Large Anterior Mediastinal Mass Research Articles

An Unusual Finding in a Woman Undergoing Resection of a Large Anterior Mediastinal Mass

An Unusual Finding in a Woman Undergoing Resection of a Large Anterior Mediastinal Mass

Atypical Incidental Presentation of Thymolipoma With Macroscopic Appearance Suggestive of Malignancy in Patient Undergoing Coronary Artery Bypass Grafting

Purpose: We report the incidental finding of a thymolipoma in a 61-year-old male undergoing urgent CABG with intra-operative findings suggestive of malignant progression. Methods: A 61-year-old male undergoing urgent CABG for triple vessel disease was noted to have a large anterior mediastinal mass upon primary median sternotomy. The 5 cm mass appeared to be infiltrating the SVC, left innominate vein junction and pericardium, with the appearance highly suggestive of malignancy. Given this, and to ensure full oncological clearance, the mass and infiltrated pericardium was excised along with the wall of the SVC and innominate vein which was subsequently repaired using a bovine pericardial patch. Following this, CPB was introduced via 2-stage cannulation and routine coronary artery bypass grafting was performed using LIMA and vein grafts. Results: The patient required a prolonged period of postoperative ventilatory support before being extubated day 4 and went on to have an uneventful recovery. Anatomical histopathology demonstrated the mass was a benign thymolipoma with significant infarction with necrosis and florid histiocytic reaction accounting for the malignant macroscopic appearance. No further follow-up was required. Conclusions: Histiocytic reaction in an infarcting anterior mediastinal thymolipoma can present with macroscopic changes highly suggestive of a malignant process in an otherwise benign lesion.

A Case of Persistent Right Ventricular Failure after Rapid Decompression of a Large Chronic Pericardial Effusion

A 33-year-old male presented to emergency with right sided pleuritic chest pain, exertional dyspnoea, and lower limb oedema over the preceding 2 months. There were no other significant cardiac or medical problems and no regular medications. He was tachycardic (130bpm) but normotensive, tachypneoic (30 min) with normal saturation. Chest x-ray showed marked cardiomegaly; urgent transthoracic echocardiogram (TTE) demonstrated a very large global pericardial effusion with diastolic RV collapse and echocardiographic evidence of tamponade. Urgent pericardiocentesis removed 2L of straw coloured fluid via the subxiphoid approach. Despite drainage the patient had persistent dyspnoea and was hypotensive. Progress TTE on day 2 showed a moderate (22 mm) residual pericardial effusion with no evidence of tamponade, however the RV was moderately dilated (base 54 mm) with severely impaired segmental systolic dysfunction. The RV basal segment was akinetic with a hyperkinetic mid-apex (McConnell's sign). LV size was normal with mildly impaired systolic function. CTPA showed an incidental large anterior mediastinal mass (10 × 18 × 14 cm) and was highly suspicious for lymphoproliferative disease. There was no pulmonary embolus and no features of pulmonary arterial hypertension apart from dilated RV. Reaccumulation of the pericardial effusion necessitated creation of a pericardial window. Biopsy of the mediastinal mass confirmed Hodgkin's lymphoma (classical nodular sclerosing type). Staging PET and CT abdomen/pelvis showed stage II disease, and treatment with BEACOPP was commenced. This case highlights the importance of gradual decompression of symptomatic pericardial effusion to avoid RV failure which could be caused by myocardial stunning or by a variant reperfusion injury as a consequence of pericardiocentesis.

Re-expansion Pulmonary Edema after Drainage of Pleural Effusion in a Pediatric Patient with a Large Anterior Mediastinal Mass

Clinical case presentation of a 13 year old male with a newly diagnosed anterior mediastinal mass who developed rapid respiratory distress after drainage of a pleural effusion. We include a discussion of the incidence, natural history, and peri-operative management of children with re-expansion pulmonary edema.

