Thymolipoma combined with hyperthyroidism discovered by neurological symptoms.

Thymolipomas are rare slow-growing mediastinal thymic neoplasms. Most cases are asymptomatic and are sometimes discovered as a huge mass on chest x-ray films. A few cases have been discovered during examinations for other diseases. We report the second case of thymolipoma combined with hyperthyroidism in the English language literature. Neurological symptoms suddenly appeared in a 45-year-old woman. Central nervous system disorder was suggested but no significant abnormalities were found on brain MR nor were there any neurological signs. Several months later, neurological and systemic examinations on admission revealed hyperthyroidism and an anterior mediastinal tumor, 9.0x5.0x3.0 cm in size on chest CT films. Despite treatment of hyperthyroidism by medication, her neurological symptoms remained. Neurologists recommended resection of the mediastinal tumor. Malignancy could not be ruled out because of the irregularity of the tumor appearance on contrast-enhanced chest CT. Furthermore, the tumor appeared to be attached to the ascending aorta, so cytological and/or pathological diagnosis by CT-guided needle biopsy before operation were contraindicated. Extended thymectomy was performed in May 2005. The pathological diagnosis was benign thymolipoma consisting of mature fatty tissue and thymic tissue structures with Hassall's corpuscles. Her neurological symptoms seemed slightly but not markedly improved. The relationship between thymolipoma and hyperthyroidism is still unknown.     

Thymic tuberculosis preoperatively evaluated with thallium-201 SPECT: two resected cases.

We present 2 resected cases of thymic tuberculosis, which had been preoperatively diagnosed as invasive thymoma, using a thallium-201 ((201)Tl) single photon emission computed tomography ((201)Tl SPECT). [Patient 1] A 74-old-male with a 32-year history of steroid therapy for rheumatic arthritis was diagnosed with an anterior mediastinal tumor by routine chest CT scans after onset of myocardial infarction. [Patient 2] A 56-old-female with a 28-year history of diabetes mellitus presented with a dry cough. A chest CT demonstrated an anterior mediastinal tumor. Neither patient showed pulmonary infiltrations on chest x-ray. (201)Tl SPECT was undertaken for each patient. Abnormal findings could not be detected on a planar image of the scintigraphy; however, on SPECT images accumulations of (201)Tl were clearly detected in the anterior mediastinal mass and a thymoma was thus suspected in each case. Total thymectomy was carried out in each case and the mass then diagnosed as caseous granuloma in the thymus. Both patients are well without recurrence after operation. In patients with a (201)Tl SPECT positive anterior mediastinal tumor associated with an immunologically deficient status, and with negative findings in planar images on thallium scintigraphy, the possibility of thymic tuberculosis should be considered.     

Thymic enlargement following treatment for a metastatic germ cell tumor: a case report

We describe a patient with metastatic testicular carcinoma in whom an anterior mediastinal mass developed 8 months after complete remission following chemotherapy and surgery. The mass was excised and pathological examination showed benign thymic hyperplasia. An anterior mediastinal mass encountered after successful chemotherapy does not always imply recurrence or relapse of malignant disease. The possibility of a benign etiology must be considered to prevent inappropriate treatment.     

General anesthesia prior to treatment of anterior mediastinal masses in pediatric cancer patients

Many children with malignant diseases who present with an anterior mediastinal mass must undergo general anesthesia for tissue diagnosis or tumor resection. One hundred sixty-three pediatric patients over a period of 6 yr were admitted to Memorial Sloan-Kettering Cancer Center with a diagnosis of anterior mediastinal mass. Forty four of these patients required surgery and their records were reviewed. In recent years perioperative radiation therapy has been advocated for this patient group prior to their receiving general anesthesia. If a tissue diagnosis has not been made, preoperative radiation therapy may distort histologic findings and prevent accurate diagnosis. All patients with an anterior mediastinal mass who must receive general anesthesia in our institution do so prior to treatment with radiation or chemotherapy even in the presence of cardiovascular or respiratory symptoms. No patient died or sustained permanent injury as a result of their anesthetic or operative experience. Two patients who experienced difficulty on induction of anesthesia required tracheal intubation with a rigid bronchoscope. Two patients developed airway obstruction during anesthetic maintenance that was corrected with changes in patient position. Four patients were unable to have their tracheas extubated at the conclusion of surgery and one patient required tracheal reintubation in the immediate postoperative period. These patients were treated with radiation therapy and chemotherapy after tissue for diagnosis had been obtained. The authors conclude that in the absence of life-threatening preoperative airway obstruction and severe clinical symptoms general anesthesia may be safely induced prior to radiation therapy.     

