Innominate venous aneurysm presenting as a rapidly expanding mediastinal mass

Thoracic venous aneurysms are extremely rare conditions. Only 14 innominate venous aneurysms have been reported in the literature. We report a case of a 13-year-old girl who presented with a mediastinal mass on chest roentgenogram, which was performed because the patient was postoperatively tachypneic after a routine appendectomy. Further investigations revealed a large left innominate venous aneurysm that was growing rapidly. The patient underwent aneurysmectomy and reconstruction of the innominate vein. The patient's postoperative course was uneventful, and her respiratory symptoms resolved.     

血管重建在原发性纵隔肿瘤中的临床应用

目的总结血管重建在原发性纵隔肿瘤中的应用经验和疗效。方法经外科手术治疗并血管重建的原发性纵隔肿瘤76例,22例（28.9%）单纯侵及上腔静脉;16例（21.1%）侵及单纯左或右无名静脉;34例（44.7%）侵及上腔静脉和左或右无名静脉;有4例（5.3%）单纯侵及主动脉外膜。行完整切除70例,部分切除6例;行血管置换46例,血管成形30例。结果全组病人无一例围术期死亡。上腔静脉阻断时间为（10-30）min,平均（18.0±5.3）min。左或右无名静脉单侧阻断时间为（11-25）min,平均（16.5±4.2）min。全组病人均获随访,时间为12-26个月,术后生活质量满意。结论纵隔肿瘤侵及上腔静脉及其属支大血管的病人,如全身无系统功能严重受损应积极手术治疗,可选用血管置换或血管成形术。     

Pulmonary venous aneurysm presenting as a mediastinal mass in ischemic cardiomyopathy.

True aneurysm of the pulmonary vein is a rare lesion and may present as a mediastinal mass. Acquired aneurysm of the right superior pulmonary vein presenting as a middle mediastinal mass in a patient with ischemic cardiomyopathy associated with severe mitral regurgitation and dilated left atrium is described. Though the natural history of this lesion is uncertain, it may progressively enlarge and become symptomatic. Presence of this lesion in this patient with cardiomyopathy may require a modification of surgical technique at cardiac transplantation or surgical resection of an aneurysm without cardiopulmonary bypass.     

Aneurysm of the superior mediastinal veins

A case of true venous aneurysm with saccular dilation of the proximal half of the superior vena cava, the right innominate vein, and the distal two thirds of the left innominate vein in an 18-year-old white woman is presented. At surgery part of the aneurysmal wall was resected, and subsequently the mediastinal venous system was reconstructed with use of the rest of the aneurysmal wall. The postoperative course was uneventful. Operative treatment of mediastinal venous aneurysms is indicated to prevent possible major complications. We strongly suggest performance of this surgery only by means of a heart-lung machine. (J VASC SURG 1995;21:505-9.)     

Spontaneous regression of an invasive thymoma

Although there are many reports of spontaneous regression of noninvasive thymoma, there are no reports of spontaneous regression of an invasive thymoma. Moreover, the mechanism of the spontaneous regression is still unknown. The present case concerns a 47-year-old man who presented with chest pain. Computed tomography (CT) showed a large anterior mediastinal mass with left pleural effusion that occluded the innominate vein. The tissue obtained by video-assisted thoracic surgery suggested a diagnosis of invasive thymic carcinoma. One month later CT showed prominent regression of the tumor, and the tumor was completely resected. On pathology, the diagnosis was thymoma type B3.     

Thymoma which is detected with a cough derived from pulmonary invasion; report of a case

A 83-year-old female was referred to our hospital for investigation of a persistent cough. A chest X-ray showed enlargement of the mediastinum. Computed tomography of the chest showed an anterior mediastinal mass with a maximal diameter of 6.5 cm, which had invasion to the lung. The patient underwent thymothymectomy combined resections of the lung, pericardium, and left innominate vein through a median sternotomy. Histological examination of the resected tumor revealed a World Health Organization (WHO) classification type B3 thymoma with infiltration into the lung. There were no infiltrations of the tumor into the pericardium and the innominate vein. A persistent cough disappeared after surgery. No adjuvant chemotherapy was performed. She is still free from disease with a follow-up period of 4 months. We report a rare case of thymoma detected with a persistent cough derived from pulmonary invasion.     

