Paraganglioma Fed by the Circumflex Artery.

Mediastinal paragangliomas are rare neuroendocrine tumors and usually identified incidentally. Surgical excision remains the mainstay of treatment. Because of their location, anatomical relations, and highly vascular nature, surgical excision can be challenging. We present such a case, where the blood supply arose directly from the circumflex coronary artery and cardiopulmonary bypass was used to aid complete surgical excision.

Neovascularization of Thymoma From Left Internal Mammary Artery Bypass Graft.

We present the case of a type AB thymoma in a 69-year-old man with previous coronary artery bypass grafting (CABG) in whom angiography revealed a left internal mammary artery graft supplying blood flow to a thymic neoplasm, which simultaneously occluded the graft. This required a redo sternotomy, lysis of pericardial adhesions, complete thymectomy, and redo one vessel off-pump CABG. This case seeks to sensitize physicians to the possibility of coronary adverse events in patients with a previous CABG in the setting of management of mediastinal neoplasms, and it presents the novel findings on cardiac imaging associated with this case.

Mediastinal paraganglioma fed by the left circumflex artery.

A 60-year-old male patient who previously underwent carotid and jugular paraganglioma resections was referred because of a mediastinal recurrence at the root of the great vessels. Coronary angiography confirmed the circumflex artery of the left coronary artery as the feeding artery of the tumour. The patient underwent surgery due to the tumour's location and malignant potential. Upon mass resection, histopathological examination characterized the tumour as a secondary paraganglioma. Neuroendocrine tumours arising from chromaffin tissues at the extra-adrenal paraganglions of the autonomic nervous system are termed paragangliomas. Clinically, they are divided into functional and non-functional types, depending on their catecholamine secretion. The mediastinal location is exceptional and its treatment is challenging.

[Mediastinal Hemangioma with Literature Review;Report of a Case].

A 58-year-old woman visited a local physician for evaluation of collagen disease and screening computed tomography (CT) showed a posterior mediastinal tumor. After referral to our hospital, CT and magnetic resonance imaging (MRI) showed a mass, approximately 2 cm in diameter, located on the right of the 1st thoracic vertebra. Since a neurogenic tumor was suspected, thoracoscopic excision was performed. Surgical findings revealed a tumor between the 1st and 2nd ribs in the close vicinity of the right brachiocephalic vein. We severed blood vessels flowing into the tumor and removed it. The tumor, 25 mm in maximal diameter, was diagnosed as hemangioma by histological examinations. The prevalence of a hemangioma is less than 0.5% of all mediastinal tumors. Since it lacks specific imaging findings, its preoperative diagnosis is quite difficult to establish. Although a hemangioma in the mediastinum is quite rare, it should be included in the differential diagnoses of mediastinal tumors.

[Complete resection of a posterior mediastinal tumor after preoperative identification of artery of Adamkiewicz].

The thoracolumbar spinal cord receives its blood supply primarily from the artery of Adamkiewicz (AA), a branch of thoracolumbar intercostal arteries. Aortic cross-clamping during operation for descending aortic aneurysms can cause paraplegia due to spinal cord ischemia secondary to low blood flow through the AA. A 69-year-old woman was diagnosed with a left posterior mediastinal tumor measuring 66 mm. The tumor was adjacent to the thoracic aorta between Th10 to Th12 vertebral levels. Preoperative 3-dimensional computed tomography (3D-CT) imaging revealed 2 AAs originated from the 10th and 11th left intercostal arteries just near the tumor. The patient underwent a left thoracotomy and the 2 intercostal arteries were carefully dissected from the encapsulated tumor. Complete resection was safely achieved with preservation of the AAs. Pathology revealed a schwannoma. There were no complications. In performing thoracic surgery for posterior mediastinal tumors, it is important to identify the AAs preoperatively and preserve them.

Giant cervico-mediastinal solitary fibrous tumor.

OBJECTIVES: Extra-pleural solitary fibrous tumor (ESFT) is an uncommon mesenchymal neoplasm that is anatomically ubiquitous and may be found anywhere in the body, including the head and neck region. It is usually asymptomatic and presents as a slowly growing painless mass. Only three cases of retropharyngeal ESFT have been reported in the literature. METHODS AND RESULTS: A 54-year-old female affected by a cervicomediastinal mass complained of progressive dysphonia, pharyngeal foreign body sensation, and mild dyspnea. CT and MR showed a huge retropharyngoesophageal lesion extending to the upper posterior mediastinum. The tumor, despite its caudal extension, was completely removed with a pure cervicotomic approach; histology was consistent with ESFT. CONCLUSIONS: Histopathology and immunohistochemistry are crucial in the diagnosis of solitary fibrous tumor. Radical excision after primary treatment is the most important indicator of prognosis, and long-term clinical follow-up is recommended due to the possibility of recurrence and/or malignant transformation.

