal cyst causing either superior vena cava syndrome or middle lobe syndrome or both simultaneously. Etiologies of both superior vena cava and middle lobe syndromes are discussed in detail.

Mediastinal cavernous lymphangioma in an adult

Cavernous lymphangioma is a rare mediastinal benign tumor. A 43-year-old woman presented with cough and dyspnea for 1 month. Computed tomography of the chest showed a 3-cm well-circumscribed cystic mass in the posterior mediastinum. At thoracotomy, a cystic tumor in the mediastinum that was adherent to the descending aorta and esophagus was removed completely. The tumor, the cystic space of which was filled with lymph fluid, was diagnosed as cavernous lymphangioma based on pathological findings. Mediastinal lymphangiomas may insinuate into surrounding organs. As incomplete resection can result in recurrence, complete tumor removal should be performed based on accurate preoperative evaluation.

Rapid Development of an Axillary Mass in an Adult: A Case of Cystic Hygroma

Cystic hygroma is a congenital anomaly of lymphatic origin, which mainly develops during childhood. Its development in adulthood, however, has been proposed to be related to several predisposing factors such as trauma, infection, tumor growth or iatrogenic stimuli. The development of cystic hygroma in the extremities of adults is extremely rare and moreover, its development in the axillary region has, to our knowledge, been reported only once in the literature. We describe an unusual case of a cystic hygroma which developed rapidly in the axillary region of a female patient in the absence of any predisposing factor. The diagnostic workup and the need for surgical excision of the mass to obtain an accurate, histologic diagnosis is presented.

Generalized lymphangiomatosis: radiologic findings in three pediatric patients

Generalized lymphangiomatosis is a rare disease that is characterized by widespread bony and soft tissue involvement of lymphangioma. Radiological evaluation is crucial because the site and extent of the lymphangioma are important prognostic factors. We reported here on three cases of generalized lymphangiomatosis and all three cases showed similar radiologic findings, but a different clinical course. The CT, US and MR images showed sharply defined, non-enhanced cystic lesions involving the mediastinum, bones, spleen, lung and lower neck. The whole body MR imaging with the short tau inversion recovery (STIR) sequence showed good capability for evaluating the extent of disease.

Mediastinal lymphangioma: Mayo Clinic experience of 25 cases

OBJECTIVE

To describe the clinical findings, treatment outcomes, disease recurrence rates, and survival of patients with pathologically confirmed mediastinal and cervicomediastinal lymphangioma.

PATIENTS AND METHODS

There are 2 patient cohorts. Cohort A consisted of 12 Mayo Clinic patients with pathologically confirmed medilastinal or cervicomediastinal lymphangioma identified from 1986 to 1999. Cohort B consisted of 13 additional patients with mediastinal lymphangioma who had been previously reported from the Mayo Clinic (from 1976 to 1986). All patients were retrospectively identified, and follow-up was performed by either telephone or medical record review.

RESULTS

The mean age at the time of diagnosis was 36.5 years, with a male-female ratio of 1:3. All but 3 patients were symptomatic at presentation, with dyspnea being the most common symptom. Computed tomographic scans commonly revealed a homogeneous, low-attenuation mass that often Involved vascular or airway structures. Although 3 patients were initially observed, all patients had surgical intervention because of symptoms or enlargement of the mass. Thoracotomy with resection was the most common surgical intervention. Five recurrences were noted. Recurrence was minimized by complete excision of the lymphangioma. On follow-up that spanned 23 years, 75% of patients were alive. These survival rates were not statistically different from the expected survival rates of the same age- and sex-matched controls. Only 1 death was attributed to complication from lymphangioma.

CONCLUSION

Mediastinal and cervicomediastinal lymphangioma are rare lesions that can be treated successfully with surgical excision. Prognosis appears to be excellent because no difference in survival was found between patients and age- and sex-matched controls.

Posttraumatic active bleeding of mediastinal mixed vascular malformation: a case report

A case of an actively bleeding mediastinal mass in a 4-year-old boy who sustained multitrauma is described. A computed tomography (CT) scan of the chest upon admission demonstrated a mediastinal mass, which enlarged significantly as seen by repeat CT scan at 3 days with a concomitant drop in serum hemoglobin levels. The lesion was excised, and pathological examination established the diagnosis of a lymphatic-venous malformation containing bloody fluid. Lymphatic-venous malformations are rare vascular malformations and are usually found in the head and neck and less commonly at other sites. Spontaneous bleeding is a known complication, and there are few reports describing posttraumatic hemorrhage. Our case is the first description in the English medical literature of a posttraumatic bleeding mediastinal mixed vascular malformation and includes sequential CT scans illustrating the dynamic nature of hemorrhage.