Neonatal intrapericardial teratoma: a challenge for the pediatric surgeon

Congenital intrapericardial teratoma can present in the fetal and neonatal period, but prenatal diagnosis is difficult. Its clinical course, similar to that of an anterior mediastinal mass, may be fatal if the tumor is not promptly excised. We report the case of a fetus with a large anterior mediastinal mass associated with hydramnios, pleural effusion, and ascites. Perinatal surgical removal is the only lifesaving therapy; any conservative approach in these neonates should be avoided even if critically symptomatic.     

Aneurysm of an aortocoronary saphenous vein bypass graft presenting as an anterior mediastinal mass

Fifteen years after aortocoronary bypass surgery, a 52-year-old asymptomatic man was found to have a large anterior mediastinal mass. Angiographic studies showed no evidence that a vascular structure was responsible. At operation, a saphenous vein graft to the left anterior descending artery was found to be affected by a large thrombus-filled aneurysm. This is one of the few known cases in which such an aneurysm has presented as a mediastinal mass.     

Pulmonary edema during cesarean delivery in a patient with a mediastinal mass

Purpose

To report the management of a Cesarean delivery complicated by postpartum pulmonary edema in a parturient with a large mediastinal mass.

Clinical findings

A patient with an anterior mediastinal mass presented to the labour and delivery floor at 37 weeks of gestation with cough, severe dyspnea, and chest pain. Radiological investigations revealed that the mass occupied mainly the right side of the thorax and produced compression of the mediastinal structures. The patient underwent an elective Cesarean delivery under epidural anesthesia; however, immediately following the placental delivery, she developed unilateral pulmonary edema. She was managed successfully with diuretics, and her subsequent course in the hospital was uneventful. The biopsy of the mass revealed a lymphoma, which was treated eventually by chemotherapy. Both the mother and her baby are doing well after two years of follow-up.

Conclusion

A multidisciplinary approach should be considered in the management of a pregnant patient with symptomatic anterior mediastinal mass. Practitioners should be aware of the possibility of unilateral pulmonary edema in patients with an anterior mediastinal mass compressing pulmonary veins. Such patients should be treated promptly with diuretics to prevent further adverse outcomes.     

Anterior mediastinal mass in a pregnant patient: Anesthetic management and considerations

Patients with anterior mediastinal masses are recognized to be at risk for cardiorespiratory compromise when general anesthesia is induced.^1,2 Likewise, pregnancy has a widely known constellation of potential complications that confront the anesthesiologist. The combination of both problems in a single patient presents an unusual anesthetic challenge. The following is a case report of a pregnant patient with a large, symptomatic anterior mediastinal mass who required general anesthesia for a diagnostic procedure before definitive therapy could be initiated.     

The “forgotten” goiter after total thyroidectomy

INTRODUCTION“Forgotten” goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy.PRESENTATION OF CASEWe report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves’ disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures.DISCUSSIONIn the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter.CONCLUSIONRetrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.     

A pediatric patient with a mediastinal mass and pulmonary embolus

When anesthetizing a patient with an anterior mediastinal mass, sudden hypoxaemia and cardiovascular collapse may result from compression of a large airway or vascular structure in the mediastinum. We report the case of a pediatric cancer patient with an anterior mediastinal mass, who developed sudden and fatal hypoxaemia and cardiovascular collapse in the hours following sedation. A massive pulmonary thromboembolism was diagnosed at autopsy. We suggest that pulmonary embolism should be considered in the differential diagnosis when a patient with a mediastinal mass develops perioperative hypoxaemia, cardiovascular collapse, or both.     

