A multilocular thymic cyst associated with mediastinal seminoma: evidence for its medullary epithelial origin highlighted by POU2F3-positive thymic tuft cells and concomitant myoid cell proliferation.

Multilocular thymic cyst (MTC) and germ cell tumors are common diseases that impact the mediastinum. Correctly diagnosing these diseases can be difficult because several other conditions can mimic them. We report a male patient with MTC associated with mediastinal seminoma. A needle biopsy of the mediastinal tumor revealed numerous epithelioid cell granulomas that mimicked sarcoidosis or mycobacterial infection. However, large atypical cells positive for Oct3/4 and KIT were noted between the granulomas; thus, we diagnosed the patient with mediastinal seminoma. The resected tumor, after chemotherapy, consisted of multiple cystic lesions, and a residual germ cell tumor was first considered. However, thymic medulla-specific elements, namely, POU2F3-positive thymic tuft cells and rhabdomyomatous myoid cells accompanying the epithelium, led to the correct diagnosis of MTC. Our case underscores the importance of recognizing the histological features associated with mediastinal seminoma and provides novel findings for MTC pathogenesis, namely, the presence of thymic tuft cells.

Double-Needle Lavage for Effective Treatment of Difficult-Aspiration Thyroid Cystic Nodules: A Single-Center Controlled Trial.

PURPOSE: To explore the safety and efficacy of double-needle lavage (DNL) in the treatment of difficult aspiration thyroid cystic nodules. MATERIALS AND METHODS: This single-center, prospective, randomized controlled trial was conducted using 100 thyroid cysts from 100 patients who were treated in our hospital from January 2018 to August 2019. These patients were placed into 2 groups; group A including 40 patients treated with single-needle aspiration (SNA), and group B including 60 patients treated with DNL. The safety and efficacy of these 2 aspiration methods were compared. RESULTS: Ten patients in group A that did not benefit from SNA were transferred to group B. No complication occurred in either group. Notably, DNL showed significantly higher efficacy than SNA. This was evidenced by the higher extraction rate of materials in the capsule (A vs B, 91 ± 6.51% vs 98.45 ± 1.74%, P < .001) and overall nodule volume reduction rate in group B (A vs B, 87.54 ± 7.84% vs 95.62 ± 3.66%, P < .001). In group B, patients who received DNL treatment with 2 needles pointed at the upper and lower extremes of the cystic nodules (B2) exhibited significantly better aspiration effects compared to patients in which the 2 needles were pointed at the same ultrasound plane (B1) (P < .05), especially for patients with maximum diameter of nodules ≥3 cm (P < .01). CONCLUSIONS: DNL treatment could efficiently and safely replace cystic material from thyroid gland. Moreover, our results indicate that DNL treatment in which 2 needles are pointed at the 2 extremes of cystic nodules yields higher efficacy in patients with maximum diameter of nodules ≥3 cm.

Clinical characteristics and management of primary mediastinal cysts: A single-center experience.

BACKGROUND: In this study we aimed to assess the clinical outcomes of performing video-assisted thoracic surgery (VATS) to treat primary mediastinal cysts (PMCs) and investigate the clinical factors which increase the difficulties associated with VATS. METHODS: The medical records of all consecutive PMC patients, who underwent surgical resection from April 2001 to July 2016, were reviewed and 282 patients were included. Clinical characteristics, imaging features, and surgical outcomes were analyzed. Follow-up data were successfully obtained from 230 PMC patients by telephone or outpatient clinic annually. The latest follow-up was July 2019. RESULTS: VATS was performed in 278 patients and four patients were converted into thoracotomy. The mean operation time and intraoperative bleeding were 102.4 ± 40.9 minutes (range 25-360 minutes) and 52.4 ± 75.1 mL (range 5-600 mL), respectively. The intra- and postoperative complication rates were 2.8 and 5.7%, respectively. Seven patients with bronchogenic cysts showed severe cyst adhesion to vital mediastinal structures and thus had incomplete resection. Multivariable logistic analysis revealed that a maximal cyst diameter greater than 5 cm was significantly associated with increased risks of operation time extension (OR = 2.106; 95% CI: 1.147-3.865, P = 0.016) and intraoperative blood loss increase (OR = 4.428; 95% CI: 1.243-16.489, P = 0.022). A total of 230 patients had follow-up data. The median follow-up time was 70 months (range, 36-210 months). No local recurrence was observed. CONCLUSIONS: Surgical resection by VATS may be recommended for PMC management as a primary therapeutic strategy. Cysts with a maximum diameter greater than 5 cm or cysts adjacent to vital mediastinal structures can increase the surgical difficulties. KEY POINTS: • Significant findings of the study A diameter >5 cm and adhesions significantly increased the risk of operation time extension together with increased blood loss. • What this study adds Cysts with a diameter >5 cm or those adjacent to vital mediastinal structures increased the potential for surgical difficulties.

