Cystic intrathoracic derivatives of the foregut and their complications

Non-Neoplastic Thoracic Cysts: A Clinicopathologic Study of 136 Cases

Benign cysts of the thoracic cavity represent a group of rare lesions, the spectrum of which is expanding. Most of these are congenital in nature, secondary to abnormal development during embryogenesis while a smaller subset represents acquired lesions. We retrospectively reviewed the clinicopathologic features of 136 patients with thoracic cysts that were treated in our institution over a span of 20 years. The patients were 85 female and 51 male patients with an average age of 51 years. Eighty-four of the patients were asymptomatic (62%), the remainder mainly presented with chest pain, shortness of breath, or cough. Surgical resection was performed in 123 patients while 12 patients were treated with aspiration only and 1 underwent core biopsy. The cyst size ranged from 0.5 to 14.8 cm (mean, 4.4 cm); histologically, the lesions included 50 thymic cysts (28 multilocular; 22 unilocular), 37 bronchogenic cysts, 23 pleuropericardial cysts, 12 unclassified cysts, 6 Müllerian cysts, 5 enteric cysts, and 3 parathyroid cysts. Clinical follow-up revealed that 97 patients were alive and well 4 months to 37 years after initial diagnosis; 25 patients were lost to follow-up and 14 patients died of unrelated causes. The current study is one of the largest studies on the subject with emphasis on clinicopathologic characteristics. This series has a higher incidence of thymic cysts compared with prior publications and covers a wider spectrum of different histologic types than previously reported.

A sudden hemorrhage in the esophageal duplication cyst: A rare cause of acute dysphagia in an adult

A 42-year-old male pediatrics physician was admitted with a history of acute chest pain and sudden severe dysphagia to solids and liquids. He denied any history of abdominal pain, vomiting, dyspnea, nausea weight loss. He could not even swallow saliva. The patient denied any history of drug abuse. A computed tomographic scan of the chest (CT)showed a posterior mediastinal mass inseparable from the esophagus and descending aorta. Magnetic resonant imaging (MRI)scan revealed a cystic mass full of blood inseparable from the esophagus and adherent to the aorta. The mass was resected entirely through the left thoracotomy; post-operative recovery was uneventful; dysphagia resolved as the post-operative contrast swallow study showed a free flow of contrast to the stomach patient resumed his regular diet.

•

A 42 years old male presented with chest discomfort and acute dysphagia.

•

CT scan and MRI showed hemorrhagic large posterior mediastinal cystic mass compressing the esophagus.

•

Oral contrast study showed obstruction of lower esophagus.

•

Complete surgical excision was done with uneventful outcome.

Large Recurrent Mediastinal Abscess Presenting With Cardiopulmonary Collapse

Mediastinal abscesses are rarely encountered but pose a potential threat for cardiopulmonary collapse given the close proximity of vital structures. Our focus is to illustrate a case of a mediastinal abscess that was promptly diagnosed and treated, leading to complete resolution of the airway and circulatory compromise. The proposed pathogeneses behind mediastinal abscesses are discussed at length.

Non-Neoplastic Mediastinal Cysts

Primary mediastinal cysts are infrequent lesions that can arise from a variety of mediastinal organs or structures. Most of these are congenital in origin and incidental findings during investigations for unrelated conditions. Histologically, the cysts may be composed of various tissues, including bronchogenic, pericardial, thymic, enteric, Müllerian, lymphatic, and parathyroid types. Mediastinal cysts typically demonstrate a benign clinical course and patients are cured after complete surgical resection. In this review, the embryogenesis, clinical, radiologic, and pathologic characteristics of non-neoplastic mediastinal cysts are examined with discussion of the role of immunohistochemistry and the most pertinent differential diagnosis.

Adenocarcinoma arising from an enteric cyst of the posterior mediastinum

Mediastinal enteric cysts are rare congenital thoracic cysts. The majority of mediastinal enteric cysts occur in infants, while they are rare in adults. Although most of these cysts are benign, surgical resection is sometimes performed, and malignant changes found in enteric cysts are rare. A 52-year-old man was incidentally discovered to have a posterior mediastinal mass and we excised the mass thoracoscopically. Histopathological findings showed an enteric cyst with adenocarcinoma. Comparing the pathological and magnetic resonance imaging (MRI) findings, MRI would help to detect malignant changes in such cysts. Although malignant changes found in mediastinal enteric cysts are extremely rare, clinicians should always keep in mind that those cysts have malignant potential and careful evaluation of MRI would be a clue for surgical indication.

