Analysis of 25 surgical cases of thymic neuroendocrine tumors and thymic carcinoma

BACKGROUND

The purpose of this study was to evaluate the clinicopathological characteristics of patients who underwent surgical resection for thymic neuroendocrine tumors (TNET) or thymic carcinoma.

METHODS

In this study, we retrospectively evaluated the clinicopathological characteristics of our surgical patients at Fukuoka University Hospital from January 1995 to December 2018.

RESULTS

There were nine cases of TNET and 16 cases of thymic carcinoma. Regarding the pathological type, the TNET group included three atypical carcinoid cases, two large cell neuroendocrine tumor cases, two small cell carcinoma cases, and two other cases. The thymic carcinoma group included 15 squamous carcinoma cases and one case of adenosquamous carcinoma. Based on the Masaoka-Koga staging system, six TNET cases and 11 thymic carcinoma cases were stage III or IV. The complete resection rate was 77% in the TNET group and 81% in the thymic carcinoma group. Additional chemotherapy and/or radiotherapy was performed in five cases of TNET and 11 cases of thymic carcinoma. The five-year survival rate and five-year disease-free survival rate were 87.5% and 75.0% in the TNET group and 58.9% and 57.1% in the thymic carcinoma group, respectively, with no significant difference between the two groups (P = 0.248 and P = 0.894, respectively). In the univariate analysis, complete resection was a statistically significant prognostic factor (P = 0.017).

CONCLUSION

In this study, no difference in prognosis was observed between TNET and thymic carcinomas. To understand the characteristics of these tumors, further case accumulation and multicenter clinical studies are needed. (243words).

A huge mediastinal teratoma in a 14-year-old girl

INTRODUCTION AND IMPORTANCE

Mediastinal teratoma is the most common mediastinal germ cell tumor. Mature mediastinal teratomas are infrequent and often found incidentally.

CASE PRESENTATION

We report the case of a 14-year-old girl who was presented dyspnea for 2 years. A computed tomography of the chest revealed a 19 cm heterogenous right-sided anterior mediastinal mass suggesting mature teratoma. The mass compressed vital structures. The tumor was considered resectable. By hemiclamshell approach, we punctured the tumor and aspirated its contents. The tumor was totally resected en bloc with a cuff of pericardium, phrenic nerve and azygos vena. The pericardial defect was repaired using Mersilene mesh. Histopathology of the tumor revealed a mature cystic teratoma. Postoperative course was uneventful.

CLINICAL DISCUSSION

Complete surgical excision is the treatment of choice for mediastinal mature teratoma. The choice of incision for removing the tumor depend on the tumor size, location and the relashionships with the associated vital structures. Lengthy incisions were required for the safe mobilization of the tumor. In addition, contents aspiration through a small incision in the giant tumor wall helped improve tumor mobilization.

CONCLUSION

Appropriate surgical strategy for a well selected case maintains functional status and results total tumor resection.

Bronchogenic Cyst: Lessons Learned in 20 Years of Experience at a Tertiary Pediatric Center

BACKGROUND

Bronchogenic cysts are benign congenital malformations of the primitive ventral foregut. The aim of this study is to analyze and report 20 years of experience in the diagnosis and treatment of bronchogenic cysts at a tertiary pediatric center.

METHODS

A retrospective review was conducted of all patients diagnosed with a bronchogenic cyst between 2000-2020. Presence of symptoms, cyst location, surgical technique, postoperative complications, need for pleural drainage, and recurrence were reviewed.

RESULTS

Forty-five children were included in the study. In 37 patients a partial resection of the cyst was done, followed by cauterization or chemical obliterateration with iodopovidone of the mucosa of the remaining cyst wall that was adherent to the airway. A lobectomy was done in patients who had intrapulmonary cysts (n = 8). Cyst location was subcarinal in 23 (51.1%), paratracheal in 14 (31.1%), and intrapulmonary in eight patients (17.8%). The majority of subcarinal and paratracheal cysts (90%) were approached by thoracoscopy. Complications occurred in seven patients (15%): subcutaneous emphysema after pleural drain removal in one, extubation failure in two, reoperation due to bleeding in one, surgical site infection in one, bronchopleural fistula in one, and pneumothorax in one. Reoperation due to cyst recurrence was necessary in two patients (4.4%). Mean follow-up was 56 months (range, 0-115).

CONCLUSION

A minimally invasive approach is a safe option for the management of paratracheal and subcarinal bronchogenic cysts with no history of infection in specialized pediatric surgery center. Thoracoscopic partial resection is a feasible option in most patients with subcarinal and paratracheal bronchogenic cysts with a low complication and reoperation rate.

LEVEL OF EVIDENCE

IV.

Cholesterol granuloma of the anterior mediastinum: A case report and literature review

INTRODUCTION

Cholesterol granulomas, which frequently present in the temporal bone of the skull, are recognized as benign lesions occurring due to chronic inflammation or hemorrhage. However, cholesterol granuloma of the mediastinum is extremely rare.

PRESENTATION OF CASE

An asymptomatic 43-year-old man with an incidental finding of anterior mediastinal mass by positron emission tomography scan was referred to our hospital. Preoperative computed tomography showed a well-circumscribed nodule 2 cm in size in the anterior mediastinum. A total tumor resection through a suprasternal approach was performed. Microscopically, numerous cholesterol clefts with an alveolar-like growth pattern and foreign body reaction were observed, indicating a pathological diagnosis of cholesterol granuloma.

DISCUSSION

Cholesterol granuloma is generally thought to be initiated by cell degeneration and hemorrhage resulting from trauma or inflammation. The patient's long-term rugby experience may have played a role in the development of cholesterol granuloma. It is difficult to diagnose a cholesterol granuloma based on preoperative imaging alone, and anatomy often makes preoperative biopsy or cytology difficult.

CONCLUSION

Complete resection and pathological examination may be unavoidable for diagnosis and treatment.

Aortic transection for resection of middle mediastinal tumor

BACKGROUND

Visceral mediastinal tumors are rare with challenging surgical approaches due to their location in close proximity with the great vessels and the pulmonary trunk. The aim of this paper is to discuss surgical strategies for complex cases of primary mediastinal tumors.

METHODS

We present two cases of patients with middle mediastinal tumor, one synovial sarcoma and one paraganglioma. For both patients, surgical access was performed through a sternotomy with beating heart cardio-pulmonary bypass and aortic transection, allowing optimal exposure of the carina, of the common pulmonary artery and its bifurcation. Both tumors were resected 'en-bloc'. The postoperative course was uneventful and the two patients had a 3 months postoperative follow-up CT-scan showing no evidence of recurrence.

RESULTS

Surgery remains the cornerstone of treatment for synovial sarcoma and for paraganglioma of the visceral mediastinum and this location may be difficult to deal with. Many different surgical accesses exist and our approach of ascending aortic transection allows optimal exposure to the pulmonary artery, but also provides access to the upper airways.

CONCLUSION

For visceral mediastinal tumor with close contact with vascular and respiratory structures, aortic transection allows an excellent exposure and control of the tumor with oncological resection.

