Mediastinal Cyst Research Articles

A Mediastinal Cyst With Mullerian Differentiation in a Patient With an Ovarian Cyst

A Mediastinal Cyst With Mullerian Differentiation in a Patient With an Ovarian Cyst

Posterior Mediastinal Paravertebral Müllerian cyst (cyst of Hattori): literature review.

Mediastinal cysts are typically of bronchogenic, thymic or neurenteric origin, but may also represent oesophageal duplication. Posterior paravertebral mediastinal Müllerian cysts of undetermined pathogenesis are very rare occurrences. The first case of a ciliated cyst arising in the mediastinum, of probable Müllerian origin, was reported by Hattori in 2005, which gave rise to the name cyst of Hatorri (COH) The number of reported cases in literature of a similar nature have since then increased significantly. One of the main concerns about this pathology is the possibility of malignant transformation of the Müllerian tissue. Over the course of this paper we will discuss the pathogenesis, immunohistochemistry and its role in differential diagnosis as well as optimal treatment of such cysts.

Pilot Study of the Difference C-TBNA with EBUS-TBNA in Mediastinal Bronchial-Derived Cysts

Objective: To investigate the difference value of conventional transbronchial needle aspiration (C-TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in mediastinal bronchogenic cysts. Method: A retrospective analysis of clinical data and follow-up data of 27 patients using conventional TBNA and EBUS-TBNA techniques diagnosed as mediastinal bronchogenic cysts from May 2008 to December 2016 in the First Affiliated Hospital of Soochow University was done. Results: In 8 years, there were 13 cases of C-TBNA and 14 cases of EBUS-TBNA-diagnosed mediastinal bronchogenic cysts. C-TBNA extracted clear liquid and its volume was 8.9 ± 1.5 ml. The 14 patients examined by EBUS had a homogenous anechoic signal. Clear liquid was extracted, and its volume was 29.1 ± 7.5 ml. The cyst liquid extracted with EBUS-TBNA was significantly more than that extracted with CTBNA (P < 0.05). During follow-up, 1 patient had cyst rupture after being punctured by C-TBNA, secondary pulmonary infection and right pleural effusion, followed by surgical treatment. The recurrence rate for C-TBNA was 100.00% (13/13), and that for EBUS-TBNA was 14.29% (2/14) (P < 0.05). Conclusion: The C-TBNA and EBUS-TBNA technologies have high diagnostic value for the mediastinal bronchogenic cysts. Both C-TBNA and EBUS-TBNA technologies have the risk of secondary infection and recurrence of cysts.

Non-Neoplastic Mediastinal Cysts.

Primary mediastinal cysts are infrequent lesions that can arise from a variety of mediastinal organs or structures. Most of these are congenital in origin and incidental findings during investigations for unrelated conditions. Histologically, the cysts may be composed of various tissues, including bronchogenic, pericardial, thymic, enteric, Müllerian, lymphatic, and parathyroid types. Mediastinal cysts typically demonstrate a benign clinical course and patients are cured after complete surgical resection. In this review, the embryogenesis, clinical, radiologic, and pathologic characteristics of non-neoplastic mediastinal cysts are examined with discussion of the role of immunohistochemistry and the most pertinent differential diagnosis.

Bronkojenik ve Perikardiyal Kistin Eş Zamanlı Videotorakoskopik Rezeksiyonu

Primary mediastinal cysts are rare, congenital and benign lesions originating from various embryological tissue types. However, it can present with similar clinical and radiological findings at almost every age. We present this case to emphasize that two separate mediastinal cysts originating from different embryological origins in different compartments of the mediastinum are extremely rare and that these cysts can be simultaneously resected by videothoracoscopic surgery.

Mutiloculated thymic cyst: unusual presentation of mediastinal mass

Here we present a case of 47 year male found to have large multiloculated thymic cyst during work up done for recurrent pleural effusion. Mediastinal cyst constitutes 10-15% of all radiographically detected mediastinal masses. Thymic cyst account only 5% of mediastinal masses. Thymic cyst can cause difficulty in diagnosis due to its rare presentation, invasive nature and occasional associated with thymic neoplasm. They have been detected incidentally and associated with Sjögren’s syndrome, aplastic anemia myasthenia gravis and immunocompromised patients. Here we present a case of 47-year-old male initially work up done for recurrent pleural effusion turned out to be large multilocuated thymic cyst improved after excision which had no associated syndromes and immunocompromised state.

