Primary mediastinal cysts: clinical evaluation and surgical results of 32 cases.
ABSTRACT The purpose of this retrospective study was to analyze our experience with mediastinal cysts, emphasizing the clinical presentations and results of surgery.Thirty-two patients with mediastinal cysts underwent surgery from January 2000 through June 2005. The records of these patients were reviewed for age at presentation, sex, signs and symptoms at presentation, results of the imaging techniques, types of mediastinal cysts, location and size of cysts, types of surgical procedure, length of hospital stay, early postoperative complications, death, and other follow-up information.The 32 mediastinal cysts comprised 12 bronchogenic, 9 pericardial, 7 thymic, and 2 enteric cysts, together with 2 cystic teratomas. Overall, 14 of the 32 patients with mediastinal cysts were asymptomatic. The surgical approach was thoracotomy in 30 patients and median sternotomy in 2 patients. The mean length of hospital stay was 7.7 ± 2.6 days. All patients were free from recurrence during the mean follow-up period of 4.4 ± 3.3 years.Surgery for mediastinal cysts is associated with low morbidity and mortality rates and a very low recurrence rate. It offers a definitive diagnosis and cure, avoiding the higher morbidity and mortality risks associated with conservative observation.
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ABSTRACT: An 11-year old boy presented with a painless mass in the left side of the posterior cervical triangle and reported dyspnoea during physical exercise. Total surgical resection and histological examination of the mass confirmed the diagnosis of a cervical thymic cyst. With just few reported cases, cervical thymic cysts represent a rare entity. They usually present as painless masses. The clinical symptoms, differential diagnosis and therapeutic approach are discussed herein.Hellēnikē cheirourgikē. Acta chirurgica Hellenica 03/2013; 85(2).
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ABSTRACT: Bronchogenic cyst (BC) is a benign congenital mediastinal tumor whose natural course remains unclear. In adults, most BCs are removed by thoracotomy after complications. Currently, prenatal diagnosis is generally feasible and allows an early thoracoscopic intervention. The purpose of this retrospective study was to ascertain the best time for the operation. Reviewed were 36 patients (11 children, 25 adults) with a BC managed from 2000 to 2011. Clinical history, cyst size, duration of hospitalization, preoperative and postoperative complications, and detection of inflammatory elements were compared (Student t tests) between pediatric and adult patients. In the pediatric group, diagnosis was made prenatally in 7 patients, during the neonatal period in 2, and later in 2. Nine were asymptomatic. In the adult group, 20 patients were treated for complications. Thoracotomy was performed in 2 children and thoracoscopy in 9 (no conversion). A thoracoscopic operation was performed in 9 adults (2 conversions), and 17 adults required additional procedures (4 pericardial and 9 lung resections, 3 bronchial, and 1 esophageal sutures). The average length of hospitalization was 4.45 days for children (3.33 days in the thoracoscopic subgroup) and 8 days for adults. Mean maximal cyst diameter was 2.2 cm in children and 6.5 cm in adults (p < 0.10). Pathologic study revealed inflammatory reaction in 2 children (18%) vs 21 adults (84%; p < 0.001). Early surgical resection of BCs provides better conservation of pulmonary parenchyma, a lower incidence of inflammatory lesions, and a reduced rate of complications, and should be proposed after prenatal diagnosis, between the 6th and 12th month of life.The Annals of thoracic surgery 08/2012; 94(5):1695-9. · 3.45 Impact Factor
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ABSTRACT: Thymic cysts are usually diagnosed accidentally during radiological evaluation of the chest for unrelated conditions. Symptoms appear late when the mass compresses on adjoining tissues. We report an unusual case of asymptomatic mediastinal thymic cyst which was seen in the neck whenever the patient was asked to perform Valsalva maneuver. This case is being reported for the unusual clinical presentation of a rare disease. The role of imaging in the diagnosis and common differential diagnoses are also discussed.Journal of clinical imaging science. 01/2012; 2:11.
Texas Heart Institute Journal
Primary Mediastinal Cysts and Surgery 371
© 2011 by the Texas Heart ®
Primary Mediastinal Cysts
Clinical Evaluation and Surgical Results of 32 Cases
The purpose of this retrospective study was to analyze our experience with mediastinal
cysts, emphasizing the clinical presentations and results of surgery.