Giant thymoma with complete superior vena cava obstruction

Thymomas are rare epithelial tumors of the mediastinum with relatively good prognosis compared to other thoracic malignancies. Surgery is considered the best treatment and the most important determinant of long-term survival even in advanced stages. Nevertheless, complete resection may be challenging and require a multimodality approach. We present a case of a stage IVa thymoma surgically treated. The superior vena cava was completely occluded and, after resection, reconstruction was deemed unnecessary due to sufficient venous return through the azygos-inferior vena cava system. In our opinion, despite the morbidity of surgery in advanced thymomas, it should always be considered in expert hands.

Ruptured mediastinal mature teratoma with shigellosis empyema: A case report

INTRODUCTION AND IMPORTANCE

Mediastinal mature teratomas are often benign and asymptomatic, but ruptured mediastinal mature teratoma is rare and induces severe complications.

CASE PRESENTATION

A male, 23 year old, complained shorthness of breath, right chest pain, fever, and cough. Radiological examination (X-ray, CT-Scan and MRI) showed mediastinal teratoma and pleural effusion. The patient received supportive therapies, including oxygen, symptomatic therapy, antibiotics, and lateral thoracotomy. Empyema culture was positive for Shigella dysenteriae. He was discharged after thirty-six days of hospitalization in good clinical condition.

CLINICAL DISCUSSION

Perforation of mature teratoma is a rare but severe complication. Ruptured mediastinal teratoma can cause extensive pleural adhesions and empyema, making it challenging to perform VATS because of the risk of bleeding and damage to adjacent organs during surgery.

CONCLUSION

Ruptured mediastinal mature teratoma has a good prognosis post-surgical partial resection despite tumor attachment to the pericardium and heart.

Ectopic PTH-producing parathyroid cyst inside the thymus: a case report

BACKGROUND

The hallmark of hyperparathyroidism is hypersecretion of parathyroid hormone (PTH) which results in hypercalcemia and hypophosphatemia. While hypercalcemia due to malignancy is often brought about by PTH-related protein in adults, PTH-producing tumors are quite rare in clinical practice. Additionally, from the point of embryology, it is very difficult to examine ectopic PTH-producing tissue such as ectopic parathyroid glands. Furthermore, clear histopathological criteria are not present.

CASE PRESENTATION

A 57-year-old woman was referred to our hospital for hypercalcemia. Her parathyroid hormone (PTH) level was elevated, but there were no enlarged parathyroid glands. Although 99mTc-MIBI confirmed a localized and slightly hyperfunctioning parathyroid tissue in the anterior mediastinum, it was not typical as hyperfunctioning parathyroid. We finally diagnosed her as ectopic PTH-producing cyst-like tumor with venous sampling of PTH. She underwent anterosuperior mediastinal ectopic PTH-producing cyst-like tumor resection. It is noted that intact-PTH concentration of the fluid in the cyst was very high (19,960,000 pg/mL). Based on histopathological findings, we finally diagnosed her as ectopic PTH-producing parathyroid cyst inside the thymus. After resection of anterosuperior mediastinal thymus including ectopic PTH-producing parathyroid cyst, calcium and intact-PTH levels were decreased, and this patient was discharged without any sequelae.

CONCLUSIONS

We should know the possibility of superior mediastinal ectopic PTH-producing parathyroid cyst inside the thymus among subjects with ectopic PTH-producing parathyroid glands. Particularly when the cyst is present in the superior mediastinum, it is necessary to do careful diagnosis based on not only positive but also negative findings in 99mTc-MIBI. It is noted that the patient's bloody fluid in the cyst contained 19,960,000 pg/mL of intact-PTH, and its overflow into blood stream resulted in hyperparathyroidism and hypercalcemia. Moreover, in such cases, the diagnosis is usually confirmed after through histological examination of ectopic PTH-producing parathyroid glands. We think that it is very meaningful to let clinicians know this case.

Analysis of the efficacy of the da Vinci robot in surgery for posterior mediastinal neurogenic tumors

BACKGROUND

The present research is designed to evaluate the short-term outcome of robot-assisted thoracoscopic surgery (RATS) for the treatment of posterior mediastinal neurogenic tumors.

METHODS

We retrospectively analyzed clinical data on 39 consecutive patients with mediastinal neurogenic tumors after RATS treatment completed by the same operator in the Department of Thoracic Surgery, Gansu Provincial People's Hospital from January 2016 to September 2022. There were 22 males and 17 females with a mean age of (35.1 ± 6.9) years in this analysis report. The tumors of the patients were localized and evaluated preoperatively using magnetic resonance imaging (MRI) or enhanced CT.

RESULTS

All 39 patients successfully underwent the resection of posterior mediastinal neurogenic tumors under RATS, and no conversion to thoracotomy occurred during the operations. The average operative time was (62.1 ± 17.2) min, the average docking time was (10.1 ± 2.5) min, the average intraoperative bleeding was (32.8 ± 19.5) ml, the average 24-h postoperative chest drainage was (67.4 ± 27.9) ml, the average postoperative chest drainage time was (2.2 ± 1.3) days and the average post-operative hospital stay was (3.2 ± 1.3) days. Postoperative complications occurred in 3 patients, including 2 patients with transient Horner's syndrome after surgery and 1 patient with transient anhidrosis of the affected upper limb after surgery.

CONCLUSION

RATS for posterior mediastinal neurogenic tumors is safe, effective, feasible and bring the superiority of robotic surgical system into full play.

Rare solitary splenic metastasis from a thymic carcinoma detected on fluorodeoxyglucose-positron emission tomography: A case report

BACKGROUND

Thymic carcinoma is a rare, aggressive tumor arising from the thymus. In less than 7% of patients with thymic carcinoma, extrathoracic metastases occur in the extrathoracic lymph nodes, liver, and bone. Isolated splenic metastasis can occur but is very uncommon. To date, only 2 cases of splenic metastases from thymic carcinoma have been reported.

CASE SUMMARY

A 45-year-old man presented with chronic cough, dyspnea, persistent hoarseness and unintentional weight loss 17 kgs in 6 mo. Neck magnetic resonance imaging revealed a large, lobulated, soft-tissue mass measuring 5.4 cm × 6.6 cm × 3.8 cm which involved the left superior mediastinum and supraclavicular fossa. Chest computed tomography (CT) revealed a confluent and lobulated soft tissue mass encased the right brachiocephalic artery, right and left carotid arteries, and left subclavian artery in the mediastinum. A fluorodeoxyglucose-positron emission tomography was arranged for malignancy survey. The image revealed intense fluorodeoxyglucose avidity in a soft tissue lobulated mass occupying the superior mediastinum, over the cystic lesion in the spleen and in few enlarged nodules over the left supraclavicular fossa. CT-guided biopsy of the thymic mass and the ultrasound-guided biopsy of the splenic lesion were consistent with a thymic carcinoma with splenic metastasis. The patient was diagnosed of thymic carcinoma, cT2N2M1b, stage IVb.

CONCLUSION

A fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan can provide a useful diagnostic value in conjunction with pathological result in evaluating tumor staging. Our case emphasizes the utility of FDG-PET for metastasis detection in thymic carcinoma.

