Concurrent cysts of the mediastinum, pleura and neck

Mesothelial Cysts

OBJECTIVES

Peritoneal mesothelial cysts have been reported under various terms, including benign cystic mesothelioma, usually in the form of case reports/series, whereas extraperitoneal cases are rarely reported. Our objective was to report the detailed characteristics of cystic lesions of the serosal cavities.

METHODS

We retrospectively examined the clinicopathologic findings of a series of mesothelial cystic lesions (n = 79).

RESULTS

Most cases (n = 68, 86%) concerned the peritoneum, whereas 11 (14%) concerned the pericardium. No pleural cases were found. A total of 51 (64.5%) lesions were solitary, whereas 28 (35.5%) were multiple. Peritoneal lesions harbored a plump eosinophilic mesothelium and a loose connective stroma, whereas pericardial lesions showed a cuboidal/flattened mesothelium, collagenous stroma, intense inflammation, and other tissue types, like adipose and muscle tissue. Solitary peritoneal lesions are usually extrapelvic and found in older patients incidentally during other surgeries, whereas multiple lesions are found in younger patients and usually in the pelvis. The lesions show a benign clinical course with rare recurrences but no malignant transformation.

CONCLUSIONS

Most mesothelial cysts are peritoneal and rarely pericardial. Peritoneal cysts differ from pericardial cysts. Peritoneal solitary lesions differ from multiple lesions, also suggesting their pathogenetic differences.

Pulmonary Lymphangioleiomyomatosis originates in the pleural mesothelial cell population

Lymphangioleiomyomatosis (LAM) is a cystic lung disease mainly affecting women, in which degradation of the lung parenchyma is associated with a cell of unknown provenance, known as a LAM cell. LAM cells carry TSC2 mutations and can be identified in the lung parenchyma by their expression of both smooth muscle actin and antigens characteristic of melanocytes and melanocytic tumors. The nature of the cell-of-origin of LAM is controversial, and despite continued research effort remains elusive. Further, it has not been possible to culture pulmonary LAM cells in vitro, and current research relies on cells and animal models which may not recapitulate all features of the disease. We noted aberrant expression of melanoma antigens in pleural mesothelial cells in lung tissue from LAM patients, indicating that these cells could be the precursors of parenchymal LAM cells. We hypothesise that loss of tuberin function following TSC2 mutation in the mesothelial cell lineage gives rise to the cell-of-origin of pulmonary LAM (P-LAM), and of other associated conditions commonly noted in LAM patients. The unique properties of mesothelial cells provide a straightforward explanation of the diverse presentation of LAM.

[Mediastinal tumors: introduction]

Mediastinal tumors are relatively uncommon, usually incidentally discovered on a chest X-ray in asymptomatic patients. Young adults are particularly concerned. Mediastinal masses represent a group of heterogeneous histological type cell. A definite diagnosis is essential leading to an adequate prompt therapeutic strategy when either benign disease or aggressive malignant tumor is conceivable. Indeed the therapeutic management of such tumors could be strictly medical, requiring exclusive surgical approach or includes a multimodal treatment. Clinical examination and imaging are important tools in the diagnostic approach. However the specific diagnosis could be complex and requires histological confirmation by an experienced pathologist after examination of large biopsies of the tumor. Several investigations, including surgical invasive exploration, should be quickly requested in order to achieve a final diagnosis and refer patients in an adequate therapeutic scheme without delay. The aim of this article is to point out the available diagnostic tools in mediastinal masses, including surgical approach, and to identify the role of surgical resection in specific subtypes.

Review and update of uncommon primary pleural tumors: a practical approach to diagnosis

OBJECTIVE

We address the current classifications and new changes regarding uncommon primary pleural tumors. Primary pleural tumors are divided according to their behavior and are discussed separately as benign tumors, tumors of low malignant potential, and malignant neoplasms.

DATA SOURCES

Current literature concerning primary pleural neoplasms was collected and reviewed.

STUDY SELECTION

Studies emphasizing clinical, radiological, or pathologic findings of primary pleural neoplasms were obtained.

DATA EXTRACTION

Data deemed helpful to the general surgical pathologist when confronted with an uncommon primary pleural tumor was included in this review.

DATA SYNTHESIS

Tumors are discussed in 3 broad categories: (1) benign, (2) low malignant potential, and (3) malignant. A practical approach to the diagnosis of these neoplasms in surgical pathology specimens is offered. The differential diagnosis, including metastatic pleural neoplasms, is also briefly addressed.

CONCLUSIONS

Uncommon primary pleural neoplasms may mimic each other, as well as mimic metastatic cancers to the pleura and diffuse malignant mesothelioma. Correct diagnosis is important because of different prognosis and treatment implications for the various neoplasms.

Foregut duplications: is there an advantage to thoracoscopic resection?

PURPOSE

Thoracoscopy has an expanding role in the treatment of FD cysts (bronchogenic cysts and esophageal duplications). We examined this trend in our patients and reviewed our overall experience.

METHODS

All charts of children undergoing surgery for foregut duplications (FDs) in 2 pediatric hospitals between 1992 and 2003 were retrospectively reviewed. Data gathered included age, weight, symptoms, diagnostic tests, operative technique, postoperative course, complications, and outcome.

RESULTS

There were 39 children, with FD resected by thoracotomy in 21 patients, thoracoscopy in 11 patients (no conversions to open), cervical incision in 6 patients, and laparotomy in 1 patient for an FD near the gastroesophageal junction. Diagnosis was made by antenatal ultrasound in 7 cases. Four of these neonates had tachypnea or cough, and the rest were asymptomatic. Seventy-five percent of patients diagnosed postnatally presented with respiratory symptoms. Excision of isolated FD (without lung resection) was compared between those who had a thoracotomy (n = 16) vs thoracoscopy (n = 11). The age, weight, operating time, and anesthesia time were not different between the 2 groups. However, the thoracoscopy group had significantly fewer chest tube days (1.6 vs 3.3 days) and a shorter hospital stay (2.6 vs 6.6 days). Intraoperative complications consisted of tracheal injury in 3 patients (2 thoracotomy, 1 thoracoscopy) and esophageal mucosal injury in 2 patients (both thoracotomy), which were all recognized and repaired.

CONCLUSION

Foregut duplications may present in a variety of ways and locations. Thoracoscopy is advantageous for isolated intrathoracic FDs.

A multidisciplinary approach to recurrent cervicothoracic cystic hygroma in an adult

Cystic hygroma is a benign congenital lymphatic malformation affecting mainly the head and neck region in children. Although mediastinal or multiorgan lymphangiomatosis is rare, it can present at any age. We report an unusual case of recurrent bilateral cystic hygroma in an adult affecting both neck and mediastinum. When the extensive lesion became symptomatic, a multidisciplinary approach was necessary to remove the expanding mass to achieve the optimal functional and cosmetic outcome.