Anesthetic management of children with an anterior mediastinal mass

Study ObjectiveTo review the anesthetic management and perioperative course of children with an anterior mediastinal mass.DesignRetrospective review.SettingUniversity-affiliated children's hospital.MeasurementsThe records of 46 children presenting with an anterior mediastinal mass between October 1, 1998 and Octobber 1, 2006 were studied. Preoperative symptoms, diagnostic imaging and physical examination findings, anesthetic techniques, and perioperative complications were recorded.Main ResultsSpontaneous ventilation was maintained in 21 of 46 cases. Five patients had mild intraoperative complications, including upper airway obstruction, mild oxyhemoglobin desaturation, wheezing, partial airway obstruction, and a pneumothorax after mediastinal mass biopsy. There were no serious complications or perioperative deaths.ConclusionsChildren with a symptomatic anterior mediastinal mass underwent general anesthesia without serious complications. Spontaneous ventilation was preferred for all patients with severe airway compression.     

Inflammatory myofibroblastic tumor mimicking anterior mediastinal malignancy

Inflammatory myofibroblastic tumor arising in the anterior mediastinum is rare. A 58-year-old woman had an anterior mediastinal mass invading the sternum, pericardium, and pleura. It was completely resected and found to be an inflammatory myofibroblastic tumor. The patient was well and had no recurrence 6 months after surgery.     

Surgical therapy of HCG-producing mediastinal tumor accompanied with intrapulmonary metastasis]

The patient is a 31-year-old man who was suffering from hyperthyroidism and left hemothorax. His serum HCG level was extremely elevated and chest X-ray showed a mass shadow of anterior mediastinum and bilateral multiple intrapulmonary metastasis. Our clinical diagnosis was primary HCG-producing germ cell carcinoma of mediastinum and immediately administered CDDP and VP-16. Chemotherapy was effective and tumor extirpation was carried out for mediastinum and lungs by median sternotomy. All of the resected specimen showed no cancer cells and 4 years have passed with no evidence of recurrence. Aggressive surgical approach is indicated for mediastinal germ cell carcinoma accompanied with intrapulmonary metastasis when chemotherapy is effective.     

Large mediastinal cyst of an ectopic thyroid with small nodules diagnosed as papillary carcinoma

A 49-year-old man was admitted to hospital for investigation of a mediastinal shadow seen on a chest radiograph. Chest completed tomography revealed a mediastinal mass of 65 × 55 mm. At surgery, the mass was found to be contained within the upper mediastinum and adherent to the vertebrae, esophagus, trachea, and superior vena cava. We therefore selected sequential approaches using a lateral incision for the thoracotomy and a modified transmanubrial approach. The lateral incision enabled detachment of the adhesion between the mass and the posterior to median mediastinum, and the modified transmanubrial approach was useful for separating the mass from the upper to anterior mediastinum. The mass had no connection to the cervical thyroid gland. Histological examination revealed a large mediastinal cyst of an ectopic thyroid with small nodules diagnosed as papillary carcinoma. There was no recurrence 14 months after surgery.     

Chylothorax post thoracoscopic surgery for an anterior mediastinal tumor

Chylothorax after anterior mediastinal surgery is rare. We treated a 39-year-old woman who presented with progressive dyspnea over 6 months. Chest computed tomography revealed a 12-cm round mass in the right anterior mediastinum. She underwent video-assisted thoracoscopic surgery for successful excision of the tumor; however, the surgery was complicated by the development of chylothorax. It was treated surgically with no recurrence of the tumor and/or chylothorax for 2 years. Chylothorax should be recognized as a postsurgical complication of anterior mediastinal tumors.     

Anesthesia for children with anterior mediastinal masses

Children with an anterior mediastinal mass may have cardiopulmonary compromise that can be exacerbated under general anesthesia. Signs and symptoms such as cough, shortness of breath, stridor, orthopnea, accessory muscle use, a history of respiratory arrest, and the presence of a pleural effusion and upper body edema are predictive of perioperative complications. A larger mediastinal mass on imaging is predictive of perioperative complications. Risk stratification of patients, together with an individualized plan, will best guide operative management for patients with an anterior mediastinal mass. General anesthesia (GA) should be avoided if possible, but a spontaneous breathing technique is recommended if GA is required.     