An unusual cause of posterior mediastinal cyst

Cystic lesions of the mediastinum may be congenital or acquired. The differential diagnosis depends on their location in the mediastinum. Cysts in the posterior mediastinum are generally developmental cysts and are neurogenic or of foregut origin. We report the case of a 14-year-old boy, who presented with dry cough and progressively increasing breathlessness, and was found to have a cystic lesion in the posterior mediastinum. Fine needle aspiration from the cyst helped make a diagnosis of tuberculosis.

Laparoscopic resection of intra-abdominal esophageal duplication cyst near spleen: a case report

Esophageal duplication cysts (EDCs) are congenital malformations of the posterior primitive foregut and often within the thoracic esophagus. Here we describe a rare case of intra-abdominal EDC near spleen in a 20-year-old female patient with a complaint of an asymptomatic abdominal mass for 5 years. The diagnosis of intra-abdominal EDC was confirmed by the Ultrasonography (US) and Magnetic resonance imaging (MRI) as well as Histological examination. Then the patient was received the laparoscopic resection and recovered well after the operation. We conclude that the laparoscopic resection is considered to be feasible and a reasonable treatment for intra-abdominal esophageal duplication cyst.

Tubular duplication of the oesophagus presenting with dysphagia

Duplications of the alimentary tract are rare congenital malformations, with the ileum being the most commonly affected site, followed by the oesophagus. Among oesophageal duplications, cystic duplication is the most common and the tubular variety, the rarest. Herein, we report a rare case of tubular oesophageal duplication, complicated by adenosquamous carcinoma at the lower end of the oesophagus, in a 32-year-old man who presented with progressive dysphagia. Although proton pump inhibitors may relieve dysphagia, oesophagectomy and gastric interpositioning should be the first-line treatment for patients with tubular oesophageal duplication, in order to reduce the risk of malignant transformation at the lower end of the oesophagus.

Infection of an esophageal cyst following endoscopic fine-needle aspiration

In this report, we describe an unusual presentation of an esophageal cyst. Esophageal cysts are generally benign and are frequently asymptomatic until progressive enlargement leads to symptoms of obstruction. Incidental discovery usually warrants excision. In the described case, a patient presented with signs of enlargement and concerns for infection after an attempted endoscopic biopsy of the lesion. After admission and initial management with antibiotics she was taken to the operating room for resection via a thoracotomy. We review the literature and underscore the conventional practice of operative management of esophageal cysts without the use of invasive diagnostic evaluations.

Duplication cyst of oesophagus: a case report

Duplication of the oesophagus is the second most common duplication of the gastrointestinal tract. Children with oesophageal duplication cyst usually present with dysphagia or as asymptomatic thoracic mass found o incidental chest x-ray. We report a case of oesophageal duplication cyst that presented with inspiratory stridor and dyspnoea in a 6 month old boy. Bronchoscopy revealed an external compression on the trachea. Duplication cyst arising from the oesophagus was suggested on CT and MRI. The cyst was surgically excised with resolution of symptoms.

[Benign primary cystic lesions of mediastinum in adult: the clinical spectrum and surgical treatment]

BACKGROUND AND OBJECTIVE

The mediastinal cysts form a group of heterogeneous and uncommon benign lesions of neoplastic, congenital, or inflammatory conditions. The forgoing controversy is how to manage them; surgical removal or observation. We reviewed our experience including some rare conditions, emphasizing the clinical spectrum and surgical treatment. PATIENTES AND METHODS: This is a retrospective review between 2000 and 2007 included 34 cases of primary mediastinal cystic lesions. Clinical features, imaging techniques, surgical operation, morbidity, mortality and follow-up were analyzed.

RESULTS

There were 18 females (53%) and 16 males (47%), with a mean age+/-standard deviation of 45.3+/-14.1 years (range: 22-74). Most of cysts were congenital (94%), except patients with hydatid disease (6%). 24% of cysts (n=8) were detected in anterior mediastinum. Rest of them (n=26) were located in visceral mediastinum. Patients usually were symptomatic (61%). Chest pain and discomfort was most common symptom, others were dyspnea, cough and hemoptysis, respectively. Cysts excision was performed in all cases with an uneventful recovery and with no recurrence in long term follow up.

