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• W2078707373 abstract "We report a very rare case of a huge anterior mediastinal tumor penetrating the sternum that was diagnosed in a 59-year-old woman. The tumor was completely resected en bloc with the manubrium sterni, and the chest wall defect was closed with a pectoralis major muscle flap. Histologic examination of the cystic mass revealed the diagnosis of a benign mediastinal cystic tumor, most likely a benign cystic mature teratoma. We report a very rare case of a huge anterior mediastinal tumor penetrating the sternum that was diagnosed in a 59-year-old woman. The tumor was completely resected en bloc with the manubrium sterni, and the chest wall defect was closed with a pectoralis major muscle flap. Histologic examination of the cystic mass revealed the diagnosis of a benign mediastinal cystic tumor, most likely a benign cystic mature teratoma. Mature teratomas are the most commonly encountered mediastinal germ-cell tumors. They are usually benign; however, they can sometimes rupture into the mediastinum or lung because of hemorrhage or infection [1Takeda S. Miyoshi S. Minami M. Ohta M. Masaoka A. Matsuda M. Clinical spectrum of mediastinal cysts.Chest. 2003; 124: 125-132Crossref PubMed Scopus (181) Google Scholar, 2Duwe B.V. Sterman D.H. Musani A.I. Tumors of the mediastinum.Chest. 2005; 128: 2893-2909Crossref PubMed Scopus (326) Google Scholar]. We report a rare case of a huge mediastinal cystic tumor, most likely a benign mature teratoma, penetrating the sternum, which was successfully treated by surgical resection. A 59-year-old woman presenting with a 3-month history of generalized fatigue was referred to our hospital for investigation of a huge mediastinal opacity detected on a plain chest roentgenogram. Physical examination was unremarkable, and there was no history of chest pain or discomfort, fever, dyspnea, or any symptoms or signs of inflammation. Laboratory data, including serum tumor markers (carcinoembryonic antigen, α-fetoprotein, and human chorionic gonadotropin), were all within normal limits. A chest roentgenogram revealed a huge round mass, with tracheal deviation to the left (Fig 1). Chest computed tomography revealed an anterior mediastinal multilocular mass measuring 15 × 12 × 11 cm in size, containing fluid and fat tissue. The wall of the tumor contained rim calcifications extending into the left pleural space and penetrating the manubrium sterni (Fig 2). Magnetic resonance imaging showed fat droplets floating inside the tumor, which was covered by a partially calcified wall, suggestive of a teratoma. The tentative preoperative diagnosis was malignant teratoma invading the sternum.Fig 2(A) Computed tomography imaging revealed a multilocular cystic tumor in the anterior mediastinum, 15 × 12 × 11 cm in size. (B, C) The scan also showed the tumor penetrating the manubrium sterni (arrow). (B, transverse image; C, sagittal image).View Large Image Figure ViewerDownload (PPT) Surgical exploration confirmed the tumor extended into the manubrium sterni, adjacent to but not involving the pericardium, phrenic nerves, and lungs. The tumor was completely resected along with the manubrium sterni, and the defect on the chest wall was closed with a pedicle flap prepared from the left pectoralis major muscle. Macroscopic examination of the resected tumor penetrating the sternum revealed a multilocular mass with a fibrous wall of varying thickness and scattered calcifications, filled with turbid dark-red debris (Fig 3A). Histologic examination of paraffin sections showed the cyst walls were composed of dense fibrous connective tissue, with calcification and hyalinization (Fig 3B). The inner surface of the cyst wall was mostly devoid of lining epithelium but was focally lined by stratified squamous epithelium (Fig 3C). Other teratomatous components such as skin appendages were not identified at the wall examined. The cyst also contained degenerated solid tissue carrying foam cells, cholesterin crystals, and foreign body giant cells. Thymic tissue was detected in the adipose tissue around the cystic mass, but not inside the tumor. According to the preoperative imaging and pathology findings, the tumor was diagnosed as a mediastinal benign cystic tumor, most likely a cystic mature teratoma, that had penetrated the sternum probably because of its chronic inflammation. The patient had an uneventful postoperative course and was discharged 14 days after the operation. At the latest follow-up at 5 months, the patient was well, without any evidence of recurrence. Mediastinal cysts comprise 12% to 18% of all mediastinal masses, and the most commonly encountered mediastinal cysts are congenital benign cysts, such as bronchogenic, esophageal duplication, neurenteric, pericardial, and thymic cysts. Some thymomas, germ-cell tumors, including mature teratoma, and neurogenic tumors can also undergo cystic degeneration [1Takeda S. Miyoshi S. Minami M. Ohta M. Masaoka A. Matsuda M. Clinical spectrum of mediastinal cysts.Chest. 2003; 124: 125-132Crossref PubMed Scopus (181) Google Scholar]. Benign mature teratomas contain components derived from more than one of the three primitive germ cell layers: ectoderm: hair, skin; mesoderm: bone, cartilage, muscle, fat; endoderm: bronchial, intestinal, pancreatic tissue [2Duwe B.V. Sterman D.H. Musani A.I. Tumors of the mediastinum.Chest. 2005; 128: 2893-2909Crossref PubMed Scopus (326) Google Scholar]. The tumor in our present patient had components derived from two of the three layers, namely fat tissue and stratified squamous epithelium. Mediastinal mature teratomas are benign tumors and usually do not invade adjacent organs; however, they may sometimes rupture into neighboring organs as a result of autolysis, infection, pressure necrosis, ischemia, or chemical inflammation [3Southgate J. Slade P.R. Teratodermoid cyst of the mediastinum with pancreatic enzyme secretion.Thorax. 1982; 37: 476-477Crossref PubMed Scopus (35) Google Scholar, 4Strollo D.C. Rosado de Christenson M.L. Jett J.R. Primary mediastinal tumors Part 1.Chest. 1997; 112: 511-522Crossref PubMed Scopus (289) Google Scholar]. Malignant transformation has been reported to occur in 1% to 2% of ovarian cystic teratomas and in a few cases of mediastinal teratoma, especially giant mediastinal teratoma [2Duwe B.V. Sterman D.H. Musani A.I. Tumors of the mediastinum.Chest. 2005; 128: 2893-2909Crossref PubMed Scopus (326) Google Scholar, 5Yamaguchi K. Mandai M. Fukuhara K. et al.Malignant transformation of mature cystic teratoma of the ovary including three occurring during follow-up period.Oncol Rep. 2008; 19: 705-711PubMed Google Scholar]. The possibility of malignant transformation should be considered in any cystic tumor with an invasive solid portion in the wall. In the present case, no malignant cells, digestive glands, such as pancreatic tissue, or other intestinal tissues were found in the tumor on the histopathologic examination. At the site of penetration into the sternum, the cyst wall contained foam cells, cholesterin crystals, and granulation tissue with foreign body giant cells, findings strongly suggestive of chronic inflammation. We report a rare case of a benign mediastinal cystic tumor, most likely a mature teratoma, penetrating the sternum as a result of chronic inflammation. The appearance of the tumor invading to the chest wall misled us into believing that it was malignant; however, the possibility of a benign tumor in such cases should also always be considered." @default.
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• W2078707373 title "Huge Mediastinal Cystic Tumor Penetrating the Sternum" @default.
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• W2078707373 doi "https://doi.org/10.1016/j.athoracsur.2010.02.034" @default.
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