Mediastinal epithelioid inflammatory myofibroblastic sarcoma with the EML4-ALK fusion: A case report and literature review

Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is an aggressive subtype of inflammatory myofibroblastic tumour which rarely affects the chest cavity. We, for the first time, report a case of mediastinal EIMS with the EML4-ALK fusion. A young woman presented to our hospital with cough, chest tightness and shortness of breath. Computed tomography (CT) showed a mixed attenuation soft-tissue mass in the right middle and upper mediastinum. Negative results were obtained from bronchoscopy forceps biopsy and endobronchial ultrasound-guided transbronchial fine needle aspiration. CT-guided percutaneous biopsy was finally performed. However, due to the rapidly progressed EIMS that compressed the trachea and right main bronchus, the patient died of respiratory failure 1 day before diagnosis. EIMS progresses rapidly, and an early diagnosis is important. For mediastinal EIMS, CT-guided percutaneous biopsy may be useful. Next-generation sequencing of blood may be instructive to EIMS patients who are intolerant to invasive biopsy.

A successful case of robot-assisted thoracic surgery for apical thoracic schwannoma

The thoracic apex is a narrow and complicated area with nerves and vessels, making it difficult to secure a visual field and perform surgical operations. Robot-assisted surgery enabled good visibility and highly flexible forceps manipulation, we were able to perform minimally invasive and safe thoracic apical tumour resection.

Lambert-Eaton myasthenic syndrome with primary thymic marginal zone B-cell lymphoma: A case report

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune paraneoplastic syndrome with proximal muscle weakness, that often complicates small cell lung cancer. It is known that neurological symptoms do not improve with malignancy treatment alone in many LEMS patients, therefore treatment is often difficult. Since Lambert-Eaton myasthenic syndrome is a rare disease with a frequency of about 1/100 that of myasthenia gravis, there are only a few case reports on malignancy complications other than small cell lung cancer. We report a LEMS patient in his 40s who was found to have an anterior mediastinal mass. We performed surgical resection and confirmed the diagnosis of primary thymic marginal zone B-cell lymphoma by pathological diagnosis using immunostaining. Thymectomy and malignant lymphoma treatment with rituximab had no effect on neurological symptoms. The neurological symptoms improved only after we provided comprehensive care with the haematology, neurology, and rehabilitation department.

Clinico-Pathological and Radiological Spectrum of Mediastinal Masses in a Tertiary Care Center: A Cross-Sectional Study

Introduction The phrase "mediastinal mass" refers to a mass within the mediastinum. About 50% of all mediastinal masses, including teratoma, thymoma, lymphoma, and thyroid illness, are anterior mediastinal tumors. Data on the mediastinal mass in India are relatively sparse, especially in this region, compared to those from other countries. Mediastinal masses are very infrequent lesions that might occasionally present a diagnostic and therapeutic challenge to the doctor. The current study describes the socio-demographic characteristics, symptoms, diagnosis, and location of mediastinal mass among the study participants. Methodology We carried out a retrospective, cross-sectional study in a tertiary care center in Chennai for three years. We included patients with an age above 16 years who visited the tertiary care center in Chennai during the study period. We included all patients with a mediastinal mass diagnosed by CT scan, with or without signs and symptoms of mediastinal compression. Patients under the age of 16 and those with insufficient data were both excluded from the study. As per the universal sampling technique, we included all the patients who met the eligibility criteria during the study period (three years) as study subjects. By using the hospital records, we collected all data about the patients like socio-demographic data, presenting complaints, past history, x-ray findings, and co-morbidities. Similarly, we recorded blood parameters, pleural fluid parameters, and histopathological reports from the laboratory register. Results The mean age of the study participants was 41.11 years, with a high proportion of patients belonging to the age group of 21 to 30 years. Over 70% of the study participants were male. Only about 54.5% of the study participants had symptoms because of a mediastinal mass. The most common local symptom felt by the patients was dyspnea, followed by a dry cough. Weight loss was the most common symptom for the patients. Most study participants (47.7%) had seen a doctor within one month of the onset of symptoms. About 4.5% of the patients had pleural effusion, as diagnosed by x-ray. Most of the study participants had a mass in the anterior mediastinum, followed by the posterior mediastinum. Most of the participants (15.9%) had non-caseating granulomatous inflammation suggestive of sarcoidosis.  Conclusion The most common tumor found in our study was lymphoma, which was followed by non-caseating granulomatous disease and thymoma. Anterior compartments are most commonly involved. We observed the most common presentation in the third decade of life with a male to female ratio of 2:1, with dyspnea being the most common symptom, followed by a dry cough. Our study found 4.5% of the patients had pleural effusion as a complication.