Successful Early Outcome with Low-Dose (400 cGY) Total Body Irradiation in Combination with Busulfan and Fludarabine Myeloablative Conditioning Followed By Matched Unrelated Donor Allogeneic Peripheral Blood Stem Cell Transplantation in a Patient with Non-Remission Acute Myelogeneous Leukemia with Diffuse Extramedullary Disease in Multiple Sites

Outcome after allogeneic stem cell transplantation (allo-SCT) is poor with 10-20% probability of long term survival in patients with acute myelogeneous leukemia (AML) not in remission at the time of transplant. The main cause of transplant failure in this high risk population is disease post-transplant relapse. We treated a 32 year-old male with undifferentiated AML (M0) who initially presented with leukocytosis, circulating blasts and a large anterior mediastinal mass abutting adjacent structures. A core biopsy of the mass revealed myeloid sarcoma. Patient developed respiratory distress requiring endotracheal intubation and mechanical ventilation. Cytogenetics revealed Hyperdiploid, 55, XY,+4,+6,+8,+9,+10,+11,+14,+19,+mar[12]/46,XY[14]. FLT3 ITD was positive. He did not respond to initial induction chemotherapy with 7+3 (daunorubicin 60 mg/m2/d and Cytarabine 100 mg/m2/d). He achieved morphologic and cytogenetic complete remission after re-induction with high dose cytarabine and mitoxantrone. He also received scheduled prophylactic triple intrathecal chemotherapies throughout his treatment course and started high dose cytarabine consolidation (HIDAC). His treatment courses were complicated by numerous medical problems, requiring a second prolonged hospitalization following third consolidation. He was intubated again due to diffuse alveolar hemorrhage. The patient was eventually discharged with tracheostomy collar and supplement oxygen, which was discontinued later on. A follow-up CT of chest showed increase in size of mediastinal mass but continuous CR in BM exam. While unrelated donor allogeneic SCT is in process, he received one course of decitabine. At the time of pre-transplant work-up, he relapsed of her AML first at his left conjunctivae and shortly after on his skin, presented with diffuse chloroma lesions on his trunk. He was treated with external radiation to his left eye with additional IT chemo (negative cytology). He underwent 10/10 HLA match unrelated donor allogeneic stem cell transplantation following PK-directed IV Busulfan with targeted AUC of 20,000 and Fludarabine 160 mg/m2 plus total body irradiation 200 cGY/d x 2 days. Skin lesions were active but bone marrow was in remission at the time of transplant. GVHD prophylaxis was tacrolimus and low dose methotrexate 5 mg/m2/d on days+1, +3, and +6 only. No ATG was given. His post-transplant course was relatively unremarkable. No major complications requiring re-admission to hospital occurred. His trach collar was kept thoughout his transplant and post-transplant courses due to tracheal stenosis. He achieved complete morphologic and cytogenetic remission with resolution all of his extramedullary leukemia including his mediastinal mass on day+100 evaluation. Currently he has been receving monthly 5-Azacitidine maintenance and clinically well on day+122. This case illustrates a successful early outcome after peripheral blood allogeneic stem cell transplantation using the combination of chemo-low dose radiation in a patient with non-remission AML with diffuse extra medullary disease. Optimum combination of radiation and chemotherapy in conditioning regimens may improve transplant outcomes in patients with non-remission AML and warrants prospective Phase I-II clinical trials. DisclosuresNo relevant conflicts of interest to declare.

Bridging to Second Allogeneic Peripheral Blood Stem Cell Transplantation with Nelarabine in a Patient with Multiply Relapsed/Refractory T-Cell ALL

