Clinical spectrum of mediastinal cysts

Minimally invasive, multi-disciplinary approach for surgical management of a mediastinal congenital bronchogenic cyst in a 6-month-old infant

We present a case of prenatal diagnosis of a mediastinal cyst by ultrasound, confirmed during infancy through computed tomography (CT) and magnetic resonance imaging (MRI). A 6-month-old male infant was admitted to the hospital. A mid-mediastinal cyst was detected through a province-wide fetal ultrasonography screening program. During the infancy stage, the CT scan and the MRI confirmed the finding of a mediastinal cyst. Based on the findings on prenatal ultrasonography and postnatal imaging studies (CT, MRI), a benign mediastinal cyst was suspected. The cyst was below the tracheal carina, and the patient developed symptoms of respiratory distress. Owing to the enlargement trend of the cyst, the respiratory distress it has caused, and the anxiety it caused to the patient's family, a multi-disciplinary conference reached the consensus that surgical resection is the treatment of choice and a carina-approach mediastinal lesion resection via video-assisted thoracoscopic surgery (VATS) was performed. The cyst was removed successfully. Although this report is of a single case and follow-up duration is not long enough, we nevertheless make the first move to improve the pattern to a feasible, reliable, and efficient one, which could be used to treat similar patients.

Mediastinal lesions across the age spectrum: a clinicopathological comparison between pediatric and adult patients

The objective of this study was to identify the differences in histopathological distribution and clinical features of mediastinal lesions (MLs) across the age spectrum in Chinese series of patients and to compare with the available literature. A total of 409 cases of MLs, including 137 pediatric and 272 adult patients from a single institution, was reviewed and categorized into groups according to age. Among the 409 cases, the age showed a bimodal distribution with an increased incidence of MLs among (< 10 year) and (60–< 70 year) age groups. Thymic lesions, neurogenic tumors, and cysts made up 57% of MLs among the 409 cases. A significantly higher frequency was found for neurogenic tumors, germ cell tumors, mesenchymal tumors, and lymphatic lesions, (p < 0.01) for all, in pediatric population compared to adults. On the contrary, frequencies of thymic lesions and metastatic carcinomas were significantly higher in adults compared to pediatric category, (p < 0.01) for both. Overall, 41.6% were asymptomatic, however, pediatric patients showed a significantly higher incidence of cough and fever, (p < 0.01) for both, and dyspnea (p = 0.02), than adults. Whereas adult subset showed a significantly higher incidence of chest pain (p = 0.02), or oppression (p < 0.01), than pediatric counterpart. In conclusion, the age spectrum was the factor that influenced the histopathological distribution and the clinical presentation of MLs in Chinese series of patients. Such differences might be considered in the differential diagnosis and therapeutic approach for adult as well as pediatric patients with MLs. Furthermore, our study was comparable to the literature in terms of MLs frequencies.

A Young Woman With Severe Chest Pain After Undergoing Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for a Large Mediastinal Mass

A 33-year-old woman with chest pain and hemoptysis was found to have a large mediastinal mass. As the radiology imagings were inconclusive, she underwent diagnostic endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). After the procedure she developed mediastinitis, which required video-assisted thoracoscopic surgery excision and intravenous antibiotics. Bronchogenic cysts are rare congenital anomalies. Traditionally, surgical resection has been recommended as the first-line treatment option for both symptomatic and asymptomatic bronchogenic cysts due to concerns of late complications, including malignant transformation. Recently, there have been a number of case reports of bronchogenic cysts been diagnosed and treated successfully using EBUS-TBNA. We present a case in which EBUS-TBNA was performed for a definitive diagnosis of cystic lesion in the mediastinum.

Intramural esophageal bronchogenic cyst mimicking achalasia in a toddler

Bronchogenic cysts are congenital malformations of the tracheobronchial tree. We describe a 20-month-old male who presented with persistent non-bilious emesis; manometry and imaging were consistent with esophageal achalasia. During a planned laparoscopic Heller myotomy, an intramural bronchogenic cyst was discovered in the anterior esophagus at the level of the gastroesophageal junction and successfully resected with resolution of his symptoms.