CONCLUSIONS

Asymptomatic mediastinal cysts are not rare. Surgery is a reliable method of treatment of mediastinal cysts with acceptable mortality and morbidity.

Adenocarcinoma arising in a mediastinal enteric cyst

A 39 year-old male was admitted to our hospital because of relapsing episodes of pneumonia. His chest roentgenogram showed a consolidated shadow and cavity formation in the left lower lobe. During a left lower lobectomy an enteric cyst in the posterior mediastinum involving lung was found. This cyst in the lung contained normal gastric parietal cells and pancreatic tissue, and was surrounded by adenocarcinoma characteristic of gastric cancer. This is a rare case in which an adenocarcinoma arise from an enteric cyst in the mediastinum.

Cystic lesions of the mediastinum

Cysts of the mediastinum comprise a relatively diverse group of lesions that include neoplastic and nonneoplastic constituents, the latter of which are largely congenital in nature. Therefore, a grasp of their clinicopathologic characteristics is bolstered by knowledge of which tumors in the chest may undergo cystic change, as well as the embryologic development of the thoracic organs. That information, as well as radiological and pathologic features of these lesions, is discussed in this review.

A huge posteromedial mediastinal cyst complicated with vertebral dislodgment

Background

Mediastinal cysts compromise almost 20% of all mediastinal masses with bronchogenic subtype accounting for 60% of all cystic lesions. Although compression of adjoining soft tissues is usual, spinal complications and neurological symptoms are outmost rare and tend to characterize almost exclusively the neuroenteric cysts.

Case presentation

A young patient with intermittent, dull pain in his back and free medical history presented in the orthopaedic department of our hospital. There, the initial clinical and radiologic evaluation revealed a mediastinal mass and the patient was referred to the thoracic surgery department for further exploration. The following computed tomography (CT) and magnetic resonance imaging (MRI) shown a huge mediastinal cyst compressing the T4-T6 vertebral bodies. The neurological symptoms of the patient were attributed to this specific pathology due to the complete agreement between the location of the cyst and the nervous rule area of the compressed thoracic vertebrae. Despite our strongly suggestions for surgery the patient denied any treatment.

Conclusion

In controversy with the common faith that the spine plays the role of the natural barrier to the further expansion of cystic lesions, our case clearly indicates that, exceptionally, mediastinal cysts may cause severe vertebral complications. Therefore, early excision should be considered especially in young patients or where close follow up is uncertain.

Mediastinoscopy in the treatment of mediastinal cysts

OBJECTIVE

Primary cysts constitute 25% of all masses in the mediastinum. Because radiological investigations are often inconclusive, many adults require mediastinoscopy, thoracotomy, video-assisted thoracic surgery, or computed tomography-guided transbronchial, transesophageal, or transcutaneous aspiration to confirm the cystic nature of these lesions. Minimally invasive procedures fail when the cyst contents are gelatinous and mucoid (failure to aspirate) or when the cyst wall continues to secrete fluid. Though Pursel reported mediastinoscopic extirpation of benign cysts 35 years ago, it remains a "therapeutic curiosity" with sporadic reports of its usage. We report 2 successful mediastinal cyst extirpations performed as outpatient procedures and review the literature with regards to its management.

METHODS

A rigid, 8-mm mediastinoscope was inserted into the anterior mediastinum following the creation of a 2-cm suprasternal incision and dissection along the anterior surface of the trachea. After aspiration, cytology of the contents revealed their benign nature. Right paratracheal cysts in 2 adult males were successfully removed mediastinoscopically by blunt and sharp dissection.

RESULTS

Histopathology revealed benign mesothelial cysts in both instances. Both patients had an uncomplicated procedure and were discharged within 23 hours. No other pathology was detected on mediastinoscopy, and follow-up at 3 months and 6 months has revealed no recurrence.

CONCLUSION

Mediastinoscopic cyst removal is a minimally invasive procedure with a very low morbidity and mortality rate. Morbidity, recovery, and discharge times are much less than those of more invasive procedures (video-assisted thoracic surgery / thoracotomy). We suggest that it should be the first-choice procedure for the excision of appropriately located benign mediastinal cysts.