True thymic hyperplasia associated with a unilocular thymic cyst: an unusual combination not previously reported

A mediastinal tumor mass in a 53-year-old woman with the sole complaint of persistent cough was studied and found to be a true thymic hyperplasia associated with a unilocular thymic cyst, felt to be of the congenital type. The bilobed thymus obtained was macroscopically and microscopically normal except for the size (12 x 12 x 3.5 cm) and weight (97 g). It showed normal thymic tissue segregated in lobules separated by adipose septa and with good corticomedullary separation. There were numerous Hassall corpuscles in the medullary portion. The thymus-to-adipose ratio was approximately 80:20. In the anterior aspect of the thymus, there was a 5-cm unilocular cyst, filled with a clear watery fluid, and with smooth and gray white inner surfaces. Microscopically, the cyst was lined by a cubic and low cylindrical nonciliated epithelium with normal-appearing thymic tissue in the cyst wall. This very unusual combination of true thymic hyperplasia and unilocular thymic cyst has not been previously reported in the literature.

Gorham's disease or massive osteolysis

Gorham's disease is a rare disorder characterized by proliferation of vascular channels that results in destruction and resorption of osseous matrix. Since the initial description of the disease by Gorham and colleagues (1954) and by Gorham and Stout (1955), fifty years have elapsed but still the precise etiology of Gorham's disease remains poorly understood and largely unknown. There is no evidence of a malignant, neuropathic, or infectious component involved in the causation of this disorder. The mechanism of bone resorption is unclear. The clinical presentation of Gorham's disease is variable and depends on the site of involvement. It often takes many months or years before the offending lesion is correctly diagnosed. A high index of clinical suspicion is needed to arrive at an early, accurate diagnosis. Patients with Gorham's disease may complain of dull aching pain or insidious onset of progressive weakness. In some cases, pathologic fracture often leads to its discovery. Gorham's disease is progressive in most patients; however, in some cases, the disease process is self-limiting. The clinical course is generally protracted but rarely fatal, with eventual stabilization of the affected bone being the most common sequelae. Chylous pericardial and pleural effusions may occur due to mediastinal extension of the disease process from the involved vertebra, scapula, rib or sternum, and can be life threatening. A high morbidity and mortality is seen in patients with spinal and/or visceral involvement. The medical treatment for Gorham's disease includes radiation therapy, anti-osteoclastic medications (bisphosphonates), and alpha-2b interferon. Surgical treatment options include resection of the lesion and reconstruction using bone grafts and/or prostheses. In most cases, bone grafts tend to undergo resorption and are not helpful. Surgical reconstruction and/or radiation therapy are used for management of patients who have large, symptomatic lesions with long-standing, disabling functional instability. Surgical stabilization may be required for unstable spinal lesions. Various treatment options, including pleurectomy, pleurodesis, thoracic duct ligation, radiation therapy, interferon therapy, and bleomycin, have been used for management of patients with Gorham's disease presenting with chylothorax. In general, no single treatment modality has proven effective in arresting the disease.

[Cystic intrathoracic hemolymphangioma: a rare differential diagnosis of acute bronchiolitis in an infant]

Hemolymphangioma is a benign malformation of the lymphatic vessels. Cervical localisation is the most frequent. Mediastinal localisation is rare, but may be life-threatening because of airway compression. We report on a four-month-old boy who presented, in a context of epidemics, with clinical signs of acute bronchiolitis requiring mechanical ventilation for several days. Chest X-rays showed an important mediastinal mass with airways compression. Diagnosis was evoked on CT-scan aspects and confirmed by histology. Surgery allowed complete resolution, but dysphonia and oropharyngeal disorders persisted for several months. This rare congenital malformation is reviewed.

Thoracic lymphatic disorders

Thoracic complications of lymphatic disorders can culminate in respiratory failure and death and should be considered in any patient with a lymphatic disease and clinical or radiographic evidence of chest disease. Congenital lymphatic disorders are being increasingly recognized in the adult population. The spectrum of thoracic manifestations of lymphatic disorders ranges from incidental radiographic findings to diffuse lymphatic disease with respiratory failure. This article serves to review some recent advances that allow improved diagnosis and management of thoracic lymphatic disorders. Herein, we describe their anatomical and physiologic effects, the time course of their progression, and the therapies that are currently available. The management of malignant (cancerous) lymphatic disorders of the thorax is beyond the scope of this paper.

Gorham Disease of the Spine: A Case Report and Treatment Strategies for This Enigmatic Bone Disease

Gorham disease is an extremely rare condition of unknown etiology characterized by progressive osteolysis. Only 28 cases of its spinal involvement have been reported, and some of those cases showed kyphosis, kyphoscoliosis, subluxation or dislocation. No definite regimen of treatment has been established yet. A 10-year-old boy presented with a severe and progressive kyphosis over 90 degrees caused by Gorham disease from T3 to T12. In situ posterior fusion with a hook and rod system and iliac bone grafts were performed, but after surgery, he had complete paraplegia and its cause was uncertain. Based on the unfortunate consequence of the present case and the review of the literature, we propose the treatment strategies for spinal Gorham disease.