Lipoma-Like Bronchogenic Cyst in the Right Chest Sidewall: A Case Report and Literature Review

Bronchogenic cyst most commonly occurs in the mediastinum, followed by the lung. We admitted a 59-year female patient with bronchogenic cyst being uniquely located on the right chest wall of the parietal pleura. Preoperative CT scan showed a local low-density lesion on the right chest wall. The lesion was removed by the thoracoscopic surgery. During the surgical resection, the lesion was observed to be located on the right chest wall. The lesion was surrounded by adipose tissue and covered with entire parietal pleura, which looks like lipoma. Pathological examination demonstrated that the lesion was bronchogenic cyst. In addition, previously reported cases of bronchogenic cyst were reviewed, and the relevant clinical knowledge was discussed.

Efficacy and Safety of Transbronchial Needle Aspiration in Diagnosis and Treatment of Mediastinal Bronchogenic Cysts: Systematic Review of Case Reports

BACKGROUND

Although surgical resection of mediastinal bronchogenic cysts is considered the treatment of choice, there is increasing interest in minimally invasive approaches of management. The purpose of this study was to review the literature on the role of transbronchial needle aspiration (TBNA), either conventional or endobronchial ultrasound (EBUS)-guided, in the diagnosis and management of bronchogenic cysts.

METHODS

We systematically searched the PubMed and EmBase databases for studies (until July 2014) reporting TBNA of bronchogenic cysts. Data were recorded on a standard data extraction form and is presented in a descriptive manner.

RESULTS

Our search yielded 26 studies (32 patients). The median age of the patients was 43 years. Most were men (n=15), symptomatic at presentation (n=19), and had cysts in the paratracheal location (n=14). Endosonography was performed on 16 patients. The EBUS appearance of the lesion was hypoechoic and anechoic in 11 and 5 patients, respectively. Thirty-one patients underwent TBNA (conventional: 16; EBUS-guided: 15). The intent of TBNA was therapeutic in 19 patients and diagnostic or symptomatic palliation in the others. Complications were reported in 5 (16.1%) patients [infective (n=4), bradycardia (n=1)] after TBNA; there were no deaths. The median duration of follow-up was 14 months and no recurrences were detected during the follow-up period.

CONCLUSIONS

Bronchoscopy is a useful tool in the diagnosis of bronchogenic cysts, both for confirmation of the cystic nature of the lesion by EBUS and diagnosis by TBNA (preferably EBUS-guided) of the cyst fluid. Therapeutic aspiration of the cyst may be an alternative to surgery in adults with mediastinal bronchogenic cysts.

Diagnostic imaging in spontaneous rupture of a thoracic duct cyst in the mediastinum

Thoracic duct cysts in the mediastinum are extremely rare; they can give rise to chylothorax when they spontaneously rupture or after they are operated on. We present the case of an adult woman with a thoracic duct cyst in the mediastinum and chylothorax from its spontaneous rupture; to our knowledge, this phenomenon has not been specifically reported before. We describe the clinical and radiological findings, the therapeutic management, and the pathology findings, reviewing the literature for this entity.

Pleuropericardial cyst torsion: case report

Pericardial cysts account for 12-18% of all mediastinal masses. They are usually asymptomatic and incidentally detected. However, when large, they can cause symptoms. Most pericardial cysts are located in the right cardiophrenic angle, but they can be anywhere in the mediastinum. We reported a pleuropericardial cyst torsion after physical stress, a very rare complication of this condition. The diagnosis was made by computed tomography and confirmed by video-assisted thoracoscopy.

Video-Assisted Thoracoscopic Surgery of Mediastinal Cysts: Report of 13 Cases

Mediastinal cysts are rare anomalies. The purposes of this study were to present our experience with mediastinal cysts, which were thoracoscopically treated in our clinic, and to discuss our findings along with those from the literature. We retrospectively investigated 13 patients who were diagnosed and thoracoscopically treated for mediastinal cysts in our clinic between January 2008 and December 2011. Seven patients were female and six were male. The average age of the patients was 41.3 ± 20.3 (7-82 years old). The mediastinal cysts comprised five pericardial cysts: four bronchogenic cysts, one hydatid cyst, one benign cystic teratoma, one thymic cyst, and one neurenteric cyst. In the case of a ruptured hydatid cyst, we passed it to thoracotomy intra-operatively due to the presence of advanced adhesion related to inflammation. Postoperative complications and mortality did not occur in any case. The average postoperative hospitalisation period was 3.8 days (2-7 days). Video-assisted thoracoscopic surgery in mediastinal cysts is a reliable and effective approach with low morbidity and a shorter hospital stay.