T-cell acute lymphoblastic leukemia (ALL) is a very challenging disease to attain durable remission once relapses. We treated a 40 year-old female with T-cell ALL, normal cytogenetic who relapsed twice after her matched related donor allogeneic stem cell transplantation (allo-SCT) with Nelarabine achieving third complete remission prior to second allo-SCT. She was initially treated with HyperCVAD x 5 cycles with IT chemo (negative cytopathology). After achieving complete remission (CR), she received PK-directed IV Busulfan and Fludarabine myeloablative conditioning followed by 12/12 HLA-MRD allo-SCT with 11.06 x 106 CD34+cells/kg. GVHD prophylaxis was Tacrolimus and mini-Methotrexate (5 mg/m2/dose). She engrafted on time. She never had GVHD. On day+ 100, bone marrow biopsy revealed relapsed disease involving 60% of marrow space. Patient was treated with one cycle augmented HyperCVAD resulted in second CR. She developed elevated transaminases, liver biopsy was consistent with NASH and drug-induced liver injury, negative for GVHD. She was given alpha interferon 3 million units MWF in attempt to induce GVHD/GVL while pending insurance approval for donor lymphocyte infusion. She developed full donor chimerism as well as extensive chronic GVHD involving skin, liver, skin, lung, eyes, vagina, and mouth after interferon. She was treated only with topical steroid therapies and remained in CR until day+266. On Day+266, she was again found to have relapse of her disease with significant leukocytosis and circulating blasts. CT scan showed recurrent large anterior mediastinal mass. She was treated with Cytoxan (500 mg/m2) and Etoposide (100 mg/m2 x 5 days), complicated with neutropenic fevers before receiving outpatient Nelarabine. She recovered with progressive leukemia, which was treated with a single dose of Cytoxan 600mg/m2. She developed diffuse alveolar hemorrhage, treated in the MICU with high dose steroids and antimicrobials. She was discharged to outpatient clinic and given Nelarabine at 1500 mg/m2 on days +1, +3, +5, every 3 weeks for 2 cycles. Her clinical condition and peripheral counts improved with disappearing peripheral blasts after the initial cycle of Nelarabine. She received second cycle and subsequent restaging studies showed remission marrow (CR-3) with complete resolution of mediastinal mass on CT scan. She developed mild neuropathy after Nelarabine. She is currently inpatient receiving her for second MRD allo-SCT. This case is noteworthy and clearly illustrates lack of GVL effect in T-cell ALL and an efficacy of two cycles of Nelarabine even in the setting of refractory T-cell ALL relapsing twice after allogeneic SCT. DisclosuresNo relevant conflicts of interest to declare.

Giant Thymoma and Cardiac Tamponade

SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: The thymus is a gland overlying the pericardium and great vessels in the anterior mediastinum that typically involutes after puberty. Thymomas are rare tumors of the thymus gland in which associated pericardial effusions are found in a minority while hemorrhagic pericardial effusion causing tamponade physiology is extremely rare (1). We present a case of a patient who had hemorrhagic pericardial effusion with cardiac tamponade due to a malignant Type B2 Thymoma. CASE PRESENTATION: A 51-year-old previously healthy male presented to the hospital with a four-week history of progressive dyspnea on exertion, orthopnea, and pleuritic chest pain, as well as, six months of 40-pound weight loss. On examination, he was found to be tachycardic with normal heart sounds, distended neck veins, and bilateral basal lung rales. Pulsus paradoxus was 24 mm Hg. Electrocardiogram showed sinus arrhythmia with tachycardia, diffuse low voltage QRS complexes and T-wave flattening in the inferior leads, without electrical alternans. His CBC showed leukocytosis with lymphocytic predominance. Other labs, including ESR, CRP, TSH, ANA, HIV, Rheumatoid Factor, syphilis and myasthenia gravis antibodies, were within normal limits. A Chest X-ray demonstrated an enlarged Cardiac silhouette and a large anterior mediastinal mass. Transthoracic echocardiogram showed a large pericardial effusion with tamponade physiology, as well as, a mass anterior to the right heart. An urgent pericardiocentesis was performed draining 640 ml of bloody fluid with the resolution of tamponade. Chest CT confirmed a large anterior mediastinal mass (16.3 x 19.5 x 20.6 cm) with central areas of necrosis and significant mass effect on the heart, trachea, and the bilateral main stem bronchi. Subsequently, the patient underwent mediastinoscopy with biopsy and flow cytometry demonstrating malignant Type B2 Thymoma. The patient was treated with neoadjuvant chemotherapy with cisplatin, doxorubicin, cyclophosphamide, and prednisone. He then underwent surgical debulking with plans for radiation therapy. DISCUSSION: The overall incidence of thymoma is 0.15 cases per 100,000 (2). Hemorrhagic pericardial effusion with cardiac tamponade represents a rare initial presentation of Malignant Thymoma. CONCLUSIONS: Thymic pathologies should be included as a rare etiology in the differential diagnosis of hemorrhagic pericardial effusion and cardiac tamponade. To the best of our knowledge, this case represents the largest malignant thymoma that has been diagnosed with a presentation of hemorrhagic pericardial effusion and cardiac tamponade Reference #1: Takanami I, Takeuchi K, Naruke M. Noninvasive large thymoma with a natural history of twenty-one years. J Thorac Cardiovasc Surg. 1999;118:1134-1135. doi: 10.1016/S0022-5223(99)70120-0. Reference #2: Engels EA, Pfeiffer RM: Malignant thymoma in the United States: demographic patterns in incidence and associations with subsequent malignancies. Int J Cancer 105(4):546-51, 2003 DISCLOSURE: The following authors have nothing to disclose: Irfan Ahsan, Wisam Alfay, Jenna Jarriel, Gregary Marhefka No Product/Research Disclosure Information

A case of TAFRO syndrome with a large mediastinal mass treated with debulking surgery.