[Feasibility of cardiac surgical techniques for intrathoracic tumors]

OBJECTIVE

To analyse safety and expediency of cardiac surgical technologies including cardiopulmonary bypass (CPB) in patients with locally advanced lung cancer and invasive tumors of the mediastinum.

MATERIAL AND METHODS

Cardiac surgical techniques and CPB were used in 23 patients (group 1) with locally advanced thoracic tumors between 2005 and 2015. For the same period, there were 22 patients (group 2) who underwent combined surgeries and could have had similar techniques. However, these techniques were not used for various reasons. Mediastinal malignancies and non-small cell lung cancer were diagnosed in 26 (57.8%) and 19 (42.2%) patients, respectively. Invasion of superior vena cava (n=15), aorta (n=13) and pulmonary artery (n=12) was the most common. Lesion of innominate vein (n=8), left atrium (n=6) and innominate artery (n=4) was less common. A total of 21 pneumonectomies were performed (14 in the first group and 7 in the second group). Lobectomy was less common (one patient in each group). Sublobar lung resection was performed in 10 patients (2 patients in the first group and 8 ones in the second group). All resections were total in the first group (R0) that was confirmed by routine morphological examination of resection margins of different organs and vessels. The situation was worse in the second group (R1 in 19 (86.4%) patients, R2 in 3 (13.6%) patients).

RESULTS

Total postoperative morbidity was 53.3%, mortality - 8.2%. These values are higher compared to patients undergoing surgical treatment for thoracic malignancies. Incidence of postoperative complications was higher in the first group (16 (69.6%) and 8 (36.4%), respectively). Four patients died in the first group. Sepsis (n=2), acute right ventricular failure (n=1) and acute myocardial infarction (n=1) caused death. There were no lethal outcomes in the second group. Various postoperative complications were diagnosed only in 8 (36.4%) patients. The long-term results were followed-up in 80% of patients. In the first group, 3- and 5-year survival rates were 30.5% and 25%, respectively (median 43.8 months). In the second group, these values were 25% and 2%, respectively (median 24.9 months). Long-term mortality in the second group was caused by progression of malignant process, including local recurrence, after palliative surgery (R1, R2 resection).

CONCLUSION

Higher risk of postoperative complications and mortality in patients undergoing on-pump surgery is compensated by significantly better long-term results. Further progress is associated with higher safety of CPB, as well as solving some organizational and educational problems.

Resection of a capillary haemangioma using robotic-assisted thoracic surgery: A case report

Capillary haemangioma is a rare condition that is difficult to diagnose preoperatively because of its rarity and nonspecific imaging findings. In this report, we describe a case of capillary haemangioma diagnosed by robot-assisted thoracic surgery (RATS). A 72-year-old man was incidentally found to have an anterior mediastinal tumour on chest computed tomography. The preoperative imaging findings were indicative of thymoma, and surgical treatment by RATS was selected. The intraoperative findings suggested that the tumour was a haemangioma originating from the pericardiophrenic vein. The pathological findings revealed a well-defined tumour with capillaries in a vascular-like structure and some thrombus formation. The pathological diagnosis was capillary haemangioma. The patient was discharged unaided at 7 days postoperatively and no recurrence was observed at 16 months postoperatively.