Ruptured intrathoracic cyst during induction of anaesthesia: Anaesthetic challenges

Congenital benign cysts are among the rare types of mediastinal masses. When symptomatic, complete surgical excision through thoracotomy is the definitive treatment. Rarely they may present with symptoms due to complications like rupture. However, rupture following the induction of general anaesthesia poses unique challenges for anaesthesiologist. We report our experience of a rare variant of intraparenchymal cyst (lung), which was subsequently found to be a bronchogenic cyst.

Intrapericardial bronchogenic cyst: an unusual clinical entity

Mediastinal cysts are extremely rare clinical disorders. They usually have a pericardial origin. In this report, we present a 27-year-old male patient with a mediastinal bronchogenic cyst together with clinical presentation and management of the pathology.

Removal of a giant intrathoracic cyst from the anterior mediastinum

A 45-year-old caucasian man with progressive dyspnea appeared to have a giant intrathoracic cyst in the anterior mediastinum encasing the heart and compressing both lungs. He underwent succesful removal of the cyst through a median sternotomy. Recovery was uneventful. Gross examination revealed a thin-walled cyst filled with clear fluid. Microscopic histopathologic examination revealed a cyst wall lined by cubic cells and underlying loose connective tissue with remnants of thymic tissue. The definitive diagnosis was an intrathoracic (simple) mesothelial cyst. An intrathoracic mesothelial cyst is a benign, generally asymptomatic tumor that can be located in the anterior cardiophrenic angle, the paravertebral or paratracheal regions, or in the anterior mediastinum. It can become rather large before it becomes symptomatic, at which point surgical removal is generally warranted.

Video-assisted thoracic surgery for bronchogenic cysts: is this the surgical approach of choice?

OBJECTIVES

Although there is no consensus on the management of bronchogenic cyst, most surgeons advocate early removal, even in asymptomatic patients. To evaluate the feasibility and safety of video-assisted thoracic surgery (VATS) in the management of bronchogenic cysts and long-term follow-up, a retrospective analysis was performed.

METHODS

From January 1995 to April 2013, we retrospectively reviewed the charts of 113 patients who underwent VATS resection of bronchogenic cysts in our institution. Resection of the bronchogenic cysts by VATS was initially performed in patients who had a cyst in the thoracic cavity and no evidence of severely dense adhesion to other organs or tissues on a CT scan. Also, patients with a history of previous thoracic surgeries, in addition to those with concomitant diseases requiring surgical treatment, were enrolled in our series. Operations were carried out using the conventional three-port technique and histological examinations confirmed the diagnosis of benign bronchogenic cyst containing a ciliated columnar epithelial lining.

RESULTS

The median size of the cysts was 3.7 cm in their greatest diameter (range, 1-10 cm). One hundred and nine patients with bronchogenic cyst were resected completely by VATS. In 4 cases, VATS was converted to open thoracotomy or median sternotomy: major adhesion to the bronchus in 2, left innominate venous injury in 1 and repair of bronchial tear by surgery in 1. We identified 5 intraoperative complications of tracheobronchial tear, vascular injury and oesophageal laceration. The median operation time was 96.8 min (range, 15-320 min). There were no operative mortalities or major postoperative complications. Patients with VATS excision were discharged after a median of 3.7 days postoperatively. The long-term follow-up ranged from 1 to 11 years, with a median follow-up of 4.2 years. There were no late complications or recurrences.

CONCLUSIONS

Considering the low conversion and complication rate, VATS was safe and effective in the resection of the bronchogenic cysts. The size and the location of cysts were not important considerations in selecting the surgical method. VATS excision should be considered the primary therapeutic option in the management of patients with bronchogenic cysts.