Imaging Evaluation of Pediatric Mediastinal Masses

Mediastinal masses in children are a heterogeneous group of asymptomatic to potentially life-threatening congenital, infectious, or neoplastic lesions that can present complex diagnostic and therapeutic dilemmas. This article presents the imaging features of the common mediastinal masses seen in the pediatric population. Classification of the masses is performed according to the traditional mediastinal compartment model, consisting of the anterior, middle, and posterior mediastinum. This scheme facilitates differentiation of the variety of disorders.

Laparoscopic resection of esophageal duplication cyst in an adult

We present the case of a 26-year-old woman who underwent a successful laparoscopic resection of an esophageal duplication cyst without any other congenital abnormalities. Although computed tomography (CT) scan and endoscopic ultrasonography (EUS) both assisted in determining the correct preoperative diagnosis, the definitive diagnosis was made following pathological examination of the resected lesion.

Predictive factors for acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation

BACKGROUND

Although endoscopic papillary balloon dilation may result in acute pancreatitis or hyperamylasemia, the risk factors for these complications have not been well documented. Risk factors predictive of acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation were retrospectively analyzed.

METHODS

In 118 patients who underwent endoscopic papillary balloon dilation for choledocholithiasis, postendoscopic papillary balloon dilation acute pancreatitis and hyperamylasemia (at least 3-fold elevation) were investigated. A multivariate analysis was conducted for 20 potential risk factors related to clinical and procedure characteristics.

RESULTS

Bile duct clearance was achieved in 113 patients. Early complications in the form of mild pancreatitis occurred in 7 patients (6%). Multivariate analysis identified history of acute pancreatitis as the only risk factor for postendoscopic papillary balloon dilation pancreatitis. Postendoscopic papillary balloon dilation hyperamylasemia occurred in 30 patients (25%). Multivariate analysis identified 4 independent risk factors for hyperamylasemia: an age of 60 years or less, previous pancreatitis, bile duct diameter 9 mm or less, and difficult bile duct cannulation.

CONCLUSIONS

Endoscopic papillary balloon dilation is associated with a relatively low occurrence (6%) of pancreatitis but a high frequency (25%) of hyperamylasemia. The latter may represent pancreatic irritation or latent pancreatic injury. Particular care is necessary when endoscopic papillary balloon dilation is performed in younger patients, those with a history of pancreatitis, patients with a nondilated bile duct, and when cannulation is difficult.

Congenital masses of the lung: prenatal and postnatal imaging evaluation

Congenital masses of the lung are a spectrum of interrelated abnormalities that includes congenital lobar overinflation, bronchogenic cyst, congenital cystic adenomatoid malformation (CCAM) and sequestration. The prenatal and postnatal imaging features of these lesions are reviewed, emphasizing the importance of serial prenatal sonograms and postnatal imaging studies, including radiography and computed tomography. Masses that become inconspicuous, or disappear on serial prenatal sonograms are discussed, as well as the importance of postnatal imaging studies in the evaluation of these lesions. Finally, the management of congenital masses of the lung is reviewed, emphasizing the importance of imaging studies in the preoperative evaluation.

The first reported sudden fatality from pulmonary artery compression by a thymic cyst

A 21-year-old previously well female student presented to accident and emergency having woken in the early hours of the morning with severe chest pain. On arrival she appeared, very unwell and breathless. For 1 week she had complained of a severe upper respiratory tract infection associated with chest pain which had been attributed to pleurisy. There was a strong family history of coronary heart disease but no risk factors for venous thrombosis or history of drug abuse. Over the next few minutes she began to look moribund with breathlessness and confusion. During physical examination, which was normal apart from tachypnoea and tachycardia, she had a cardiac arrest.

Advanced cardiopulmonary resuscitation for electromechanical dissociation was commenced and after two cycles the rhythm changed to ventricular fibrillation. Tension pneumothorax was excluded by intercostal fine needle aspiration and an endotracheal tube inserted. After 20 minutes of resuscitation, sinus rhythm was restored with a blood pressure of 100/50 mmHg. Physical examination revealed no rash, normal abdominal examination and no abnormal respiratory signs. She regained consciousness and sat up in an agitated state for about 30 seconds. An arterial blood gas showed pO2 10 KPa, pCO2 4 KPa, pH 6.97, bicarbonate 7.3 mmol/litre. Haemoglobin was 12g/dl, total white cell count 18.2 (neutrophils 5, lymphocytes 10). Electrolytes were normal.

