Isolated Malignant Pleural Effusion in a Child: Unusual Presentation of Acute Leukemia

Pleural effusion in the pediatric population is an abnormal pathology characterized by the accumulation of fluids between the parietal and visceral pleura. The etiology of this excessive fluid accumulation can be attributed to both infectious and non-infectious factors. Notably, Streptococcus pneumoniae stands out as the predominant infectious agent responsible for this condition. Non-infectious causative factors encompass hematolymphoid malignancies, congestive heart failure, hemothorax, hypoalbuminemia, and iatrogenic causes. Among the hematolymphoid malignancies, lymphoma emerges as the most prevalent malignancy associated with pleural effusion. It is followed by T-cell lymphoblastic leukemia, germ cell tumor, neurogenic tumor, chest wall and pulmonary malignancy, carcinoid tumor, pleuro-pulmonary blastoma, and Askin's tumor, among others. Malignant pleural effusion is predominantly linked to T-cell lymphoblastic malignancies. In the context of acute lymphoblastic leukemia (ALL), cases where T-cell presentation is accompanied by leukemic pleural effusion are commonly associated with either a mediastinal mass or significant lymphadenopathy. Here, we describe a case of a four-year-old male child who exhibited a brief history of febrile illness. Notably, this case was characterized by isolated pleural effusion, devoid of any mediastinal mass or lymphadenopathy. Pathological investigations of pleural fluid analysis revealed the presence of malignant cells, facilitating an expedited diagnosis.

T-cell Lymphoblastic Lymphoma Unveiling As Superior Vena Cava Syndrome in a 19-Year-Old Male

Superior vena cava syndrome (SVCS) is a collection of signs and symptoms resulting from superior vena cava obstruction which is either partial or complete. SVCS is a rare clinical entity, often associated with various malignancies. T-cell lymphoblastic lymphoma (T-LBL) primarily of the mediastinum (thymus) is a rare and aggressive non-Hodgkin lymphoma that can lead to SVCS. We discuss the case of a 19-year-old male who arrived at our emergency department with symptoms of cough, breathlessness, and facial puffiness along with swelling in the right anterior mediastinum for two weeks suggestive of acute SVCS. An anterior mediastinal mass was confirmed on a chest X-ray and computed tomography. A biopsy of the mass revealed primary mediastinal (thymic) T-LBL. This case report focuses on the unique presentation of a T-LBL as SVCS in a 19-year-old male. Moreover, it highlights the need for vigilance among healthcare providers in recognizing this atypical complication and underscores the critical importance of early diagnosis and timely intervention.

Hidden in the mediastinum: a case of extramedullary hematopoiesis unveiled through thoracoscopy

Extramedullary hematopoiesis (EMH) is a rare condition characterized by proliferation of hematopoietic stem cells outside the bone marrow, usually as a compensatory response to hematological disease. Although EMH primarily occurs in the liver and spleen, it can manifest in atypical locations, such as the mediastinum. We herein describe an asymptomatic 66-year-old man with incidentally discovered posterior mediastinal EMH. A 28- × 32-mm mass was detected during a routine examination. Laboratory findings were within normal limits. Computed tomography revealed a well-defined enhancing mass with a density of 60 Hounsfield units, suggestive of a neurogenic tumor. Surgical resection confirmed EMH, characterized by megakaryocytes and hematopoietic precursors. The patient recovered smoothly and was discharged 5 days postoperatively. Accurate preoperative diagnosis of EMH is challenging, as illustrated by this case. Although typically associated with anemia or hematological abnormalities, EMH can present without such signs. Surgical resection and histopathological examination are essential for diagnosis. This case emphasizes the diagnostic complexity of posterior mediastinal EMH, even in patients without overt hematological disorders. Posterior mediastinal EMH is exceedingly rare and diagnostically demanding. A high index of suspicion and histological tissue analysis are crucial for optimal management. Video-assisted thoracoscopic surgery enables both diagnosis and treatment through mass excision.

Spindle-cell thymoma colliding with a bronchogenic cyst in a Yorkshire terrier

An 8-year-old male Yorkshire terrier was presented to the Tufts Veterinary Hospital for evaluation of increased respiratory effort. A mediastinal mass composed of a spindle-cell thymoma within a bronchogenic cyst was diagnosed with computed tomography thoracic imaging, ultrasound-guided fine-needle aspirate biopsy, and histopathologic evaluation after surgical removal. Histologic evaluation showed a multilocular cyst structure as well as a mass characterized by spindle to polygonal thymic epithelial cells. The cyst was characterized by a lining of ciliated pseudostratified respiratory epithelium. To the authors' knowledge, this is the first report of a spindle-cell thymoma being associated with a mediastinal bronchogenic cyst in a dog.

Extracorporeal membrane oxygenation in the surgical management of large mediastinal masses: a narrative review

Background and Objective

The management of large mediastinal tumors requires a complex multidisciplinary approach, particularly in the perioperative setting due to increased risk of hemodynamic compromise. The utilization of extracorporeal membrane oxygenation (ECMO) provides a useful adjunct in the surgical management for biopsy and resection of these mediastinal masses. The objective of this article is to review indications and implementation of ECMO in the surgical management of mediastinal disease.

Methods

A literature review of the PubMed database was completed evaluating articles discussing 'extracorporeal circulation', 'cardiopulmonary bypass', 'anesthesia', 'mediastinal disease', and 'mediastinal cancer'. These articles were evaluated for contribution to the discussion of indications and implementation of ECMO in the management of these patients.

Key Content and Findings

Large mediastinal tumors place patients at risk of hemodynamic collapse on induction of anesthesia due to compression of vascular structures, tracheobronchial tree and creation of V/Q mismatch. Patients may be stratified regarding their risk of perioperative complications by evaluation of postural symptoms, cross sectional imaging findings and pulmonary function tests. Those patients at elevated perioperative risk may benefit from the utilization of ECMO, most commonly veno-arterial (V-A) ECMO. Guidewires or ECMO cannulas may be placed under local anesthesia prior to induction. Those patients with hemodynamic compromise may receive mechanical circulatory support to allow completion of the operation.