Giant cervicomediastinal thymic cyst in an elderly: diagnosis by multimodality imaging and fine-needle aspiration cytology with immunocytochemistry.

A 65-year-old woman, a non-smoker, presented to the pulmonary medicine outpatient department with chest pain, mild dyspnoea, right side neck swelling and mild facial puffiness. The cervical swelling was soft, non-tender and fluctuant on palpation. Multimodality imaging revealed a large, thin-walled cervicomediastinal cystic lesion with septations, haemorrhage, septal calcification and without any solid component. Image-guided fine-needle aspiration cytology from the septa with immunocytochemistry helped to establish the thymic origin and benign nature of the cyst preoperatively and differentiate it from cystic thymoma, lymphangioma, thymic carcinoma or lymphoma with confidence. As the haemorrhage resolved, the size of the swelling was significantly reduced, and the patient became asymptomatic due to which she deferred surgery but remained on close follow-up and was doing well. Thymic cysts can occur in a cervicomediastinal location, rare in elderly age, usually asymptomatic and clinically apparent when intracystic haemorrhage leads to an increase in size and chest pain.

Clinical Experience with Thymic Cystectomy: A Single-Institution Study of 117 Cases from 2013 to 2019.

BACKGROUND The aim of this study was to summarize the clinical experience of thymic cysts treatment from a single center. MATERIAL AND METHODS Clinical data, imaging, pathological results, and follow-up results of thymic cyst patients who underwent surgery from January 2013 to September 2019 were retrospectively reviewed. RESULTS A total of 117 patients were enrolled, including 76 asymptomatic patients and 41 symptomatic patients. The average diameter of thymic cysts, the cysts in asymptomatic patients, and those in symptomatic patients were 31.93±19.92 mm, 29.28±17.97 mm, and 36.85±22.50 mm, respectively. The number of cysts ranged from 1 to 3 cm, 3 to 6 cm, and >6 cm in 73 cases (62.4%), 32 cases (27.3%), and 12 cases (10.3%), respectively. There was no correlation between the size of thymic cysts and the presence or absence of symptoms. Only 20 cases (17.1%) were correctly diagnosed as thymic cysts before surgery. There were 67 patients (57.3%) who underwent video-assisted thoracic surgery (VATS) and 50 cases (42.7%) underwent open surgery. Cystectomy was performed in 93 cases (79.5%) and 24 cases (20.5%) underwent simultaneous resection of thymic cysts and other thoracic tumors. Compared with the thoracotomy group, the VATS group had shorter hospital stay and chest tube indwelling time. No serious complications occurred after surgery. The median follow-up time was 45.0 months (range 4.0-84.0 months) and there was no recurrence. CONCLUSIONS Attention should be paid to the accuracy of preoperative diagnosis of thymic cysts and the reduction of asymptomatic thymic cystectomy. For patients who have both thymic cysts and other thoracic tumors, simultaneous surgery is safe and feasible.

[Ethanol Instillation for Mediastinal Cyst].

Mediastinal cyst rarely becomes symptomatic due to compression of adjacent organs. In such case, treatment has to be considered. Either surgical extirpation or percutaneous decompression is the treatment of choice. A 53 years old woman who had been diagnosed with intractable epilepsy, mental retardation and Chilaiditi syndrome was admitted to our hospital because of dyspnea and difficulty in conversation. Chest computed tomography (CT) revealed a mediastinal cystic lesion which expanded to the right chest cavity and occupied most of the right chest cavity. That cyst was treated by percutaneous aspiration and ethanol instillation successfully. Ethanol instillation for the symptomatic mediastinal cyst is the treatment of choice in case the surgery is not feasible.

Clinical Features, Natural History, and Management of Pericardial Cysts.

