Concurrent cysts of the mediastinum, pleura and neck - European
Transcript of Concurrent cysts of the mediastinum, pleura and neck - European
Case report
Concurrent cysts of the mediastinum, pleura and neck
Wael I. Awada, Andrew G. Nicholsonb, Peter Goldstrawa,*
aDepartment of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UKbDepartment of Histopathology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
Received 14 May 2001; received in revised form 9 July 2001; accepted 12 July 2001
Abstract
A 14-year-old male was found to have a mediastinal mass on chest radiograph. Chest computed tomography scans showed a cystic lesion
behind the left main bronchus. Magnetic resonance imaging revealed additional cystic lesions in the left chest and root of the neck. He
underwent excision of mediastinal mass and a pleural cyst. The neck lesion was presumed to be a cystic hygroma. Histological examination
of the two lesions resected showed them to be a foregut cyst and a benign mesothelial cyst. We know of no other report of concurrent
multicystic lesions in the chest and neck and hypothesize that these cysts may have a common embryonic origin. q 2001 Elsevier Science
B.V. All rights reserved.
Keywords: Mediastinum; Foregut cyst; Mesothelial cyst
1. Introduction
Benign cystic lesions in the mediastinum can be conge-
nital or acquired. Primary cysts of the mediastinum include
bronchogenic cysts, enteric or duplication cysts, mesothelial
cysts, thymic cysts and thoracic duct cysts. Bronchogenic
and enteric cysts are closely related as the respiratory tree
and oesophagus arise at a common origin from the primitive
foregut. We report a case of multiple cysts in the chest and
neck and hypothesize that these cysts may have a common
embryonic origin.
2. Case report
A 14-year-old, asymptomatic, male non-smoker was
found to have a large cystic mass in the posterior mediasti-
num on routine chest radiograph. Chest computed tomogra-
phy (CT) scan revealed a well-circumscribed lesion of low
attenuation measuring approximately 6.5 cm in diameter
posterior to the left main bronchus. The lesion did not
enhance with intra-venous contrast and was compatible
with a bronchogenic cyst. The rest of the lung fields
appeared clear.
Magnetic resonance imaging (MRI) showed the large
mediastinal mass seen on the CT scan and another smaller
cystic lesion involving the left pleura (Fig. 1). In addition,
there was a lobulated polycystic mass in the suprasternal
notch consistent with cystic hygroma (Fig. 2).
It was felt that the mediastinal lesions should be excised,
to provide a definitive histological diagnosis and to prevent
future complications by compression or infection. The neck
lesion was not considered a threat and the patient was
advised to seek medical help if the situation changed.
Rigid bronchoscopy revealed compression of the poster-
ior wall of the left main bronchus. We judged that VATS
would not have allowed us to adequately inspect the left
hemithorax, and so the patient underwent a left postero-
lateral, muscle-sparing thoracotomy. There was a 7 £ 7
cm, thin-walled tense cyst arising in the posterior mediasti-
num. The cyst was adherent to the posterior surface of the
lower lobe, the inferior pulmonary vein and the pulmonary
artery. It appeared to be part of the posterior wall of the main
bronchus and herniated into the mediastinum. The lower
oesophagus was stretched across its posterior surface.
The main cyst was mobilized from the oesophagus, the
posterior aspect of the lung and pulmonary vessels, and
dissected from the bronchus without breaching its lumen.
A further thin-walled, uniloculated cyst was attached to the
main cyst. The lung appeared normal. Smaller cystic lesions
were excised from the surface of the lingula, as seen on
MRI, and the inferior pulmonary ligament. All cysts
contained thin clear fluid.
The post-operative course was uncomplicated. The
patient was discharged on day 5 and was well and asympto-
European Journal of Cardio-thoracic Surgery 20 (2001) 861–863
1010-7940/01/$ - see front matter q 2001 Elsevier Science B.V. All rights reserved.
PII: S1010-7940(01)00918-6
www.elsevier.com/locate/ejcts
* Corresponding author. Tel.: 144-2073-518559; fax: 144-2073-
518560.
E-mail address: [email protected] (P. Goldstraw).
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matic at the 4 month follow-up. Histological examination of
the mediastinal cyst wall showed it to be composed of
connective tissue and smooth muscle, lined by benign
respiratory epithelium. There were mucus glands within
the wall, but no cartilage. The features were those of a
simple congenital foregut cyst. The small cysts excised
from the lingula and inferior pulmonary ligament had thin
fibrous walls lined by cytologically bland cells that stained
for calretinin, indicating benign mesothelial cells.
3. Discussion
A CT scan may suggest a specific diagnosis of mediast-
inal cysts by way of careful evaluation of anatomic relation-
ships and convincing evidence that the mass is cystic.
