Mediastinal neoplasms in patients with Graves disease: a possible link between sustained hyperthyroidism and thymic neoplasia?

Ectopic Cervical Thymoma in a Patient Diagnosed With Graves Disease: A Systematic Literature Review

Thymomas are benign thymic epithelial neoplasms, rarely found outside the anterior mediastinum. Although hyperthyroid states have been associated with thymic hyperplasia, only 3 thymoma cases have been previously reported in patients with Graves disease (GD), all within the anterior mediastinum. Here, we report a case of ectopic cervical thymoma in a 22-year-old female patient previously treated for GD. The patient underwent ultrasonography, computed tomography, inconclusive fine-needle aspiration, and ultimately gross dissection for diagnostic workup and definitive treatment of an anterior neck mass, producing a 2.5 × 2.3 × 1.5-cm entity consistent with Masaoka stage I and type B2 thymoma per World Health Organization classification. The patient underwent an uncomplicated subsequent clinical course, with no adjuvant radiotherapy administered. After conducting a systematic literature review, we conclude that of the 109 cases of ectopic cervical thymoma reported, this is the first to describe a case of ectopic cervical thymoma in a patient with a past medical history of GD. For GD patients in stable euthyroid remission with the persistent or recurrent presence of an anterior neck mass, the extrathyroidal origin of the mass should always be considered, including the exceptional presence of a cervical ectopic thymoma.

A case of thymoma presenting as pyrexia of unknown origin

ABSTRACT

Pyrexia of unknown origin can be caused due to numerous infective and noninfective causes. It poses a diagnostic dilemma to the clinicians and requires a myriad of investigations for the confirmation of diagnosis. Thymomas are rare mediastinal tumors that present as anterior mediastinal mass; however, thymomas presenting as pyrexia of unknown origin has rarely been reported in the literature. We report an interesting case of a middle-aged male who presented as pyrexia of unknown origin due to thymoma.

Refractory Thyroid Storm Due to Graves Disease in a Patient With Thymic Lymphoepithelial Carcinoma

Thyroid storm is a life-threatening endocrine emergency that warrants early clinical recognition and aggressive intervention. We present a 64-year-old female with no known history of thyroid disease, who presented to her primary care physician with dyspnea on exertion and was found to have an anterior mediastinal mass. She had elective thymectomy. Pathology confirmed thymic lymphoepithelial carcinoma. Postoperatively, she developed altered mental status, fever, and atrial fibrillation with marked elevation of thyroid hormones, consistent with thyroid storm. She decompensated rapidly and was treated aggressively with standard therapies for thyroid storm, including beta-blockers, methimazole, cholestyramine, steroids, and iodine, with poor response. The patient eventually underwent 4 sessions of therapeutic plasma exchange (TPE) with marked improvement in her symptoms. This case reports a possible association between thymic lymphoepithelial carcinoma and Graves disease and highlights the utility of TPE in cases of severe thyroid storm that are refractory to traditional treatments. We learn from this case that evaluating thyroid function tests in patients with thymic or mediastinal masses before surgery might be helpful. TPE should be considered in patients with thyroid storm refractory to traditional therapies.

Thymic hyperplasia in patients with Graves' disease

BACKGROUND

Graves' disease (GD) is commonly associated with other autoimmune conditions, and there is also a rare but well documented association between GD and thymic hyperplasia (TH). It is hard to say the real frequency of this latter association because most cases remain asymptomatic and are consequently not thoroughly investigated.

MATERIALS AND METHODS

We reviewed the literature on GD-related thymus enlargement and found 107 cases published to date. Thymic cancer was only documented in four patients, while the majority of cases were diagnosed as TH. The causative mechanisms behind TH associated with GD have yet to be fully elucidated. Several studies support the hypothesis of a TSH receptor antibody (TRAb) mediating thymic enlargement.

RESULTS

We report on a female GD patient with an incidentally discovered anterior mediastinal mass. Our case is not consistent with the hypothesis of a TRAb-mediated mechanism because the thymus reached its largest volume at the onset of GD and shrank during remission of GD under medical treatment, despite persistently positive TRAb levels.

CONCLUSION

We support the hypothesis that two different pathogenic mechanisms might be responsible for thymus enlargement: thymic cortical tissue expansion seems to be due to a hyperthyroid state, while lymphoid hyperplasia appears to correlate with immune abnormalities underlying GD.

Analysis of ICU treatment on resection of giant tumors in the mediastinum of the thoracic cavity

OBJECTIVE

The purpose of this study was to assess prognosis after resection of giant tumors (including lobectomy or pneumonectomy) in the mediastinum.

MATERIALS AND METHODS

Patients with resection of a giant tumor in the mediastinum of the thoracic cavity received ICU treatment including dynamic monitoring of vital signs, arterial blood pressure and CVP detection, determination of hemorrhage, pulmonary function and blood gas assay, treatment of relevant complications, examination and treatment with fiber optic bronchoscopy, transfusion and hemostasis as well as postoperative removal of ventilators by invasive and non-invasive sequential mechanical ventilation technologies.

RESULTS

Six patients were rehabilitated successfully after ICU treatment with controlled postoperative errhysis and pulmonary infection by examination and treatment with fiber optic bronchoscopy without second application of ventilators and tubes after sequential mechanical ventilation technology. One patient died from multiple organ failure under ICU treatment due to postoperative active hemorrhage after second operative hemostasis.

CONCLUSIONS

During peri-operative period of resection of giant tumor (including lobectomy or pneumonectomy) in mediastinum of the thoracic cavity, the ICU plays an important role in dynamic monitoring of vital signs, treatment of postoperative stress state, postoperative hemostasis and successful removal of ventilators after sequential mechanical ventilation.