Recurrent mediastinal desmoid tumor treated by surgical resection ; report of a case

We report a rare case of mediastinal desmoid tumor in a 17-year-old man. The patient was a 17-year old man who had underwent surgery for mediastinal tumor at our hospital 2 years before. The tumor was diagnosed as a solitary fibrous tumor of the mediastinum. After 2 years, chest computed tomography(CT) and magnetic resonance imaging( MRI) showed a mass at the previously resected site. Surgery was performed again under the diagnosis of recurrent tumor. The tumor densely adhered to the superior vena cava, right innominate vein, pericardium, and the right lung. The tumor was completely resected with the aid of the partial extracorporeal circulation. Finally, both previously resected tumor and the recurrent tumor were diagnosed pathologically as desmoid tumors.     

Primary leiomyosarcoma of the innominate vein

Primary venous leiomyosarcoma is rare. We report the case of a primary leiomyosarcoma of the left innominate vein, with neoplastic thrombus extending into the left jugular and subclavian veins. The tumor was curatively resected en bloc with anterior mediastinal and laterocervical lymphatics, through a median sternotomy prolonged into left cervicotomy. Primary venous sarcomas may be associated with prolonged survival in individual cases, with curative resection recommended as the standard treatment, in the absence of distant spread.     

A surgical case of Hodgkin's lymphoma originated from thymus

We experienced a surgical case of large Hodgkin's lymphoma of the thymus. An 18 year-old male who had been complaining of a persistent cough was admitted to our hospital. Chest X-ray film showed an anterosuperior mediastinal tumor. But there was no superficial lymphadenopathy and hepatosplenomegaly. He received a surgical extirpation of the tumor approached by median sternotomy. The tumor expanded to the whole antero superior mediastinal region, which was 18.5 X 15 X 5.5 cm in size, surrounding the trachea and main branch of aortic arch and veins. The tumor directly invaded the bilateral pleura and left innominate vein, so these regions were resected with the tumor. The left innominate vein was reconstructed with a PTFE graft. The pathological diagnosis was Hodgkin's lymphoma nodular sclerosis type by LSG classification. A post operative course was uneventful.     

Bilateral Mediastinal Lymphangiohemangiomas Containing Anomalous Venous Components - A case report -

Lymphangiohemangiomas of the mediastinum are exceedingly rare and few cases have been published in the English literature. This report may be the only reported case in which lymphangiohemangiomas were found bilaterally. We report a case of a 7-year-old boy with an incidental finding of an abnormal mediastinal shadow on a chest X-ray. The chest CT showed a large mass in the left superior mediastinum and another in the right posterior mediastinum. The left mass had anomalous venous channels connected to the left innominate vein, and the right mass to the left atrium. We performed an excision of the mass in the left side first and then the right side one month later. Anomalous venous channels were dissected carefully and ligated. There were no complications and no signs of recurrence 30 months after the operation.     

Mediastinal epithelioid hemangioendothelioma

An epithelioid hemangioendothelioma arising from the innominate vein in the anterior superior mediastinum of a 62-year-old man was treated by wide local excision followed by radiotherapy. This clinicopathologic entity is a rare cause of mediastinal mass and is characterized by an intermediate malignant potential. To our knowledge, very few cases have been reported in the mediastinum; those cases are listed in this report. Gross and microscopic distinguishing features of epithelioid hemangioendothelioma, as well as differential diagnosis, are reviewed from the literature. Finally, clinical behavior is discussed and treatment options are suggested.     

Stridor due to an innominate artery compression and posterior mediastinal mass in a pediatric patient

There are many causes for stridor in a pediatric patient. We present an interesting case of a pediatric patient who had stridor due to an innominate artery compression and posterior mediastinal mass. We discuss the anesthetic complication and management of patients with stridor.     

