Differential Diagnosis Of Mediastinal Tumors Research Articles

Cavernous mediastinal hemangioma presenting with persistent cough: a rare case report and review of literature

BackgroundCavernous hemangioma is a rare benign tumor which can sometimes mimic the clinical presentation and radiological findings of malignant tumors. Here we present a rare presentation of cavernous hemangioma in the mediastinum (CHM), along with a literature review among the main databases.Case presentationWe present a 48-year-old male who had suffered from persistent cough as the sole symptom of an anterior CHM. Computed tomography scan demonstrated a 12.5 × 10.8 cm mass in the anterior mediastinum. The mass was surgically resected, and histopathological evaluation established the diagnosis of CHM. The patient was discharged in good condition, in which during his four-month follow-up period, no recurrence of the tumor has been observed.ConclusionAlthough cavernous hemangioma rarely present in the mediastinum, it should be considered in the differential diagnosis of mediastinal tumors. However, our review of literature demonstrated a female dominance and average age of 40 years, with a 52% mortality rate based on previous reports.

Posterior mediastinal myelolipoma; a case report

Background: Myelolipoma is a benign tumor of the adrenal region. However, it may exist in other regions such as presacral space, gastric, hepatic region, retroperitoneum, nasal cavity, testis, and even in thyroid. Case Presentation: We present a 55-year-old male who was presented to the emergency department complaining of left lower abdominal pain and diarrhea. Physical examination and echocardiogram were normal. Radiological examination, including non-contrast and contrast CT, magnetic resonance imaging, and positron emission tomography, showed the presence of right paraspinal lobulated soft tissue mass. This finding confirmed the diagnosis of myelolipoma The patient was treated with video-assisted thoracic surgery (VATS), and the mass was examined microscopically and by immunohistochemistry. Conclusion: Myelolipoma must be considered in the differential diagnosis of mediastinal tumors, it is rare, but it is possible to occur. Differential diagnosis of myelolipoma especially from extramedullary hematopoiesis is necessary. VATS is a feasible and safe treatment option for mediastinal myelolipoma.

MIXED GERM CELL TUMOR PRESENTING AS LARGE MEDIASTINAL MASS

SESSION TITLE: Fellows Disorders of the Mediastinum Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Extragonadal Germ cell tumors involving the mediastinum are rare and accounts for 3-4% of all germ cell tumors1.Literature review showed only small number of case reports about mixed germ cell tumors involving mediastinum or lungs. We present a rare case of young female presented with very large mediastinal mass. CASE PRESENTATION: 27-year-old female with no significant past medical history presented to the emergency room for the complaint of left-sided chest. She states she has been having intermittent chest pain for the last 2 months with pain radiates to left upper back, describes pain as sharp and stabbing in nature, gets worse with breathing movement and progressively getting worse. She also had night sweats and productive cough but denied any fevers, chills, weight loss, hemoptysis. Patient is never smoker and denied any second hand smoke exposure. Blood work-up was unremarkable, EKG showed sinus tachycardia. Chest x-ray showed left hemithorax opacification concerning for mass, she had CT chest done which showed massive left hilar mass. Patient underwent CT-guided biopsy which showed possible teratoma versus pulmonary hamartoma. Cardiothoracic surgery was consulted and patient underwent left thoracotomy with excision of left-sided intrathoracic mass. Pathology results consistent with mixed germ cell tumor comprised of teratoma with yolk sac tumor. Patient did well after surgery and discharged home with oncology follow-up. DISCUSSION: The differential diagnosis of mediastinal tumors is challenging and includes thymomas, esophageal/thyroid cancers, lymphomas, bronchogenic cysts and extra gonadal germ cell tumors. Germ cell tumors include Teratoma (mature and immature), Yolk sac tumor, Seminoma, Choriocarcinoma, Embryonal carcinoma and Mixed germ cell tumors. Germ cell tumors account for 20% of mediastinal tumors with teratoma and seminomas being most common cause. Because of multiple components of tumor, sampling of mediastinal germ cell tumors can be misleading. In one case report the germ cell tumor was misdiagnosed as hemangioma and in other case report, biopsy led to life threatening bleeding resulting in death of patient. Presenting symptoms include chest pains, shortness of breath, hemoptysis, and trichoptysis (expectoration of hair).Treatment options include complete surgical resection and chemotherapy. Complete resection is important as survival rate is low for patients with residual tumors. Mixed germ cell tumors with malignant components are more aggressive with survival rate less than 2 years. CONCLUSIONS: Extra gonadal Germ cell tumor involving mediastinum are rare, physicians need to be aware of difficulties and complications associated with diagnosis. Germ cell tumors should be considered in differential diagnosis of mediastinal mass especially in young patients. Reference #1: Moreira AL, Ströbel P, Chan JKC et al. Germ cell tumours of the mediastinum. Seminoma. In: WHO Classification of Tumours of Lung, Pleura, Thymus and Heart, 4th edn. IARC, Lyon 2015; 244–8. Reference #2: Sakane T, Okuda K, Murase T, Watanabe T, Oda R, Tatematsu T, Yokota K, Haneda H, Inagaki H, Nakanishi R. Mixed-type primary germ cell tumor of the mediastinum in a young adult male with a sudden life threatening condition: A case report. Thorac Cancer. 2020 Jan;11(1):166-169. doi: 10.1111/1759-7714.13231. Epub 2019 Nov 6.PMID: 31693305 DISCLOSURES: No relevant relationships by Imran Amer, source=Web Response No relevant relationships by Adnan Khan, source=Web Response No relevant relationships by Sana Khan, source=Web Response No relevant relationships by Thomas Maloney, source=Web Response No relevant relationships by Moeez Qureshi, source=Web Response