A chest radiograph and electrocardiogram were about to be taken when cardiac output was lost during another electromechanical dissociation arrest. Resuscitation was restarted having established central venous access, which showed a central venous pressure of about +10 cmH20. Over the next 30 minutes cardiac output could not be re-established and nearly an hour after the initial cardiac arrest the patient was pronounced dead.

Post-mortem revealed an 8.0 cm diameter non-communicating cyst in the mediastinum. This was adherent to the left atrium anteroinferiorly and there was external compression of the pulmonary artery anterosuperiorly. It was unilocular, tense, thin-walled and collapsed when punctured revealing a cloudy white serous fluid.

The trachea contained thick secretions consistent with resolving pneumonia and there were multiple pulmonary foci of consolidation. There were bilateral pleural effusions each measuring 300 ml and pulmonary oedema, but no evidence of pulmonary emboli. Otherwise, the heart, pericardium and cardiovascular system were normal apart from a small blood-stained pericardialeffusion.

Histological examination showed that the cyst had a thin fibrous wall and was lined by cuboidal cells. Immunohistochemistry showed that these cells were positive for the specific cellular antibodies CAM 5.2 and AUA 1 indicating an epithelial rather than mesothelial origin. These findings are consistent with tissue of thymic origin.

Congenital cystic adenomatoid malformation of the lung with an esophageal cyst: report of a case

The authors report the case of a 7-month-old girl found to have both congenital cystic adenomatoid malformation of the lung (CCAM) and esophageal cyst. She suffered repeated episodes of pneumonia and exhibited signs of respiratory distress on admission to our hospital. Chest radiography and magnetic resonance imaging (MRI) showed 2 different kinds of cystic lesions. Resection of the lower lobe of the right lung and excision of the posterior mediastinal cyst were performed. Histologic examination showed Stocker type I CCAM and esophageal cyst. Coexistence of both CCAM and esophageal cyst is extremely rare. The authors speculate that the pathologies of this case originated from a regional disturbance of common embryologic origin during 2 different phases of lung-bud foregut malformations.

Pericardial cyst diagnosed by two-dimensional echocardiography and computed tomography in a newborn

A one-day-old full-term female infant with massive "cardiomegaly" developed marked respiratory distress soon after birth. The two-dimensional (2D) echocardiogram demonstrated a 4 X 5-cm cystic mass adjacent to the left ventricular free wall. Computed tomography (CT) confirmed the presence and dimension of the cyst and CT number indicated the fluid within the cyst to be serous. A pericardial cyst was successfully removed at thoracotomy. Two-dimensional echocardiography and CT, both noninvasive procedures, are fully adequate tools in the diagnosis of pericardial cysts in the neonate, so that invasive investigations may be avoided.

Complete familial Currarino triad

✓ The Currarino triad is a unique complex of congenital caudal anomalies including anorectal malformation, sacral bone abnormality, and presacral mass. In this report, the authors describe three cases with the complete Currarino triad in a family. The authors treated a 30-year-old mother with an anterior sacral meningocele, her 1-year-old son with a combination of anterior sacral meningocele and dermoid cyst, and her 4-year-old daughter with an epidermoid cyst. These three patients had associated sacral agenesis and anorectal malformations. To the authors' knowledge, this is the first report describing radiological and operative findings of complete familial Currarino triad in which a mother and her two children were affected.

Ciliated hepatic foregut cyst: a study of six cases and review of the literature

Ciliated hepatic foregut cyst (CHFC) is a rare, benign, solitary cyst consisting of ciliated pseudostratified columnar epithelium, subepithelial connective tissue, a smooth muscle layer, and an outer fibrous capsule. We studied six previously unreported cases of CHFC and 50 cases from the literature. The literature search revealed that Friedreich first described the lesion in 1857 and hypothesized its congenital origin. The cyst generally is found incidentally on radiologic imaging or during surgical exploration, although one case presented with portal vein compression. It occurs more frequently in men and is found most commonly in the medial segment of the left hepatic lobe, unlike most other solitary cysts that show a female predominance and greater occurrence in the right hepatic lobe. Two of the 56 cases were multilocular. There has been an increase in the number of reports of CHFC during the past 15 years. This may reflect the increased availability and use of various radiologic imaging modalities. A large number of cases have been reported in the Japanese population, but the significance of this is unclear. CHFC should be considered in the differential diagnosis of other solitary liver cysts, including simple cysts, hepatobiliary cystadenomas, and parasitic cysts.