Conclusions

The use of a multidisciplinary team consisting of surgeons, anesthesiologists, perfusionists and OR team is critical to the success in the use of ECMO in the resection of mediastinal masses. With diligent preparation, these high-risk patients may be optimally managed at the time of resection.

An Anaplastic Thyroid Carcinoma of the Giant-Cell Type from a Mediastinal Ectopic Thyroid Gland

Anaplastic thyroid carcinoma is a rare, aggressive form of thyroid carcinoma with a mean survival of less than 6 months. Ectopic thyroid tissue can be present in the mediastinum due to faulty embryogenesis with improper descent. Primary thyroid malignancies may arise from this ectopic tissue. A 90-year-old male with a history of prostatic adenocarcinoma, hypothyroidism, and occupational and therapeutic exposure to radiation presented with a rash on his chest. A review of the dermatopathology and excised mediastinal specimen revealed rare papillary foci that tested positive for thyroid markers from a background of poorly differentiated components. Molecular analysis confirmed a BRAF V600E mutation in the specimen. The final diagnosis was anaplastic thyroid carcinoma of the giant-cell type. Given the atrophic cervical thyroid tissue in the patient's neck with no evidence of previous surgery, this carcinoma was believed to arise from ectopic mediastinal tissue associated with cutaneous and bony metastasis. In conclusion, anaplastic thyroid carcinoma is an aggressive and rare thyroid malignancy that can arise from ectopic thyroid tissue in the mediastinum and should be considered in the differential diagnosis of primary undifferentiated mediastinal malignancies with bony involvement.

Think Outside the Heart: An Unusual Cause of Large Hemopericardium

Pericardial effusions secondary to tumors are commonly metastatic, originating primarily from the lung, breast, and lymphomas. Pericardial tamponade is a rare oncological emergency warranting early identification and treatment. We describe a 66-year-old male found to have a large bloody pericardial effusion causing tamponade physiology, and multimodality imaging was consistent with intrapericardial malignancy with no identifiable primary source. He was subsequently diagnosed with type B3 thymoma after mediastinal resection.

Thymic Hyperplasia and Graves Disease: A Nonincidental Association

We present 2 cases referred for evaluation of Graves disease (GD) associated with an incidental mediastinal mass. Chest computed tomography (CT) scans showed a 1.2 × 2.4 × 4.3 cm and a 5.7 × 2.6 × 7 cm thymic enlargement, respectively, consistent with thymic hyperplasia (TH) in the 2 patients. Patient 1 had been assessed by thoracic surgery for the mediastinal mass, and thymectomy had been performed to exclude thymoma, with an anatomopathological diagnosis consistent with thymic hyperplasia. Patient 2 was treated with methimazole. CT scan was repeated after he maintained a euthyroid state, which revealed total regression of the mass. There is a well-documented association between these 2 entities, but it is often underdiagnosed and unrecognized in routine clinal practice. The benign evolution, as evidenced by regression of thymic hyperplasia after resolution of the hyperthyroidism, is characteristic. These cases highlight the importance of recognizing the association of GD and TH and warrant a conservative approach, preventing unnecessary thymic evaluation and surgery.

Abnormal Presentation and Challenging Diagnosis of Mediastinal Lymphoma: A Case Report

We describe a rare case of classical Hodgkin lymphoma (HL) in a 20-year-old female patient. She presented to our hospital with chest wall swelling after months of post-chest trauma management. The swelling was initially treated as an infected hematoma, and the patient was referred for surgical evacuation. During the surgery, the swelling was found to be a mass that extended to the mediastinum. A biopsy was taken, which later resulted in the diagnosis of a granular cell tumor (GCT). A decision on surgical resection by video-assisted thoracoscopic surgery (VATS) was taken after discussion with the multidisciplinary team of surgery, cardiothoracic surgery, oncology, pathology, and radiology. During the surgery, a frozen section biopsy was taken, which showed no features of lymphoma or granular cell tumors. The surgery was followed by a midline sternotomy to control the bleeding from an accidentally injured major vessel. The bleeding was controlled, and the mass was dissected and sent for histopathological examination. The histopathology showed nodular classical HL features, and the patient was referred for chemotherapy. In our case, the patient was initially diagnosed with GCT, but with complete resection and an adequate biopsy, the mass was found to be a classical HL. Possible cross-cellularity is questioned, and the possible correlation between the two findings encouraged us to report this case.

Massive Hemorrhage Following Spontaneous Mediastinal Inflammatory Myofibroblastic Tumor Rupture: A Case Report

A 45-year-old male in a hypertensive emergency was admitted with complaints of frontal headache, progressive chest discomfort, shortness of breath, dysphagia, and right upper quadrant abdominal pain radiating across the epigastrium and to the back that increases in intensity with deep inspiration. He denied any history of abdominal pain, vomiting, dyspnea, nausea, and weight loss. A computed tomography (CT) scan of the chest showed a posterior mediastinal mass between the esophagus and descending aorta. A magnetic resonance imaging (MRI) scan revealed a non-enhancing posterior mediastinal mass possibly compressing both the esophagus and the airway. A 30-degree thoracoscope was inserted in the chest cavity revealing a large hemothorax from a possibly ruptured inflammatory myofibroblastic tumor (IMT) encompassing nearly the entire pleural space with both fresh and clotted blood. Two liters of fresh blood was removed via a right thoracotomy procedure. Once removed, a large fibrinous clot-filled mass was resected entirely and sent to pathology. Postoperative recovery was uneventful; dysphagia and shortness of breath resolved. The patient gradually resumed his regular diet.