CT-based mediastinal compartment classifications and differential diagnosis of mediastinal tumors

Division of the mediastinum into compartments is used to help narrow down the differential diagnosis of mediastinal tumors, assess tumor growth, and plan biopsies and surgical procedures. There are several traditional mediastinal compartment classification systems based upon anatomical landmarks and lateral chest radiograph. Recently, the Japanese Association of Research of the Thymus (JART) and the International Thymic Malignancy Interest Group (ITMIG) proposed new mediastinal compartment classification systems based on transverse CT images. These CT-based classification systems are useful for more consistent and exact diagnosis of mediastinal tumors. In this article, we review these CT-based mediastinal compartment classifications in relation to the differential diagnosis of mediastinal tumors.

Debulking surgery for venous hemangioma arising from the epicardium: report of a case

BackgroundCardiac hemangiomas are rare benign vascular tumors that can occur in any cardiac layer: endocardium, myocardium, or epicardium. Histologically, cardiac hemangiomas may be classified as capillary, cavernous, or arteriovenous; venous hemangiomas are extremely rare.Case presentationA 46-year-old man reported experiencing precordial discomfort. Computed tomography revealed a massive tumor adjacent to the right ventricle. The right coronary artery was found to be located at the center of the tumor. Cardiovascular angiography showed that the artery was completely encased by the tumor without any obstruction and that the right ventricular lumen was compressed by the tumor. Surgical debulking of the tumor was performed under cardiopulmonary bypass, and the frozen section led to a diagnosis of benign hemangioma. The tumor was debulked as much as possible until the right coronary artery appeared. For decompression of the heart, the pericardium was left open to the thoracic cavity and unsutured. Histopathologic examination revealed a diagnosis of epicardial venous hemangioma.ConclusionsCardiac hemangioma should be included in the differential diagnosis of mediastinal tumor in reference to the location and flow of the coronary artery. Surgical resection, or at least tumor debulking, is required to confirm the diagnosis and prevent further complications and has a favorable clinical outcome.

Mediastinal lymphangioma in an adult with a tracheal bronchus

Introduction. Lymphangiomas, also known as cystic hygromas or cystic lymphangiomas, are cystic abnormalities of the lymph vessels and they are rare benign tumors. Tracheal bronchus (Bronchus suis or ?pig bronchus?) is a very rare congenital anomaly. The aim of this work is to present ? very rare case of ? lymphangioma with tracheal bronchus. Case outline. The article presents the rare case of a 35-year-old otherwise healthy man, who was admitted to our thoracic surgery department with a mediastinal tumor. On performing bronchoscopy a tracheal bronchus was found. A thoracic CT scan revealed a well-circumscribed mass in the superior and anterior mediastinum measuring 37 x 39 x 59 mm. First a Carlens mediastinoscopy, and then a right parasternal Chamberlain mediastinotomy were performed. The final pathological diagnosis of lymphangioma was made. In this case, surgery was not performed because the patient was asymptomatic and the tumor did not grow larger during follow-up. Conclusion. The lymphangioma of the mediastinum in an adult is a rare and benign condition with a good prognosis, but it should be considered in a differential diagnosis of mediastinal tumors. We recommend only a minimally invasive diagnostic approach (parasternal mediastinotomy) when the patient is asymptomatic.

