Large thoracic duct cysts are rare and standard lateral thoracotomy is usually used for resection. In the reported case the combination of an antero-lateral thoracotomy with a partial longitudinal median sternotomy (hemiclamshell approach) allowed an excellent visualization and dissection of a large thoracic duct cyst expanding in the anterior cervico-thoracic junction, and was associated with an uncomplicated recover

Karajiannis, Alexandros

Krueger, Thorsten

Ris, Hans-Beat

Stauffer, Eduard

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Case reportLarge thoracic duct cyst ± a case report and review of the literatureAlexandros Karajiannisa, Thorsten Kruegerb,*, Eduard Staufferc, Hans-Beat RisbaDepartment of Thoracic and Cardiovascular Surgery, University Hospital of Bern, Bern, SwitzerlandbDepartment of Surgery, University Hospital of Lausanne, Lausanne, SwitzerlandcInstitute of Pathology, University Hospital of Bern, Bern, SwitzerlandReceived 7 June 1999; received in revised form 7 March 2000; accepted 29 March 2000AbstractLarge thoracic duct cysts are rare and standard lateral thoracotomy is usually used for resection. In the reported case the combination of anantero-lateral thoracotomy with a partial longitudinal median sternotomy (hemiclamshell approach) allowed an excellent visualization anddissection of a large thoracic duct cyst expanding in the anterior cervico-thoracic junction, and was associated with an uncomplicatedrecovery. q 2000 Elsevier Science B.V. All rights reserved.Keywords: Thoracic duct cyst; Trap door incision; Case report; Clamshell; Mediastinum1. Case reportA 49-year-old man was referred to our institution with alarge cystic tumour localized in the right upper anteriormediastinum. Bronchoscopy showed a slight compressionof the middle and distal part of the trachea. The tumour wasdiscovered 8 years before admission and ®ne needle aspira-tion revealed milky-yellowish ¯uid leading to the assump-tion of a thoracic duct cyst. No further treatment was done atthat time. A CT-scan of the chest at admission revealed ahuge cystic mass in the right superior anterior mediastinumin close relationship to the superior vena cava, the ascendingaorta, the oesophagus, the trachea, which was deviated andimpressed, and the right phrenic and recurrent nerves (Fig.1). The maximum diameter was 12 cm. Physical examina-tion of the asymptomatic patient yielded no symptoms suchas stridor, dyspnea or vein distension. Lung function testingand laboratory control revealed normal values.It was decided to resect the lesion due to its unknownaetiology. Owing to its localization in the anterolateralsuperior mediastinum, a hemiclamshell thoracotomy waschosen and the cystic tumour was dissected without dif®-culty. The cyst originated from the thoracic duct and wassituated in close relationship to the right subclavian vessels,the brachiocephalic trunk, the superior vena cava, themiddle and distal trachea and the oesophagus, the ascendingaorta and the azygos vein, with displacement of the rightupper lobe of the lung. The cystic tumour was dissectedfrom these structures and removed after ligating and divid-ing the thoracic duct as well as several efferent and afferentlymphatic vessels. The phrenic and recurrent nerves werevisualized and preserved.The postoperative recovery was uneventful. Pain wascontrolled by continuous peridural analgesia for 7 days.The patient was discharged from the hospital on the 10thpostoperative day with low dose oral analgesics. The 6-month follow-up showed an asymptomatic patient with aregular performance status and normal pulmonary function.The intraoperative suspicion of a thoracic duct cyst wascon®rmed by histological examination. The cyst was unilo-cular and contained yellowish cloudy serous ¯uid. Theweight was 395 g with a size of 8 £ 10 £ 12 cm. Microsco-pically, the cyst's wall contained of an inner single layer of¯at endothelial cells, smooth muscle cells and islets oflympho-reticular tissue (Fig 2).2. DiscussionA cyst of the thoracic duct is an uncommon disease. Areview of 42 surgically treated congenital mediastinal cystsshowed only one thoracic duct cyst [1]. The ®rst reportedcase was found during an autopsy examination by Carbonein 1892 and only 27 cases of thoracic duct cyst have beenreported since Emerson [2] described the ®rst case diag-nosed during the patient's lifetime. The cyst in our patientwas found in the superior anterior mediastinum, in accor-dance with approximately one of three previous reports.European Journal of Cardio-thoracic Surgery 17 (2000) 754±7561010-7940/00/$ - see front matter q 2000 Elsevier Science B.V. All rights reserved.PII: S1010-7940(00)00447-4www.elsevier.com/locate/ejcts* Corresponding author. Tel.: 141-21-314-2408; fax: 141-21-314-2358.E-mail address: thorsten.krueger@chuv.hospvd.ch (T. Krueger).A. Karajiannis et al. / European