A Worsening Cough: An Unusual Presentation of Malignant Mesothelioma

Localized malignant pleural mesothelioma (LMPM) is a rare cancer with poor survival rates. Often affecting males with asbestos exposure, we report a case of a 56-year-old female with no history of occupational exposure presenting with a worsening cough. A radiological examination revealed left pleural effusion and pleural thickening. Cytological and pathological reports of pleural samples were consistent with malignant mesothelioma of epithelioid type, with the histological examination via video-assisted thoracoscopic surgery (VATS) consistent with a clear cell epithelioid mesothelioma. We discuss the rapid presentation of the disease with emphasis on considering the disease in young patients with no prior asbestos exposure.

Intrathoracic eosinophilic sclerosing fibroplasia with intralesional bacteria in a cat

Case summary

A 9-year-old neutered female domestic shorthair cat was presented for investigation of a cranial mediastinal mass. Moderate peripheral eosinophilia and mild-to-moderate polyclonal gammopathy were identified. A thoracoabdominal CT scan documented a cranial mediastinal mass encircling the trachea. Ultrasound-guided fine-needle aspiration and core-needle biopsy were performed, but cytology and histopathology were inconclusive. Surgical debulking was performed. Further histological samples identified severe pyogranulomatous and eosinophilic fibrosing mediastinitis, consistent with feline eosinophilic sclerosing fibroplasia. Gram staining and fluorescence in situ hybridisation (FISH) identified numerous Gram-positive coccoid bacteria. Eosinophilia and hyperglobulinaemia resolved after surgery and combined antimicrobial and immunosuppressive therapy. The cat died 3 months later after developing acute haemorrhagic diarrhoea and dyspnoea.

Relevance and novel information

Eosinophilic sclerosing fibroplasia is reportedly mainly confined to the gastrointestinal tract in cats. Less commonly, extragastrointestinal cases have been described. Lesions in the mediastinal or sternal lymph nodes have been reported, all in association with evident gastrointestinal involvement. The presence of pleural effusion was variable in these cases. To the authors' knowledge, this is the first report of eosinophilic sclerosing fibroplasia presenting due to lower respiratory signs in a cat. Intralesional bacteria were identified using Gram staining and FISH examination. The presence of intralesional bacteria in the normally sterile mediastinal tissue may support the involvement of penetrating injuries in the pathogenesis of the disease. Eosinophilic sclerosing fibroplasia should be suspected in any cat with abdominal and/or thoracic masses, particularly if associated with peripheral eosinophilia and polyclonal gammopathy.

A Case Report of Mediastinal Teratoma in a Pediatric Patient With Nephrotic Syndrome: Paraneoplastic Syndrome or Incidental Finding?

A 12-year-old female presented with weight gain, edema, and shortness of breath. Laboratory and urine studies confirmed nephrotic syndrome and presence of a mediastinal mass, identified as a mature teratoma after resection. Nephrotic syndrome persisted despite resection and renal biopsy confirmed minimal change disease, which ultimately responded to steroid treatment. She had two relapses of nephrotic syndrome after vaccination administration, both of which occurred within eight months of tumor resection and were responsive to steroids. Autoimmune and infectious workup for other causes of nephrotic syndrome was negative. This is the first reported case of nephrotic syndrome associated with mediastinal teratoma.

Mediastinal Bronchogenic Cyst With Superior Vena Cava Syndrome: A Case Report

Bronchogenic cysts are rare in adults and often remain undetected until discovered incidentally on imaging or during a symptomatic investigation. The possibility of superior vena cava (SVC) compression due to a bronchogenic cyst arises in complex patient presentations. SVC syndrome poses several unique challenges due to the wide range of clinical symptoms and difficulty identifying the cause when symptoms first manifest. This case report examines a 39-year-old male who presented with symptoms resulting from SVC compression caused by a bronchogenic cyst, leading to SVC syndrome. We discuss the various imaging modalities used to assess the severity of the obstruction and the surgical interventions employed to alleviate the symptoms. A surgical intervention provides symptomatic relief and promises an excellent prognosis when performed without complications.

Multimodality imaging of mediastinal masses and mimics

A wide variety of neoplastic and nonneoplastic conditions occur in the mediastinum. Imaging plays a central role in the evaluation of mediastinal pathologies and their mimics. Localization of a mediastinal lesion to a compartment and characterization of morphology, density/signal intensity, enhancement, and mass effect on neighboring structures can help narrow the differentials. The International Thymic Malignancy Interest Group (ITMIG) established a cross-sectional imaging-derived and anatomy-based classification system for mediastinal compartments, comprising the prevascular (anterior), visceral (middle), and paravertebral (posterior) compartments. Cross-sectional imaging is integral in the evaluation of mediastinal lesions. Computed tomography (CT) and magnetic resonance imaging (MRI) are useful to characterize mediastinal lesions detected on radiography. Advantages of CT include its widespread availability, fast acquisition time, relatively low cost, and ability to detect calcium. Advantages of MRI include the lack of radiation exposure, superior soft tissue contrast resolution to detect invasion of the mass across tissue planes, including the chest wall and diaphragm, involvement of neurovascular structures, and the potential for dynamic sequences during free-breathing or cinematic cardiac gating to assess motion of the mass relative to adjacent structures. MRI is superior to CT in the differentiation of cystic from solid lesions and in the detection of fat to differentiate thymic hyperplasia from thymic malignancy.

Hydropneumothorax: A Presentation of Infected Bronchogenic Cyst

Bronchogenic cysts are closed sac-like cystic lesions resulting from abnormal budding of the primitive foregut during the early development of the alimentary and respiratory systems. We describe the case of a 54-year-old man who presented to the emergency department with complaints of fever, chills, shortness of breath, and a productive cough with intermittent hemoptysis for the past two to three months. Initial workup revealed a right lung hydropneumothorax with complete atelectasis of the right lung and a mass effect on the left lung. During intercostal drainage, pleural fluid analysis revealed empyema with E. coli treated with antibiotics. However, the symptoms persisted after five days of antibiotic treatment and drainage. A multidisciplinary team of thoracic surgeons, anesthesiologists, and pulmonologists was assembled due to the non-resolving nature of the lung abscess. The patient underwent a right middle lobe lobectomy with decortication via open thoracotomy, and a bronchogenic cyst, an uncommon cause of the lung abscess, was suggested by histopathological analysis.