Single-incision port robot-assisted surgery for thymic carcinoid tumor resection

BACKGROUND

Multiple endocrine neoplasia (MEN) is divided into MEN type 1 (MEN-1) and MEN type 2 (MEN-2). MEN-1 may be associated with thymic carcinoid tumors. We present a case of the surgical removal of a thymic carcinoid associated with MEN-1 via a single-incision port RATS.

CASE PRESENTATION

A 39-year-old male patient with multiple endocrine neoplasia type 1 (MEN-1) who had an anterior mediastinal mass was referred to our hospital. The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago. Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm. Thymic carcinoid tumor is classified as MEN-1 and has a poor prognosis, so we decided to remove the tumor. Single-incision port RATS was performed, and thymic carcinoid was confirmed in pathology.

CONCLUSIONS

This report demonstrates that thymic carcinoid tumor removal is feasible and easy to perform via single-incision port RATS.

Peripheral primitive neuroectodermal tumor: a case report

Background

Primitive neuroectodermal tumors are extremely rare and highly aggressive malignant small round cell tumors that arise from the primitive nerve cells of the nervous system or outside it. These tumors share similar histology, immunohistologic characteristics, and cytogenetics with Ewing’s sarcoma. Peripheral primitive neuroectodermal tumors of the chest wall are rare malignant tumors seen in children and young adults.

Case presentation

We report a rare case of peripheral primitive neuroectodermal tumor in a 4-year-old Albanian girl with a mediastinal tumor and an unusual clinical presentation. She was initially treated for acute polyradiculoneuritis (Guillain–Barré syndrome) owing to pain, weakness in the lower limbs, and walking difficulty, as well as severe irritability. During the second week of treatment, the child began to experience dry cough, chest discomfort, and worsening dyspnea. Chest radiography, chest computed tomography, and contrast-enhanced computed tomography demonstrated a large mass in the right hemithorax that was derived from the posterior mediastinum with expansive growth in all directions and that shifted the mediastinal structures in the anterolateral left direction. Consequently, histopathology and immunohistochemical examination of the markers S-100, CD99, and Ki-67 showed that the tumor cells stained positively for S-100 and CD99. The proliferative index measured by Ki-67 was approximately 20%, which suggested primitive neuroectodermal tumor.

Conclusions

Even though other diseases, including leukemia, lymphoma, and neuroblastoma, may be accompanied by musculoskeletal manifestations in children, other solid tumors, such as peripheral primitive neuroectodermal tumors, should be considered in the differential diagnosis in any child presenting with musculoskeletal symptoms.

Unusual giant multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum

Background

Teratoma is the second most common mediastinal neoplasm, but malignant transformation in mature teratomas is uncommon, and cases of carcinoid tumor with teratoma are described in only a few studies. In addition, multilocular thymic cyst associated with mature mediastinal teratoma is also a rare entity. There have been no reports of case with the coexistence of these three pathological lesions.

Case presentation

The patient was a 24-year-old man who was referred to our hospital due to a 2-day history of left shoulder pain, a feeling of severe chest tightness and high fever. Pre-operative computed tomography (CT) showed a large, fluid-filled and well-demarcated multilocular cyst in the anterior to superior mediastinum measuring up to 12 cm in size. Contrast-enhanced CT also revealed that the tumor contained a solid component with slight contrast enhancement and spotty wall-thickening septation. Therefore, cystic thymoma, thymic cyst, cystic teratoma, or germ cell tumor with an inflammatory reaction were considered as differential diagnoses. The patient underwent tumor extirpation under median sternotomy. The pathological diagnosis was multilocular thymic cyst with mature teratoma including carcinoid tumor (Grade 2) in the mediastinum.

Conclusions

The relationship between thymic cyst, teratoma and carcinoid tumor is unclear at present; therefore, further research is needed to clarify the relationship between these entities. In this report, we present a case of multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum that was detected by complete surgical resection.

A successful trimodality therapy for difficult-to-diagnose primary mediastinal dedifferentiated liposarcoma, which originated from the perihilar fat and invaded the right lungs

A 40-year-old man with high fever, hemoptysis, and fatigue showed a 10-cm mass in the middle and lower lobes of the right lung on computed tomography. Histological examination of transbronchial biopsy specimens showed sheets of small round tumor cells and mild staining for CD99. Primary Ewing sarcoma was suspected, and a trimodality therapy consisting of chemotherapy, intensity-modulated radiation therapy, and right pneumonectomy with surrounding tissue resection was performed. In surgical specimens, negative outcome of NKX2.2 in immunostaining and EWSR1 rearrangement in fluorescence in situ hybridization did not support the diagnosis of Ewing sarcoma. Positive immunostaining for MDM2 and CDK4 led to a diagnosis of dedifferentiated liposarcoma, which probably originated from an adipose tissue of the right perihilar mediastinum, and then invaded the lungs. The postoperative course was uneventful, without recurrence for more than 16 months.

A rare primary posterior mediastinal angiolipoma: A case report

Mediastinal angiolipoma is a rare benign neoplasm composed of mature adipose tissue with an abnormal vessel. Owing to its unspecific symptoms and slow progressions, the diagnosis of this disease is often delayed by clinicians. Here we present a 68-years-old-woman presented with mild chest pain radiates to the back with chronic dry cough. Chest imaging showed right medial posterior intrathoracic mass attached to 3rd-5th vertebrae body without bone destructions. Exploratory thoracotomy with segmentectomy was successfully performed. Histopathology examinations showed adipose tissue surrounded by a blood vessel nest, typical for angiolipoma. The patient showed rapid recovery and was discharged a week after the surgery. After two years of follow-up, the patient showed no sign of tumor recurrence and was clinically stable. This case is the first occurrence of non-infiltrating mediastinal angiolipoma reported in Southeast Asia.

•

This is the first case report of non-infiltrating mediastinal angiolipoma in Southeast Asia.

•

Histopathology examination may be performed by using an invasive or non-invasive procedure.

•

In developing countries where VATS cannot be carried out, early complete resection is essential to get favorable outcomes.

Successful excision of a giant subcarinal bronchogenic cyst by video-assisted thoracoscopic surgery

Mediastinal bronchogenic cysts, regarded as congenital foregut abnormalities, are uncommon. These cysts can compress adjacent structures, causing obstructive symptoms and complications. A 57-year-old man was admitted to our hospital with complaints of tachycardia, dyspnea, and chest pain. Enhanced computed tomography revealed a 90 × 90 mm, well-defined subcarinal cystic mass causing significant compression and stenosis of the right main bronchus, right pulmonary artery, and right inferior pulmonary vein. The mass was successfully excised using one window and two-port video-assisted thoracoscopic surgery with partial resection and repair of pulmonary artery, and the postoperative course was good with no recurrence.

Artificial pneumothorax suppresses postoperative inflammatory reaction in mediastinal tumor surgery

OBJECTIVE

The induction of artificial pneumothorax has many intraoperative advantages. However, few reports on the postoperative effects of artificial pneumothorax induction are available. In this study, we investigated the effect of artificial pneumothorax on postoperative clinical course in patients with mediastinal tumors.

