Robotic Resection of Ectopic Thyroid Tissue of the Mediastinum - Case Report and Literature Review.

Introduction: Ectopic thyroid tissue (ETT) is a rare cause of mediastinal masses, representing less than 1% of all mediastinal tumors (1). ETT could be detected anywhere along the path of the first embryonic descent of the thyroid gland from the primordial foregut floor to its usual pre-tracheal position. ETT mediastinal localization accounts for fewer than 1% of all ectopic thyroid cases (2,3). Various surgical methods for approaching mediastinal masses have been documented in the literature, including median sternotomy, posterolateral thoracotomy, and, video-assisted thoracoscopic surgery (VATS) (4). More recently, robotic-assisted thoracoscopic surgery (RATS) has been proposed for these masses. The aim of this article is to present the use of robotic-assisted thoracoscopic surgery (RATS) for a rare case of a mediastinal ETT. Case presentation: We present the case of a 40-year-old male with no significant medical history who discovered a mediastinal mass on a thoracic CT scan following COVID-19 infection. Symptoms were dysphagia and anterior thoracic pain with cervical extension. Scintigraphy confirmed the presence of ectopic thyroid tissue in the mediastinum as well as a normal cervical thyroid gland. ETT was histologically confirmed by endoscopic ultrasound guided biopsy. Robotic assisted surgery was the chosen approach to surgically treat this mass and the technical details are presented. The mass was extracted through the cervical incision. Total surgical time was 230 minutes, and the blood loss was 60 ml. The patient was discharged after 48 hours with follow up showing a full recovery with no residual pain or respiratory symptoms. Conclusion: Ectopic thyroid tissue (ETT) is a rare cause of mediastinal masses, and the diagnosis is always a challenge. Robotic assisted thoracoscopic surgery was proved to be safe and efficient in this rare case of ETT developed in the superior mediastinum.

Robotic Assisted Thoracoscopic Repair of Iatrogenic Tracheal Rupture.

Introduction: Tracheal rupture is a rare condition, and its most common cause is head and neck trauma. Iatrogenic rupture is extremely rare and has multiple causes of which orotracheal intubation is the most common (1). Its importance derives from the associated high morbidity and mortality. The specific therapy is either conservatory or surgical, either through a posterolateral thoracotomy or minimally invasive (VATS). Robotic assisted surgery to repair the postintubation iatrogenic tracheal rupture after elective surgery has not been described so far in the literature. Case presentation: We present a 54-year-old female patient with no significant underlying conditions, who presented subcutaneous emphysema of the supraclavicular fossa less than 24 hours after surgery for an L5-S1 disc herniation. The CT and bronchoscopy confirmed the suspicion of tracheal rupture in the membranous area, revealing a lesion of more than 5 cm, with minimal chances of healing through a conservative attitude. Surgery was decided and a robotically assisted approach was offered by a team with experience in applying this technology for thoracic/mediastino-pulmonary pathology. Using the DaVinci Xi platform, the mediastinal dissection was performed, the 5 cm tracheal breach was revealed at the lateral border of the membranousa, azygos vein and vagus nerve, followed by closing the defect with resorbable PDO 4-0 monofilament thread and the application of co-polymer adhesive (Coseal) on the suture line. The operative time was 220 minutes and the intraoperative bleeding was minimal, (50 ml), without intraoperative complications. The robotic approach demonstrated the advantages of a generous exposure of the operative field, with a clear visibility of the meticulously dissected structures and facilitated the efficient suturing of the tracheal defect. Favorable post-operative outcome with both bronchoscopy and follow-up radiographs showed no signs of recurrence. Conclusion: The presented case demonstrates the advantages of an efficient use of robotic assisted thoracoscopic surgery to treat a very rare complication, the iatrogenic rupture of the trachea. Although the good results are obvious, the large-scale application of robotic technology for tracheal surgery requires prospectively analyzed comparative studies.

Primary Pleural Hydatidosis-A Rare Occurrence: A Case Report and Literature Review.