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.

Surgical resection of mediastinal ectopic thyroid tissue: a case series

Background

Ectopic thyroid tissue (ETT) is characterized by the presence of thyroid tissue in any location other than its normal anatomic position. Mediastinal ectopic thyroid gland is a rare entity, accounting for 1% of all ETT cases. In this article, we present seven cases with mediastinal ETT over the last 26 years admitted to Stanford hospital.

Case Description

Searching Stanford pathology database for specimens that contained term "ectopic thyroid" between 1996 and 2021, a total of 202 patients were collected. Among those seven were classified as mediastinal ETT. Patients' electronic medical records were reviewed for data collection purposes. The mean age of our seven cases was 54 years on the day of surgery, and four were female. Chest pressure, cough, and neck pain were most reported presenting symptoms. Four of our patients had thyroid stimulating hormone (TSH) checks all within normal limits. All patients in our study had computed tomography (CT) imaging of the chest detecting the mediastinal mass. Histopathology of the mass revealed ectopic thyroid tissue negative for malignancy in all cases.

Conclusions

Ectopic mediastinal thyroid tissue is a rare clinical entity that should be considered in the differential diagnosis of all mediastinal masses as it usually requires different management and treatment.

Thyroid Cancer Presenting as Aspiration Pneumonia: A Tale of Retrosternal Goiters

Abnormal enlargement of the thyroid gland is called goiter. Structurally, it can be nodular or diffuse. Usually, it presents as an anterior cervical mass; however, less commonly, it presents as a retrosternal mass causing symptoms of compression on the surrounding structures. Most patients with goiter are asymptomatic due to the euthyroid nature of the disease. However, sometimes they can be hypo or hyperthyroid depending on the etiology of the goiter. Here, we present the case of a patient without any previously known goiter who presented to the hospital with shortness of breath and was found to have hypoxic respiratory failure as his first noticed sign of thyroid disease. Diagnostic workup revealed retrosternal goiter causing compression effect on the esophagus and trachea resulting in dysphagia and aspiration. The patient was treated with feeding tube placement, followed by surgical resection of the mediastinal mass.

Application of the Clamshell Thoracotomy in an Infant with a Large Mediastinal Tumor

Historically it was recommended for emergency thoracotomy in thoracic trauma as the last resort when there was cardiopulmonary arrest. Nowadays, the only indications are lung transplantation and huge mediastinal masses. We report the use of a clamshell thoracotomy in a 7-month-old boy with a large anterior mediastinal mass extending into the bilateral thoracic cavities.

Case Report: Desmoid fibromatosis in the mediastinum of a 6-month-old toddler, what to do?

Desmoid fibromatosis is a rare, aggressive borderline lesion arising from soft tissues. Treatment will depend on the structures that the tumor has involved. Surgery with negative margins is the recommended strategy as it can usually achieve disease control; however, the tumor's location sometimes does not allow it. Therefore, a combination of medical therapies along with strict surveillance is crucial. We present the case of a 6-month-old boy with a chest mass. After further evaluation, a rapidly growing mediastinal mass involving the sternum and costal cartilage was detected. Desmoid fibromatosis was the final diagnosis.

Large mediastinal mass diagnosed as Nocardia infection by endobronchial ultrasound-guided transbronchial needle aspiration in a ceramic worker: A case report

Background

Nocardia is a ubiquitous soil saprophyte transmitted through airborne or direct cutaneous inoculation routes. Although Nocardia is more common in immunocompromised patients, Nocardia may also arise in apparently immunocompetent patients.

Case presentation

We report a rare case of Nocardia infection presenting as a large mediastinal mass in an immunocompetent ceramic worker. A 54-year-old man with no previous history of immune dysfunction, a ceramic worker by profession, was referred and admitted to our hospital because of a persistent fever for 19 days. Chest CT showed a large middle mediastinal mass. However, conventional anti-infective treatment was ineffective. Under the guidance of the Virtual bronchoscopic navigation (VBN) system, he underwent Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The purulent exudate obtained by EBUS-TBNA was further identified as Nocardia by weak acid-fast and metagenomic next-generation sequencing (mNGS). He was subsequently treated with intravenous imipenem/amikacin, switched to intravenous imipenem and oral trimethoprim/sulfamethoxazole, and the clinical symptoms were significantly improved.

Conclusions

Even in immunocompetent patients, Nocardiosis cannot be excluded. For the public, especially soil contact workers, precautions should be taken to avoid Nocardia infection from occupational exposure. This rare case may provide a diagnosis and treatment reference for clinicians.

Initial experience with robotic-assisted thoracic surgery for superior mediastinal masses

Objective

Minimally invasive surgery is challenging for masses located in the superior mediastinum, especially for those close to the chest outlet. This study aimed to evaluate the feasibility and safety of robotic-assisted thoracic surgery (RATS) for these masses.

Methods

From June 2015 to January 2020, 35 patients (19 males, 16 females), with a mean age of 41.6 (range, 13-66) years, underwent RATS for the treatment of superior mediastinal masses. Data regarding the operation time, blood loss, pathology, conversion rate, morbidity, mortality, and cost were collected and analyzed.