With the increased use of medical imaging, there has been an increase in the numbers of pericardial cysts identified. However, there is a paucity of data regarding the clinical course for pericardial cysts. Hence, we aimed to study the clinical features and natural history of pericardial cysts. We retrospectively studied all patients with the diagnosis of pericardial cysts based on computed tomography (CT) chest or cardiac magnetic resonance imaging (CMR) between 2008 and 2014. The maximum diameter of the cyst was measured at the initial study (CT/CMR) and was compared with the most recent follow-up imaging modality of the same type if available. A change in the maximum diameter more than 10% was considered significant. We included 103 patients in the study; 89% were asymptomatic and 67% were females. Twenty-nine asymptomatic patients had repeat imaging with the same modality (CT/CMR) with a mean follow-up of 23 months. The maximum cyst diameter decreased by a mean of 25% in 34% of the patients and increased by a mean of 13% in 17% of the patients. The remaining patients (48%) had no significant change. All 29 patients remained asymptomatic. In conclusion, most pericardial cyst cases were asymptomatic. On repeat imaging, approximately 1/3 of pericardial cysts were found to decrease in size, whereas interval enlargement was infrequent and unlikely to be clinically relevant. Therefore, within the limitations of our study, serial imaging in asymptomatic patients with CT or CMR does not appear to impact management decisions.

Spontaneous retropharyngeal and mediastinal thoracic duct cyst in an infant with respiratory distress.

Thoracic duct cysts (TDC) within the retropharyngeal space and mediastinum are exceedingly rare lesions, with the majority related to trauma or neoplasm. We describe a case of an otherwise healthy 8-month-old boy who presented with severe respiratory distress, which was found to be caused by a large, spontaneous TDC occupying most the retropharyngeal and mediastinal space. To our knowledge, this is the youngest patient to date presenting with TDC. Ultimately, his TDC was completely resolved with sclerotherapy, however the patient's age and size presented unique challenges to his medical management, which we describe below.

Neoplastic Pericardial Disease.

Pericardial tumors are rare lesions that include a range of neoplastic conditions that may arise within the pericardium or metastasize to involve it secondarily. Understanding the spectrum of lesions that are included in the differential diagnosis of a pericardial mass-lesion is critical to making timely, accurate diagnoses and getting the appropriate therapy should one be necessary. This review summarizes the radiologic and pathologic findings of the most commonly encountered of these entities.

Congenital Abnormalities of the Pericardium.

Congenital abnormalities of the pericardium are a rare group of disorders that include congenital absence of the pericardium, pericardial cysts, and diverticula. These congenital defects result from alterations in the embryologic formation and structure of the pericardium. Although many cases are incidentally found, they can present as symptomatic, life-threatening disease. Owing to their rarity, many cases are inappropriately diagnosed. Alterations in the embryologic formation and structure may result in the formation of these congenital abnormalities. We review the presentation, diagnosis, and management of congenital absence of the pericardium, pericardial cysts, and diverticula. A summary of multimodality imaging features is provided.

Fate of traumatic pulmonary pseudocyst: factors of resolution.

BACKGROUND: Traumatic pulmonary pseudocysts are rarely talked about, developing in less than 3% of patients with pulmonary parenchymal injuries. Resolution usually occurs within a few weeks to a few months. METHOD: A prospective study was undertaken in 21 cases treated in Menoufia University Hospital, Egypt from August 2011 through August 2013. RESULTS: The overall mean time for complete resolution was 61.1 days. The mean time for resolution of simple traumatic pulmonary pseudocysts was 21 days (n = 6), and the mean time for resolution of complicated (blood filled) traumatic pulmonary pseudocysts was 77.1 days (n = 15). Mean resolution time was 26.3 days for small pulmonary pseudocysts ≤22 mm (n = 11) and 99.4 days for those >22 mm (n = 10). The resolution time was 42.6 days in patients 17-years old or younger (n = 11) and 81.4 days in patients older than 17 years (n = 10). CONCLUSION: There was a highly significant difference in resolution time between simple and complicated pseudocysts. There was also a highly significant delay in the resolution time of pseudocysts larger than 22 mm and in patients older than 17 years.

Nontyphoidal cardiac salmonellosis: two case reports and a review of the literature.

