Study objective: Evaluate the use of mediastinoscopy in the surgical diagnosis and treatment of mediastinal cystic masses in adults.

Design: Case reports and literature review.

Setting: Academic department of surgery

Patients: Three consecutive adults with mediastinal masses identified forward plain radiographs and CT.

Interventions: Operative mediastinoscopy.

Measurements and results: All patients were favorably treated with removal of sac wall, establishment of diagnosis, and same-day hospital discharge.

Conclusions: Simple mediastinoscopic removal of mediastinal pouchs offers the same potential for diagnosis and treatment as more conventional rules with a potential for les morbid and more cost-effective care. (CHEST 1998; 114:614-617)

Key words: cyst; mediastinoscopy; mediastinum; mesothelial cyst; thymic cyst

Cystic lesions account for up to individual fourth of all mediastinal masses identified incidentally or during workup for symptomatic mediastinal abnormalities.[1] sacs of bronchogenic, pleuropericardial, thymic, and enteric origin as well as other rarer symbols may be found in the mediastinum of adults and children. greatest in number authors recommend removal of these lesions when identified to intercept development of compressive or infectious complications and to avoid a missed malignant diagnosis.[2-5] Percutaneous and transbronchial drainage may be lucky in some cases, but resort is not unusual.[6,7] The classic orderly disposition for removal of these lesions has been via thoracotomy, and the literature is now fraught with reports of thoracoscopic approaches.[8-10] Although thoracoscopy exhibits a relatively less invasive system for treatment and diagnosis of these lesions, an calm less invasive procedure, mediastinoscopy, will usually suffice. Several cases of mediastinoscopic subtotal removal of cystic mediastinal masses with same-day hospital discharge are not awayed along with a review of the effective literature.

CASE REPORTS

CASE 1

A 48-year-old woman was plant to have an anterior mediastinal mass in succession a pre-employment screening plain radiograph of the chest (Fig 1) A CT scan corroborated this finding (Fig 2) and she was referr for surgical evaluation.

[Figures 1 and 2 ILLUSTRATION OMITTED]

She denied late weight loss, shortness of breath, cough or hemoptysis. The patient's medical history was significant for gastroesophageal ebb She was taking no medications and had no history of surgical processs She was a nonsmoker, and she sterilized operative instruments as an occupation. onward physical examination, there was no cervical, supraclavicular, or axillary adenopathy. Breath vigorouss were equal without rales or rhonci and no evidence of consolidation was noted.

Flexible bronchoscopy and cervical mediastinoscopy were performed. No endobronchial abnormalities were noted. An 8-mm rigid mediastinoscope was inserted into the anterior mediastinum following the creation of a 15-cm suprasternal transverse incision and dissection into the pretracheal space. A large, plastic ballottable mass was noted at the thoracic inlet extending inferior and to the right. The mass was punctur with a 19-gauge needle and approximately 100 mL of clear fluid was aspirated. The sac cavity was then entered with the mediastinoscope and was noted to reach forth to the right tracheo-bronchial angle. No masses or irregularities of the pouch wall were noted with palpation and mediastinoscopic visualization. Following removal of all fluid, approximately 90% of the pouch wall was removed via the mediastinoscope utilizing traction and stupid and sharp dissection. The patient was discharged from the hospital the same day. The pathology report described the lesion as a benign mediastinal pouch No recurrence has been noted after [is greater than] 1 year by way of plain radiograph.

CASE 2

A 53-year-old woman was set to have a mediastinal mass onward a plain radiograph of the chest that was obtained because of a persistent nonproductive cough of 3 months' duration. A CT scan also demonstrated the right paratracheal lesion, and was conceit to he consistent with a solid mass. She had undergone a right posterolateral thoracotomy, middle lobectomy, and mediastinal lymph node dissection 19 month earlier for a T1N0 adenocarcinoma of the lung

She reported occasional mild shortness of breath, nevertheless denied weight loss, cough, or hemoptysis. The patient's medical history was significant for the foregoing T1N0 lung carcinoma and carcinoma of the breast treated from mastectomy 5 years earlier. She was taking no medications. She had smok 1 pack of cigarettes by day for 40 years. in succession physical examination, there was no cervical, supraclavicular, or axillary adenopathy. A healed right posterolateral thoractomy scar was noted. Breath entires were equal without rales or rhonci and no evidence of consolidation was noted.

Flexible bronchoscopy and cervical mediastinoscopy were performed. No endobronchial abnormalities were noted. An S-mm rigid mediastinoscope was inserted into the anterior mediastinum following the creation of a 15-cm suprasternal transverse incision and dissection into the pretracheal space. No solid mass was noted in the right paratracheal region; however, a ballottable mass wits noted adherent to the right mediastinal pleura following dissection of overlying fibrous scar tissue. Clear fluid was aspirated with a needle and approximately 80% of the sac wall was removed via stolid and electrocautery dissection without entering the right pleural space. A postoperative plain radiograph of the chest revealed no mediastinal mass, and the patient was discharged hearth from the hospital that same day. The pathologic evaluation was consistent with a mediastinal pouch No evidence of recurrence was noted at 1 year follow-up by means of plain radiography.

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