Results

The mean (±standard deviation) operation time, blood loss, chest tube use duration, and postoperative hospital day were 117 ± 45.2 (range, 60-270) min, 59.7 ± 94.4 (range, 10-500) ml, 4.1 ± 2.1 (range, 1-10) days, and 5.1 ± 2.1 (range, 2-11) days, respectively. The pathological diagnoses included schwannoma (26 cases), ganglioneuroma (4 cases), bronchogenic cysts (3 cases), ectopic nodular goiter (1 case), and cavernous hemangioma (1 case). The mean diameter of the resected tumor was 4.6 ± 2.0 (range, 2.5-10) cm. No conversion or mortality occurred. Postoperative complications included Horner's syndrome (18 cases: 6 patients with preoperative Horner's syndrome), weakened muscular power (2 cases), and chylothorax (2 cases). The mean cost was $ 8,868.7 (range, $ 4,951-15,883).

Conclusions

Our experience demonstrated that RATS is safe and feasible for superior mediastinal mass resection. However, the high incidence of postoperative Horner's syndrome requires further research.

Refractory Chylothorax Secondary to Sizeable Azygos Vein Hemangioma: Tailored Multimodal Treatment of a Challenging Case Report

BACKGROUND

Mediastinal hemangiomas are rare, and their etiology remains unclear. Most patients affected have no pathognomonic clinical symptoms, and the diagnosis is often incidental. Due to the paucity of the available literature regarding the management of this disease, the choice and timing of treatment remains controversial.

CASE PRESENTATION

Herein, we report the case of a hemangioma of the azygos vein arch in a 66-year-old woman who presented with dyspnea, chest discomfort, dysphagia, and weight loss. A simultaneous right chylothorax refractory to conservative management was found. A CT-guided biopsy of the mass was performed, and it confirmed the vascular nature of the lesion. Therefore, the patient underwent an angiography followed by endo-vascular embolization. Three days later, thoracoscopic surgical resection of the mass and the repair of the chyle leakage were performed safely. The patient was discharged uneventfully on postoperative day seven, with complete resolution of all the presenting symptoms.

CONCLUSIONS

Treatment of symptomatic mediastinal hemangiomas could be mandatory, but a thorough multidisciplinary approach to these rare malformations is essential. Despite the risk of intraoperative bleeding, selective endovascular embolization followed by thoracoscopic surgery allowed for a complete and safe resection with a good outcome.

Clinical Presentation and Surgical Management of Five Pediatric Cases with Bronchogenic Cysts: Retrospective Case Series

BACKGROUND

Bronchogenic cysts (BCs) refer to congenital lesions that result from primitive or abnormal foregut budding, and can be pulmonary or mediastinal. Their occurrence can take place at any point on the tracheobronchial tree, but they are usually localized in the lung parenchyma and mediastinum, and may be symptomatic or asymptomatic. Bronchogenic cyst symptoms can vary, depending on the size and location of the cyst.

METHODS

A retrospective review of the charts of five patients with a histopathological diagnosis of bronchogenic cysts was performed between 2014 and 2020. The patients reported in this study were diagnosed and managed at Abha Maternity and Children Hospital, Abha, southwest Saudi Arabia. In addition, demographic information, as well as diagnostic and therapeutic information, was provided for each patient, both at discharge and after discharge. All patients had confirmed congenital bronchogenic cysts with different clinical phenotypes and radiological findings.

RESULTS

All patients had histopathologically confirmed bronchogenic cysts with different clinical and radiological presentations. Two patients had mediastinal-located cysts; one had a laryngeal cyst; and the last two patients had infected intrapulmonary bronchogenic cysts. All patients underwent complete excision and did not experience recurrence or other postoperative complications during the follow-up period. The latter two patients required lobectomies of the right middle and upper lobes.

CONCLUSIONS

Although bronchogenic cysts are considered a rare congenital pulmonary malformation, they should be considered in the differential diagnosis of pediatric patients with unusual airway and parenchymal lung manifestations, particularly, persistent stridor, feeding difficulty, and complicated pneumonia. Surgical excision of the cyst is the gold-standard therapy for symptomatic bronchogenic cysts and is highly recommended for asymptomatic ones. Long-term follow-up studies will be required to explore any long-term complications of BCs, particularly regarding the malignancy transformation.

Superior vena cava syndrome in a child with mediastinal mass: A case report

Facial puffiness as a consequence of superior vena cava syndrome (SVCS) can be a presentation from which the physician would have to conjecture a diagnosis of a mediastinal mass including lymphomas. Pediatric SVCS can rapidly progress and pose a greater challenge for airway protection as was in our case.

Pediatric superior vena cava syndrome (SVCS) due to malignancy can be a rapidly progressive life‐threatening condition that leads physicians to decide between choosing either immediate therapeutic management or further diagnostic procedures considering the case at hand.

Adaptive Radiation Therapy Using Weekly Hypofractionation for Thymoma Treatment: a Retrospective Study of 10 Rabbits

Radiation therapy (RT) is being utilized more commonly for rabbit thymomas due to high perioperative mortality rates with surgery. Median overall survival times reported for rabbit thymomas treated with a variety of RT protocols and techniques range from 6 months to greater than 2 years. As thymomas are radiation-responsive tumors and may shrink rapidly after RT, adaptive radiotherapy (ART) is often warranted. The purpose of this single-institution retrospective case series was to investigate the tumor volume reduction during RT, the frequency of replanning during RT, and survival time in rabbit thymomas treated using intensity-modulated/image-guided radiation radiation therapy (IMRT/IGRT) and a weekly hypofractionated protocol delivering a total dose of 30 Gy. Ten rabbits met the inclusion criteria from October 2014-October 2019. The median progression-free survival was 561days and the median overall survival was 634 days (range: 322-1118 days). The tumor volume gradually decreased with each RT fraction. On post-hoc analysis, only the first RT fraction was associated with a significant GTV reduction (of more than 50% on average, p<0.001). All subsequent RT fractions did not further reduce the GTV significantly (p>0.06). Hypofractionated RT using a weekly protocol of 5 fractions of 6 Gy is a reasonable option to treat rabbit thymomas and replanning should be anticipated. The results of this study support the use of RT to rapidly relieve thymoma-induced dyspnea in rabbits. This article is protected by copyright. All rights reserved.