Proposal for a new mediastinal compartment classification of transverse plane images according to the Japanese Association for Research on the Thymus (JART) General Rules for the Study of Mediastinal Tumors.

There is no existing worldwide published method for mediastinum compartment classification based on transverse section images for the differential diagnosis of mediastinal tumors. Herein, we describe a new method for anatomic mediastinal compartment classification using transverse section computed tomography (CT) images and the use of this method to classify mediastinal lesions, and thus evaluate whether the method is sufficiently user-friendly and useful. In a publication of the Japanese Association for Research on the Thymus (JART), we proposed the following four mediastinal compartments based on transverse CT images: superior portion of mediastinum, anterior mediastinum (prevascular zone), middle mediastinum (peri-tracheoesophageal zone), and posterior mediastinum (paravertebral zone). In the present study, we retrospectively analyzed 445 pathologically proven mediastinal mass lesions, and categorized them into the proposed four compartments by consensus reading. Mass lesions were classified into compartments based on the location of the lesion centroid, and each lesion was satisfactorily categorized into a compartment. Almost all thymic epithelial tumors (99%, 244/246), all 24 thymic malignant lymphomas and a majority of germ cell neoplasms (93%, 54/58) were classified as being in the anterior mediastinum compartment. The majority of intrathoracic goiters (82%, 14/17) were categorized as being in the superior portion of the mediastinum compartment. Approximately two-thirds of mass lesions in the middle mediastinum were cysts, including foregut and pericardial cysts. Approximately 80% of 37 mass lesions in the posterior mediastinum were neurogenic tumors. Correspondingly, 29 of the 49 neurogenic tumors (60%) were categorized as being in the posterior mediastinum, while 10 (20%) were in the superior portion of the mediastinum, 4 (8%) in the anterior mediastinum, and 6 (12%) in the middle mediastinum. Our findings showed that the newly proposed mediastinal compartment classification using transverse images appears to be user-friendly enough for practical clinical application and may be helpful in differential diagnoses.

Primary Extraskeletal Mesenchymal Chondrosarcoma of the Anterior Mediastinum

Primary extraskeletal mesenchymal chondrosarcoma (EMC) of the mediastinum is an extremely rare disease. To date, only seven cases have been reported in the literature 1-4 since it was first reported by Chetty in 1990.1 We experienced a case of primary mediastinal EMC presenting as an anterior mediastinal mass, a previously unreported site. Here, we describe the characteristic features of the lesion with a review of the literature to emphasize that EMC should be considered in the differential diagnosis of mediastinal tumors.

THYMOMA – AN IMPORTANT DIFFERENTIAL DIAGNOSIS OF MEDIASTINAL TUMOURS

A 69-year-old man with slight dyspnoea underwent routine X-ray examination by his primary care physician. The X-ray and the CT showed a homogenous mass at the right side of the anterior mediastinum. The benignity and the origin of the tissue were still unknown. Therefore, we performed a CT-guided fine needle aspiration biopsy of the mediastinal mass. Histopathological examination finds out a spindle-cell or type A thymoma. Based on these findings we decide for a thoracoscopic resection of the thymoma. After the surgical intervention the patient was completely asymptomatic. In conclusion, because thymomas are prone to ectopic occurrence, they should be considered in the differential diagnosis of mediastinal tumors.

Airway obstruction due to giant non-parathyroid hormone-producing parathyroid adenoma

We present a case of a 39-year-old female patient with acute stridor due to a large tumor located at the level of the upper third of her thoracic esophagus. Parathyroid gland tumors are unusual in the differential diagnosis of mediastinal tumors. This tumor was removed via a thoracocervical approach, which offers multiple advantages when used for tumors in this location. The eventual diagnosis on histology was parathyroid adenoma. The patient had no clinical evidence of metabolic abnormalities and her pre- and postoperative calcium and postoperative parathyroid hormone (PTH) levels were within normal limits. This case poses the interesting question of whether identification of elevated PTH levels is an absolute prerequisite for diagnosing parathyroid adenomas. It is an example of a difficult diagnostic and therapeutic problem.