A thyroglossal duct cyst of the anterior mediastinum

Thyroglossal duct cysts (TGDCs) are developmental anomalies arising from the embryonic thyroglossal duct. They are commonly midline cervical structures associated with the hyoid bone. We report a 3.5-cm diameter isolated TGDC of the anterior mediastinum in a 65-year-old European woman who was treated by transcervical excision. The mass was limited to the mediastinum with a normal neck on computed tomographic scan and clinical examination. This is the second case of mediastinal TGDC known to be reported, and the oldest known age at presentation. The TGDC should be considered as an uncommon differential diagnosis of an anterior mediastinal mass.     

Primary mediastinal seminoma

Three new cases of primary mediastinal seminoma are presented, and 124 other cases in the literature are reviewed. These tumors primarily affect white males in the third decade. Chest pain is the most common symptom, but 20 per cent of the patients can be asymptomatic. Testicular atrophy occurred in only 7 patients. In one of these a testicular seminoma developed seven years after treatment of a primary mediastinal tumor. Supraclavicular adenopathies were found in 10 patients. Chest x-ray films typically show an anterior mediastinal noncalcified mass with smooth lobulated borders. Twenty-eight of 74 surgical resections attempted were successful; 13 of these received adjuvant irradiation. Of 64 cases in which radiation therapy was the primary mode of treatment, local failures occurred only in 7 cases. These tumors spread primarily by distant metastases. Theories of tumoral origin and patterns of spread are discussed. A dose of 3,000 rad in three weeks and 4,500 rad in four and one-half weeks to the mediastinum and supraclavicular areas is recommended for minimal and bulky disease. Primary mediastinal seminoma is as radiosensitive as its testicular counterpart.     

When laparoscopy for fertility preservation prior to gonadotoxic treatment of an anterior mediastinal mass is a dilemma: A case report

IntroductionThe management of anterior mediastinal masses is a challenge for anesthesiologists. Recommendations for their management in the context of diagnostic or curative surgery are well described. The added risk of laparoscopic surgery for fertility preservation has however never been discussed in the literature.Presentation of caseWe present the case of a 32-year-old female patient with a large malignant anterior mediastinal mass. She was referred for anesthesia evaluation before laparoscopic ovarian tissue harvesting as part of fertility preservation prior to gonadotoxic treatment. The patient presented dyspnea at rest. Chest computed tomography revealed a tracheal deviation and a partial obstruction of the left mainstem bronchus. Transthoracic echocardiography showed a pericardial effusion. Proceeding to high risk anesthesia for a non-curative surgery in a patient with a highly symptomatic mass was considered unacceptable and the procedure was postponed. The patient received a single cycle of neoadjuvant chemotherapy. Clinical and radiological improvement were shown after this single dose and laparoscopic surgery was performed under general anesthesia without complications.ConclusionIn the context of an anterior mediastinal mass and fertility preservation a thorough benefit-risk analysis must be undertaken before non-curative laparoscopic surgery. In case of severe symptoms, surgery should be postponed until the patient’s condition improves after the minimum necessary chemotherapy treatment. So far it is impossible to say whether the risk exceeds the expected benefit in this difficult situation. Further studies need to be conducted in this area.     

Lateral position prevents respiratory occlusion during surgical procedure under general anesthesia in the patient of huge anterior mediastinal lymphoblastic lymphoma

Lymphoblastic lymphoma, an aggressive mediastinal mass, is recognized as serious threat to the patient in developing cardiac tamponade or airway obstruction. Surgical procedure is often required to relieve clinical emergency and to establish prompt pathological diagnosis. However, in such a patient, acute respiratory occlusion in the spine position can be a life-threatening complication during general anesthesia. We describe a 17-year-old man whose cardiac tamponade was treated by pericardial-pleural window through a left anterior thoracotomy in the lateral position. The patient recovered from hemodynamic compromise without showing respiratory occlusion during general anesthesia and remained in the lateral position until extubation. Pathological diagnosis was precursor T-lymphoblastic lymphoma. There were no complications attributable to the operative procedure. Further chemotherapy reduced the mediastinal mass in size after two weeks when the patient developed sepsis and died. Lateral position prevents respiratory occlusion during surgical procedure under general anesthesia in the patient of huge anterior mediastinal tumor with airway obstruction.