Successful Diagnosis of Epithelial Thymic Cancer Case Using EBUS-TBNA

Mediastinal masses are relatively uncommon. Surgical approach is often needed to diagnose mediastinal masses. Using endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) toward approaching a mediastinal mass has yet to be established. Here, we present a case of successful diagnosis of thymic cancer with the use of EBUS-TBNA.

A rare case of mediastinal lymphatic venous malformations in children

We report a case of mediastinal lymphatic venous malformations (LVM) in a 11-year-old boy who presented with chest pain after jumping into a swimming pool, with review of the literature. A superior mediastinal mass was incidentally found from the chest x-ray. Chest computed tomography revealed a large heterogenous mass at the left-sided mediastinum containing fat, minimal enhancing solid portion, non-enhancing cystic portion and calcification. Because of the large size of the mass, the patient underwent tumour removal. Operative findings gave a definitive diagnosis of mediastinal LVM. The patient had an uneventful clinical course and was discharged without complication. This report highlights that it is possible to misdiagnose mediastinal LVM especially if its predominant portion is lymphatic tissue with only minimal contrast enhancement. Tissue biopsy must be avoided because it may lead to haemorrhagic complication.

Primary thromboprophylaxis to prevent thrombotic events in pediatric oncology patients with a malignant mediastinal mass

Children with malignant mediastinal masses have increased thrombotic events (TE). Eligible subjects with malignant mediastinal masses between January 2000 and December 2017 were evaluated for TE, with 19 among 76 subjects receiving enoxaparin thromboprophylaxis. There were 13 TEs among 76 subjects for an incidence of 17.1%. Mediastinal compression directly led to TE in 9.2% of subjects who also had statistically significant superior vena cava compression at diagnosis. Primary thromboprophylaxis did not significantly affect TE occurrence; however, larger studies are warranted to consider strategic thromboprophylaxis guided by radiological monitoring of dynamic vascular compression to improve TE outcomes.

Micronodular Thymoma with Lymphoid Stroma: A Mediastinal Mass Masquerading as a Pericardial Mass

A 61-year-old man presented to the emergency room with lower extremity edema. Physical exam was only remarkable for a diastolic murmur in the right carotid area and left lower extremity edema. Venous Doppler revealed a deep venous thrombosis in the left lower extremity. Chest computed tomography (CT) with intravenous contrast ruled out pulmonary embolism but showed a mediastinal mass adjacent to the pericardium. Further imaging with cardiac magnetic resonance imaging (CMR) and cardiac CT angiography (CCTA) enabled localization and evaluation of the structural characteristics of the mass. The decision was made to excise the mass due to increasing size compared with its measurements on prior chest CTs and a high degree of vascularization seen on CMR and CCTA, which was concerning for an enlarging arteriovenous malformation or a hemangioma. However, histopathologic analysis of the mass revealed it to be a micronodular thymoma.

Castleman Disease Presenting as a Mediastinal Mass

Castleman disease is a complex benign lymphoproliferative disorder characterized by the enlargement of a single lymph node or a group of lymph nodes. Its etiology is unclear, with the mechanism of action of IL-6 and HHV-8 implicated as possibly associated with the development of the disease. Diagnosis depends on the histopathological findings of the involved lymph nodes. Surgical resection can be curative, but a small number of cases may be unresectable and need radiation and chemotherapy with subsequent resection if possible.

Cognitive Aids for the Management of Thoracic Anesthesia Emergencies: Consensus Guidelines on Behalf of a Canadian Thoracic Taskforce

A cognitive aid is a tool used to help people accurately and efficiently perform actions. Similarly themed cognitive aids may be collated into a manual to provide relevant information for a specific context (eg, operating room emergencies). Expert content and design are paramount to facilitate the utility of a cognitive aid, especially during a crisis when accessible memory may be limited and distractions may impair task completion. A cognitive aid does not represent a rigid approach to problem-solving or a replacement for decision-making. Successful cognitive aid implementation requires dedicated training, access, and culture integration. Here the authors present a set of evidence-based cognitive aids for thoracic anesthesia emergencies developed by a Canadian thoracic taskforce.

Thymoma and Tuberculoma: Unexpected Coexistence

Mediastinal tumours can be incidental findings on chest x-ray or present with systemic symptoms and/or direct effect of the mediastinal mass. We report the case of a woman with symptomatic thymoma B1 and simultaneous thymus tuberculosis.

LEARNING POINTS

The association of tuberculosis (TB) of the thymus and thymoma is extremely rare.The differential diagnosis of a mediastinal mass should include TB, particularly in endemic regions.Mediastinal mass resection or biopsy can be of great value in diagnostic work-up.

Educational Case: Thymoma

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040. ¹

Azygos Vein Aneurysm Mimicking a Mediastinal Mass

BACKGROUND/AIM

Azygos vein aneurysm (AVA) is a rare thoracic pathological entity that mimics a posterior mediastinal mass as well as a right paratracheal mass. Usually asymptomatic, AVA is often accidentally discovered during routine chest x-rays; however, depending on the aneurysm size and complications, some symptoms may be present. The aim of this paper is to report a case of idiopathic AVA and to discuss its aetiology, embryonic origin, symptoms, complications, diagnostic methods and treatments.

CASE REPORT

A 74-year-old female was investigated for diffuse thoracic pain and submitted to standard chest x-ray, which identified a right paratracheal, well-defined, homogenous opacity, considered to be part of the mediastinal shadow. The patient was further submitted to thoracic computed tomography, which confirmed the presence of a tumoral mass at the level of the right paratracheal area. The patient was submitted to surgery and the tumoral mass was resected; however, the tumor proved to be a completely thrombosed aneurism of the azygos vein arch.

CONCLUSION

AVA is a rare pathology that must be taken into consideration during the differential diagnosis of right postero-superior mediastinal masses.