Journal of Cardio-thoracic Surgery 17 (2000) 754±756 755Fig. 1. Computed tomography of the chest. Large cystic lesion localized in the superior anterior mediastinum.Fig. 2. Histology (hematoxylin/eosin staining). Cyst wall containing of an inner single layer of ¯at endothelial cells, smooth muscle cells and islets of lympho-reticular tissue.In contrast to our patient, symptoms were reported inother reports such as dyspnea on effort, thoracic or backdiscomfort and dysphagia, often aggravated by intake offood. Life-threatening complications, such as acute respira-tory insuf®ciency, have also been reported [3].Computed tomography rose the suspicion of a cysticlesion, but failed to clear its dignity. The differential diag-nosis included pericardial or pleural mesothelial cysts, tera-tomatous cysts, bronchial or oesophageal cysts, thymic cystsand neurenteric and lymphangiomatous cysts [1]. Only threeof the published cases of mediastinal thoracic duct cystswere diagnosed prior to surgery [4±6]. Lymphangiographyand direct injection of contrast into the cyst with visualiza-tion of a communication between the cyst and the thoracicduct have been reported. The diagnosis in our patient wasbased on the relation between the cyst and the thoracic ductas assessed during the operation and on the microscopic®ndings displaying the cyst's wall with an inner singlelayer of ¯at endothelial cells, smooth muscle cells and isletsof lympho-reticular tissue [7].Surgical resection of the cyst is usually recommended.Only one investigator suggested an expectative approachin asymptomatic patients with con®rmed diagnosis [6].Surgical resection was performed via a lateral thoracotomyin 15 of 20 reviewed cases [8]. The most common compli-cation seen after surgery was chylothorax [7,9], requiringre-operation. As an alternative to standard thoracotomy thehemiclamshell approach may be used to access largemediastinal tumours situated in the superior part of themediastinum, since the adjacent structures, especially therecurrent nerve may be better visualized by use of thisapproach than a lateral thoracotomy. The hemiclamshellapproach offers an excellent visualization of the entiremediastinum and the entire cervico-thoracic junction withlittle morbidity regarding shoulder girdle function, chestwall complaints or pulmonary function as compared to stan-dard thoracotomy [10]. Video-assisted thoracoscopicsurgery (VATS) may offer an alternative to resect benignmediastinal tumours [11]. However, it may jeopardizeimportant structures such as the recurrent or phrenic nervesin situations with large expanding cysts situated at thecervico-thoracic junction. Moreover, the risk of rupture ofthe cyst during dissection with subsequent spillage of itscontent within the chest cavity is increased by use ofVATS as compared by an open approach.The frequency of complaints, the risk of potential life-threatening complications and the need to establish a diag-nosis justify the resection of those cysts even in asympto-matic patients. The surgical access has to be chosenaccording to the size and localization of the lesion inorder to achieve complete resection with save control ofadjacent structures and efferent and afferent lymphaticvessels.References[1] Ochsner JL, Ochsner SF. Congenital cysts of the mediastinum: 20-year experience with 42 cases. Ann Surg 1966;163:909±920.[2] Emerson GL. Supradiaphragmatic thoracic-duct cyst. An unusualmediastinal tumor. N Engl J Med 1950;242:575±578.[3] Fromang DR, Seltzer MB, Tobias J. Mediastinal compression andacute respiratory insuf®ciency. Chest 1975;67:725±727.[4] Hori S, Harada K, Morimoto S, Uchida H, Okumura K. Lymphangio-graphic demonstration of thoracic duct cyst. Chest 1980;78:652±654.[5] Tsuchiya R, Sugiura Y, Ogata T, Suemasu K. Thoracic duct cyst ofthe mediastinum. J Thorac Cardiovasc Surg 1980;79:856±859.[6] Morettin LB, Timothy EA. Thoracic duct cyst: diagnosis with needleaspiration. Radiology 1986;161:437±438.[7] Mori M, Kidogawa H, Isoshima K. Thoracic duct cyst in the medias-tinum. Thorax 1992;47:325±326.[8] Okabe K, Miura K, Konishi H, Hara K, Nobuyoshi S. Thoracic ductcyst of the mediastinum: case report. Scand J Thorac Cardiovasc Surg1993;27:175±177.[9] Cervantes-Perez P, Fuentes-Maldonado R. Thoracic duct cyst of themediastinum: case report. Chest 1976;70:411.[10] Lardinois D, Sippel M, Gugger M, Dusmet M, Ris HB. Morbidity andvalidity of the hemiclamshell approach for thoracic surgery. Eur JCardio-thorac Surg 1999;16(2):194±199.[11] Demmy TL, Krasna MJ, Detterbeck FC, Kline GG, Kohman LJ,DeCamp Jr MM, Wain JC. Multicenter VATS experience withmediastinal tumors. Ann Thorac Surg 1998;66:187±192.A. Karajiannis et al. / European Journal of Cardio-thoracic Surgery 17 (2000) 754±756756

Large thoracic duct cyst - a case report and review of the literature

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