Introduction: The larvae of Echinococcus, a parasitic tapeworm, cause hydatid disease. The most commonly involved organ after the liver is the lung but there are cases of hydatid cysts in all systems and organs, such as brain, muscle tissue, adrenal glands, mediastinum and pleural cavity. Extra-pulmonary intrathoracic hydatidosis can be a diagnostic challenge and a plain chest x-ray can be misleading. It can also lead to severe complications such as anaphylactic shock or tension pneumothorax. The purpose of this paper is to present a severe case of primary pleural hydatidosis, as well as discussing the difficulties that come with it during diagnosis and treatment. Case Report: We present the case of a 43-year-old male, working as a shepherd, presenting with moderate dyspnea, chest pain and weight loss. Chest x-ray revealed an uncharacteristic massive right pleural effusion and thoracic computed tomography (CT) confirmed it, as well as revealing multiple cystic formations of various sizes and liquid density within the pleural fluid. Blood work confirmed our suspicion of pleural hydatidosis with an elevated eosinophil count, typical in parasite diseases. Surgery was performed by right lateral thoracotomy and consisted of removal of the hydatid fluid and cysts found in the pleura. Patient was discharged 13 days postoperative with Albendazole treatment. Conclusion: Cases of primary pleural hydatidosis are very rare but must be taken into consideration in patients from endemic regions with jobs that may have exposure to this parasite. Proper treatment, both surgical and antiparasitic medication, can lead to a full recovery and a low chance of recurrent disease.

Pleural Solitary Fibrous Tumors-A Retrospective Study on 45 Patients.

Introduction: The purpose of this paper is to study the type, the clinical presentation, and the best diagnostic methods for pleural solitary fibrous tumors (PSFTs), as well as to evaluate which is the most appropriate treatment, especially as PSFTs represent a rare occurrence in the thoracic pathology. Material and Method: A retrospective study was conducted on a group of 45 patients submitted to surgery between January 2015 and December 2019. In most cases, the diagnosis was established through imaging studies-thoracic computed tomography (CT) scan with or without contrast-but also using magnetic resonance imaging (MRI) or positron emission tomography (PET) scans when data from CT scans were scarce. All patients were submitted to surgery with curative intent. Results: Most patients included in this study were asymptomatic, with this pathology being more common in patients over 60 years of age, and more common in women. The occurrence of malignant PSFT in our study was 17.77% (8 cases). All cases were submitted to surgery with curative intent, with a single case developing further recurrence. In order to achieve complete resection en bloc resection of the tumor with the chest wall, resection was performed in two cases, while lower lobectomy, pneumectomy, and hemidiaphragm resection, respectively, were needed in each case. Postoperative mortality was null. Conclusion: Thoracic CT scan remains the most important imagistic investigation in diagnosing. MRI is superior to thoracic CT, especially in cases that involved the larger blood vessels within the thorax, spinal column, or diaphragm. Complete surgical resection is the gold standard in treatment of PSFT, and the prognosis in benign cases is very good.

Lung neuroendocrine tumors: A systematic literature review (Review).

Neuroendocrine tumors (NETs) can have multiple localizations in the human body however, most often, it appears in the in thorax at tracheobronchial tree and the thymus. NETs are a group of tumors with heterogenous malignancy that evolve from neuroendocrine cells, with the lung being the second target organ after the gastrointestinal tract. These rare tumors are usually asymptomatic and non-functional with little information regarding incidence in the specialty literature. The main purpose of this review, was the analysis of the available literature in all aspects while mainly focusing on molecular diagnosis data and secondly, by using this molecular landscape to establish a differentiation of lung neuroendocrine tumors (LNETs). By analyzing the literature, new data were revealed regarding histological evaluation, genetic aberrations, prognosis depending on the type of LNET and therapeutic options that derive from these. Efficient management of these tumors is essential in the handling of symptoms and increase in life expectancy, especially in patients with functional tumors. Histological differentiation of LNETs is important in establishing proper therapeutic options and prognosis. Combined types of LNETs remain a controversial topic of discussion regarding diagnosis and treatment, a topic on which further studies are required in order to improve diagnosis in this group of tumors with heterogenous malignancy.

Pulmonary Mucinous Cystadenoma - A Rare Pathology.