Pleural Effusion: A Rare Presentation of Mature Teratoma in a Young Patient

Mediastinal masses always present a diagnostic challenge to clinicians and radiologists. There are wide varieties of pathologies ranging from benign to malignant conditions. Teratomas are one of the rare causes of mediastinal tumors. In this case, we report a young male who presented to the emergency room with acute pleuritic chest pain. The chest X-ray showed massive right-sided pleural effusion. Subsequently, bedside chest ultrasound ruled out septations and helped drain the fluid. The pleural fluid analysis demonstrated transudate chemistry. A computerized tomography (CT) of the chest was performed, revealing a complex anterior mediastinal mass suspected of Mature Teratoma. The tumor was surgically removed in its entirety, and pathology confirmed it a mature teratoma. The patient remained asymptomatic on postoperative follow-up.

Mediastinal Masses in Contrast-Enhanced Ultrasound - Retrospective Analysis of 58 Cases

OBJECTIVES

To determine contrast enhancing features of mediastinal masses (ML) using transcutaneous contrast-enhanced ultrasound (CEUS).

METHODS

Retrospective analysis of n = 58 patients with histologically confirmed ML, which were examined in the period from October 2005 to February 2018 using transcutaneous B-mode ultrasound and CEUS. In n = 29 (50%) histological confirmation was performed by ultrasound guided core-needle biopsy. The lesions were evaluated using CEUS in regard to the enhancement pattern (hyper-, iso-, hypoenhancement, non-enhancement, homogenous, inhomogenous) compared to enhancement of the spleen as an in vivo reference.

RESULTS

N = 53 (91.4%) of ML were malignant (m) (lymphoma n = 36, metastasis n = 11, thymoma n = 2, teratoma n = 1, sarcoma n = 2, seminoma n = 1). In n = 5 (8.6%) cases there was a benign (b) histology (thyroid tissue n = 2, thymus residue n = 1, ganglioneurinoma n = 1, scar tissue: n = 1). In ultrasound, n = 53 (91.4%; (48 = m, 5 = b)) were hypoechoic, n = 5 (8.6%, (5 = m,0 = b)) hyperechoic. In CEUS, n = 35 lesions presented an arterial isoenhancement (60.3%; 33 = m, 2 = b). An arterial hypoenhancement had n = 21 (36.2%, (20 = m,1 = b)), and no enhancement showed n = 2 (3.5%, (0 = m, 2 = b) of the ML. A parenchymal isoenhancement was observed in n = 1 (1.7%, (1 = m, 0 = b)), a hypoenhancement in n = 54 (93.1%; 51 = m, 3 = b) of the patients and almost no enhancement in n = 3 ML (5.2%, (1 = m, 2 = b).) The enhancement was homogeneous in n = 26 (44.8%, (25 = m,1 = b)) cases, in n = 31 (53.5%, (28 = m,3 = b)) inhomogeneous and n = 1 (1.7%) benign lesion was exclusively cystic.

CONCLUSION

In CEUS, mediastinal tumor formations showed variable arterial enhancement, followed by parenchymal hypoenhancement (wash-out).

Percutaneous CT Fluoroscopy-Guided Core Needle Biopsy of Mediastinal Masses: Technical Outcome and Complications of 155 Procedures during a 10-Year Period

PURPOSE

To evaluate technical outcome, diagnostic yield and safety of computed tomographic fluoroscopy-guided percutaneous core needle biopsies in patients with mediastinal masses.

METHODS

Overall, 155 CT fluoroscopy-guided mediastinal core needle biopsies, performed from March 2010 to June 2020 were included. Size of lesion, size of needle, access path, number of success, number of biopsies per session, diagnostic yield, patient's position, effective dose, rate of complications, tumor localization, size of tumor and histopathological diagnosis were considered. Post-interventional CT was performed, and patients observed for any complications. Complications were classified per the Society of Interventional Radiology (SIR).

RESULTS

148 patients (age, 54.7 ± 18.2) underwent 155 CT-fluoroscopy-guided percutaneous biopsies with tumors in the anterior (114; 73.5%), middle (17; 11%) and posterior (24; 15.5%) mediastinum, of which 152 (98%) were technically successful. For placement of the biopsy needle, in 82 (52.9%) procedures a parasternal trajectory was chosen, in 36 (23.3%) a paravertebral access, in 20 (12.9%) through the lateral intercostal space and in 17 (11%) the thoracic anterior midline, respectively. A total of 136 (89.5%) of the biopsies were considered adequate for a specific histopathologic analysis. Total DLP (dose-length product) was 575.7 ± 488.8 mGy*cm. Mean lesion size was 6.0 ± 3.3 cm. Neoplastic pathology was diagnosed in 115 (75.7%) biopsies and 35 (23%) biopsy samples showed no evidence of malignancy. Minor complications were observed in 18 (11.6%) procedures and major pneumothorax requiring drainage insertion in 3 interventions (1.9%).

CONCLUSION

CT fluoroscopy-guided percutaneous core needle biopsy of mediastinal masses is an effective and safe procedure for the initial assessment of patients with mediastinal tumors.