Combined embolization and surgical resection of a giant mediastinal tumor.

Large mediastinal tumors typically have a rich blood supply derived from multiple arteries, and surgical resection can be associated with a large blood loss. Embolization is used to treat a variety of malignant and benign conditions preoperatively, as well as an alternative to surgery, however, the use of preoperative embolization of large mediastinal tumors has not been extensive. Herein, we report a case of a giant mediastinal tumor measuring >15 cm and extending into both chest cavities in which preoperative embolization was used to reduce the surgical blood loss and facilitate excision of the lesion.

Embolization of bronchial artery-supplied ectopic parathyroid adenomas located in the aortopulmonary window.

Ectopic parathyroid adenomas in the aortopulmonary window (APW) are extremely rare, constituting only 1% of ectopic mediastinal adenomas and 0.24% of all parathyroid adenomas. The authors have encountered three patients with ectopic adenomas in the APW. In each case, the primary arterial supply to the APW adenoma arose from the bronchial artery. In addition, there was a small anastomotic arterial channel connecting the bronchial artery supplying the adenoma to the left inferior thyroid. All three adenomas were treated with transcatheter embolization, with control of hyperparathyroidism in two of three patients. One patient required thoracoscopic removal of the adenoma. It is critical that the interventionalist be aware of this arterial supply pattern to allow successful embolization of an APW ectopic adenoma.

Transarterial embolization of metastatic mediastinal hepatocellular carcinoma.

This paper introduces an innovative treatment for extra-hepatic metastasis of hepatocellular carcinoma. A 71-year-old patient had a stable liver condition following treatment for hepatocellular carcinoma, but later developed symptomatic mediastinal metastasis. This rapidly growing mediastinal mass induced symptoms including cough and hoarseness. Serial sessions of transarterial embolization (TAE) successfully controlled this mediastinal mass with limited side effects. The patient's survival time since the initial diagnosis of the mediastinal hepatocellular carcinoma was 32 mo, significantly longer than the 12 mo mean survival period of patients with similar diagnoses: metastatic hepatocellular carcinoma and a liver condition with a Child-Pugh class A score. Currently, oral sorafenib is the treatment of choice for metastatic hepatocellular carcinoma. Recent studies indicate that locoregional treatment of extra-hepatic metastasis of hepatocellular carcinomas might also significantly improve the prognosis in patients with their primary hepatic lesions under control. Many effective locoregional therapies for extrahepatic metastasis, including radiation and surgical resection, may provide palliative effects for hepatocellular carcinoma-associated mediastinal metastasis. This case report demonstrates that TAE of metastatic mediastinal hepatocellular carcinoma provided this patient with tumor control and increased survival time. This finding is important as it can potentially provide an alternative treatment option for patients with similar symptoms and diagnoses.

Anterior mediastinal paraganglioma: a case for preoperative embolization.

BACKGROUND: Paraganglioma is a rare but highly vascular tumor of the anterior mediastinum. Surgical resection is a challenge owing to the close proximity to vital structures including the heart, trachea and great vessels. Preoperative embolization has been reported once to facilitate surgical treatment. CASE PRESENTATION: We report a case of anterior mediastinal paraganglioma that was embolized preoperatively, and was resected without the need for cardiopulmonary bypass and without major bleeding complications. CONCLUSION: We make a case to further the role of preoperative embolization in the treatment of mediastinal paragangliomas.

Venous hemangioma of the posterior mediastinum.

Here, we describe our experience in treating a patient with mediastinal hemangioma, a rare neoplasm. An abnormal shadow was noted in the thoracic region of a 54-year-old woman at a health checkup, and she was referred to our hospital. A neurogenic tumor was suspected based on the findings of the chest X-ray and computed tomography scan. Thoracoscopic tumorectomy was performed. The tumor surface was smooth with a reddish-dark reddish color, and capillary blood vessels showed marked growth around the tumor. The tumor was composed of medium or large blood vessels with a relatively thick vascular wall containing smooth muscle. On immunostaining, anti-CD34 antibody and Factor VIII were positive and D2-40 was negative. Based on these findings, the tumor was diagnosed as mediastinal venous hemangioma.

Vascular image patterns of lymph nodes for the prediction of metastatic disease during EBUS-TBNA for mediastinal staging of lung cancer.