Endobronchial ultrasound: a useful tool in the diagnosis of bronchogenic cyst

Diagnosis of bronchogenic cysts is possible with computed tomography, where the cysts are seen usually as well-circumscribed lesions of water density. However, many of the cysts have a soft-tissue density thus rendering them indistinguishable from neoplasms. In this article, we describe a case of bronchogenic cyst presenting as soft-tissue mass that was evaluated and diagnosed by endobronchial ultrasound (EBUS). We discuss the ultrasound image characteristics of the cyst and its histopathology findings. EBUS seems to be a valuable tool in the diagnosis of bronchogenic cysts and also enables their complete aspiration.

Endobronchial ultrasound-guided needle aspiration of a bronchogenic cyst to liberate from mechanical ventilation: case report and literature review

An 86-year-old man developed stridor and acute respiratory failure after being treated for a chronic obstructive pulmonary disease exacerbation and a urinary tract infection that required mechanical ventilation. A contrast computed tomography of the chest revealed a 4.2×5.7×7 cm homogeneous mass in the thoracic inlet, consistent with a bronchogenic cyst producing mass effect over the trachea. Patient was deemed a poor surgical candidate given significant comorbidities. We performed endobronchial ultrasound-guided transbronchial needle aspiration successfully to drain the bronchogenic cyst, allowing successful extubation within hours after the procedure.

Single institutional experience with primary mediastinal cysts: clinicopathological study of 108 resected cases

PURPOSE

To review our institutional surgical outcomes with primary mediastinal cysts (PMCs) and elucidate the clinicopathological differences among several histological PMC variants.

METHODS

We retrospectively reviewed 108 patients who underwent surgery for PMC at our institution between 1997 and 2012.

RESULTS

There were 54 thymic cysts (TCs), 26 bronchogenic cysts (BCs), 16 mature cystic teratomas (MCTs), 11 pericardial cysts (PCs), and 1 esophageal duplication cyst. Surgical approach was via thoracoscopy in 44, thoracotomy in 24, median sternotomy in 39, and hemiclamshell incision in 1. Pathological complete resection was achieved in all patients. Postoperative complications occurred in 13 patients. There was no postoperative mortality. All patients were recurrence-free after a mean follow up of 41 ± 26 months. MCT was significantly associated with larger cyst size (p <0.001) more frequent combined resection of invaded organs (p <0.001), more intraoperative bleeding (p = 0.005), and longer duration of operation (p = 0.022) than the 3 other groups (TC, BC, and PC).

CONCLUSION

Surgical treatment for PMC is safe and efficacious regardless of approach. Patients with MCT may require more aggressive surgeries than those with other histological variants, reflecting their potential for invasion into surrounding structures and larger cyst size.

Primary mediastinal hydatid cysts

PURPOSE

Hydatid disease is endemic in many parts of the world. Mediastinal hydatidosis is seen less than 0.1% of all hydatid diseases. We want to report our primary mediastinal hydatid cysts.

MATERIALS AND METHODS

In this retrospective study, from January 2010 to December 2012, 158 patients with intrathoracic hydatid cysts were operated in our thoracic surgery clinic. Nine of 158 (5.69%) patients had mediastinal hydatid cyst. Chest X-ray and computed tomography (CT) were used as diagnostic tools.

RESULTS

Hydatid cyst was confirmed surgically and pathologically in all the patients. Anterior mediastinal hydatid cysts and one cardiac involvement were determined in our study. While total cyst excision was performed in seven patients, partial pericystectomy could be done in two patients. In one patient, left ventricle invasion was seen and it was totally excised. Postoperative albendazole was applied to patients and there was no recurrence of disease till now.

CONCLUSIONS

Mediastinal hydatid cysts are uncommon and should be kept in mind in differential diagnosis of mediastinal cystic lesions especially in endemic regions. Surgical resection must be done and then medical therapy is needed to prevent recurrence.