Distribution of Mediastinal Lesions Across Multi-Institutional, International, Radiology Databases.

Mediastinal lesions are uncommon; studies on their distribution are, in general, small and from a single institution. Furthermore, these studies are usually based on pathology or surgical databases and, therefore, miss many lesions that did not undergo biopsy or resection. Our aim was to identify the distribution of lesions in the mediastinum in a large international, multi-institutional cohort. At each participating institution, a standardized retrospective radiology database search was performed for interpretations of computed tomography, positron emission tomography-computed tomography, and magnetic resonance imaging scans including any of the following terms: "mediastinal nodule," "mediastinal lesion," "mediastinal mass," or "mediastinal abnormality" (2011-2014). Standardized data were collected. Statistical analysis was performed. Among 3308 cases, thymomas (27.8%), benign mediastinal cysts (20.0%), and lymphomas (16.1%) were most common. The distribution of lesions varied among mediastinal compartments; thymomas (38.3%), benign cysts (16.8%), and neurogenic tumors (53.9%) were the most common lesions in the prevascular, visceral, and paravertebral mediastinum, respectively (p < 0.001). Mediastinal compartment was associated with age; patients with paravertebral lesions were the youngest (p < 0.0001). Mediastinal lesions differed by continent or country, with benign cysts being the most common mediastinal lesions in the People's Republic of China, thymomas in Europe, and lymphomas in North America and Israel (p < 0.001). Benign cysts, thymic carcinomas, and metastases were more often seen in larger hospitals, whereas lymphomas and thymic hyperplasia occurred more often in smaller hospitals (p<0.01). Our study confirmed that the spectrum and frequency of mediastinal lesions depend on mediastinal compartment and age. This information provides helpful demographic data and is important when considering the differential diagnosis of a mediastinal lesion.

Role of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in the Diagnosis and Management of Mediastinal Cyst.

Foregut cysts account for >50% of cystic lesions in the mediastinum, of which bronchogenic cysts are most common. Surgical resection is the most definitive approach for its diagnosis and treatment. A recent systematic review, however, suggests that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has a role in the management of bronchogenic cyst. We report our experience with EBUS-TBNA in the diagnosis and management of bronchogenic cysts. Medical records of patients with evidence of mediastinal cysts who underwent EBUS-TBNA between 2008 and 2016 were reviewed.The primary aims of this study were to assess EBUS-TBNA diagnostic yield of peri-bronchial cysts and their specific type/origin and to determine its short-term and long-term drainage efficacy. A total of 26 patients met the inclusion criteria. The cytopathology diagnosis was compatible with bronchogenic cyst in 4 cases, pleural-pericardial cyst in 3 cases, and 19 were indeterminate cysts. Successful long-term treatment occurred in 5.5% of the subjects. One patient developed inflammatory pericarditis after EBUS-TBNA. Diagnostic and therapeutic yield of EBUS-TBNA for mediastinal cysts is limited and surgical resection remains the treatment of choice.

Late Sterile Cyst Formation Following Use of Bioglue in Carotid Endarterectomy

Introduction - Achieving adequate suture line haemostasis is the backbone of successful vascular surgery and high-pressure sealants such as bovine serum albumin-glutaraldehyde glue (BioGlue, CryoLife Inc., Kennesaw) are available to aid successful anastomosis. BioGlue has been shown to be an important and useful adjunct in achieving suture line haemostasis however literature suggests its use is associated with psuedoaneurysm formation, thromboembolic events due to leakage through suture holes, local tissue damage and late aseptic cyst formation. We present a case of late sterile cyst formation following the use of BioGlue in carotid endarterectomy (CEA). Methods - An 88-year-old female was admitted follow left lacunar stroke with significant right arm weakness and dysarthria. Also noted was one week history of an asymptomatic, enlarging right sided neck mass. Patient had undergone a right carotid endarterectomy 9 months previously for tight 90% stenosis of the right internal carotid artery (ICA). BioGlue (BG3515-5-G, LOT 15MGV110) was used during right CEA to aid haemostasis along the suture line. Examination revealed a 5x3x2cm collection inferior to right sternocleidomastoid muscle. Patient afrebrile and inflammatory markers not raised. Duplex ultrasound of the left ICA confirmed 80% stenosis. CT angiogram of carotids showed concentric soft tissue thickening surrounding the right internal carotid artery but anterolaterally there was an irregular 26mm x 19mm x 22mm fluid attenuation component with faint marginal enhancement. There was no evidence of pseudoaneurysm. Left ICA was managed conservatively however surgical exploration of the right neck swelling was performed. Using an oblique incision to open the neck it was evident there was chronic inflammation and a superficial abscess present with connecting sinus to the patched ICA. A large amount of BioGlue was returned with 1cm area of distal patch appearing to be the central focus of possible infective process. Washout performed and deep drain placed. Results - Empirical antimicrobial therapy of 7 days intravenous teicoplanin followed by 7 days oral docycycline was initiated. All microbiological analysis on theatre specimens (routine culture, extended anaerobic culture, actinomyces and AFB culture, 16S RNA viral assay) was negative. Patient was discharged to a local stroke rehabilitation unit. Conclusion - BioGlue has both adhesive and sealant properties. It acts by formation of strong covalent bonds, within 2-3 minutes, allowing rapid haemostasis and reinforcement of friable tissues A large amount of BioGlue was returned on exploration of the neck which is similar to a case of BioGlue associated aseptic mediastinal cyst after coronary artery bypass described by Szafranek et al [1]. At present, we note no cases of late sterile cyst formation after use of BioGlue in vascular surgery. Agents used to aid haemostasis should be used with caution with minimal volume application used to achieve desired effect.