Thirty-two patients with mediastinal cysts underwent surgery from January 2000
through June 2005. The records of these patients were reviewed for age at presenta-
tion, sex, signs and symptoms at presentation, results of the imaging techniques, types
of mediastinal cysts, location and size of cysts, types of surgical procedure, length of hos-
pital stay, early postoperative complications, death, and other follow-up information.
The 32 mediastinal cysts comprised 12 bronchogenic, 9 pericardial, 7 thymic, and 2
enteric cysts, together with 2 cystic teratomas. Overall, 14 of the 32 patients with medias-
tinal cysts were asymptomatic. The surgical approach was thoracotomy in 30 patients and
median sternotomy in 2 patients. The mean length of hospital stay was 7.7 ± 2.6 days. All
patients were free from recurrence during the mean follow-up period of 4.4 ± 3.3 years.
Surgery for mediastinal cysts is associated with low morbidity and mortality rates and
a very low recurrence rate. It offers a definitive diagnosis and cure, avoiding the higher
morbidity and mortality risks associated with conservative observation. (Tex Heart Inst J
discovered incidentally upon radiologic investigation of some other condition. They
are particularly significant because of the difficulty in making a differential diag-
nosis: they can simulate multiple lesions, both benign and malignant. There is still
no consensus on whether the best approach to treatment for mediastinal cysts is a
conservative medical one (particularly in application to pericardial and bronchogenic
cysts) or a surgical approach.2-4 The objectives of this study were to review the clinical
presentations and the results of surgery in patients with mediastinal cysts.
ystic lesions of the mediastinum are uncommon, comprising 12% to 18%
of all primary mediastinal tumors.1 Unless they attain a large size and cause
compressive symptoms, these tumors are generally asymptomatic and are
Patients and Methods
The medical records of 32 patients with mediastinal cysts who underwent surgery
from January 2000 through June 2005 were studied retrospectively. The records of
these cases were analyzed for age, sex, signs and symptoms at presentation, results of the
imaging techniques, type of mediastinal cyst, location and size of cyst, type of surgical
procedure, length of hospital stay, sequelae during the immediate postoperative period
(1st month), death, and follow-up after the 1st postoperative month.
Of 35 cases evaluated at the outset, one case of small and asymptomatic mediastinal
bronchogenic cyst was followed clinically but excluded from this study. In addition, 2
cases of bronchogenic cysts in the lung parenchyma were excluded from this study.
Preoperative analysis of the 32 mediastinal cysts that were incorporated into the
study included a variety of radiologic and endoscopic diagnostic tests, which were
performed in accordance with initial clinical suspicion, cyst location, and the patient’s
age at presentation. These diagnostic tests included chest radiography (all patients),
computed tomography (CT) (n=23), magnetic resonance imaging (MRI) (n=8), 2-
dimensional echocardiography (n=6), barium swallow (n=6), percutaneous fine-
needle aspiration under CT guidance (n=3), esophagoscopy (n=3), and transesopha-
geal echocardiography (n=2).
The diagnosis of mediastinal cyst was confirmed surgically in every case. All the
patients underwent surgery in our thoracic surgery departments and were reviewed as
outpatients at 1 month, 3 months, 1 year, and biannually thereafter.
Hidir Esme, MD
Sevval Eren, MD
Murat Sezer, MD
Okan Solak, MD
Key words: Bronchogenic
cyst; mediastinal cyst/com-
From: Department of Tho-
racic Surgery (Dr. Esme),
Konya Training & Research
Hospital, 42090 Konya;
Department of Thoracic
Surgery (Dr. Eren), Dicle
University School of Medi-
cine, 21300 Diyarbakir; and
Departments of Pulmonary
Disease (Dr. Sezer) and
Thoracic Surgery (Dr. Solak),
Kocatepe University School
of Medicine, 03200 Afyon;
Address for reprints:
Hidir Esme, MD, Konya
Egitim ve Arastirma Hasta-
nesi, Gogus Cerrahisi Klinigi,
Meram Yeniyol, 42090
Volume 38, Number 4, 2011372 Primary Mediastinal Cysts and Surgery
During a span of 4.5 years, 32 mediastinal cysts were
treated with surgery. Patients’ clinical details, treat-
ments, and duration of follow-up are summarized in
Table I. The mean length of hospital stay was 7.7 ± 2.6
days. All patients were free from recurrence during the
mean follow-up period of 4.4 ± 3.3 years.