METHODS

We retrospectively investigated the clinical courses of 89 patients who had undergone mediastinal tumor resection between January 2010 and December 2020. Sixty-five patients had undergone resection with artificial pneumothorax.

RESULTS

The tumor location significantly varied across patients. The proportion of patients in whom artificial pneumothorax was induced was higher among those having anterior mediastinal tumors. The number of ports and the total skin incision length were significantly higher in patients without artificial pneumothorax. The C-reactive protein level elevation on postoperative day 2 and pleural effusion at 24 h after surgery were significantly higher in patients without artificial pneumothorax. Furthermore, the albumin level reduction and hospital stay after surgery were significantly lower in patients with artificial pneumothorax. Multiple regression analysis showed that the use of artificial pneumothorax was an independent predictive factor of the C-reactive protein level elevation on postoperative day 2 and pleural effusion at 24 h after surgery. In patients without artificial pneumothorax, the operation time positively correlated with the C-reactive protein level (r = 0.646, P < 0.001).

CONCLUSIONS

Artificial pneumothorax suppressed the postoperative inflammatory response, pleural effusion, and albumin reduction, and shortened the hospital stay in patients undergoing mediastinal tumor surgery.

A desmoplastic fibroblastoma that developed in the anterior mediastinum: a case report

BACKGROUND

Desmoplastic fibroblastoma (also known as collagenous fibroma) is a benign, slowly growing soft-tissue tumor. Most desmoplastic fibroblastomas develop in the limbs, neck, or trunk. A mediastinal origin is quite rare.

CASE PRESENTATION

A 32-year-old Asian female was referred to us for the diagnosis and treatment of an anterior mediastinal tumor. The tumor was 80 mm in the largest diameter and was located on the pericardium. No invasion was evident. She underwent resection of the tumor via video-assisted thoracoscopic resection. The tumor was totally encapsulated, and its pedicle was on the pericardium. The resected specimen was very rigid, making it difficult to remove from the intercostal space. Histologically, the tumor was composed of a paucicellular dense collagenous tissue. Mitosis was rarely observed, and cellular atypia was not evident, suggesting that the tumor was benign. We diagnosed the tumor as a desmoplastic fibroblastoma by morphology and immunohistochemistry.

CONCLUSIONS

Desmoplastic fibroblastoma of the mediastinum is an extremely rare disease. Preoperative diagnosis is difficult. Early surgical resection is suitable for diagnosis and treatment planning.

Use of uniportal video-assisted thoracic surgery combined with a posterior approach to resect a dumbbell-shaped mediastinal granular cell tumor: A case report

Introduction

A dumbbell-shaped mediastinal granular cell tumor has never been reported, and there have been no reports of dumbbell-shaped tumors resected with a combination of uniportal video-assisted thoracic surgery and the posterior approach.

Presentation of case

An 18-year-old woman was diagnosed with a mediastinal dumbbell-shaped granular cell tumor by computed tomography. Complete resection was achieved via a posterior approach combined with the uniportal video-assisted thoracic surgery. First, a T3 left hemilaminectomy was performed in the prone position and the tumor located inside the intervertebral foramen was removed as far as possible. Next, the patient was repositioned to the right lateral decubitus position, a 2.5-cm skin incision was made on the 4th intercostal posterior axillary line, and resection of the residual tumor was performed. Pathological diagnosis of the resected tumor revealed a benign granular cell tumor. The patient recovered post-surgery and no tumor was reported in the 4-month follow-up magnetic resonance imaging.

Discussion

This is the first reported case of a mediastinal dumbbell-shaped granular cell tumor and its successful resection using a combined posterior and uniportal video-assisted thoracic surgery approach.

Conclusion

This is a potentially safe and effective procedure for mediastinal granular cell tumors, with outstanding cosmetic advantages.

•

Our case presented with a rare mediastinal dumbbell-shaped granular cell tumor.

•

The tumor was resected using a combined posterior and uniportal VATS approach.

•

This is a safe and effective procedure for mediastinal dumbbell-shaped tumors.

Port placement in robotic thoracic surgery for inferior mediastinal tumors

Robotic surgery for inferior mediastinal tumors located below the inferior vein is rare. The difficulty of resection varies depending on port placement and approach, especially on the left side. Considering that we have tried three different approaches for left inferior mediastinal tumors, we identify the advantages and disadvantages of each method. The approach from three arms and one assist placed on the ventral side of the inferior angle of the scapula is the best access for inferior mediastinal tumors. If the Si system is used, the patient cart should approach from the caudal side and dock on the dorsal side.

Giant coronary sinus aneurysm misdiagnosed as an extracardiac mediastinal tumor

Coronary sinus aneurysm is a rare heart anomaly. Herein, we report a rare case with giant coronary sinus aneurysm misdiagnosed as an extracardiac mediastinal tumor. The preoperative diagnostic imaging failed to diagnose the correct location of the tumor and a simple resection was planned. It turned out to be coronary sinus aneurysm intraoperatively and required cardiopulmonary bypass support for the resection.

Surgical therapy for hemangioma of the azygos vein arch under thoracoscopy: A case report

BACKGROUND

Azygos vein aneurysms are extremely rare, and their pathogenesis is not clear. The overwhelming majority of patients have no obvious clinical symptoms and are found to have the disease by physical examination or by chance. There are few reports on the diagnosis of and treatment strategy for this disease. Moreover, the choice of therapeutic schedule and the treatment window are controversial.

CASE SUMMARY

We report a case of azygos vein arch aneurysm in a 53-year-old woman. The patient had symptoms of back pain, chest tightness, and choking. Enhanced chest computed tomography showed a soft-tissue mass in the right posterior mediastinum, which was connected to the superior vena cava. The enhancement degree in the venous phase was the same as that of the superior vena cava. The patient received video-assisted thoracoscopic surgery. After the operation, her back pain disappeared, and her dysphagia and chest tightness were also significantly relieved. The postoperative pathology confirmed hemangioma. The patient was discharged on the seventh day after surgery without any comp-lications.

CONCLUSION

Some patients with hemangioma of the azygos vein arch may experience dysphagia and chest tightness caused by the tumor compressing the esophagus and trachea. Enhanced computed tomography scanning is vital for the diagnosis of azygos vein aneurysms. In addition, despite the difficulty and risk of surgery, thoracoscopic surgery for azygos vein aneurysms is completely feasible.

Lung autotransplantation for bronchial necrosis after radiotherapy: a case report

Background

Bronchial necrosis is a rare but fatal complication after radiation therapy. Because of the anatomical complexity and rarity of this condition, determining the most appropriate management for individual patients is extremely challenging. Lung autotransplantation is a surgical technique that has been applied to hilar neoplastic lesions to preserve pulmonary function and avoid pneumonectomy. We herein report a case of bronchial necrosis secondary to radiotherapy that was treated with lung autotransplantation.