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English

THE EXPANDING ROLE OF EBUS: USE OF ENDOBRONCHIAL ULTRASOUND FOR MANAGEMENT OF A LARGE THORACIC CYST

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: The role of endobronchial ultrasound in the diagnosis and staging of malignancy, infections, and other inflammatory conditions causing enlarged lymph nodes has been well established. However, there have been only a number of case reports suggesting a role for EBUS in the diagnosis and management of mediastinal and thoracic cysts as well. We present a case of a large right apical, fluid filled cyst which was successfully drained with EBUS guidance. CASE PRESENTATION: A 73 y/o female with PMH of polycystic kidney disease and multiple brain aneurysms s/p clipping presented with chest pain and dyspnea. She was referred to the ED by her PCP after a failed trial of azithromycin. CXR revealed a large, right upper lobe mass which was further evaluated with a CT chest showing a 7.1 x 10 cm fluid filled lesion in the right apex with compression of the mediastinum. She was evaluated by both CT surgery and Interventional Pulmonology with the recommendation to attempt bronchoscopic biopsy and drainage. Using EBUS guidance, the Olympus 22g ViziShot needle was advanced into the cyst at the right paratracheal location with successful drainage of 100 cc of clear, yellow fluid. Bacterial, fungal, and AFB cultures were negative. Pathology review showed significant lymphocytes and epithelial cells. The decrease in size of the lesion was visible with EBUS, but also confirmed with post procedure CXR. The patient tolerated the procedure well with resolution of symptoms and no recurrence on imaging at 4 months. DISCUSSION: Despite the significant size of the initial lesion, bronchoscopic drainage of the thoracic cyst using EBUS guidance was both safe and effective. While a clear diagnosis was not obtained to establish the cause of the lesion, the patient had immediate improvement in symptoms with the decrease in size of the lesion and no recurrence to date. EBUS proved to be a useful tool as direct visualization of the lesion during drainage of the cyst allowed for adjustment of needle positioning as the underlying lung re-expanded. The patient was spared the side effects and potential complications that could be associated with a blind biopsy or a surgical intervention. CONCLUSIONS: EBUS appears to be a safe and effective means of drainage of even large thoracic or mediastinal cysts and should be considered prior to more invasive alternatives. Additional studies would be required before routine use of EBUS for this indication can be recommended. Reference #1: Takeda, S et al. "Clinical Spectrum of Mediastinal Cysts." CHEST Journal. Vol 124, Issue 1, pp 125-132. Juy 2003. DISCLOSURES: no disclosure on file for Neeraj Desai; No relevant relationships by Jessica Johnson, source=Web Response

ENDOBRONCHIAL ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION OF A BRONCHOGENIC CYST