Cardiac rhabdomyoma as an unusual mediastinal mass in a newborn

A newborn case with cardiac rhabdomyoma is presented to discuss the differential diagnosis of mediastinal tumors around the heart in children. The diagnosis of rhabdomyoma can be suggested by modern visualization methods such as computerized tomography, magnetic resonance imaging and echocardiography. However, surgery is clearly indicated in cases with obstruction of flow tracts, valvular dysfunction and dysrhythmia, and in cases with indefinite diagnosis, or in the absence of association with tuberous sclerosis. Cardiac rhabdomyoma should be included in the differential diagnosis of masses located adjacent to the heart in infants.

Primary Intrathoracic Goiter

Nodular goiter is a common disease in Taiwan, and substernal or intrathoracic goiters are not infrequent. However, intrathoracic goiters are mainly of the secondary type and primary intrathoracic goiters are rarely seen. We report a 55-year-old woman who was incidentally found to have an ectopic goiter located in the anterior upper mediastinum with the initial presenting symptom of productive cough. Imaging studies including chest X-ray and computed tomography identified the lesion, and 131I-uptake scan showed weak uptake in the thorax. Surgical removal via thoracotomy was performed and the diagnosis was confirmed by pathology. A primary intrathoracic goiter, although rare, should also be considered in the differential diagnosis of mediastinal tumor.

A Case of Mediastinal Angiomyolipoma

Angiomyolipoma is a common tumor of the kidney but has rarely been found in the mediastinum. We report a case of angiomyolipoma of the posterior mediastinum in a 62-year-old woman. She experienced exertional dyspnea and intermittent cough at admission. Computed tomography indicated a tumor located at the left paravertebral and upper posterior mediastinum and MRI imaging demonstrated a mass with low signal intensity in T1-weighted image at T4-5 level. Thoracotomy was done for surgical removal of the tumor and histologic examination revealed a mesenchymal tumor composed of mature fat, capillaries and smooth muscle fibers. The tumor was immunohistochemically positive for CD34 and factor-VIII (for vascular component) smooth muscle actin (for smooth muscle component) and S-100 protein (for fat component). There have been four case reports about mediastinal angiomyolipoma, namely three Japanese cases and one French case. It is suggested that angiomyolipoma could be considered for the differential diagnosis of mediastinal tumors.

Immunoreactivity of a new CD5 antibody with normal epithelium and malignant tumors including thymic carcinoma.

CD5, first recognized on subsets of lymphocytes, also is detected in thymic carcinoma but not in thymoma or other malignant tumors. We studied CD5 expression in 73 cases of malignant tumors of various organs, 22 cases of thymoma, and 7 cases of thymic carcinoma by immunohistochemistry using the new monoclonal anti-CD5 antibody, NCL-CD5-4C7, with a pressure cooker antigen retrieval method. All cases of thymic carcinoma showed positive staining for CD5, predominantly on the cell membrane. Two of 4 cases of atypical thymoma also showed focal positivity, whereas the other types of thymoma were negative. CD5 was detected in cases of malignant tumors other than squamous cell carcinoma and in the normal epithelium of their counterparts. Squamous cell carcinomas of various organs were negative for CD5. Malignant mesothelioma showed peculiar intracytoplasmic staining in contrast to the other tumors. The NCL-CD5-4C7 positivity in thymic epithelial tumors may support the hypothesis suggesting progression of atypical thymoma to thymic carcinoma. NCL-CD5-4C7 may be useful in the differential diagnosis of mediastinal tumors, especially between thymic carcinoma and metastatic squamous cell carcinoma of various primary sites, and for distinguishing malignant mesothelioma from adenocarcinoma of the lung by the different staining pattern.

Neoplastic epithelial cells in a subset of human thymomas express the B cell-associated CD20 antigen.