Case presentation

A 46-year-old man developed broad necrosis and infection of the right bronchus secondary to previous stereotactic body-radiation therapy. This treatment was supplied close to a right hilar metastatic pulmonary tumor derived from a mediastinal malignant germ cell tumor that had been surgically resected with the left phrenic nerve. The bronchial necrosis accompanied by infection with Aspergillus fumigatus was progressive despite antibiotics and repetitive bronchoscopic debridement. Because of the patient’s critical condition and limited pulmonary function, right lung autotransplantation with preservation of the right basal segment was selected. An omental flap was placed around the bronchial anastomosis to prevent later complications. The postoperative course involved multiple complications including contralateral pneumonia and delayed wound healing at the bronchial anastomosis with resultant stenosis, the latter of which was overcome by placement of a silicone stent. The patient was discharged 5 months postoperatively. Three months after discharge, however, the patient developed hemoptysis and died of bronchopulmonary arterial fistula formation.

Conclusions

We experienced an extremely challenging case of bronchial necrosis secondary to radiotherapy. The condition was managed with lung autotransplantation and omental wrapping; however, the treatment success was temporary and the patient eventually died of bronchopulmonary arterial fistula formation. This technique seems to be a feasible option for locally advanced refractory bronchial necrosis, although later complications can still be fatal.

A giant posterior mediastinal malignant peripheral nerve sheath tumor and benign neurofibroma in body surface: a case report

Background

Neurofibromatosis comprises neurofibromatosis type 1 (NF1) and type 2 (NF2). Major tumor type of NF1 are neurofibroma recognized as benign peripheral nerve tumor, malignant peripheral nerve sheath tumor (MPNST), and glioma.

Case presentation

We report a woman with a special condition, whose tumors in body surfaces were benign neurofibroma and tumors in posterior mediastinum are MPNST. The chest-enhanced CT suggested a round soft tissue density in posteriormediastium. The diagnosis was established by pathology and immunohistochemistry. A single-stage thoracoscopic mediastinal mass resection was performed. The whole operation went smoothly and the CT scan of lungs did not show relapse of tumor three months later.

Conclusions

The appearance of neurofibroma should draw particular attention to the possibility of developing MPNST. More careful imaging examinations should be carried out, and pathological examination could diagnose it.

Rare diseases of esophagus: Surgical treatment of cysts in adults. Case report

INTRODUCTION AND IMPORTANCE

Esophageal cysts (EC) are congenital, extremely rare malformation. Up to 80% of EC are diagnosed in childhood, therefore, we can find only few clinical observations of EC in adults in literature.

CASE PRESENTATION

During the period from October to December 2019, a successful surgical treatment of 2 patients (1 male and 1 female) with enterogenous and duplication cysts of esophagus was performed at the Clinic of Faculty Surgery at Sechenov University. In both cases thoracic tumors were incidental findings during routine health investigation.

CLINICAL DISCUSSION

Clinical manifestations of ECs are caused by compression or displacement of the adjacent anatomical structures, therefore, most often patients complain of dysphagia, vomiting, pain in the chest, which may be constant or occur during an act of breathing. There are also observations of neurological symptoms due to compression of the radicular nerves The method of choice in the treatment of ECs is their surgical removal.

CONCLUSION

Patients with mediastinal tumors should be treated in specialized hospitals by experienced surgeons who can cope with an unexpected intraoperative finding and carry out the appropriate surgery.

Mediastinal hemangioma mimicking an invasive tumor growth: A case report

•

Mediastinal hemangiomas may exhibit an infiltrating appearance.

•

Extensive surgery is often required due to an inaccurate preoperative diagnosis.

•

A hemangioma should be raised as a differential diagnosis to avoid extensive surgery.

Introduction and importance

Mediastinal hemangiomas are a rare entity frequently developing in the anterior mediastinum. They may exhibit an infiltrating appearance into the surrounding tissue, and extensive surgery is often required despite its benign nature. We report a case of a mediastinal hemangioma mimicking an invasive tumor growth requiring a combined resection of the lung and diaphragm.

Case presentation

An asymptomatic 73 year-old-man presented with a 50 mm-sized mass on his chest radiography. A combined resection of the mediastinal mass with the part of the lower lobe of left lung and diaphragm not necessitating a patch repair was performed. The pathological findings were compatible with a diagnosis of a mediastinal hemangioma. Only fibrous adhesions were observed between the tumor and resected lung and diaphragm without any histological invasion.

Clinical discussion

While imaging examinations play a key role in determining a preoperative diagnosis, mediastinal hemangiomas may pose a diagnostic challenge mainly due to its rarity. With a clinical suspicion of a hemangioma during the diagnostic work up, a dynamic CT might be helpful.

Conclusions

In mediastinal hemangiomas, a preoperative diagnosis is essential in order to avoid extensive surgery. A hemangioma should be raised as a differential diagnosis for anterior mediastinal tumors, especially in cases with an infiltrative appearance that suggests the necessity for a combined resection of the surrounding organs.

Extrinsic compression of the left main coronary artery: A rare cause of cardiogenic shock

A left main coronary artery (LMCA) stenosis due to extrinsic compression by mediastinal tumor is a rare finding. In this case reports, we present a 63-year-old woman, who was transferred to the emergency department with chief complains of persistent chest and back pain. An electrocardiogram revealed diffuse ST-segment depression (elevation in lead aVR). Contrast-enhanced computed tomography (CT) showed a huge cystic mass above the left atrium. After the CT examination, she was temporarily in shock. Compression of the LMCA was evident on the CT angiography and a diagnosis of acute myocardial infarction due to compression of the LMCA by a tumor was made. An emergent resection of the tumor was performed. Histopathological assessment of the resected cyst revealed that it was a schwannoma. She made an uneventful postoperative recovery. A follow-up 3-dimensional CT scan performed after the operation confirmed no evidence of LMCA compression.

Image-Guided Biopsies and Interventions of Mediastinal Lesions

Optimal assessment of the mediastinal masses is performed by a combination of clinical, radiological and often histological assessments. Image-guided transthoracic biopsy of mediastinal lesions is a minimally invasive and reliable procedure to obtain tissue samples, establish a diagnosis and provide a treatment plan. Biopsy can be performed under Computed Tomography, MRI, or ultrasound guidance, using a fine needle aspiration or a core-needle. In this paper, we review the image-guided strategies and techniques for histologic sampling of mediastinal lesions, along with the related clinical scenarios and possible procedural complications. In addition, image-guided mediastinal drainage and mediastinal ablations will be briefly discussed.

Traumatic pseudoaneurysm of the brachiocephalic artery obstructing the airways

•

Pseudoaneurysm of the brachiocephalic artery is a very rare condition, with the majority occurring post chest trauma.

•

The delayed presentations are usually nonspecific and may vary from mild to very severe and potentially life threating symptoms.

•

CT angiogram is the most accurate diagnostic tool that sets the pathway for a well-planned surgical intervention.

This is a case report of a young patient referred to our ER as a case of mediastinal tumor compressing the airways. On presentation, the patient had severe stridor and tachypnea, with oxygen saturation less than 60%. As the patient presented alone to the ER, obtaining any history was not possible. Chest x-ray showed a huge right paratracheal mediastinal mass compressing the airway. The patient was not able to lie supine and was taken to the OR for intubation under fiberoptic bronchoscopy guidance. Bronchoscopic evaluation showed significant compression of the trachea from the right side. A small endotracheal tube (size 5) was successfully inserted. Then, the patient was taken for a chest CT with IV contrast. Chest CT showed a huge vascular mass compressing the trachea, the right mainstem bronchus, and the superior vena cava. The study showed the proximal innominate artery, followed by a pseudoaneurysm. There was an interruption of the right subclavian artery at its origin. Collaterals were seen supplying the right upper limb. Surgical resection was done. Postoperatively the patient gave a history of chest-penetrating injury in the right infraclavicular area, 15 years prior to presentation. The pseudoaneurysm of the innominate artery is a rare delayed complication of chest trauma.