SESSION TITLE: Case Report Semifinalists 12 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Bronchogenic cysts are rare congenital malformations that can occur in various parts of the tracheobronchial tree and if symptomatic, can lead to a range of symptoms depending on location [1-2]. Historically, diagnostic confirmation and treatment was achieved via surgical means [1-2]; however, a growing body of evidence exists for the safety and efficacy of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) of bronchogenic cysts [3]. CASE PRESENTATION: A 63-year-old female with a known asymptomatic non-FDG avid mediastinal lesion since 2008 presented for a chronic cough. She had previously presented with a right lower lobe pneumonia in early 2017.Physical exam was notable for an oxygen saturation of 97%, comfortably breathing ambient air with clear lung sounds bilaterally. Computed tomography (CT) imaging in late 2017 revealed significant interval increase in the mediastinal lesion which grew from 1.6x2.3cm to 3.0x2.5cm with associated luminal narrowing of the right bronchus intermedius. The mass was noted to be smoothly marginated, 30-40 Hounsfield units in density, and without associated lymphadenopathy or contrast enhancement, most consistent with an enteric duplication or other mediastinal cyst. Additionally, right lower lobe bronchiectasis and associated bronchial mucous plugging with air trapping was noted. The patient underwent flexible EBUS bronchoscopy. The bronchus intermedius was extrinsically obstructed by 75%. EBUS revealed a well demarcated hypoechoic fluid collection most consisted with a cyst. Transbronchial needle aspiration was performed removing 35mL of fluid. Complete resolution of bronchial luminal narrowing was achieved post-aspiration. The patient recovered without complications. Cystic fluid was sent for analysis. Microbiologic stains and cultures were negative. Cytology was notable for rare bland degenerative epithelial cells in a background of mucoid debris. No malignant cells were identified. DISCUSSION: Bronchogenic cysts are rare and may be associated with symptoms ranging from chronic cough to bronchial obstruction with recurrent infections [1-2]. CT imaging has known limitations in establishing the benign cystic characteristics of bronchogenic cysts [1]. They may be diagnosed and treated via surgical resection, which is invasive and has been associated with increased postoperative complications in symptomatic patients [1]. CONCLUSIONS: EBUS-TBNA is a safe and effective alternative to diagnosis and treatment of bronchogenic cysts. Reference #1: Patel SR, Meeker DP, Biscotti CV, et al. Presentation and management of bronchogenic cysts in the adult. Chest 1994;106(1):79-85. Reference #2: Liu HS, Li SQ, Cao ZL, et al. Clinical features and treatment of bronchogenic cyst in adults. Chin Med Sci J 2009;24(1):60-3. Reference #3: Maturu VN, Dhooria S, Agarwal R. Efficacy and Safety of transbronchial Needle Aspiration in Diagnosis and Treatment of Mediastinal Bronchogenic Cysts: Systematic Review of Case Reports. J Bronchology Interv Pulmonol 2015;22(3):195-203 DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Please note: $5001 - $20000 Added 03/17/2019 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Adrian Mayo, source=Web Response No relevant relationships by Scott Oh, source=Web Response

CT and MRI characteristics for differentiating mediastinal Müllerian cysts from bronchogenic cysts

To evaluate how computed tomography (CT) and magnetic resonance imaging (MRI) characteristics can be used to differentiate immunohistochemically confirmed mediastinal Müllerian cysts (MMCs) from bronchogenic cysts (BCs). Sixteen patients with histopathologically and immunohistochemically confirmed mediastinal cysts (four with MMCs and 12 with BCs) were included in this study. CT and MRI images were reviewed retrospectively and the location, size, CT attenuation, and MRI signal intensity of the two pathologies were compared. On review of CT images, cysts could be located to the anterior mediastinum in four BCs, middle mediastinum in three MMCs and seven BCs, and posterior mediastinum in one MMC and one BC. Contact with a vertebral body was observed in 4/4 MMCs (100%) and 6/12 BCs (50%). The ratios of minimum-to-maximum diameter (0.57±0.09 versus 0.74±0.11, p<0.01), CT attenuation (7.8±6 versus 44.3±12 HU, p<0.01), and cyst-to-spinal cord signal intensity ratios (SIRs) on T1-weighted images (0.56±0.2 versus 1.31±0.4, p<0.01) were significantly lower for MMCs than BCs. No significant differences in maximum diameter, minimum diameter, and SIRs on T2-weighted images were found between MMCs and BCs. In characterising mediastinal cysts in a middle-aged female patient, contact with a vertebral body, flattened configuration, hypodensity on CT, and hypointensity compared to spinal cord on T1-weighted images are features that are specific to MMCs.

