Benign lesions of the mediastinum

[CA 19-9 Secreting Extralobar Sequestration Presenting as a Bifocal Posterior Mediastinal Tumour]

A 60-year-old female patient was referred for further diagnosis and treatment of a posterior mediastinal lesion. The lesion was incidentally discovered in a CT scan of the chest and abdomen, which had been performed due to an increased CA 19-9 in routine blood tests. At the time point of the referral, the lesion had already been biopsied twice (CT guided and through EUS) but the histopathology was inconclusive. Upon referral, we repeated the CT guided biopsy and the transoesophageal ultrasound. The latter did not reveal any invasion of the oesophagus. Both biopsies were inconclusive again. We discussed thoracoscopic exploration with the patient. The procedure began with a right uniportal VATS. The lesion originated in the right lower lobe. After dissection of the lesion from the right lower lobe and its adhesions to the diaphragm, the lesion was mobilised from the mediastinal adhesions. A supplying vessel from the descending aorta was ligated and the patient was turned in order to continue the procedure from the left side. During the left sided thoracoscopy, the lesion was dissected from the diaphragm and the descending aorta. There was no invasion of the lung on the left side. The lesion was pulled through the mediastinum between the aorta and the oesophagus and was successfully extracted through the left uniportal incision. The histopathological report revealed extralobar pulmonary sequestration.

Multilocular Thymic Cyst with High F18 Fluorodeoxyglucose Uptake and Rheumatoid Arthritis: A Case Report

Background: multilocular thymic cysts are uncommon acquired cysts in the anterior mediastinum caused by incomplete thymic involution. They may be associated with autoimmune diseases, such as rheumatoid arthritis and systemic sclerosis. Methods: a 61-year-old man with a history of rheumatoid arthritis for 8 years was referred to our unit because of a multiloculated mass in the anterior mediastinum with a high F18 fluorodeoxyglucose uptake at PET-CT scan. Histology showed a multilocular thymic cyst with lymphoid tissue, organized in germinal centers and internodal areas. Results: rheumatoid arthritis-related symptoms progressively disappeared after the excision of the mass. Conclusions: to our knowledge, this is the first report in the English language of rheumatoid arthritis symptoms improvement after multilocular thymic cyst surgical removal.

Ectopic Mediastinal Thyroid: A Crossroad Between a Multi-Layered Endocrine Perspective and a Contemporary Approach in Thoracic Surgery

An ectopic thyroid (ET) involves numerous scenarios of detection and outcomes, while its current management is not standardised. A mediastinal ET (MET) represents a low index of suspicion. In this paper, we introduce a 47-year-old female who was accidentally identified with an MET, and a modern surgical approach was provided. An anterior mediastinal mass of 3.2 cm was found at CT upon a prior COVID-19 infection. Previous to the infection, she experienced non-specific complaints for a few months (intermittent night sweats, facial erythema, chest pressure, and dyspnoea). Also, CT identified a thymus-like mass and a left adrenal incidentaloma of 3 cm. The endocrine panel was normal, and the subject declined further investigations. She was re-admitted 12 months later: the MET had increased +1 cm (+45% volume) and was confirmed at a 99mTc pertechnetate scintigraphy. Noting the symptoms, mediastinal anatomy, and size change, the MET was removed via a minimally invasive trans-cervical approach (eutopic gland preservation) with the help of a Cooper thymectomy retractor (which also allowed for a synchronous thymus mass resection). No post-operatory complications were registered, the thyroid function remained normal, and the mentioned symptoms were remitted. A histological exam confirmed a benign MET and thymus hyperplasia, respectively. To conclude, this case pinpoints important aspects, such as the clinical picture became clear only upon thoracic surgery due to the complete remission of the complaints that initially seemed widely non-specific. The incidental MET finding was associated with a second (adrenal) incidentaloma, a scenario that might not be so rare, following multiple imaging scans amid the COVID-19 era (no common pathogenic traits have been identified so far). The co-presence of a thymus mass represented one more argument for surgery. Minimally invasive cervicotomy associated with eutopic gland conservation and the use of a Cooper thymectomy retractor highlight modern aspects in video-assisted thoracic surgery, which provided an excellent outcome, involving one of the lowest mediastinal thyroids to be removed by this specific procedure. Awareness of such unusual entities helps inform individualised, multidisciplinary decisions for optimum prognoses.

Personalized Management of Malignant and Non-Malignant Ectopic Mediastinal Thyroid: A Proposed 10-Item Algorithm Approach

We aimed to analyze the management of the ectopic mediastinal thyroid (EMT) with respect to EMT-related cancer and non-malignant findings related to the pathological report, clinical presentation, imaging traits, endocrine profile, connective tissue to the cervical (eutopic) thyroid gland, biopsy or fine needle aspiration (FNA) results, surgical techniques and post-operatory outcome. This was a comprehensive review based on revising any type of freely PubMed-accessible English, full-length original papers including the keywords "ectopic thyroid" and "mediastinum" from inception until March 2024. We included 89 original articles that specified EMTs data. We classified them into four main groups: (I) studies/case series (n = 10; N = 36 EMT patients); (II) malignant EMTs (N = 22 subjects; except for one newborn with immature teratoma in the EMT, only adults were reported; mean age of 62.94 years; ranges: 34 to 90 years; female to male ratio of 0.9). Histological analysis in adults showed the following: papillary (N = 11/21); follicular variant of the papillary type (N = 2/21); Hürthle cell thyroid follicular malignancy (N = 1/21); poorly differentiated (N = 1/21); anaplastic (N = 2/21); medullary (N = 1/21); lymphoma (N = 2/21); and MALT (mucosa-associated lymphoid tissue) (N = 1/21); (III) benign EMTs with no thyroid anomalies (N = 37 subjects; mean age of 56.32 years; ranges: 30 to 80 years; female to male ratio of 1.8); (IV) benign EMTs with thyroid anomalies (N = 23; female to male ratio of 5.6; average age of 52.1 years). This panel involved clinical/subclinical hypothyroidism (iatrogenic, congenital, thyroiditis-induced, and transitory type upon EMT removal); thyrotoxicosis (including autonomous activity in EMTs that suppressed eutopic gland); autoimmune thyroiditis/Graves's disease; nodules/multinodular goiter and cancer in eutopic thyroid or prior thyroidectomy (before EMT detection). We propose a 10-item algorithm that might help navigate through the EMT domain. To conclude, across this focused-sample analysis (to our knowledge, the largest of its kind) of EMTs, the EMT clinical index of suspicion remains low; a higher rate of cancer is reported than prior data (18.8%), incident imagery-based detection was found in 10-14% of the EMTs; surgery offered an overall good outcome. A wide range of imagery, biopsy/FNA and surgical procedures is part of an otherwise complex personalized management.