Multicentric Castleman’s disease is a polyclonal lymphoproliferative disorder. Recently, a new variant of the disease was reported and named TAFRO syndrome, an acronym for thrombocytopenia, ascites, myelofibrosis, renal dysfunction, and organomegaly. A 55-year-old woman presented to our hospital with dyspnea on exertion and high fever. Laboratory tests revealed anemia, thrombocytopenia, and proteinuria. Computed tomography (CT) revealed a large anterior mediastinal mass, mild splenomegaly, bilateral pleural effusion, pericardial effusion, and mild systemic lymphadenopathy. A CT-guided biopsy was unable to establish a definitive diagnosis, so we resected the mediastinal mass for diagnostic and therapeutic purposes. Pathological findings were consistent with the hyaline vascular type of Castleman’s disease (CD), and she was diagnosed with TAFRO syndrome. There has been no description of a patient with TAFRO syndrome with a large mass, and this is the first case of TAFRO syndrome treated with debulking surgery.

Thoracoscopic thymectomy in a patient with pemphigus.

The presenting case is a 50-year-old man with pemphigus foliaceus who was found to have a thymoma. Computed tomography (CT) scans revealed a large anterior mediastinal mass, 6 cm in diameter, which was heterogeneous in appearance with no evidence of invasion. CT-guided biopsy confirmed the diagnosis of type AB thymoma. The patient was otherwise functionally independent, with an Eastern Cooperative Oncology Group (ECOG) status of 1 and normal pulmonary function. Informed consent was obtained for a video-assisted thoracoscopic surgery (VATS) radical thymectomy.

Bilateral Saphenous Vein Graft Aneurysms

SESSION TITLE: Procedures Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: More than 50 years have passed since CABG was first successfully performed in humans. Despite many improvements in surgical technique, complications of CABG continue to occur. Here, we present a rare case of bilateral saphenous vein graft aneurysm as a late complication of CABG. CASE PRESENTATION: 77 yo man with CAD status post CABG 12 years ago, presented for evaluation of chest pain and dyspnea. On examination, his vitals were stable and his exam was unremarkable. Basic labs, including cardiac enzymes, were unrevealing. A chest x-ray demonstrated fullness in the right hilum worrisome for a mass (1). CT of the chest with contrast confirmed two large anterior mediastinal masses as well as mediastinal lymphadenopathy. Percutaneous CT guided biopsy showed only blood and was complicated by a hemothorax. Further work up with bronchoscopy and biopsy was non diagnostic. Coronary CT angiography revealed aneurysms of two coronary bypass vein grafts (2). The right graft was patent to the RCA, but the left was occluded. Patient was offered surgical treatment, but he declined, opting for conservative management. He is doing well 1 year after initial diagnosis. DISCUSSION: Saphenous Vein Graft Aneurysm (SVGA) is a rare complication of CABG. The overall incidence is likely less than 0.5% of grafts. Proposed etiologies include exposure to arterial pressures, atherosclerotic changes, infection, and technical factors during harvest and transplant. Typical presentation is with chest pain, dyspnea, and MI, but a large number of patients are asymptomatic. Multiple studies have documented aneurysmal enlargement, however the rate of growth is variable. Large aneurysms have higher rates of mechanical complications, but increasing size has not been demonstrated to increase the risk of rupture or death. Treatment data is limited, with some case series advocating conservative management 1, and others suggesting surgical treatment 2. Recently, increasing percutaneous options are becoming available. CONCLUSIONS: Anterior mediastinal mass with a history of CABG should raise suspicion for SVGA. More data is needed to determine optimal treatment. Reference #1: Dieter, R. S., et al. (2003). “Conservative vs. invasive treatment of aortocoronary saphenous vein graft aneurysms: Treatment algorithm based upon a large series.” Cardiovasc Surg 11(6): 507-513. Reference #2: Sareyyupoglu, B., et al. (2009). “Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization.” Ann Thorac Surg 88(6): 1801-1805. DISCLOSURE: The following authors have nothing to disclose: Michael Tatusov No Product/Research Disclosure Information