Six of the 12 patients with bronchogenic cysts were
asymptomatic. The most common symptom was chest
pain in 6 patients, followed by dyspnea in 2. Chest
radiography revealed a mass effect in the anterior-
superior mediastinum in all patients. A CT chest scan,
performed in 8 patients, revealed round, well-circum-
scribed masses of water density in the middle medias-
tinum in 6 patients; similar masses were seen a little
higher in the anterior mediastinum in 2 patients. Mag-
netic resonance imaging helped to clearly define the
cystic lesions in the middle mediastinum in the other
4 patients. Compared with the low signal intensity in
T1-weighted images, the bright signal intensity in T2-
weighted images indicated the cystic content of the me-
diastinal mass—a characteristic sign that differentiates
a solid mediastinal mass. The surgical approach was
thoracotomy in all 12 patients.
Five of 9 patients with pericardial cysts were asymptom-
atic; the cyst was an incidental radiologic finding (Fig.
1). Dyspnea or chest pain was the presenting symptom
in the other 4 patients with pericardial cysts. Chest
radiography in all patients revealed a right paracardial
mediastinal tumor. A CT scan performed in 6 patients
had revealed thin-walled, sharply defined, oval, homo-
geneous masses of slightly higher-than-water density, in
the right cardiophrenic angle. All 9 patients underwent
surgery via right thoracotomy. Pneumonia and atelec-
tasis developed in 1 patient during the postoperative
Two of 7 patients with thymic cysts were asymptomat-
ic; 2 presented with dyspnea, 2 with cough, and 3 with
angina. Five patients underwent chest CT scans for the
evaluation of anterior-superior mediastinal masses de-
tected on chest radiography (Fig. 2). Thymic cysts were
located in the anterior mediastinum in 4 patients and in
the middle mediastinum in 1 patient. In the remaining
TABLE I. Summary of 32 Patients’ Clinical Details, Treatment, and Follow-Up
7/5 4/5 5/2 2/0 1/1
Age, yr 45 ± 15 40 ± 13 34 ± 24 17 ± 24 12 ± 14
Chest pain (6)
and dyspnea (2)
Chest pain (3)
and dyspnea (2)
Chest pain (3),
and cough (2)
and vomiting (1)
and cough (2)
Location of cyst
Anterior (2) and
and middle (1)
Posterior (2) Anterior (2)
Size of cyst, cm 5.6 ± 1.7 7.3 ± 1.5 5.2 ± 1.4 4.5 ± 0.7 5 ± 1.4
Thoracic MRI 4
and sternotomy (1)
and sternotomy (1)
Length of hospital
7.7 ± 2.3 7.6 ± 3.2 7.4 ± 2.7 10 ± 2.8 6.5 ± 0.7
None Heart failure (1) None
CT = computed tomography; F = female; M = male; MRI = magnetic resonance imaging
Data are expressed as mean ± SD unless otherwise stated.
4.1 ± 2.2
7.3 ± 4.5
2.5 ± 1.1
1.5 ± 0.7
2 ± 1.4
Texas Heart Institute Journal
Primary Mediastinal Cysts and Surgery 373
2 patients, MRI showed multilocular masses in the an-
terior mediastinum, which appeared as a high-intensity
area in both T1-weighted and T2-weighted images. In
2 patients, percutaneous fine-needle aspiration under
CT guidance was not diagnostic and did not relieve the
symptoms. The cysts were resected via thoracotomy in
6 patients and via sternotomy in 1.
One of 2 patients with enteric cyst was clinically asymp-
tomatic. Dyspnea, signs of poor nutrition, and vomiting
were present in the other. Preoperative CT scanning
confirmed the presence of posterior mediastinal cysts
in both patients. The surgical approach was via thora-
cotomy in both patients. In the postoperative period,
the symptomatic patient developed heart failure.
Dyspnea and cough were the presenting symptoms in
the 2 patients with cystic teratoma. In 1 patient, the
mediastinal cystic teratoma occupied the entire ante-
rior and left mediastinum and a substantial portion
of the left hemithorax. The left-lung parenchyma and
mediastinal structures were compressed. Percutaneous
fine-needle aspiration under CT guidance was not di-
agnostic at biopsy, but aspiration of some of the cystic
contents partially relieved the patient’s symptoms. In
the 2nd patient, the cystic teratoma was also located in
the anterior mediastinum. The approach was via tho-
racotomy in 1 patient and via sternotomy in the other.