Primary thymic MALT lymphoma in a patient with Sj\xf6gren\u2019s syndrome and multiple lung cysts: a case report

BackgroundThymic mucosa-associated lymphoid tissue (MALT) lymphoma is rare and also known for its association with autoimmune diseases, especially Sjögren’s syndrome (SjS), which could affect the systemic organs, and pulmonary involvement often reveals multiple lung cysts.Case presentationA 40-year-old woman presented with an anterior mediastinal mass and multiple lung cysts on computed tomography. We suspected thymoma concomitant with lymphangioleiomyomatosis and performed a total thymectomy and wedge resection of the lung as a surgical biopsy. The histopathological diagnosis of the mediastinal mass was a MALT lymphoma, and there were no specific findings in the lung specimen. She had a history of SjS, which had been overlooked during the initial work-up.ConclusionsA history of SjS should raise suspicion of a MALT lymphoma for the differential diagnosis of an anterior mediastinal mass. A precise history taking is crucial for the correct diagnosis, and we could have avoided a lung resection in our case.

Anesthesia in robotic thoracic surgery: case series

Introduction The first thoracic lobectomies and robotic transsegmental resections date from 2003, since then robotic-assisted thoracic surgeries have been increasing (1). Extensive benefits of robotic-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) have been demonstrated, among which we find improvement in surgical field vision, reduction in bleeding and decreased postoperative morphine consumption (2). Therefore, and due to its boom, it's necessary to know the surgical technique and the anesthetic implications involved in the implementation of robotic surgery in our daily clinical practice (3). Methods This is a retrospective descriptive study that includes patients undergoing thoracic surgery using a robotic technique from January 2018 to May 2018 in our hospital. It includes a total of 10 patients, 70% undergoing transsegmental lobar resections and 30% with exeresis of mediastinal cysts. Subsequently, we describe both the anesthetic technique used, as well as the stay in the ICU, the hospital stay and the incidence of postoperative complications. Results Surgical positioning was lateral decubitus in all patients. The anesthetic induction was performed with intravenous midazolam, propofol, fentanyl and rocuronium. Pulmonary separation was performed by double lumen tube with embedded camera (VivaSight DL) for continuous airway monitoring and to facilitate repositioning of the device, invasive blood pressure monitoring, and central venous catheterization. The anesthetic maintenance included inhaled sevoflourane and continuous infusion of remifentanil and rocuronium; after surgery muscle relaxation was reverted with sugammadex. The average length of stay in the ICU and hospital stay was 1.6 days and 6.3 days, respectively. Only 2 patients presented postoperative complications as nosocomial pneumonia, bilateral pleural effusion and presence of atelectasis. One of these was death after 18 days of hospital admission. The 6-month survival was 90%. Discussion Robotic surgery allows performing thoracic interventions in a less invasive way. We must take into account the difficulty in accessing both the airway and peripheral intravenous catheters and we need using of advanced monitoring devices. More studies comparing postsurgical events of interventions performed by robotic surgery versus thoracoscopic surgery are necessary.

Case Report: Congenital Thymic Cyst in an Iraqi Child

AbstractBackground: A nine months female child presented with dyspnea was diagnosed by third author applying echocardi-ography who discovered a large thymic cyst. The diagnosis was confirmed by CT scan; the patient was operated on by the first author applying median sternotomy with smooth post operative recovery and complete absence of symptoms.Aim of Study: We intended to report this rare case world-wide so that to throw light on every case with mediastinal cyst to include it in the differential diagnosis, and to be kept in mind always during investigating such a case.

A Cyst Close to the Heart

A 49-year-old Lebanese man presented to the hospital with right-sided pleuritic chest pain without associated respiratory or systemic symptoms. His vitals on presentation were stable, and examination was unremarkable. He had mild leukocytosis with 9.8% eosinophils. Imaging including cardiac magnetic resonance imaging with and without contrast revealed an extra pericardial, multiloculated anterior mediastinal cyst (Figure 1). A diagnosis of hydatid cyst was suspected based on epidemiologic history and radiologic appearance. Echinococcus serology was found to be positive. Patient was started on empiric anthelminthic treatment followed by surgical excision. Intraoperatively, the wall of the excised cyst showed calcification and sebaceous contents (Figure 2). Histopathologic exam showed multilocular cyst lined by squamous epithelial cells and foci of mature bone tissue (Figure 3), pancreatic acini, and ciliated columnar epithelial ducts consistent with a diagnosis of benign mature cystic teratoma. No parasite was seen. Anthelminthic therapy was discontinued, and the patient reported to be doing well on the follow-up visit. Similar cases have been reported in the past.1Patel I.J. Hsiao E. Ahmad A.H. Schroeder C. Gilkeson R.C. AIRP Best Cases in radiologic-pathologic correlation: mediastinal mature cystic teratoma.RadioGraphics. 2013; 33: 797-801Crossref PubMed Scopus (19) Google Scholar, 2Jaakik B. Benjelloun H. A Rare pericardial cyst resembling hydatid cyst on echocardiography.Intern Med. 2010; 49: 1673-1674Google Scholar, 3Montebello A. Mizzi A. Cassar P.J. Cassar K. Benign cystic mediastinal teratoma presenting as a massive pleural effusion in a 17-year–old boy.BMJ Case Reports. 2017; 2017 (bcr2016217439)Google ScholarFigure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3View Large Image Figure ViewerDownload Hi-res image Download (PPT) The authors wish to acknowledge Dr Khushi Nagori, MBBS, Department of Pathology, Ascension St John Hospital, Detroit, Michigan.