Utility of immunohistochemical staining for the diagnosis of Extra-adrenal mediastinal paraganglioma

Extra-adrenal, mediastinal paraganglioma are rare tumors that origin from sympathetic ganglia. Common diagnostic steps include CT, MRI and PET-Scan. We present a case where immunohistochemical staining was an essential step for final diagnosis in a patient without symptoms of endocrine activity and an uncommon location of this tumor entity. In combination with clinical particularities on the origin of the tumor and characteristic morphology, the immunohistochemical staining of tumor tissue is a necessary diagnostic tool for paraganglioma.

Anterior mediastinal ectopic pancreatic cyst incidentally identified by pericarditis: a case report

Ectopic pancreas often occurs in the gastrointestinal tract. However, the identification of a mediastinal ectopic pancreas is extremely rare. Herein, we report a case of ectopic pancreas of the anterior mediastinum, which was incidentally detected during treatment for pericarditis with widespread ST elevation on electrocardiogram. A 40-year-old woman complaining of chest pain was admitted with suspected pericarditis. A closer examination revealed a cystic mass in the anterior mediastinum, which was diagnosed as a pancreatic cyst of the anterior mediastinum on thoracoscopic tumor resection.

The Role of Hypertension and Renin-angiotensin-aldosterone System Inhibitors in Bleomycin-induced Lung Injury

INTRODUCTION

The risk factors for bleomycin-induced lung injury (BLI), a fatal complication of cancer chemotherapy, are not well-established. The renin-angiotensin-aldosterone system (RAAS) has recently been suggested to play a role in the development of lung injury. This study clarified the impact of hypertension (HTN) and the administration of RAAS inhibitors on BLI occurrence in patients treated with bleomycin-containing regimens.

PATIENTS AND METHODS

We retrospectively analyzed the data of 190 patients treated with a bleomycin-containing regimen for Hodgkin lymphoma or germ cell tumors at our institutions from 2004 to 2018.

RESULTS

Overall, 190 patients received bleomycin, and symptomatic BLI occurred in 21 (11.1%) cases. In the multivariate analysis, age ≥ 65 years (odd ratio, 10.90; 95% confidence interval, 3.72-32.20; P < .001) and history of HTN (odds ratio, 3.32; 95% confidence interval, 1.07-10.30; P = .04) were found to be significant risk factors for BLI onset. BLI occurred in 3.6% (n = 5) of patients with no risk, 11.8% (n = 2) of those whose only risk factor was HTN, 31.6% (n = 6) of those whose only risk factor was age ≥ 65 years, and 57.1% (n = 8) of those with both risk factors (P < .001). BLI-induced mortality rates in each group were 0.0% (n = 0), 5.9% (n = 1), 10.5% (n = 2), and 42.9% (n = 6) (P < .001), respectively. Among 31 patients with HTN, BLI incidence was 12.5% in patients who were administered RAAS inhibitors and 53.3% in those who were not (P = .02).

CONCLUSION

Older age and history of HTN were independent risk factors for the development of BLI, and the administration of RAAS inhibitors might reduce the onset of BLI.

Unusual giant multilocular mesothelial cyst of mediastinum

Background

Intrathoracic mesothelial cysts are congenital lesions induced by the abnormal development of the pericardial coelom. There have been a few reports of giant mesothelial cyst of the superior mediastinum, but the preferred treatment remains a controversial topic. We herein report a rare case of successful removal of giant mesothelial cyst that was incidentally detected during a medical checkup.

Case presentation

A 53-year-old man with a feeling of mild chest tightness was referred to our hospital for the evaluation of an abnormal shadow of the mediastinum on chest X-ray. Computed tomography showed a multilocular, homogenous, large cyst in the superior mediastinum measuring 18 cm in size without contrast enhancement and with spotty calcification, and magnetic resonance imaging showed a low intensity on T1-weighted images and high intensity on T2-weighted images. Therefore, a cystic thymoma, thymic cyst, lymphangioma, cystic teratoma or pericardial cyst was suspected as the preoperative diagnosis. Despite mild symptoms, the patient underwent total thymectomy under median sternotomy for an appropriate diagnosis and treatment. The pathological diagnosis was giant multilocular mesothelial cyst.

Conclusions

Intrathoracic mesothelial cyst is a benign cyst and generally asymptomatic, but can sometimes induce critical chest clinical symptoms if untreated, depending on its size. In our case, complete surgical resection and a detailed pathological evaluation was effective for making the appropriate diagnosis and delivering treatment. In addition, an immunohistological evaluation is effective for diagnosing mesothelial cysts when it is difficult to distinguish the cyst from other cystic lesions.

Comparison of different surgical approaches for anterior mediastinal tumor

Background

Different video-assisted thoracoscopic surgery (VATS) approaches may related to heterogeneous clinical outcomes in anterior mediastinal tumor surgery. Herein, we assessed the comparison between the subxiphoid and intercostal approach, and also compare the left versus the right incision in the intercostal approach for anterior mediastinal tumor patients.

Methods

Clinical data of patients receiving thoracoscopic anterior mediastinal tumor resection were retrospectively collected. Patients were divided into two groups according to the approaches: subxiphoid and the intercostal group. The intercostal group was further subdivided into two groups according to different sides: left and right incision group. Intraoperative and postoperative variables were compared between subgroups.

Results

A total of 238 patients were consecutively included in this analysis; 198 (83.2%) patients received intercostal procedure and 40 (16.8%) patients received subxiphoid approach. After 1:1 propensity score matching, all baseline characters were well balanced between intercostal and subxiphoid approach, left and right intercostal approach. The visual analogue scale (VAS) pain score was lower in patients underwent subxiphoid approach than intercostal group at first post-operative evaluation in 12–24 h (4.36 vs. 2.23; P=0.03). According to left and right approach, postoperative drainage time (1.9 vs. 1.2 days, P=0.016), postoperative drainage volume (312.1 vs. 193.9 mL, P=0.041) and hospitalization time (5.3 vs. 4.1 days, P=0.043) were significantly increased in the left thoracic approach group compared with the right thoracic approach.

Conclusions

Subxiphoid approach is associated with less pain compared with intercostal approach. The right intercostal thoracic approach may offer better clinical effect of short-term postoperative recovery.

Resection of a cavernous hemangioma of the posterior mediastinum by sclerotherapy and uniport thoracoscopic surgery

A 44-year-old female presented with cavernous hemangioma of the posterior mediastinum. Imaging revealed that it was approximately 2 cm in size and without an arterial supply from either the thoracic aorta or intercostal artery. The patient was treated with intraoperative sclerotherapy and hemangioma resection by uniport thoracoscopic surgery via a small 3-cm surgical wound. The surgical outcome and follow-up were good.