Bronchogenic cyst rupture and pneumonia after endobronchial ultrasound-guided transbronchial needle aspiration: a case report

We report a 54-year-old woman who presented with a well-defined, homogeneous, and non-enhancing mass in the retrobronchial region of the bronchus intermedius. The patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for histological confirmation. Serous fluid was aspirated by EBUS-TBNA. Cytological examination identified an acellular smear with negative microbiological cultures. The patient was finally diagnosed with bronchogenic cysts by chest computed tomography (CT) and EBUS-TBNA findings. However, 1 week after EBUS-TBNA, the patient developed bronchogenic cyst rupture and pneumonia. Empirical antibiotics were administered, and pneumonia from the bronchogenic cyst rupture had resolved on follow-up chest CT. To our knowledge, this is the first reported case of pneumonia from bronchogenic cyst rupture after EBUS-TBNA.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of non-lymph node thoracic lesions

AIMS:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has shown excellent diagnostic capabilities for mediastinal and hilar lymphadenopathy. However, its value in thoracic non-lymph node lesions is less clear. This study was designed to assess the value of EBUS-TBNA in distinguishing malignant from benign thoracic non-lymph node lesions.

METHODS:

From October 2009 to August 2011, 552 patients underwent EBUS-TBNA under local anesthesia and with conscious sedation. We retrospectively reviewed 81 of these patients who had tracheobronchial wall-adjacent intrapulmonary or isolated mediastinal non-lymph node lesions. On-site cytological evaluation was not used. Immunohistochemistry (IHC) was performed to distinguish the origin or type of malignancy when necessary.

RESULTS:

EBUS-TBNA was performed in 68 tracheobronchial wall-adjacent intrapulmonary and 13 isolated mediastinal non-lymph node lesions. Of the 81 patients, 77 (95.1%, 60 malignancies and 17 benignancies) were diagnosed through EBUS-TBNA, including 57 primary lung cancers, 2 mediastinal tumors, 1 pulmonary metastatic adenocarcinoma, 7 inflammation, 5 tuberculosis, 3 mediastinal cysts, 1 esophageal schwannoma, and 1 focal fibrosis. There were four false-negative cases (4.9%). Of the 60 malignancies, there were 9 (15.0%) which originally had no definite histologic origin or type. Thus, IHC was performed, with 7 (77.8%) being subsequently confirmed. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EBUS-TBNA in distinguishing malignant from benign lesions were 93.4% (60/64), 100% (17/17), 100% (60/60), 81.0% (17/21), and 95.1% (77/81), respectively.

CONCLUSION:

EBUS-TBNA is a safe procedure with a high sensitivity for distinguishing malignant from benign thoracic non-lymph node lesions within the reach of EBUS-TBNA, with IHC usually providing a more definitive diagnosis.

Mullerian cysts of the posterior mediastinum: report of two cases and review of the literature

Cystic lesions can be occasionally be found in the mediastinum, and typically include bronchogenic cysts, esophageal duplication cysts, and neuroenteric cysts. In 2005, Hattori described the first mediastinal cyst with Mullerian differentiation. Since that time, three other authors have described similar cysts occurring in the posterior mediastinum. Here we present two cases of patients with ciliated cysts with Mullerian differentiation with expression of estrogen receptor, progesterone receptor, PAX8 and Wilm's tumor 1, occurring in the posterior mediastinum and review the related literature.

A diagnostic approach to the mediastinal masses

Background

Multiple different types of mediastinal masses may be encountered on imaging techniques in symptomatic or asymptomatic patients. The location and composition of these lesions are critical to narrowing the differential diagnosis.

Methods

Radiological compartmentalisation of the mediastinum helps in focusing the diagnosis of masses on the basis of their site. Some diseases, however, do not occur exclusively in any specific compartment and can spread from one compartment to another.

Results

Tissular components of the mass, the degree of vascularisation and the relationships with mediastinal structures assessed by computed tomography (CT) or magnetic resonance imaging (MRI) are a leading edge of the radiological diagnosis. Special applications at MRI have been developed over the recent years in order to identify accurately tissular components of the mediastinal masses. The likelihood of malignancy of the mediastinal masses is influenced by the symptomatology and the age of the patient. This article reviews the most commonly encountered mediastinal masses considering clinical history and manifestations, anatomical position and certain details seen on different imaging modalities that allow correct diagnosis in many cases.