BACKGROUND: Pulmonary cystadenoma is a very rare benign tumor of the lung with slow growth rate and most often, asymptomatic. CASE REPORT: We present the case of a 58-year-old patient admitted in the hospital for coughing with hemoptoic sputum. Standard thoracic radiography revealed a 4/5 cm macronodular opacity in the right inferior lobe, paracardiac. Thoracic computed tomography (CT) with contrast discovered a 3.8/4.7 cm homogenous mass in the right inferior lobe. After intraoperative assessment of the lesion a lower right lobectomy with mediastinal and local lymphadenectomy was performed. CONCLUSION: Pulmonary mucinous cystadenoma is one of the primary pulmonary mucinous cystic neoplasia (PMCT) alongside PMCT of low malignancy and pulmonary mucinous cystadenocarcinoma (PMCAC). Because of this and because of the clinical and imagistic similarities between these main entities, establishing a preoperative diagnosis becomes very difficult. Therefore, histopathological and immunohistochemistry studies are mandatory in order to establish the correct diagnosis.

Primary Leiomyoma of the Visceral Pleura: An Unexpected Occurrence.

BACKGROUND/AIM: Leiomyoma is a rare benign tumor originating from smooth muscle fibres. In the respiratory tract, these tumors are rare and in the pleura, cases are exceptional, with only a few reported so far. This is the main reason we decided to present this case of primary leiomyoma of the visceral pleura. CASE REPORT: We present a case of a 51-year-old asymptomatic patient who, during a routine medical examination using standard chest radiography, presented with a 3 by 2 cm homogenous mass in the right superior pulmonary area, tangent to the chest wall (same level with the 3rd rib). Further investigation using computed tomography (CT) in the chest confirmed the presence of a 31/18 mm solid mass in the right upper lobe, in contact with the parietal pleura. Surgery was performed for two reasons: i) removal of the tumoral mass and ii) establishing a histopathological diagnosis. Intraoperatively, a well-defined, homogenous, ivory white non-infiltrating mass was discovered in the right upper lobe on the visceral pleura and in close proximity to the minor fissure. The mass was removed with negative surgical margins and was left with healthy tissue. Histopathological examination and immunohistochemistry came as a surprise, establishing our diagnosis of leiomyoma. CONCLUSION: Primitive pleural leiomyoma must remain a possibility when considering the differential diagnosis of pleural tumors. The main course of treatment is complete surgical resection. In our case, long-term follow up did not present any local recurrence.

A Large Thymoma Resected via Left Antero-lateral Thoracotomy.

Background/Aim: Thymomas are a rare type of mediastinal tumors with a slow growth rate. Because of this, they are well tolerated and patients usually present with large masses, which can extend in either of the thoracic cavities. The surgical approach for such tumors is dictated by the size and localization of the mass. Case Report: We present the case of a patient with a large thymoma, resected through surgery performed by left antero-lateral thoracotomy. The patient presented in our clinic with a persistent cough, dyspnea, chest pain and tightness. Standard thoracic X-ray revealed a bilateral increase in size of the mediastinal shadow, mainly on the left side, with well-defined margins and subcostal intensity. A thoracic computed tomography (CT) scan discovered a tumoral mass within the antero-superior mediastinum, with compression of the mediastinal organs; presentation being suggestive for a thymoma. Surgery was performed, removing a 15/13/10 cm thymoma with a weight of 1126 g. Pathological examination as well as immunohistochemistry confirmed our diagnosis of type AB thymoma, stage I Masaoka-Koga. Conclusion: In conclusion, surgical treatment remains the main therapeutic option in thymomas, but it is often difficult to perform due to tumor size and local invasion. However, even in large thymomas of stages I and II, surgery can be performed using an antero-lateral thoracotomy.

Azygos Vein Aneurysm Mimicking a Mediastinal Mass.

BACKGROUND/AIM: Azygos vein aneurysm (AVA) is a rare thoracic pathological entity that mimics a posterior mediastinal mass as well as a right paratracheal mass. Usually asymptomatic, AVA is often accidentally discovered during routine chest x-rays; however, depending on the aneurysm size and complications, some symptoms may be present. The aim of this paper is to report a case of idiopathic AVA and to discuss its aetiology, embryonic origin, symptoms, complications, diagnostic methods and treatments. CASE REPORT: A 74-year-old female was investigated for diffuse thoracic pain and submitted to standard chest x-ray, which identified a right paratracheal, well-defined, homogenous opacity, considered to be part of the mediastinal shadow. The patient was further submitted to thoracic computed tomography, which confirmed the presence of a tumoral mass at the level of the right paratracheal area. The patient was submitted to surgery and the tumoral mass was resected; however, the tumor proved to be a completely thrombosed aneurism of the azygos vein arch. CONCLUSION: AVA is a rare pathology that must be taken into consideration during the differential diagnosis of right postero-superior mediastinal masses.