Regional anesthesia for an upper extremity amputation for palliative care in a patient with end-stage osteosarcoma complicated by a large anterior mediastinal mass

Tumor progression during end-of-life care can lead to significant pain, which at times may be refractory to routine analgesic techniques. Although regional anesthesia is commonly used for postoperative pain care, there is limited experience with its use during home hospice care. We present a 24-year-old male with end-stage metastatic osteosarcoma who required anesthetic care for a right-sided above-the-elbow amputation. The anesthetic management was complicated by the presence of a large mediastinal mass, limited pulmonary reserve, and severe chronic pain with a high preoperative opioid requirement. Intraoperative anesthesia and postoperative pain management were provided by regional anesthesia using an interscalene catheter. He was discharged home with the interscalene catheter in place with a continuous local anesthetic infusion that allowed weaning of his chronic opioid medications and the provision of effective pain control. The perioperative applications of regional anesthesia in palliative and home hospice care are discussed.

A Unique Case of Mediastinal Teratoma with Mature Pancreatic Tissue, Nesidioblastosis, and Aberrant Islet Differentiation: a Case Report and Literature Review

Mediastinal teratomas with elements of mature pancreatic tissue are rare. Only a very few cases of pancreatic tissue with nesidioblastosis in teratoma have been reported. Here, we report a case of a 12-year-old male who presented with pleural effusion and was revealed to have a large anterior mediastinal mass. Biopsy of the mass revealed benign mature teratoma. After biopsy, the teratoma ruptured into the right thoracic cavity. It was then excised and sent to pathology for further evaluation. Preoperatively, there was no evidence of hyperinsulinemia or hypoglycemia. Postoperatively, there was no change in blood glucose levels. Histologically, the mass showed large areas of mature pancreatic tissue flanking a small intestine-like structure. Numerous endocrine cell islets, poorly defined groups of neuroendocrine cells and ductular-insular complexes characteristic of nesidioblastosis were dispersed in the exocrine pancreatic parenchyma. In addition, other parts of the tumor containing keratinizing squamous epithelium with cutaneous adnexal glands, small intestine, and bronchus including cartilage and respiratory epithelium were observed. Some islets contained two or more cell types while others were monophenotypic. Immunohistochemical staining showed pronounced expression of pancreatic polypeptide, moderate expression of somatostatin and insulin and nearly complete absence of glucagon-containing cells. The selective deletion of glucagon might hold clues to an important regulatory mechanism in pancreatic development.

Controlled Trachea Suspension for Tracheomalacia After Resection of Large Anterior Mediastinal Mass

Tracheomalacia is a disorder of the large airways that is often caused by a large anterior mediastinal mass. This study describes 7 patients who underwent controlled trachea suspension as a surgical intervention to prevent severe tracheomalacia and provide potent relief of airway symptoms. All patients recovered well. The results demonstrate this procedure may be safe and effective for resection of a large mediastinal mass compressing the trachea with collapsed segments.

Extracorporeal Membrane Oxygenation as a Bridge through Chemotherapy in B-Cell Lymphoma

A 41-year-old female presented with a large anterior mediastinal mass adjacent to the heart. Biopsy demonstrated lymphoma. Upon administration of chemotherapy, she developed cardiogenic shock requiring a 5-day course of extracorporeal membrane oxygenation (ECMO) as a bridge through her treatment. After one cycle of chemotherapy, ECMO was discontinued and the patient completed her course of chemotherapy and recovered to hospital discharge.

A Case of Complete Video-Assisted Thoracoscopic Surgery (VATS) for Thymoma With Pure Red Cell Aplasia (PRCA)

Introduction: Although thymoma is the most common anterior mediastinal tumor, only 5% of thymoma cases develop pure red cell aplasia (PRCA). Case Presentation: In this article we have reported a 59-year-old man with a large anterior mediastinal mass (diameter of 10 cm) and severe anemia, that thymoma and pure red cell aplasia have been demonstrated by histopathologic and hematological examination. Despite the large mass, a complete video-assisted thoracoscopic surgery (VATS) thymectomy and combinational medical therapy were performed for him successfully. Aplasia remission occurred 6 months after thymectomy and his hemoglobin level reached to 13 g/dL. Conclusions: We believe that a complete resection in combination with medical therapy is necessary to achieve total remission of PRCA symptoms and conclude that VATS thymectomy is an effective and technically feasible procedure for surgery without any contraindications about the size of the thymoma in these patients.