Nontyphoidal Salmonella, especially Salmonella enterica, is a rare cause of endocarditis and pericarditis that carries a high mortality rate. Proposed predisposing conditions include immunodeficiency states, congenital heart defects, and cardiac valve diseases. We present 2 cases of cardiovascular salmonellosis. The first case is that of a 73-year-old woman with mechanical mitral and bioprosthetic aortic valves who died from sequelae of nontyphoidal Salmonella mitral valve vegetation, aortic valve abscess, and sepsis. The second case is that of a 62-year-old man with a recent systemic lupus erythematosus exacerbation treated with oral steroids, who presented with obstructive features of tamponade and sepsis secondary to a large S. enteritidis purulent pericardial cyst. He recovered after emergent pericardial drainage and antibiotic therapy. Identifying patients at risk of cardiovascular salmonellosis is important for early diagnosis and treatment to minimize sequelae and death. We reviewed the literature to identify the predisposing risk factors of nontyphoidal Salmonella cardiac infection.

Quiste de conducto torácico, tratamiento esclerosante / Thoracic duct cyst, sclerosing treatment

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Direct puncture sclerotherapy of a thoracic duct cyst presenting as an enlarging left supraclavicular mass.

A 58-year-old woman presented with a palpable mass at the base of the left neck which she had first noticed 12 years previously, shortly after abdominal surgery. The mass had progressively enlarged, resulting in dysphagia, dyspnea and occasional pain. Imaging showed a septated but otherwise simple cystic mass extending into the mediastinum and containing lymphocytic fluid on aspiration. A diagnosis of the rare entity of a thoracic duct cyst with supraclavicular extension was made. The patient opted for percutaneous sclerotherapy of the lesion, which was performed using glacial acetic acid. This resulted in complete resolution of the mass with one treatment. After exclusion of other causes of cystic left supraclavicular masses including cystic neoplasms and pseudoaneurysms of the carotid or subclavian arteries, direct puncture sclerotherapy can be safe and effective.

Direct puncture sclerotherapy of a thoracic duct cyst presenting as an enlarging left supraclavicular mass.

A 58-year-old woman presented with a palpable mass at the base of the left neck which she had first noticed 12 years previously, shortly after abdominal surgery. The mass had progressively enlarged, resulting in dysphagia, dyspnea and occasional pain. Imaging showed a septated but otherwise simple cystic mass extending into the mediastinum and containing lymphocytic fluid on aspiration. A diagnosis of the rare entity of a thoracic duct cyst with supraclavicular extension was made. The patient opted for percutaneous sclerotherapy of the lesion, which was performed using glacial acetic acid. This resulted in complete resolution of the mass with one treatment. After exclusion of other causes of cystic left supraclavicular masses including cystic neoplasms and pseudoaneurysms of the carotid or subclavian arteries, direct puncture sclerotherapy can be safe and effective.

Multilocular thymic cyst associated with thymoma: a clinicopathologic study of 20 cases with an emphasis on the pathogenesis of cyst formation.

Multilocular thymic cysts (MTCs) are considered to be acquired lesions associated with various inflammatory conditions and/or malignant tumors. MTCs associated with thymomas are rare, with only 11 cases having been reported. On reviewing 110 consecutive patients with thymomas, we found 20 cases of MTCs. The patients included 18 men and 2 women aged 32 to 65 years (median 52 y). Eleven of the patients were symptomatic, and 6 presented with symptoms associated with inflammation. Computed tomography images were available for 11 patients, and cystic lesions were identified in 4 patients. The histologic subtypes of thymoma observed were: 3 tumors of type AB, 4 tumors of type B1, 9 tumors of type B2, and 4 tumors of type B3. In addition, 2 tumors were in advanced stages. Multilocular cystic structures accompanied by acute and chronic inflammation were observed in the remnant thymic tissues. Immunohistochemically, CK13 was diffusely expressed in the inner surface cells lining the cysts, whereas CK5/6 and p63 were primarily expressed in the basal cells of the cysts. D2-40 was weakly expressed in a small number of basal epithelial cells. The immunohistochemical profiles of the cysts were similar to those of Hassall corpuscles of normal thymi. A clinical follow-up showed that 15 patients continued to be alive without any evidence of disease, 1 patient with tumor recurrence continued to be alive, and 3 patients had died of other diseases. Our results suggest that MTCs associated with thymomas are not as uncommon as thought and may develop from the promotion of differentiation of increased numbers of epithelial cells into Hassall corpuscles by inflammatory processes. Our data also suggest a better clinical behavior for patients with thymomas accompanied by MTCs than patients with thymomas unaccompanied by those cysts, although further investigation is needed.