Diagnosis and treatment of mediastinal ectopic thyroid tissue with normally located thyroid gland and primary hyperparathyroidism: a case report

Mediastinal ectopic thyroid tissue (ETT) is rare entity, accounting for 1% of all mediastinal tumours. A 53-year-old lady, presented with cough and atypical chest pain. A computed tomography (CT) scan of chest showed a 95 mm × 75 mm × 115 mm tumour mass; CT guided biopsy of mediastinal mass showed ETT. Thyroid scintigraphy with Technetium-99m (^99mTc) pertechnetate showed homogenous and intense uptake in the thyroid gland (TG) lodge and in the mediastinum. Primary hyperparathyroidism (PHPT) was diagnosed during laboratory evaluation. Technetium-99m sestamibi (^99mTc-MIBI) parathyroid scintigraphy with single photon emission CT (SPECT)/CT showed uptake of radionuclide in two locations, one in the eutopic position [right inferior parathyroid gland (PTG)] and second ectopic (mediastinal). After surgery, histopathological examination confirmed mediastinal ETT and two PTG adenomas. During follow-up, laboratory analyzes were maintained within the reference range and the patient remained stable and free of symptoms and clinical signs, which supports a good prognosis. The existence of an ectopic mediastinal thyroid and an ectopic parathyroid tissue may be partly explained by a similar embryological origin. Diagnosis of ectopic thyroid and parathyroid tissues is demanding; requires a multidisciplinary team and approach using highly accurate radiological and nuclear imaging. The simultaneous existence of mediastinal ETT, nodular eutopic TG and PHPT for which two adenomas are responsible (cervical eutopic and mediastinal ectopic) is a complex diagnostic and therapeutic challenge, which we have described so far as unique. Comprehensive and multidisciplinary surgery planning is a cornerstone of treatment, when recommendations in guidelines are lacking.

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Clinical Practice Guidance for Non-Vascular Thoracic MRI

Historically thoracic MRI has been limited by the lower proton density of lung parenchyma, cardiac and respiratory motion artifacts and long acquisition times. Recent technological advancements in MR hardware systems and improvement in MR pulse sequences have helped overcome these limitations and expand clinical opportunities for non-vascular thoracic MRI. Non-vascular thoracic MRI has been established as a problem-solving imaging modality for characterization of thymic, mediastinal, pleural chest wall and superior sulcus tumors and for detection of endometriosis. It is increasingly recognized as a powerful imaging tool for detection and characterization of lung nodules and for assessment of lung cancer staging. The lack of ionizing radiation makes thoracic MRI an invaluable imaging modality for young patients, pregnancy and for frequent serial follow-up imaging. Lack of familiarity and exposure to non-vascular thoracic MRI and lack of consistency in existing MRI protocols have called for clinical practice guidance. The purpose of this guide, which was developed by the Canadian Society of Thoracic Radiology and endorsed by the Canadian Association of Radiologists, is to familiarize radiologists, other interested clinicians and MR technologists with common and less common clinical indications for non-vascular thoracic MRI, discuss the fundamental imaging findings and focus on basic and more advanced MRI sequences tailored to specific clinical questions.

Ultrasound-Guided Transthoracic Mediastinal Biopsy: A Safe Technique for Tissue Diagnosis in Middle- and Low-Income Countries

Background and objectives

The high cost of video-assisted transthoracic procedures precludes their use in the diagnostics of mediastinal masses in low- and middle-income countries (LMICs). This study aims to assess the technical success rate and diagnostic yield of ultrasound-guided transthoracic mediastinal biopsies at a tertiary care hospital.

Methods

This descriptive cross-sectional study was conducted in patients presenting with mediastinal masses referred to radiology services at Dr. Ziauddin University Hospital. Karachi, Pakistan. Ultrasonography was performed using Toshiba Xario 200 & Aplio 500 using convex and linear probes accordingly. Biopsy was performed using a combination of 18G semiautomatic trucut and 17G co-axial needles. Complications and overall diagnostic yields were determined.

Results

In all 70 patients referred, the procedure was completed successfully with an overall procedural yield of 95.7%. Inconclusive biopsies due to inadequate specimen were seen in two (4.2%) patients. No post-procedure major complication or mortality was observed. Minor complications were seen in three (4.2%) out of 70, including hematoma (<3 cm) in one patient and small pneumomediastinum in two patients.

Conclusion

Ultrasound-guided transthoracic mediastinal biopsy may be the pragmatic technique of choice in LMICs for the diagnosis of mediastinal masses as they provide real-time visualization and is cost-effective and safe.

Case Report: Mediastinal Mass in SARS-COV-2 Pandemic: A Word of Caution

Background: SARS-CoV-2 is a new disease with some manifestations not yet well-known. Sharing experiences in this topic is crucial for the optimal management of the patients.

Case Presentation: Left upper extremity deep vein thrombosis (UEDVT) due to a mediastinal mass strongly suspected of lymphoproliferative disease in a patient affected by SARS-CoV-2, disappearing at the resolution of the viral infection.

Conclusion: Before proceeding to surgical biopsy, mediastinal mass in SARS-CoV-2 patients must be revaluated after the resolution of the infection.

Thymoma Presenting as a Pleural-Based Mass

We present a unique case of a satellite pleural-based thymoma. The patient is a 66-year-old Caucasian female with a history of a left pericardial soft tissue mass. She had been asymptomatic. Chest radiograph incidentally revealed an acute increase in the size of the mass. CT scan identified a 5.6 X 5.2 X 4.2 cm mediastinal mass in the left infrahilar region along the left lateral pericardium. Positron emission tomography (PET) scan showed the mass had an increased F18 FDG uptake with standardized uptake value (SUV) of 7.2. Left thoracotomy resected a 81g, 6 X 5.5 X 5.0 cm tan-pink well-encapsulated pedunculated mass displacing the left phrenic nerve. The mass was under the parietal pleura and not attached to the pericardium. Immunohistochemical profile identified the tumor as a thymoma, B1 type. Thymomas are relatively rare in the United States, pleural-based thymomas even more so. Early detection of thymomas is critical to avoid late-stage growths. Pericardial involvement of thymomas increases risk of pericardial effusion, tamponade and a complicated thymectomy. Pleural-based thymomas can result in diaphragmatic paralysis secondary to phrenic nerve involvement.

Thoracic mucormycosis in immunocompetent patients

BACKGROUND

Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes.

METHODS

We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm.

RESULTS

The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment.

CONCLUSION

Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

A young immunocompetent female with anterior mediastinal mass

A 23-year-old female presented with 3 months of central chest pain and fever. Clinico-radiological investigations were consistent with an anterior mediastinal mass. This clinicopathologic conference discusses the differential diagnoses of such a presentation and their management options.