Giant Coronary Aneurysm Diagnosed as Incidental Mediastinal Mass

A 41-year-old man with epigastric pain and nephrolithiasis was found to have an incidental large anterior mediastinal mass on computed tomography ([Figure 1A][1]). Transthoracic echocardiography was suggestive of a giant coronary aneurysm (GCA) versus pericardial cyst ([Figure 1B][1], [Online

Safety and Early Efficacy in an Ongoing Pilot Study of Brentuximab Vedotin and AVD Chemotherapy Followed By 30 Gray Involved-Site Radiotherapy for Newly Diagnosed, Early Stage, Unfavorable Risk Hodgkin Lymphoma

Background: Brentuximab vedotin has not been previously studied in combination with combined modality therapy for the frontline treatment of early stage Hodgkin lymphoma. We designed a pilot study to assess the safety and early efficacy of four cycles of brentuximab vedotin (BV) + AVD chemotherapy followed by 30 Gray involved-site radiotherapy (ISRT) for the treatment for early stage, unfavorable risk HL.Methods: Patients with newly diagnosed, stage I/II, classical HL with unfavorable risk profile (defined by the German Hodgkin Study Group (GHSG) with one of the following criteria: bulky mediastinal mass (≥1/3 maximum transverse thoracic diameter on PA-CXR or ≥10cm by CT imaging in transaxial plane), ESR≥50mm/h or ESR≥30mm/h in patients with “B” symptoms, extranodal involvement, or >2 involved lymph node sites) were eligible. Patients with stage IIB disease with disease bulk or extranodal involvement were included (conventionally classified as advanced stage per GHSG). Patients were treated with four cycles of brentuximab vedotin 1.2 mg/kg with AVD chemotherapy every 2 weeks followed by 30 Gray involved-site radiotherapy. The primary endpoint of the study was to evaluate the safety of this regimen, with particular attention to the development of pulmonary toxicity. A PET/CT was performed after 2 and 4 cycles of therapy. PET scans were interpreted using the Deauville 5-point scale and a negative scan was defined as Deauville 1-3.Results: Interim data for the first 19 of a planned 30 patients enrolled are presented here. Median age was 32 (range, 18-50), 47% female, 100% stage II disease, 53% with disease bulk by GHSG criteria, 53% elevated ESR, 34% B-symptoms, 37% extranodal involvement, 42% >2 involved lymph node sites. All patients with disease bulk had large anterior mediastinal masses measuring >10cm by CT in transverse plane (range, 10-16.9 cm). There were eight patients enrolled who would be considered to have advanced stage disease by the GHSG classification: 3 with IIBX, 3 with IIBE, and 2 with IIBXE disease. To date, 79% (15/19) and 63% (12/19) have completed interim PET-2 and PET-4 imaging studies, respectively. Ninety-three percent of patients (14/15) achieved a negative PET scan after 2 cycles (6, 8, and 1 patients achieved Deauville score of 2, 3, 4, respectively). All patients with disease bulk were PET-2 negative (10/10). Ninety-two percent of patients achieved a negative PET scan after 4 cycles of therapy (1, 8, 2, and 1 patients achieved Deauville score of 1,2,3,4, respectively). The patient with a positive PET-4 scan had a subsequent positive biopsy and will be treated off study for primary refractory HL. The study treatment has been well-tolerated. No pulmonary toxicity has been observed. Serious adverse events have been documented in two patients: febrile neutropenia and grade 3 hypertension. One patient discontinued protocol treatment due to the development of grade 3 peripheral neuropathy after one treatment with BV+AVD. The four patients who have completed combined modality therapy and an end-of-treatment imaging assessment achieved complete responses and no relapses have occurred to date.Conclusion: The combination of BV+AVD chemotherapy followed by ISRT appears well-tolerated with no early signal of increased pulmonary toxicity. In this interim analysis of 19 newly diagnosed patients with early stage, unfavorable risk HL, over ninety percent of the evaluable patients have achieved negative interim PET scans after 2 and 4 cycles of BV + AVD, suggesting this is a highly active treatment program even in patients with substantial disease bulk. Updated safety and response data will be presented at the meeting. DisclosuresHamlin:Spectrum, GSK, Jansen and Jansen/Pharmacyclics, Portola, Seattle Genetics: Research Funding; Gilead, Spectrum, Seattle Genetics, Genentech: Consultancy. Horwitz:Celgene: Consultancy, Research Funding; Millennium: Consultancy, Research Funding; Infinity: Research Funding; Kiowa Kirin: Research Funding; Seattle Genetics: Consultancy, Research Funding; Spectrum: Research Funding; Amgen: Consultancy; Bristol Myers Squibb,: Consultancy; Jannsen: Consultancy. Matasar:Genentech: Consultancy; Spectrum: Consultancy. Younes:Novartis: Research Funding; J & J: Research Funding; Curis: Research Funding; Bayer; Bristol Meyer Squibb; Celgene; Incyte; Janssen R & D; Sanofi; Seattle Genetics; Takeda Millenium: Honoraria. Moskowitz:Seattle Genetics, Inc.: Consultancy, Research Funding; Genentech: Research Funding; Merck: Research Funding.