Aberrant pancreatic tissue in a giant mediastinal cyst: an uncommon entity

BackgroundHeterotopia of pancreatic tissue in the thorax and mediastinum is uncommon, although, a common developmental anomaly in the gastrointestinal tract where the aberrant tissue is a component of gastrointestinal duplication cysts, intralobular pulmonary sequestration or teratomas.Case presentationWe report a case of an ectopic pancreas located in a giant mediastinal cyst in a 2-year old girl who presented with severe dyspnoea due to external compression of the intra-thoracic structures, mainly the right main bronchus. Surgical resection was carried out with complete relief of symptoms. The cyst was confirmed histopathologically to contain pancreatic tissue. Literature review showed that this is an uncommon presentation hence the need to report the case.ConclusionHeterotopia of the pancreas although, an uncommon occurrence in the thorax and mediastinum, should be considered when dealing with cystic lesions of the mediastinum and surgery plays an important role in its management.Trial registrationJUTH/DCS/ADM/127/XXV/203. Registered 2nd September 2018.

Role of Convex Probe Endobronchial Ultrasound in the Diagnosis and Treatment of Nonmalignant Diseases.

Here we present a comprehensive review of the literature concerning the utility of convex probe endobronchial ultrasound (CP-EBUS) in the diagnosis and treatment of nonmalignant conditions and discuss the associated complications. CP-EBUS has been conventionally used for the staging of lung cancer and sampling of mediastinal and hilar nodes. However, its application is not limited to malignant conditions, and it is gaining acceptance as a diagnostic modality of choice for nonmalignant conditions such as tuberculosis, sarcoidosis, pulmonary embolism, thyroid lesions, and cysts. Moreover, its therapeutic value allows for extended applications such as mediastinal and thyroid cyst drainage, fiducial marker placement for radiation therapy, and transbronchial needle injection. The noninvasiveness, low complication rate, high diagnostic yield, and satisfactory sensitivity and specificity values are the main attributes that lend credence to the use of CP-EBUS as a standalone primary diagnostic and therapeutic tool in pulmonary medicine in the foreseeable future.

Foregut duplications in the superior mediastinum: beware of a common wall with the tracheo-bronchial tree.

Foregut duplication cysts (FD) with a common muscular wall with the oesophagus are well recognised. Our case series highlights the existence of a common wall between superior mediastinal FD and the tracheo-bronchial tree. Over the last 15 years, we have thoracoscopically resected 41 FD. Five cases were identified to have a common wall with the tracheo-bronchial tree at operation. The clinical history, radiology, findings at operation and pathology were evaluated to highlight learning points. Five superior mediastinal cysts with a common wall were identified, with two antenatally and three postnatally diagnosed. All three postnatal cases and one antenatal case presented with symptoms of respiratory compromise and stridor. Only one neonate was relatively asymptomatic before resection. CT similarities in all cases were: separation of trachea and oesophagus by the cyst, oesophageal deviation to the right or compression and compression of trachea/bronchus. Thoracoscopically, two cysts were resected without injury to the airway, while three had inadvertent tracheo-bronchial injury. Repair of the tracheal injury was possible in one case thoracoscopically, while two cases required conversions, as adequate oxygenation could not be maintained despite on-table endotracheal tube advancement beyond the injury and thoracoscopic manoeuvres. All cases had excellent outcomes at follow-up (median 25months, range 4-39months) with resolution of symptoms and no recurrences. Our report highlights the existence of a common wall between the superior mediastinal FD and the tracheo-bronchial tree. Thoracoscopic resections are feasible including repair of inadvertent airway injury, provided adequate oxygenation can be maintained.