Clear Cell Carcinoma of the Thymus: An Improbable Enemy

Introduction

Thymic clear cell carcinoma is the most uncommon subtype of thymic carcinoma, with 20 cases reported worldwide.

Case description

We present the case of a 61-year-old female with dyspnoea and chest pain for 2 days. Computed tomography (CT) angiography showed pulmonary thromboembolism and the existence of mediastinal and bilateral hilar lymphadenopathy, the largest infracarinal with an inferior axis of 25 mm, and also, micronodules on the left pulmonary parenchyma. The patient was admitted for aetiological assessment and underwent anticoagulant therapy. After a month, she had an ischaemic stroke, the sequelae of which proved to be fatal. The autopsy showed a mass in the superior-anterior mediastinum, with dimensions of 11×8×6 cm, corresponding to a thymus signet ring cell primary carcinoma. The immunohistochemistry study revealed that this mass was positive for AE1/AE3, CK5/6 and CK7.

Conclusion

The clinical, morphological and immunophenotypic diversity of this tumour makes its diagnosis a difficult multidisciplinary challenge, which requires a high level of clinical knowledge and accurate imaging and histological investigation.

LEARNING POINTS

Thymic clear cell carcinoma is a very rare entity with an aggressive and nonspecific clinical behaviour.There are no defined diagnostic criteria, although diagnosis could be established with histologic/cytology analysis.There are no clear guidelines for treatment, which can include highly invasive surgery and chemotherapy or radiation therapy.

Unilateral pleural effusion with capillary haemangioma

Here, we report a case of haemangioma on middle mediastinum accompanied by unilateral pleural effusion, which was initially suspected to be lung cancer and pleurisy. During annual check-up, chest radiography of a 30-year-old female showed homogeneous opacity in the left lower pulmonary field. Excision was performed, and the mass was pathologically diagnosed as benign mediastinal vascular tumour with exudative pleural effusion. To our knowledge, this presentation occurs in <0.5% of tumours of the mediastinum, and furthermore, the presence of pleural fluid is extremely rare, and the underlying mechanism is unknown. Although mediastinal haemangioma is hard to diagnose without surgery, we should include it in the differential diagnosis of a tumour with unilateral pleural effusion.

Giant Cystic Mediastinal Lymphangioma

Cystic lymphangioma mainly occurs in children and develops from the lymphatic vessels. The present study reports the case of a 36-year-old female patient with a giant cystic mediastinal lymphangioma. She was asymptomatic and the diagnosis was accidental. Imaging studies are important for referral to the Cardio-Thoracic Surgery Department for surgical intervention in order to remove the lesion. It is important that in the case of an enlargement of the mediastinum observed in a thoracic X-ray, the possible diagnosis takes into consideration various hypotheses. Early diagnosis may prevent further growth and infiltration of structures that hinder the surgical approach.

LEARNING POINTS

Cystic lymphangioma corresponds to approximately 0.7 to 4% of all mediastinal tumours.They are usually asymptomatic and, in adults, the diagnosis is accidental.After an imaging study with computed tomography and nuclear magnetic resonance, patients are usually candidates for surgical excision.

Intra-oesophageal invasion of thymoma

This is the first report of a thymoma developing with unusual invasion into the oesophageal lumen.

Primary Mediastinal HER2-positive Apocrine Carcinoma in Mature Teratoma Treated With Anti-HER2 Therapy and Chemoradiation

BACKGROUND

There are no established guidelines for the management of apocrine carcinomas of the breast; they are treated as a non-specific type of breast cancer.

CASE REPORT

We report on the case of a 40-year-old man who developed primary mediastinal apocrine carcinoma overexpressing human epidermal growth factor-2 (HER2). The patient initially underwent complete resection of a mediastinal mature teratoma with a focal apocrine carcinoma component. Two years after surgery, relapse was detected in multiple mediastinal lymph nodes. He received induction chemotherapy including docetaxel, trastuzumab, and pertuzumab; consolidative concurrent chemoradiation was added after six cycles. A complete response was confirmed using computed tomography following this multimodal therapy. After chemoradiation, adjuvant trastuzumab and pertuzumab were administered for 1 year and the patient has since had no evidence of progressive disease.