Conclusion

Familiarity with the radiological features of mediastinal masses facilitates accurate diagnosis, differentiation from other mediastinic processes and, thus, optimal patient treatment.

Teaching Points

• CT and MRI are important for the diagnosis of mediastinal masses.

• The location and tissue characteristics on imaging studies are critical to narrow down the differential diagnosis of mediastinal masses.

• Symptomatology and patient age affect the likelihood of malignancy.

[Benign cysts of the mediastinum: series of 28 cases]

INTRODUCTION

Benign cystic mediastinal mass form a group of heterogeneous and uncommon lesions. Surgical resection is the gold standard in these conditions. We reported our institutional experience in management of these benign tumours. In this review, cardiac and ganglionary benign mass were excluded.

METHODS

We retrospectively reviewed the records of 28 patients with benign cysts of the mediastinum, who are operated in our department between January 2003 and December 2009 (7years period).

RESULTS

There were 13 females (46.4%) and 15 males (53.5%), with a mean age of 36.8years (range: 13-63years). Most lesions (n=22) were equally in the anterior and middle mediastinum, only six were in the posterior mediastinum. Seventeen patients (60.7%) were symptomatic, with chest pain and cough as the most common symptoms. The diagnosis of mediastinal cyst was fortuitous in 11 patients with the waning of an assessment made for another reason. Surgery was indicated in all patients in order to both diagnostic and therapeutic. Posterolateral thoracotomy incision is the most common. Complete resection of the cyst was possible only in 18 cases (64.3%), whereas in ten (35. 7%) other cases part of the cyst was left in place due to tight adhesions to vital structures. After histological study, there were: nine bronchogenic cysts (32.1%), seven hydatid cysts (25%), four cystic lymphangiomas (14.3%), three mature cystic teratomas (10.7%) and three pleuropericardial cysts, one thymic cyst and one parathyroid cyst. The postoperative course was uneventful and no recurrence has been observed until now.

CONCLUSION

The benign cysts of the mediastinum is a rare entity, the hydatid etiology remains common in our context. Surgical treatment remains the treatment of choice for mediastinal cysts, when the patient is operable, to save the risk of complications or degeneration.

Foregut duplication cyst: an unusual presentation during childhood

Congenital duplications can occur anywhere in the GIT, one third of all duplications are foregut duplications (esophagus, stomach, first and second part of duodenum). Respiratory symptoms are the most common symptoms in foregut duplications, most cases present with respiratory distress which may be present from birth, or symptoms may be insidious with cough, wheeze, or recurrent respiratory infections. We are presenting a 2-year-old boy presenting with cough and fever. Radiological investigation showed left mediastinal mass that was removed by excisional biopsy and revealed an esophageal cyst. Cough with or without fever could be rare presentations for esophageal cyst.

Mediastinal lymphangioma treated using endobronchial ultrasound-guided transbronchial needle aspiration

Lymphangiomas are localized malformations of the lymphatic system that most commonly occur in the head and neck. However, less than 1% of all lymphangiomas are confined to the mediastinum. The standard treatment has been surgical excision, but the involvement of vital structures in the area local to the lymphangioma makes total excision virtually impossible in most cases. To our knowledge, there has been no report of mediastinal lymphangioma treated with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). We report here the first case of safe, effective treatment of a very large mediastinal lymphangioma using EBUS-TBNA in a 29-year-old man.

A thymic cyst in the middle mediastinum: report of a case

BACKGROUND

Thymic cysts are usually located in the neck or anterior mediastinal compartment. Thymic cysts arising in the middle mediastinum are extremely rare, with only 2 previously reported cases. We herein describe the third case of a thymic cyst in the middle mediastinum.