Clinical outcome of thymic lymphoepithelioma-like carcinoma: Case report of a 14-year-old male.

Thymic carcinoma is a rare type of cancer, which arises from the thymic epithelium and accounts for ~1–4% of anterior mediastinal tumors in the USA. It rarely occurs in children, and is rarer among adults. Thymic lymphoepithelioma-like carcinoma (LELC) is an uncommon subtype of thymic carcinoma in children, however, it is one of the common histological subtypes of thymic carcinoma in adults. In the present study, a 14-year-old male patient presented to the Tokyo Metropolitan Cancer and Infectious diseases Center, Komagome Hospital (Tokoyo, Japan) with chest pain due to a large anterior mediastinal mass. The patient was histologically diagnosed with thymic LELC via a needle biopsy specimen, which was obtained from the primary site and indicated the Epstein-Barr virus infection, whose markers are also associated with oncogenesis. Immunohistochemical analysis demonstrated positive staining for keratin (AE1/AE3), epithelial membrane antigen, and latent membrane protein-1 and negative staining for cluster of differentiation 5. Thus, the patient was diagnosed with metastatic thymic LELC. First-line chemotherapy comprising of a cisplatin- and adriamycin-based chemotherapy regimen achieved a partial response, however, the patient succumbed within 10 months of the initial diagnosis due to rapid disease progression and refractory to subsequent cycles of chemotherapy. Thus, the current study, as well as previously reported cases, demonstrates that pediatric patients with thymic LELC continue to have a poor prognosis.

Focused echocardiogram by emergency physicians (EP) in resuscitation room of Accident and Emergency (A&E) Department

Results Patient A, elderly lady with lung cancer presented with progressive dyspnoea, desaturation, and low blood pressure. Bedside echo showed dilated right ventricle and McConnell sign. Diagnosis of pulmonary embolism was confirmed by CTPA. She was given thrombolytic in A&E with hemodynamic improvement. Patient B, 55 year old man presented with vomiting, diarrhoea, hypotension and tachycardia. Bedside echo showed severely depressed myocardial contractility. Provisional diagnosis of myocarditis was made, which proved to be the eventual diagnosis. Patient C, 49 year-old lady presented with epigastric discomfort and desaturation. Bedside echo showed right atrial (RA) mass. CT in A&E showed large anterior mediastinal mass with invasion into RA. The diagnosis was later confirmed to be spindle cell carcinoma with RA invasion. Patient D, 63 year-old man presented with dizziness and breathlessness. Clinically he was in profound shock, with pale appearance and cold extremities. BP was not recordable and blood gas showed severe lactic acidosis with pH 6.9. Bedside echo showed a large circumferential pericardial effusion with collapsed right chambers and plethoric IVC. Emergency pericardiocentesis was done with dramatic improvement in hemodynamic status. CT thorax showed a right lung tumour abutting the pericardium.

English

We report a 35-year-old gentleman who presented to us with respiratory distress. He was diagnosed to have a large anterior mediastinal mass and was and posted for debulking of mediastinal mass. Immediately after intubation, airway collapsed and there was difficulty in ventilating the lungs, followed by drop in oxygen saturation. After sternotomy, oxygen saturation and airway pressures improved. In this report we discussed in detail about the successful anaesthetic considerations for patients with large anterior mediastinal tumour including the management of airway obstruction.