Giant Intrathoracic Schwannoma: A Case Report.

BACKGROUND/AIM: Thoracic neurogenic tumors are most frequently located in the posterior part of the mediastinum or on the chest wall, along the intercostal nerves. Schwannomas are very well tolerated for a long period, until the tumor reaches a large size and compression of the neighbouring mediastinal organs, chest wall or spine appears. The purpose of this article was to present a case of a giant right forth intercostal nerve Schwannoma, completely resected by a right antero-lateral thoracotomy. In addition, intrathoracic giant neurogenic tumors are a rarity. CASE REPORT: The patient presented with only diminished tolerance to physical activity with no other obvious symptoms. Standard chest radiography revealed a well-defined opacity of subcostal intensity, occupying two thirds of the right hemithorax, forming a common body with the mediastinal shadow. Thoracic computed tomography (CT) identified a 21/11 cm solid mass that compresses the right lung and the right main bronchus with both a solid component and a central liquid area. Open surgery was performed in order to remove the tumor, which was 20.5/12.5/9 cm in size and weighed 1,830 g, well defined, with no invasion of the adjacent organs, having a solid-fibromatous aspect as well as a central necrotic area. The origin of the tumor was confirmed from the posterolateral part of the forth intercostal nerve. Pathology examination and immunohistochemistry confirmed the diagnosis of a benign Schwannoma. CONCLUSION: Benign intrathoracic Schwannomas are asymptomatic for long periods and the main therapeutic option is complete surgical resection. The surgical approach, either open or video-assisted is dictated by the localisation of the tumor, local extension and most importantly the size of the neurogenic mass.

Persistent Left Superior Vena Cava - Accidental Finding.

BACKGROUND/AIM: The presence of the superior left vena cava represents a rare anomaly of the thoracic venous system. CASE REPORT: An asymptomatic case of this type of anomaly, discovered as an accident during investigations for a different pathology (superior left pulmonary lobe tumor), is presented. A 56-year-old, heavy smoker was admitted in our clinic with a tumoral mass in the left superior pulmonary lobe discovered during a routine chest x-ray. Physical and clinical examination was normal. However, transthoracic echography noted a coronary sinus enlargement, which led to the suspicion of a thoracic venous anomaly. Contrast chest computed tomography pointed out a venous anomaly at the level of the left hemithorax originating from the cervical region, crossing the aortic arch and draining in the coronary sinus. During the examination, contrast substance was not detected in the right superior vena cava, either early or late during the computed tomography. During surgery the presence of a persistent left superior vena cava was observed, coming from the cervical region, crossing lateral to the aortic arch and draining in the coronary sinus. CONCLUSION: The presence of an enlarged coronary sinus should warn the surgeon about the possibility of a thoracic venous anomaly. Identifying a persistent left superior vena cava is important due to its clinical implications, especially during certain procedures such as mounting central venous lines, cardiac cannulation or implantation of cardiac stimulators.

Neuroendocrine syndrome in bronchial carcinoid tumors.

Pulmonary carcinoid tumors represent bronchopulmonary neuroendocrine neoplasms which might synthetize serotonin, histamine, bombesin or other types of hormones responsible for the development of a broad spectrum of signs and symptoms, known as carcinoid syndrome. Data of 98 patients submitted to surgery for bronchial carcinoid tumors in the Thoracic Surgery Clinic of the 'Marius Nasta' Institute of Pneumophtisiology between 2014 and 2018 were retrospectively reviewed. All patients were submitted to paraclinical tests, imagistic studies (computed tomography or magnetic resonance imaging), bronchoscopy and biopsy in order to have a positive diagnostic of pulmonary carcinoid. The most common clinical symptoms at the time of presentation were: Persistent cough followed by dyspnea and recurrent pulmonary infections. The main neuroendocrine syndromes found were Cushing and Carcinoid Syndrome. All patients were submitted to surgery with curative intent consisting of wedge resection (in 4 cases, 4.08%), lobectomy (in 79 cases, 80.61%), bilobectomy (in 5 cases, 5.1%) and pneumonectomy respectively (in 10 cases, 10.2%). In all cases neuroendocrine specific symptoms disappeared once the carcinoid tumor was removed. In conclusion, bronchial carcinoid tumors have a positive outcome in most cases. Specific neuroendocrine markers as well as neuroendocrine syndrome disappears once the tumor is removed.