Long-term outcome in mediastinal malignancies: video-assisted thoracoscopic versus open surgery

Purpose

There are not many studies comparing long-term oncological outcomes between video-assisted thoracoscopic surgery (VATS) and open surgery for mediastinal malignancies. This study aimed to compare perioperative and long-term outcomes of these two techniques in the treatment of mediastinal malignancies.

Methods

This is a retrospective study: patients with mediastinal malignancies underwent VATS or open surgery from 2010 to 2013 and were followed until 2019. The primary endpoints were long-term oncological outcomes, including tumor recurrence and mortality. Secondary endpoints were perioperative outcomes (operative duration, blood loss, pain, chest drainage duration, hospital length of stay, and complications).

Results

There were 36 patients in the VATS group and 49 patients in the open group. The median follow-up duration was 90 months. VATS significantly reduced operation time (84.6 versus 124.8 min), blood loss (59.8 versus 235.2 ml), postoperative pain score (4.9 versus 6.7), the duration of chest tube drainage (2.1 versus 3.1 days), and postoperative hospital stay (5.2 versus 8.0 days). The two groups were comparable regarding the recurrence rate (2.4 versus 2.1/100 person-years) and mortality rate (0.8 versus 0.9/100 person-years).

Conclusion

Compared with open surgery, VATS is less traumatic, reduces postoperative chest drainage, and shortens hospital stay with comparable long-term oncological outcomes. We advocate the VATS approach as a favored option for the resection of mediastinal malignancies.

Mediastinal tumor resection in a patient with spinocerebellar degeneration

Background

In spinocerebellar degeneration (SCD) patients, general and regional anesthesia may cause postoperative dysfunction of respiratory, nerve and muscle systems. We present the surgical case of thymoma developed in patient with SCD.

Case presentation

A 47-year-old woman with spinocerebellar degeneration was admitted because of a well-defined mass measuring 48 × 31 mm in anterior mediastinum. She showed limb, truncal, ocular, and speech ataxia; hypotonia; areflexia; sensory disturbances; and muscle weakness. Her eastern cooperative oncology group performance status was 4. Surgical resection was performed via video-assisted thoracic surgery and under general anesthesia only without epidural analgesia. The mass was diagnosed as type B1 thymoma without capsular invasion (Masaoka stage I). The patients got a good postoperative course by cooperation with anesthesiologists and neurologists in perioperative managements. She has been well over 3 years of follow-up.

Conclusions

In conclusion, careful surgical and anesthesia management is essential for providing an uneventful postoperative course in patients with SCD. Especially, selection of minimal invasive approach and avoid diaphragmatic nerve damage are the most important points in surgical procedures.

Multifocal cholesterol granulomas of the anterior mediastinum

BACKGROUND

Cholesterol granuloma in the mediastinum is rarely observed, accounting for 1% of all mediastinum tumors. There have been only a few reports of multifocal cholesterol granulomas of the thymus. We herein report a rare case of multifocal cholesterol granuloma in the thymus that was incidentally detected during follow-up of an aortic aneurysm.

CASE PRESENTATION

The patient was a 70-year-old man with dyslipidemia and hypertension who was referred to our hospital to undergo an operation for chest aortic aneurysm. Preoperative computed tomography (CT) showed 4 lesions in the anterior mediastinum measuring up to 4 cm in size with slight contrast enhancement and spotty calcification. Therefore, a thymoma, bronchogenic cyst, or lymphangioma were considered as the preoperative diagnosis. The patient underwent total thymectomy under thoracotomy followed by aortic arch replacement for the aortic aneurysm. The pathological diagnosis was multifocal cholesterol granulomas in the thymus.

CONCLUSIONS

Cholesterol granulomas should be included in the differential diagnosis of cystic tumor in the mediastinum, especially in patients with basal disease such as dyslipidemia and hypertension, which may lead to aortic aneurysm. Furthermore, complete surgical resection and a detailed histological evaluation are important for the accurate diagnosis and treatment.

An extremely rare case of rapidly growing mediastinal well-differentiated liposarcoma with a sclerosing variant: a case report

Background

Liposarcoma arising from the mediastinum is rare, accounting for less than 1% of mediastinal tumors. Furthermore, a rapidly growing well-differentiated liposarcoma is extremely rare. A well-differentiated liposarcoma is usually considered a low-grade malignancy. However, we present an extremely rare case of a sclerosing variant of well-differentiated liposarcoma that grew rapidly within a year.

Case presentation

A 77-year-old man with a giant mass in the left thoracic cavity was referred to our hospital. This mass measured about 10 cm and occupied the left-sided mediastinum on a chest radiography; however, there was no abnormal finding on the previous year’s chest radiography. Chest-enhanced computed tomography revealed a well-circumscribed 11-cm mass in the left-sided anterior mediastinum. Positron emission tomography showed accumulation of fluorodeoxyglucose uptake in this tumor (maximum standard uptake value = 3.3). The radiological findings of computed tomography and positron emission tomography indicated that this tumor was a benign or low-grade malignancy; therefore, the chest radiographic findings were difficult to explain. To explain this discrepancy and establish the diagnosis, tumor resection was performed via left posterolateral thoracotomy. Intraoperatively, the left phrenic nerve and pericardium were adhered tightly to the tumor, so we resected them. The tumor was well-circumscribed and fibrous; therefore, the initial diagnosis was solitary fibrous tumor. However, based on its histopathological and immunohistochemical patterns, the tumor was diagnosed as a sclerosing variant of well-differentiated liposarcoma. Five years postoperatively, the patient remains alive with no evidence of disease recurrence.

Conclusions

A well-differentiated liposarcoma is usually considered a low-grade malignancy. Nevertheless, the giant tumor in the present case appeared within 1 year. Thus, this was an extremely rare case of a sclerosing variant of well-differentiated liposarcoma with rapid growth.

A case of an unexpected posterior mediastinal functional paraganglioma: case report and literature review

Background

Paraganglioma can be found in a wide range of locations. However, paraganglioma in the posterior mediastinum is rare. An unexpected paraganglioma located in the posterior mediastinum was found during surgery. The anesthesia management of this patient was challenging.

Case presentation

A 65-year-old male with a posterior mediastinal tumor was scheduled for thoracoscopic mediastinal tumor resection. Severe hemodynamic changes during the operation and postoperative pathological diagnosis showed that the patient had a rare case of posterior mediastinal functional paraganglioma, which was not found before the operation. Although the patient did not experience side effects after surgery, he did experience a dangerous surgical process.

Conclusions

The correct diagnosis of paraganglioma, intensive preoperative screening, adequate preoperative preparation, and accurate intraoperative anesthesia management could provide better anesthesia for paraganglioma patients.

[Mediastinal abscess due to Aspergillus in a patient with atypical chronic myeloid leukemia, BCR-ABL1-negative]

A 64-year-old male presented with a rapidly growing anterior mediastinal mass during the clinical course of atypical chronic myeloid leukemia. A needle biopsy performed for suspected myeloid sarcoma revealed the presence of Aspergillus abscess. Early diagnosis of mediastinal abscesses, which are associated with a high mortality rate, can prevent the progression of severity. Infectious abscesses should be considered for prompt qualitative diagnosis in patients with mediastinal masses. Thymoma, germ cell tumor, and malignant lymphoma are the most common anterior mediastinal tumors, whereas infectious abscesses should also be considered when myeloid sarcoma is suspected in patients with an underlying myeloid tumor.