CONCLUSION

A multi-modal regimen that includes an anti-HER2 agent appears to be a promising treatment for patients with HER2-positive extramammary apocrine carcinoma.

Azygos vein varix mimicking bronchial cysts

Azygos vein varix is a very rare disease associated with a risk of rupture or thrombosis. Here, we report a case of azygos vein varix mimicking bronchogenic cysts. A 79-year-old female patient presented with abnormal shadows on a chest X-ray during an annual check-up. A plain chest computed tomography (CT) showed a well-defined tumour, approximately 66 X 65 X 45 mm in size, behind the trachea. An enhanced CT scan was refused due to asthma complications. A high signal on T2W1 images from magnetic resonance imaging (MRI) indicated a cystic tumour. Diagnosed as a bronchogenic cyst, a cyst excision was scheduled. Upon observation with a thoracoscope, a dark purple-red saccular tumour was observed continuing on to the azygos vein and was removed using linear staplers. The patient is alive and well 4 years after the operation. If a cystic tumour located in the right upper mediastinum is observed, the presence of azygos vein varix should be considered.

Mediastinal peripheral T-cell lymphoma diagnosed by repeated biopsies after an initial diagnosis of fibrosing mediastinitis

We report a case of mediastinal peripheral T‐cell lymphoma not otherwise specified (PTCL‐NOS) diagnosed by repeated biopsies. A 44‐year‐old man was admitted to our hospital with a 2‐week history of facial swelling, neck distension, and dyspnoea on exertion. Computed tomography of the chest showed a mediastinal mass. Initial needle biopsy and video‐assisted thoracoscopic biopsy revealed the pathological diagnosis of fibrosing mediastinitis (FM). Glucocorticoid therapy (prednisolone) was temporarily effective in reducing tumour size. However, other laboratory features suggested that the diagnosis of FM might not be correct. After repeated biopsies, we established the diagnosis of mediastinal PTCL‐NOS. With this correct diagnosis, appropriate therapy for PTCL resulted in the improvement of the clinical manifestations. This report suggests that the presence of malignant lymphoma should be considered in cases of mediastinal tumours, and repeated biopsies may be occasionally needed for consistent diagnosis.

Aggressive solitary intracranial metastatic malignant melanoma from a primary mediastinal tumour

Malignant melanoma is the third most common tumour to cause cerebral metastases, following breast and lung cancer. Central nervous system metastases occur in 10-40% of patients with melanoma. Intracranial metastasis from a primary malignant melanoma of the anterior mediastinum is uncommon. We report a case of solitary intracranial metastatic melanoma arising from a primary mediastinal tumour. We then discuss the clinico-radiological features and treatment options.

A rare mediastinal tumour in a young male mimicking massive pleural effusion

A 30-year-old male, carpenter by profession, presented with a history of dry cough and progressive shortness of breath for two months along with right-sided chest pain for one and a half months. The clinico-radiological picture was suggestive of right-sided massive pleural effusion. Computed tomography (CT) scan of the thorax showed a huge mediastinal mass occupying the entire right hemithorax with very small amount of pleural effusion. CT-guided fine needle aspiration cytology and tru-cut biopsy from the mass both revealed small round-cell tumour, possibly small cell carcinoma of the lung. However, on immunohistochemistry tumour cells expressed Mic-2 and it was consistent with a diagnosis of primitive neuroectodermal tumour.

Primary mediastinal synovial sarcoma

Synovial sarcoma occurs predominantly in the soft tissues of the extremities, but is exceedingly rare in the mediastinum. It has overlapping histological and immunophenotypic features with other tumours in the differential diagnosis. We report a case of a patient who had an incidental finding of such a tumour. Because of the rarity of this tumour in the mediastinum, optimal therapy is unknown and the prognosis remains guarded.