Mediastinal parathyroid cysts revisited

BACKGROUND: A case of a functioning mediastinal cyst is presented. METHODS: A comprehensive review of the literature found 93 patients in whom a parathyroid cyst or cysts extended into, or was completely contained within, the mediastinum. Including our patient, there were 46 men and 45 women, and the gender was not recorded in three. RESULTS: The cysts were located in the anterosuperior region in 56 patients, in the middle region of the mediastinum in 26, and in the anterior, prevascular region in 12. Thirty-nine patients had functioning cysts associated with hyperparathyroidism of varying severity; seven patients presented with a hypercalcemic crisis. Local symptomatology consisted of a neck mass, respiratory distress, and occasional dysphagia or chest pain. Recurrent laryngeal nerve paresis was present in nine patients, and innominate vein compression or thrombosis was present in two. The cysts in all but four patients were treated by open surgical excision; two were treated by thoracoscopy, and two patients only had fine-needle aspiration of the cyst. The cyst was excised via a cervical approach in 67 patients and by a thoracotomy or median sternotomy or a variation thereof in 23. There was no operative mortality and morbidity was minimal. CONCLUSION: Surgical resection was successful in all and remains the treatment of choice for mediastinal parathyroid cysts.     

侵及胸廓上口大血管的纵隔肿瘤的外科治疗

目的　探讨侵及胸廓上口大血管的纵隔肿瘤的外科治疗经验。方法　回顾分析 11例侵及胸廓上口大血管的纵隔肿瘤患者的临床资料 ,全组患者均行纵隔肿瘤切除 ,其中 2例于麻醉诱导前辅以股 -股转流并行体外循环 ,2例辅以颈静脉、股静脉 -股动脉转流并行体外循环。同期行上腔静脉重建 2例 ,成形 2例 ,左无名静脉成形 3例 ,右无名静脉成形 1例 ,无名动脉、左颈总动脉、左锁骨下动脉人造血管置换各 1例。结果　全组病例无手术死亡。术后随访 2～ 7年 ,3例于 2～ 4年后死于癌瘤复发 ,6例无瘤健康生存 ,均未出现血管栓塞。结论　侵及胸廓上口的大血管纵隔肿瘤宜积极手术治疗 ,麻醉诱导前辅以股 -股转流或颈、股 -股转流。同期作血管成形或重建。术后小剂量抗凝治疗     

Primary leiomyosarcoma of the anterior mediastinum encasing the aortic arch, left common carotid and left subclavian arteries

A 66-year-old man presented with a one month history of hoarseness. Left recurrent nerve palsy and a left upper mediastinal mass were observed by an otorhinolaryngologist who referred the patient to our department. Chest computed tomography showed a superior mediastinal mass, which seemed to involve the left common carotid and left subclavian arteries from the greater curvature of the aortic arch. The innominate vein was compressed, and collateral circulation was well developed. The left upper lobe of the lung was also seemed involved. A mediastinal biopsy conducted via left thoracoscopy revealed a malignant spindle cell tumor. The mediastinum was irradiated (40 Gy), and surgical extirpation was subsequently undertaken 3 weeks later. The tumor was successfully removed without the use of extracorporeal circulation. Because only smooth muscle actin was focally but strongly expressed immunohistochemically, leiomyosarcoma was confirmed. The patient was discharged on day 14. A solitary left pleural metastasis was observed and resected 12 months after the surgery and the patient is well without further recurrence 16 months after the initial surgery.     

Atypical carcinoid of thymus associated with multiple endocrine neoplasia syndrome type 1

Thymic carcinoid associated with multiple endocrine neoplasia syndrome type 1 (MEN-1) is a rare tumor. We report a case of MEN-1-related thymic carcinoid. The patient reported herein had already been diagnosed with MEN-1 and was found to have a mediastinal mass. She underwent thymectomy with partial resection of the left innominate vein and lung. Histological examination revealed atypical carcinoid with infiltration. MEN-1 gene mutation was detected by employing the direct nucleotide sequencing method. Postoperative 2-fluoro-2-deoxyglucose positron emission tomography showed probable multiple metastases in the vertebrae and myocardium. However, she has been alive and asymptomatic for 2 years postoperatively. MEN-1-related thymic carcinoid is often insidious with a poor prognosis. We suggest chest computed tomography scan or magnetic resonance imaging for MEN-1 patients and serological or genetic screening for patients with thymic carcinoid to screen for MEN-1.     