Primary mediastinal tumors: part II. Tumors of the middle and posterior mediastinum

Lymphoma, mediastinal cysts, and neurogenic neoplasms are the most common primary middle and posterior mediastinal tumors. Lymphoma may involve the anterior, middle and/or posterior mediastinum, frequently as lymphadenopathy or as a discrete mass. Foregut cysts are common congenital mediastinal cysts and frequently arise in the middle mediastinum. Pericardial cysts are rare. Schwannoma and neurofibroma are benign peripheral nerve neoplasms, represent the most common mediastinal neurogenic tumors, and rarely degenerate into malignant tumors of nerve sheath origin. Sympathetic ganglia tumors include benign ganglioneuroma and malignant ganglioneuroblastoma and neuroblastoma. Lateral thoracic meningocele is a rare cause of a posterior mediastinal mass.

Esophageal duplication cyst associated with pulmonary cystic malformations

Two cases of esophageal duplication cyst associated with pulmonary cystic malformations (cystic bronchiectasis with pneumonia in one, intrapulmonary bronchogenic cysts with bronchial atresia in the other) are reported. The coexistence of these complex anomalies supports the recognition that esophageal duplication cyst also is an entity of a broad spectrum of developmental abnormalities caused by abnormal budding of the primitive foregut. Nine cases of similar complex anomalies in the lung and esophagus have been reported. Although rare, this malformation complex should be borne in mind in the treatment of pediatric mediastinal and pulmonary malformations.

Recurrent bronchogenic pseudocyst 24 years after incomplete excision. Report of a case

Bronchogenic cysts (BCs) are uncommon congenital anomalies. Due to the inherent complications, the mere presence of a BC should warrant surgical therapy. Partial excision of these structures leads to recurrence. Complete surgical excision using a thoracotomy or video-assisted thoracic surgery is the goal. We report a case of recurrent bronchogenic pseudocyst 24 years after initial excision. This case supports the argument for complete surgical excision of BCs at the time of diagnosis.

Case report: oesophageal duplication cyst causing left lung collapse and hypoperfusion

Oesophageal duplication cysts are very rare congenital abnormalities. We report a case of one sited in the middle third of the oesophagus causing stenoses of both pulmonary arteries, with collapse of the left lung due to left main bronchus obstruction.

Surgical management and radiological characteristics of bronchogenic cysts

Forty-two patients with bronchogenic cysts were treated over a 30-year period (1962 to 1991). The location was mediastinal in 37 and intrapulmonary in 5. Cysts were symptomatic in 21 patients (50%) and complications occurred in 11 (26%). The complications included infection in 5 patients, hemorrhage into the cyst in 2 patients, dysphagia due to esophageal compression in 2, adenocarcinoma arising from a bronchogenic cyst in an 8 1/2-year-old girl, and an esophagobronchopleurocutaneous fistula as a result of previous incomplete resection in 1 patient. Magnetic resonance imaging has been found to provide specific diagnostic information about bronchogenic cysts. All but 2 patients were treated with complete excision. One patient was managed by observation and another had drainage of the cyst by mediastinoscopy. Complications of treatment occurred in only 2 patients. One had a minor wound infection and the other had Clostridium difficile enterocolitis. Only 4 patients were lost to follow-up. No late complication or recurrence developed in those patients having complete excision. We recommend complete excision in most instances to confirm the diagnosis, relieve symptoms, and prevent complications.

Recurrent respiratory obstruction from a mediastinal bronchogenic cyst

A large mediastinal bronchogenic cyst presented acutely with paroxysmal atrial fibrillation and severe airflow obstruction. The patient had experienced identical symptoms on two other occasions over the previous 24 years. These had been previously misdiagnosed as due to a mediastinal lymphoma. Percutaneous extrapleural aspiration successfully decompressed the cyst with substantial improvement in lung function. Recurrent swelling of the cyst occurred that could not be relieved surgically. After repeat aspiration percutaneous instillation of bleomycin and alcohol has been used to prevent further increase in the size of the cyst.