A series of 36 human thymomas have been immunohistochemically analyzed using a panel of antibodies recognizing B-cell markers including CD20. Most thymomas exhibiting the cortical pattern, according to the criteria of Marino and Muller-Hermelink, were characterized by areas of medullary differentiation containing variable numbers of CD20+ B lymphocytes, thus mimicking the medulla of normal thymus. On the other hand, B cells were absent or rare in thymomas recognized as mixed using the same morphological criteria. Surprisingly, we observed in most mixed thymomas variable numbers of CD20+ spindle cells, characterized by long slender processes. Using double-marker analysis we could demonstrate the epithelial nature of these cells (expression of keratin and lack of lymphoid and B-cell-related markers). The immunoreactivity of thymoma epithelial cells with L26, an antibody widely used in the characterization of B-cell lymphomas, can represent a drawback of practical relevance in the differential diagnosis of mediastinal tumors.

MR imaging of thymoma: radiologic-pathologic correlation.

MR images in 17 patients with surgically proved thymomas (12 malignant and five benign) were reviewed and compared with pathologic specimens. In nine cases, MR images of excised specimens also were made and evaluated. On T2-weighted images, 11 of 12 malignant thymomas had an inhomogeneous signal intensity, half with and half without a lobulated internal architecture. None of the five benign thymomas had a lobulated internal architecture, and they all had a moderately or slightly inhomogeneous signal. Cystic regions and/or hemorrhage were noted pathologically, and corresponded to areas of inhomogeneous high signal intensity seen on T2-weighted images. Examination of the excised specimens in malignant thymomas showed that the lobulated configuration seen in the tumors was caused by thick fibrous septa. Our experience suggests that, although calcification cannot be identified, MR is helpful in making a differential diagnosis of mediastinal tumors and in determining malignancy of thymoma.

Bronchogenic cyst

The article describes a patient with a right paratracheal bronchogenic cyst in whom the preoperative diagnosis was unclear. The fluid component of the cyst was not readily apparent by CT or T1-weighted MR images. Very intense signal on T2-weighted MR images suggested a cystic lesion. Inhomogeneities evident on MR but not CT images provided further soft tissue characterization. These soft tissue elements correlated with a macroscopic ring of hyaline cartilage in the resected specimen. The usefulness of MRI for the differential diagnosis of mediastinal tumors is discussed.

Thymolipoma: A report of three cases

Three cases of thymolipoma, seen in a 6 year old boy, a 34 year old woman and a 24 year old man are presented herein. The weight of each tumor was 1380 g, 670 g and 560 g respectively. The 2 male patients had no symptoms and the woman only complained of a fever. On CT scan the thymic tissue was recognized as islands of soft tissue density within a fatty mass, and T1 weighted MRI was helpful in demonstrating the predominant fatty nature of this tumor. Thus, our experience demonstrates that CT and MRI are valuable for establishing a diagnosis of thymolipoma. In a review of the literature on the subject, some clinical features of this non-malignant tumor in the mediastinum are discussed. Although rare, thymolipoma should be considered in the differential diagnosis of mediastinal tumors.

Mediastinal Mass Caused by Vertebral Osteomyelitis

POSTERIOR mediastinal occurring in early infancy are usually neuroblastomas or gastrointestinal duplications. Such are rare. In a recent study at the Boston Children's Hospital only eight infants had neuroblastoma and ten had duplications in the mediastinum, as compared to a total of 402 patients with esophageal atresia. 1 Other posterior mediastinal tumors to be considered in infancy are bronchogenic cysts, esophageal lesions such as achalasia or hiatus hernia, herniation of solid viscera through the foramen of Bochdalek, and mediastinal meningocele. Two patients are reported who had vertebral osteomyelitis which extended into the surrounding soft tissue, forming a posterior mediastinal mass. This lesion is not usually considered in the differential diagnosis of mediastinal tumors. Report of Cases Case1.—A female infant born on June 24, 1955, required an exchange transfusion for erythroblastosis. On July 8, 1955, she had an abscess on the right palm which was treated by incision

The differential diagnosis of mediastinal tumor and aortic aneurysm. Value of contrast cardiovascular visualization: Steinberg, Israel, Robb, George P., and Roche, Ursula J.: New York State J. Med. 40: 1168, 1940

The differential diagnosis of mediastinal tumor and aortic aneurysm. Value of contrast cardiovascular visualization: Steinberg, Israel, Robb, George P., and Roche, Ursula J.: New York State J. Med. 40: 1168, 1940