Thymic carcinoma with tumor thrombus into the superior vena cava

Tumor thrombus into the vena cava have been reported in cases with renal cell carcinoma, thyroid tumor and in those with thymoma. These tumors are frequently invasive and continuous from the main tumor that shows direct vessel wall invasion. Here, we report a case of thymic carcinoma with superior vena cava syndrome, which was caused by a tumor thrombus in the superior vena cava without vessel wall invasion. The main mediastinal tumor did not show innominate vein invasion, and the superior vena cava syndrome was a result of separate tumor thrombus that was free of vessel wall invasion. The tumor thrombus could be removed through a simple venotomy. To prevent stenosis in the superior vena cava and the left innominate vein, we used a pericardial patch to close the venotomy site.     

Safety of left innominate vein division during aortic arch surgery

BACKGROUND: The surgical approach to the aortic arch via median sternotomy can be hindered by the left innominate vein (LIV). Retraction of the LIV may injure the vein. The safety of LIV ligation has been controversial. Opinion has also differed regarding whether a divided vein should be reanastomosed after arch replacement is completed. We report our experience with division and ligation of the LIV for improved aortic arch exposure and facilitated excision of mediastinal tumors. METHODS: From January 1996 to June 1998, the LIV was divided and ligated in 14 patients (8 men, 4 women) after consideration of local anatomy, adequacy of aortic arch exposure, level of distal aortic anastomosis, and in case of mediastinal tumors, extent of involvement of mediastinal structures. The LIV was divided between clamps, doubly ligated, and the ends oversewn. Patients were assessed at 1 month and at yearly intervals for upper extremity edema and neurologic symptoms. RESULTS: In 12 patients LIV division improved aortic arch access, and in 2 patients, it facilitated excision of mediastinal tumors. The mean age of patients was 56 years (range 22 to 80). Follow-up ranged from 1 week to 30 months. All patients had left upper extremity edema for 7 to 10 days, which resolved with arm elevation. One early patient required reexploration for bleeding from the LIV stump. One patient died because of multiorgan dysfunction. None had any residual left upper extremity edema or neurologic symptoms. CONCLUSIONS: We conclude that, although not uniformly or commonly necessary, division of the LIV can safely be utilized to facilitate aortic arch exposure without significant long-term morbidity. LIV reanastomosis is not necessary.     

Life-threatening giant mediastinal goiter: a surgical challenge

Mediastinal goiter is a well known benign disease, usually resectable through a cervical approach with minimal morbidity and mortality. Only occasionally a median sternotomy or a lateral thoracotomy may be required. The present case is worthy of presentation because of the exceptional dimension of the disease and the surgical challenge that it presented. In a 72-year-old woman a large intrathoracic goiter of the right thorax caused a severe dyspnoea due to an important contralateral mediastinal shift with compression of the lung, superior vena cava system and trachea. At surgical exploration, through a cervico-sternotomic approach, the mediastinal structures dislocation and the strong adherences between the anomalous neovascularized capsula of the mass and the surrounding structures, complicated the surgical dissection. An accidental lesion of the innominate artery required its reimplantation on the ascending aorta. An immense mass, was finally removed and pathological examination revealed a rare case of neovascularized, pseudosarcomatoid capsula among a benign hyperplastic proliferation. In spite of its benign nature, a giant goiter caused a life-threatening compression of the respiratory tract and lung parenchyma in this patient. The dimension of the lesions, the mediastinal anatomy alterations and the severe intraoperative haemorrhage represented major technical difficulties during surgical resection.     

Thymic basaloid carcinoma with aggressive invasion of the lung and pericardium: Report of a case

We report a case of basaloid carcinoma of the thymus, invading the lung and pericardium. The patient was a 72-year-old man who suffered thoracic trauma in a fall and was taken to his family physician. Computed tomography revealed a huge mediastinal tumor with cystic components, pressing into the lung. He was referred to our hospital, where magnetic resonance imaging showed suspicious invasion of the pericardium and mediastinum. We made an assumed diagnosis of a mediastinal malignancy and performed mediastinal tumor resection. The tumor was adherent to the lung, pericardium, and left innominate vein. The final pathological diagnosis was a basaloid carcinoma of the thymus. Basaloid carcinoma is often a component of a multiloculated thymic cyst (MTC) and should be considered when MTC is identified within an anterior mediastinal tumor.