Mediastinal paraganglioma successfully resected by robot-assisted thoracoscopic surgery with en bloc chest wall resection: a case report

Background

Robot-assisted thoracoscopic surgery (RATS) is useful for surgery in the apical region of the chest cavity, as it narrows towards the head. Here, we describe a nonfunctional, rib-invasive paraganglioma arising in the posterior mediastinum that was successfully removed using RATS combined with chest wall resection.

Case presentation

A 31-year-old woman presented with a posterior mediastinal mass on chest computed tomography (CT) scan during a medical check-up 2 years prior. Positron emission tomography/computed tomography scan with F-18 fluorodeoxyglucose revealed a mass associated with standardized uptake maximum value of 2.69. With a preoperative diagnosis of neurogenic tumor by CT-guided percutaneous fine-needle aspiration biopsy, we performed robot-assisted tumor resection combined with chest wall resection. The wristed instruments of the robotic surgical system have increased range of motion and enabled the tumor resection without organ injury in the thoracic cavity. Histopathology examination revealed a non-functional paraganglioma with rib invasion.

Conclusions

RATS is a useful technique, enabling safer and easier resection of a mediastinal tumor adjacent to surrounding organs.

Sclerosing thymoma followed up for eight years as mediastinal goiter: A case report

•

We present an extremely rare variant of thymoma, known as sclerosing thymoma.

•

Misdiagnosis as goitre provided follow up information for eight years.

•

Regression of the tumor was significant prior to treatment with thymectomy.

•

The patient recovered and is recurrence-free after 12 months.

Introduction

Sclerosing thymoma (ST) is an extremely rare disease with less than 20 cases ever been described. Here, we present a case of sclerosing thymoma that was followed up as mediastinal goiter for eight years.

Presentation of case

A 77-year-old man was presented with a superior mediastinal tumor. The patient was asymptomatic and not affected by myasthenia gravis. Computed tomography showed a well-defined superior mediastinal tumor whose size had regressed over time. Ultrasonography-guided core-needle biopsy revealed type B1 to B2 thymoma, and total-thymectomy was performed. Histopathologically, most of the tumor showed hyalinization and sclerosis, and slight signs of type AB thymoma were found at the tumor’s periphery. The patient was diagnosed with ST. No evidence of recurrence was observed 12 months following surgery.

Discussion

Since sclerosing thymoma is mostly composed of fibrous tissue, small specimens such as needle biopsies do not contain tumor cell nests and are difficult to confirm. Complete resection is currently the most common treatment for ST. Spontaneous regression of ST has been reported; however, the mechanisms involved have not yet been elucidated.

Conclusion

This rare case of sclerosing thymoma is an unusual case since it has follow up information for an eight year period due to the misdiagnosis of goiter. The follow up visits showed significant regression of the tumor over the eight year period without treatment; however, the etiology of sclerosis and regression remain unknown. The patient was treated by thymectomy with no recurrence after 12 months.

A rapidly growing mature mediastinal teratoma with a testicular epidermoid cyst and familial Mediterranean fever

Anterior mediastinal teratomas are common and are generally characterized as slow growing tumors. Very few reports documenting rapidly growing tumors exist. Here, we describe a case of a mature teratoma showing rapid growth in 1 year treated with complete surgical resection.

•

A 25-year-old man was diagnosed with teratoma in the anterior mediastinum.

•

Additionally, he had testicular epidermoid cyst and familial Mediterranean fever.

•

Both tumors were surgically resected.

•

The postoperative course was uneventful with no evidence of recurrence.

A case of emergent operation for a life-threatening infectious mediastinal cyst

PURPOSE

Congenital mediastinal cysts are an uncommon but important diagnostic group. Most of these cysts are benign and asymptomatic in adults. However, some of them are clinically problematic due to the compression of neighboring organs, infection, or perforation.

CASE PRESENTATION

A 20-year-old man presented with severe dyspnea. Imaging revealed a mediastinal cyst in the subcarinal space compressing his right pulmonary artery and airway, which was later diagnosed as a bronchogenic cyst. Due to quick symptom exacerbation, emergent cyst wall fenestration was performed through video-assisted thoracic surgery with "stand-by" extracorporeal membrane oxygenation. Complete cyst resection was difficult owing to adhesion of the cyst to the surrounding organs. The symptoms immediately resolved after surgery and the postoperative course was uneventful.

CONCLUSION

Mediastinal bronchogenic cysts with life-threatening complications are rarely reported in adults. However, this case was life-threatening due to airway and vascular compression; emergent surgical care should be considered in such cases.

Two-year disease remission of an unresectable basaloid thymic carcinoma with second line chemotherapy drugs: report of a case

Thymic carcinomas are extremely infrequent neoplasms (15% of all thymic epithelial tumors). Basaloid carcinoma is a peculiar tumor that represents no more than 2% of those infrequent thymic carcinomas. Surgical excision is the recommended treatment. As it's extremely rare, there is no evidence of the impact of different modalities of treatment. There are no reported cases that did not include surgery as part of their management. We herein present a case of an unresectable thymic basaloid carcinoma treated only with concurrent chemotherapy and radiotherapy that obtained a complete remission and free of disease after 2 years.

Thoracotomy of an asymptomatic, functional, posterior mediastinal paraganglioma: A case report

BACKGROUND

Paragangliomas in the mediastinum are rare, accounting for only 1%-2% of all paragangliomas and < 0.3% of all mediastinal tumors. Most paragangliomas are nonfunctional, therefore, asymptomatic functional paragangliomas in the left posterior mediastinum are extremely rare. Perioperative management including preoperative preparation, careful intraoperative procedures, and strict postoperative care is important, and one-stage surgical resection should be performed only after appropriate perioperative measures are undertaken. Because those tumors are rare, it is necessary to report known cases to raise awareness regarding them.

CASE SUMMARY

We report the case of a 47-year-old male who was admitted to our hospital with the chief complaints of intermittent tearing pain on the left side of the chest and back for more than 10 mo. A chest contrast-enhanced computed tomography scan revealed a round, solid mass in the left posterior mediastinum, with low-density cystic lesions in the middle, and no enlarged lymph nodes in the hilum or mediastinum (Figure 1). After the diagnosis of paraganglioma, the patient was preoperatively given an oral adrenoceptor blocking drug (phenoxybenzamine), and intravenous fluid resuscitation for two weeks, subsequently the patient underwent a one-stage resection of lesions via left thoracotomy. The patient’s blood pressure increased to 220/120 mmHg when the tumor was touched, which could be relieved by symptomatic treatment such as accelerating liquid transfusion or other intervention to lower blood pressure. The patient recovered uneventfully after surgery, with no abnormal blood pressure or recurrence during one year of follow-up visits.

CONCLUSION

Surgical resection is the preferred treatment for asymptomatic functional paragangliomas.