Occasionally, bronchogenic cysts may be a source of confu-
sion because the fluid density may be relatively high due to a
high protein content. In situations where the CT scans are
equivocal, MRI can be used as a problem-solving tool.
Enteric cysts are discovered more commonly in child-
hood. Generally, they lie in the middle or posterior medias-
tinum adjacent to the oesophagus, or even embedded in its
muscular wall. They are lined by stratified squamous epithe-
lium or by gastric or intestinal mucosa which distinguishes
them from bronchogenic cysts, which are lined with ciliated,
columnar epithelium and may contain mucus glands or
cartilage in their walls. Bronchogenic cysts account for
approximately 60% of mediastinal cysts. They are often
located posterior to the carina but may be located more
distally in association with the bronchi. Rarely, they may
communicate with the tracheobronchial tree. They are
usually asymptomatic incidental findings, unless they
compress adjacent structures. In children, bronchogenic
cysts may present with severe respiratory distress and
even respiratory failure [1]. Overall, complications are
reported to occur in up to 26% of patients [2]. Surgery is
indicated because of the unpredictable risk of haemorrhage,
infection, enlargement with associated pressure symptoms
or malignant change [2].
Mesothelial cysts comprise a variety of cysts that have
been reported as pleuropericardial, pleural and simple
mesothelial cysts. They are unilocular cysts whose walls
consist of a single layer of flattened endothelial cells with
an underlying connective tissue stroma, and are most often
incidental radiological findings, as in our case.
Cervical cystic hygromas are believed to occur as a result
of the failure of establishment of appropriate connection to
the normally present lymphatic channels. They are usually
encountered at birth or in early infancy. Very few hygromas
extend into the mediastinum [3]. The cervical cyst in our
case, which was small and found incidentally, was consis-
tent with a cystic hygroma, although it is possible that it
W.I. Awad et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 861–863862
Fig. 1. MRI scan of the chest demonstrating a large multilocular mediastinal
cyst and a pleural cyst (shown by an arrow) in the left hemithorax.
Fig. 2. MRI scan of the neck demonstrating a lobulated polycystic mass in
the suprasternal notch.
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represented a thymic cyst. These can present as either cervi-
cal or anterior mediastinal masses, and are frequently symp-
tomatic [4]. Hendrickson and colleagues [4] encountered 14
patients with congenital thymic cysts, ranging in age from 2
weeks to 16 years, and reported that seven patients had
cervical masses, five had mediastinal masses and two had
both sites involved. We elected not to surgically pursue the
cervical cysts in our patient in view of the high probability
that this was a cystic hygroma.
Yamauchi and colleagues [5] describe a rare case of
double mediastinal cysts (one in the anterior and one in
the posterior mediastinum) in a 60-year-old male, which
were confirmed as a thymic cyst and a thoracic duct cyst,
respectively. Their patient was managed successfully by
video-assisted thoracic surgery. Indeed, selected patients
with mediastinal cysts can be managed safely and effec-
tively by thoracoscopic means [6]. We elected to perform
thoracotomy in our case and this decision seemed to be
indicated by the difficulty in resecting the lesion from the
back of the left main bronchus, oesophagus and pulmonary
vessels.
We have reported a unique case of multiple cysts in a 14-
year-old boy. The concurrent occurrence of multiple cysts in
the neck and mediastinum may reflect a common embryonic
origin. We recommend complete excision in most instances
to confirm the diagnosis, relieve any symptoms and to
prevent complications.
References
[1] Bohle AS, Dohrmann P, Mengel W, Schroder H. Acute respiratory
insufficiency in an infant caused by a tracheogenic cyst. Thorac
Cardiovasc Surg 1999;47(2):124–125.
[2] Suen HC, Mathisen DJ, Grillo HC, LeBlanc J, McLoud TC, Moncure
AC, Hilgenberg AD. Surgical management and radiological character-
istics of bronchogenic cysts. Ann Thorac Surg 1993;55(2):476–481.
[3] Grosfeld JL, Skinner MA, Rescorla FJ, West KW, Scherer 3rd LR.
Mediastinal tumours in children; experience with 196 cases. Ann Surg
Oncol 1994;1(2):121.
[4] Hendrickson M, Azarow K, Ein S, Shandling B, Thorner P, Daneman
A. Congenital thymic cysts in children — mostly misdiagnosed. J
Pediatr Surg 1998;33(60):821–825.
[5] Yamauchi A, Watanabe A, Itimiya Y, Abe T. Double simultaneous
cysts of the mediastinum. Ann Thorac Cardiovasc Surg 2000;6(2):125–
126.
[6] Schwarz CD, Puschmann R, Eckmayr J, Hartl P, Mayer KH, Zisch RJ.
Videoendoscopic removal of a mediastinal cyst. Chest 1994;105(4):
1254–1256.
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