There were no postoperative complications.
One controversial aspect of mediastinal cysts concerns
appropriate treatment, which ranges from observation
to surgical resection.2,3 Many authors have maintained
that the treatment of choice is complete excision of the
cyst, even in asymptomatic patients, in order to prevent
complications and to establish diagnosis.1,5 Ginsberg and
colleagues6,7 proposed that small asymptomatic bron-
chogenic cysts may be monitored with periodic radiog-
Fig. 1 A) Chest radiograph shows a pericardial cyst (arrows) in
the right paracardial area. B) Photograph shows intraoperative
appearance of the pericardial cyst (arrows) in the same patient.
Fig. 2 Chest radiograph (A) and computed tomogram (B) show
anterior-superior mediastinal masses that were determined
upon surgery to be thymic cysts.
Volume 38, Number 4, 2011 374 Primary Mediastinal Cysts and Surgery
raphy of the chest, whereas enlarging or symptomatic
cysts should be removed. We periodically monitored
2 adult patients (not included in this study) who had
asymptomatic and incidental bronchogenic cysts of 2
cm in diameter. The cyst progressively increased in size
in one of the patients, so we removed it surgically. In
the other patient, no progression or symptoms have de-
veloped in the 3-year follow-up period. Video-assisted
thoracic surgery might be an acceptable surgical pro-
cedure for patients with mediastinal cysts, but we had
no video-assisted thoracoscopic equipment before 2005.
Despite the value of various noninvasive diagnos-
tic studies, definitive diagnosis is established only by
surgical excision and tissue biopsy. Transtracheal and
percutaneous cystic aspirations have been proposed as
alternatives to operation, but these methods are not
widely accepted because of possible cystic recurrence,
which carries a substantial morbidity rate.8,9 Many of
the patients who do not undergo surgery at diagno-
sis develop symptoms related to growth of the cyst,10
which means that an operation then involves a higher
morbidity and mortality rate, together with a risk of
malignancy and development of complications.4 Al-
though complications associated with pericardial cysts
are uncommon, serious consequences of enlarged cysts
have included hemorrhage,11 spontaneous rupture,12,13
and hemodynamic compromise, including cardiac
tamponade.14,15 In light of the potential morbidity as-
sociated with complications of pericardial cysts, the
potential for cyst recurrence after aspiration alone, and
the inability to make a definitive histologic diagnosis
in the absence of a tissue sample, many investigators
endorse a surgical approach.
Percutaneous fine-needle aspiration may be suggest-
ed for histologic diagnosis and possible cure of thymic
cysts. However, in 2 of our patients with thymic cysts
we found this technique useful neither for cure nor for
diagnosis, probably because these cysts were surrounded
by dense fibroinflammatory tissue or a thick fibrous
capsule. Options other than surgical excision for the
treatment of bronchogenic cysts and thymic cysts—
including mediastinoscopic aspiration in symptomatic
patients—have been reported. However, these methods
should be exceptional, reserved as temporary proce-
dures for application to selected patients.1 In our study,
2 of the 7 thymic cysts were asymptomatic, but these
patients underwent surgery because the cystic diam-
eters were 5 and 6 cm and cystic thymoma could not
be excluded. For cystic teratomas, the standard therapy
is complete surgical resection.
There are those who recommend conservative treat-
ment for mediastinal cysts, on the ground that it avoids
surgical morbidity and mortality. To the contrary, the
prognosis after complete excision is excellent, and the
morbidity and mortality rates associated with surgery
are low.1,3 In our study sample, there were complications
in 2 patients (6%) and no deaths. No patient had a re-
currence during the follow-up period of 4.4 ± 3.3 years.
In light of these findings, we conclude that surgery
for mediastinal cysts has low morbidity and mortality
rates and a very low recurrence rate. It offers a defini-
tive diagnosis and cure, while avoiding the higher mor-
bidity and mortality risks associated with conservative
observation. A conservative approach can be considered
for small, asymptomatic mediastinal cysts that do not
compress adjacent structures, enlarge progressively, dis-
play atypical characteristics, or arouse suspicion of ma-
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