Asymptomatic bronchogenic cysts: what is the best management?

The management of patients with uncomplicated bronchogenic cysts has evolved over the last decade with the development of more precise diagnostic techniques and a better understanding of the variable natural history of these lesions. Although an aggressive surgical approach is still indicated for infants and children, it is acceptable to treat asymptomatic bronchogenic cysts in adults in a conservative manner. Observation alone may be indicated for small, classic, asymptomatic cysts. The use of mediastinoscopy or percutaneous or transbronchial needle techniques for carinal or paratracheal cysts offers the option of fluid aspiration or wall biopsy, thus avoiding thoracotomy. An air-fluid level in the cyst, the presence of malignant cells in the aspirate or biopsy, the development of symptoms, or enlargement or recurrence of the cyst on follow-up examination mandates complete surgical removal at thoracotomy. This is also indicated for intraparenchymal bronchogenic cysts, which are more prone to bronchial communication and infectious complications and for which the distinction from a carcinoma with a cystic component may be difficult.

Hereditary sacral agenesis with presacral mass and anorectal stenosis: the Currarino triad

A family with autosomal dominant inheritance of sacral agenesis is described. Ten members were affected; four had associated presacral teratomas and anterior sacral meningoceles, giving rise to serious complications in three, including bacterial meningitis, local recurrence of teratoma and perianal sepsis. Three of those with presacral masses presented initially with anorectal anomalies. Other associated abnormalities included tethering of the cord, hydrocephalus, duplex ureter, hydronephrosis, vesicoureteric reflux, neurogenic bladder, bicornuate uterus, rectovaginal fistula and hereditary spherocytosis. Early diagnosis and surgical excision of a presacral mass is advised to prevent future morbidity and mortality.

Adenocarcinoma arising in a foregut cyst of the mediastinum

A case of malignant transformation in a mediastinal cyst of the esophageal reduplication type is presented. The cyst had been recognized 39 years previously, but remained asymptomatic until sudden growth occurred. It was resected totally from the esophagus and the patient recovered well. A review of the literature showed that malignancy in mediastinal foregut cysts is extremely rare.

Imaging of congenital esophageal cysts in adults

The radiologic imaging of esophageal cysts (EC) in adults is described. These rare cysts, often detected incidentally on routine chest radiographs, seldom produce symptoms, but they may cause precordial sensations, arrhythmias, and dysphagia. They may also bleed and become malignant. As surgical excision is the treatment of choice, the preoperative diagnosis must be exact. For this, magnetic resonance imaging (MRI) or endoscopic ultrasound seem to be the imaging methods of choice even if a plausible diagnosis can be advanced on computed tomography (CT). Chest x-ray or esophagus roentgenogram have little differential diagnostic value.

Acute symptoms due to a huge duplication cyst ruptured into the esophagus

A 36-year-old housewife complained of a tight feeling in the pharynx with increasing dysphagia, dyspnea, and mild fever. Chest roentgenogram was interpreted as a cystic mass in the middle mediastinum. Computed tomography showed a cystic mass compressing the carina and the esophagus. Ten days after onset, symptoms were suddenly relieved followed by a tarry stool. The chest mass shadow decreased. Esophagofiberscopy showed two fistulas communicating with a cyst that had two chambers. Thoracotomy performed 40 days after onset showed a true duplication of the esophagus with rupture into the esophagus. This is a rare case in which it was possible to observe the sequence of events of a ruptured intramural duplication cyst by means of chest roentgenography, computed tomography, esophagofiberscopy, and cystogram.

Central bronchogenic cyst: treatment by extrapleural percutaneous aspiration

Images

The value of transoesophageal ultrasonography in the management of a mediastinal foregut cyst

Mediastinal foregut cysts account for approximately 10% of primary mediastinal masses. The differentiation of these cysts from other mediastinal masses is important, especially if a policy of aspiration and observation of cysts is adopted. Computed tomography (CT) is generally regarded as the definitive imaging modality in these cases, but it may occasionally fail to identify the cystic nature of the mass. We report a case in which transoesophageal ultrasound contributed to the diagnosis and demonstrated features of the cyst contents that were not visible on CT.