CASE

A 41-year-old female was referred to our department because of an incidental mediastinal mass detected on chest X-ray. Computed tomography showed a well-defined 7 cm mass located in the retroinnominate vein area. Magnetic resonance imaging showed a cystic lesion without any soft tissue density in the circumference. The border of the tumor was clear, without any invasion and continuity with the surrounding tissue. We performed thoracoscopic surgery. After aspiration of the serous contents in an end-pouch, the tumor was removed from the thoracic cavity. A pathological examination showed a fibrotic cyst wall containing the thymic cyst, which diagnosed it as thymic cyst.

CONCLUSION

Thymic cysts in the middle mediastinum are extremely rare. A surgical resection provided the histological diagnosis of a thymic cyst in the present case.

[Dyspnea, fatigue and subpulmonary mass]

A 52-year-old man was referred for progressive dyspnea and fatigue. The medical history was unremarkable and there were no signs of late infections or previous tumorous diseases. Physical examination revealed diminished breath sounds and a dull tone over the right lower side. Routine blood tests, arterial blood gas and body plethysmography were all within normal ranges. Chest X-ray and thorax computed tomography (CT) showed the presence of a homogeneous subpulmonary mass with a diameter of 10 cm which had a water-like density of approximately 1 Hounsfield unit (HU). The presence of an extraordinary large pericardial cyst compromising the right lower lobe and therefore causing dyspnea was confirmed by video-assisted thoracoscopic surgery (VATS). Pericardial cysts are rare congenital mediastinal masses. They are usually asymptomatic and are usually found incidentally during routine chest X-ray, CT, magnetic resonance imaging (MRI) or echocardiography. Most pericardial cysts are situated at the right cardiophrenic angle. When reaching a relevant size they can cause symptoms such as dyspnea, coughing, chest pain and fatigue. The imaging studies most useful for diagnosis are CT, MRI and echocardiography. Differential diagnoses are diaphragmatic hernia, trapped pleural effusion or other pleural or mediastinal tumors.

Asymptomatic thymic cyst appearing in the neck on valsalva: unusual presentation of a rare disease

Thymic cysts are usually diagnosed accidentally during radiological evaluation of the chest for unrelated conditions. Symptoms appear late when the mass compresses on adjoining tissues. We report an unusual case of asymptomatic mediastinal thymic cyst which was seen in the neck whenever the patient was asked to perform Valsalva maneuver. This case is being reported for the unusual clinical presentation of a rare disease. The role of imaging in the diagnosis and common differential diagnoses are also discussed.

Persistent wheezing as manifestation of esophageal tubular duplication cyst

Duplications of esophagus are rare congenital anomalies and the second most common duplications of the gastrointestinal tract. This form of bronchopulmonary foregut malformation may appear as a cystic mediastinal mass. On chest radiographs they may be visible as middle or posterior masses. On CT they are well marginated and oppose the esophagus. Usually they are asymptomatic, unless they become infected or cause obstruction. We report a case of thoracic tubular duplication cyst in a 10-month-old boy who presented with persistent wheezing that was unsuccessfully treated in out-patient services.

Bronchogenic cyst associated with pericardial defect: case report and review of the literature

Partial defect of the pericardium combined with bronchogenic cyst is a very rare congenital anomaly. We describe the case of a 32-year-old man with a partial defect of the left pericardium and a bronchogenic cyst arising from the border of the pericardial defect. The cyst was successfully resected with the harmonic scalpel by three-port videothoracoscopic approach.

Role of endobronchial ultrasound in the diagnosis of bronchogenic cysts

Diagnosis of bronchogenic cysts is possible with computed tomography, but half of all cases present as soft tissue densities. Two such cases are highlighted where asymptomatic bronchogenic cysts that presented as soft tissue masses were evaluated by endobronchial ultrasound (EBUS). After studying the ultrasound image characteristics, the diagnosis was confirmed using EBUS-guided transbronchial needle aspiration (EBUS-TBNA). The first case had ultrasound findings of an anechoic collection, and the aspirate was serous with negative microbiologic cultures. The second was an echogenic collection within a hyperechoic wall. Needle aspirate was purulent and cultured Haemophilus influenza. The diagnosis of a bronchogenic cyst complicated by infection was made, and the lesion was surgically resected. This potential for EBUS in the diagnosis of bronchogenic cysts and in identifying complications such as infection should be considered in the management of such cases.