INTRODUCTION: The aims of this study were to establish and assess the utility of Power/Color Doppler-mode vascular image pattern classification of lymph nodes (LN) during mediastinal staging by endobronchial ultrasound (EBUS) for the prediction of metastasis in patients with lung cancer. METHODS: One hundred and seventy-three LNs were retrospectively evaluated. The convex probe EBUS was used with the endoscopic ultrasound scanner. The vascular image patterns were graded as follows: Grade 0, no blood flow or small amounts of flow; Grade I, a few main vessels running toward the center of the LN from the hilum; Grade II, a few punctiforms or rod-shaped flow signals or a few small vessels found as a long strip of a curve; and Grade III, rich flow, more than four vessels found with different diameters or twist- or helical -low signal. The blood flow from the bronchial artery (BA) toward the LN was also recorded using Color Doppler imaging as a sign for BA inflow. RESULTS: When we defined Grade 0 and I as "benign" and Grade II and III as "malignant," the sensitivity, specificity, and diagnostic accuracy rate were 87.7%, 69.6%, and 78.0%, respectively. The accuracy of predicting metastasis solely from a positive BA inflow sign was 80.3%. Of the LNs, 84.5% were shown to be metastatic when they were determined as malignant, and 84.7% were proven nonmetastatic when it was determined as benign. CONCLUSIONS: Vascular image patterns of LN using Power/Color Doppler mode is helpful in the prediction of metastatic LN during EBUS-TBNA.

Preferred surgical approach for dumbbell-shaped tumors in the posterior mediastinum.

We present the case of a 67-year-old male smoker with a posterior mediastinal hemangioma. Radiological findings revealed a dumbbell-shaped tumor with a neuroforaminal extension in the right paravertebral space. Under the preoperative diagnosis of a neurogenic tumor, surgery was performed using a combined anterior and posterior approach. During the thoracotomy, the tumor was found to be a hemangioma. We ligated the involved vessels before performing laminectomy, thus ensuring that complete tumor resection was achieved without massive bleeding in the spinal canal. Dumbbell-shaped hemangiomas are rare, and preoperative confirmation of the diagnosis is challenging. Thoracotomy before laminectomy is optimal for the resection of dumbbell-shaped tumors of the mediastinum, especially with marked vascularity, given that the initial thoracotomy procedures facilitate the subsequent laminectomy procedures.

Mediastinal hemangioma arising in setting of partial anomalous pulmonary venous drainage to azygous vein in a 57-year-old woman.

Partial anomalous pulmonary venous drainage (PAPVD) to the azygous vein and benign posterior mediastinal hemangioma in adults are both rare entities in isolation. The coexistence of these two lesions in the same patient has not been reported. We describe a unique case of PAPVD to the azygous vein in an adult woman, where the anomalous left inferior pulmonary vein transited first through a large hemangioma, and then eventuated in the azygous vein.

Postoperative paraplegia after resection of a giant posterior mediastinal tumour. Importance of the blood supply in the upper spinal cord.

A 10-cm diameter tumour was revealed in the left upper posterior mediastinum in a 15-year-old female. After exclusion of the possibility of a dumbbell tumour and confirmation of a ganglioneurinoma, an encapsulated, but vascularised tumour was removed via a left posterolateral thoracotomy from the level of the first-third costo-vertebral angle, without intraoperative complications. Following surgery, acute paraplegia was diagnosed, with a spinal cord lesion at the high thoracic level. Magnetic resonance imaging did not reveal any disorder in the spinal cord. In response to medical treatment, the patient's locomotor and sensation functions normalised within six months. On revising the preoperative computed tomography, we found dilated vessels passing through the tumour and the hypoplastic vertebral artery on the left side. This finding led us to suspect that the spinal cord circulation was partially supplied by the arteries passing through the tumour, which were clipped during surgery. Verification of the blood supply of the spinal cord is therefore highly recommended before resection of a giant tumour from the posterior mediastinum.

Diffusion and perfusion MRI of the lung and mediastinum.

With ongoing technical improvements such as multichannel MRI, systems with powerful gradients as well as the development of innovative pulse sequence techniques implementing parallel imaging, MRI has now entered the stage of a radiation-free alternative to computed tomography (CT) for chest imaging in clinical practice. Whereas in the past MRI of the lung was focused on morphological aspects, current MRI techniques also enable functional imaging of the lung allowing for a comprehensive assessment of lung disease in a single MRI exam. Perfusion imaging can be used for the visualization of regional pulmonary perfusion in patients with different lung diseases such as lung cancer, chronic obstructive lung disease, pulmonary embolism or for the prediction of postoperative lung function in lung cancer patients. Over the past years diffusion-weighted MR imaging (DW-MRI) of the thorax has become feasible with a significant reduction of the acquisition time, thus minimizing artifacts from respiratory and cardiac motion. In chest imaging, DW-MRI has been mainly suggested for the characterization of lung cancer, lymph nodes and pulmonary metastases. In this review article recent MR perfusion and diffusion techniques of the lung and mediastinum as well as their clinical applications are reviewed.