Ann Thorac Surg 1997;64:334-337
© 1997 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Unusually Located Hydatid Cysts: Intrathoracic but Extrapulmonary
Fahri O
uzkaya, MD,
Yiit Akçali, MD,
Cemal Kahraman, MD,
Naci Emiroullari, MD,
Mehmet Bilgin, MD,
Atalay 
ahin, MD
Department of Thoracic and Cardiovascular Surgery, Erciyes University Medical Faculty, Kayseri, Turkey
Accepted for publication January 31, 1997.
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Abstract
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Background. Hydatid cyst disease is still a problem in Turkey, as well as in many other places in the world. Extrapulmonary location of the disease in the thorax is very rare, and surgical procedures can be considered that differ from those used for pulmonary hydatid cysts.
Methods. We reviewed retrospectively our experience in the surgical treatment of 22 patients with intrathoracic, extrapulmonary hydatid cysts. In our department, 297 patients with thoracic hydatid cysts were managed surgically in the last 14 years, in 22 (7.4%) of whom the cysts were localized extrapulmonarily in the thorax. The locations of these hydatid cysts were a fissure, the pleural cavity, chest wall, mediastinum, myocardium, and diaphragm.
Results. Total resection was chosen as the surgical procedure in all patients except 4 (18.2%), 1 of whom had cystectomy and capitonnage for cardiac hydatid cyst and 3 of whom had cystectomy and local curettage for cysts located in the chest wall. Empyema developed postoperatively in 1 case (4.5%) with a cyst in the fissure. The follow-up period was 1 year, and there were no deaths.
Conclusions. Hydatid cyst may be found in many different sites, including extrapulmonarily in the thorax, and bearing this in mind will facilitate planning of the operation.
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Introduction
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Hydatid cyst is a parasitic disease known from the time of Hippocrates, and it is still endemic in many places in the world. Liver and lung are the most common sites of the disease, but it can also be seen elsewhere in the body. Extrapulmonary location of the disease in the thorax is very rare, and surgical procedures can be considered that differ from those used for pulmonary cysts. We report 22 cases of hydatid cyst with intrathoracic but extrapulmonary location for which surgical procedures were performed.
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Material and Methods
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We reviewed retrospectively 22 cases of hydatid cysts located in the thorax without involving the lung between 1982 and 1995. Fourteen patients were male and 8 were female. Their ages ranged from 4 to 67 years, with an average of 31.3 years.
Various imaging techniques were used in the diagnosis of our cases. These included chest roentgenogram in 22 (100.0%), thoracic ultrasonography in 16 (72.7%), thoracic computed tomographic (CT) scan in 13 (59.1%), and echocardiography in 1 (4.5%). In 1 case imaged using CT, the cyst was enlarged both inside and outside of the thorax through a costal hole, forming an "hourglass" appearance in the thoracic CT scan (Fig 1
). In the case of echocardiography, the results demonstrated a cardiac (intramural) hydatid cyst in a 14-year-old female who was admitted to the emergency department with the complaint of syncope. Finally, esophagoscopy was performed in 1 case (4.5%) and showed a narrowing in the 17 cm of the esophagus due to compression from outside the esophageal wall in a female patient who was admitted to the hospital with the complaint of dysphagia.
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Fig 1. . Computed tomographic scan demonstrating an "hourglass" appearance of hydatid cyst located in the chest wall.
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Pleural cysts were the most frequent types among extrapulmonary intrathoracic hydatid cysts (16, 72.9%). Among these, the cyst was in the fissure in 12 (54.6%) and in the pleural space in 4 (18.3%). In the former group, the preoperative radiodiagnostic findings revealed that these cysts were located in the right hemithorax in 9 cases (41%) and in the left in 3 cases (13.6%). Other locations of the cysts included the chest wall in 3 (13.6%) (2 cysts in the right hemithorax and 1 cyst in the left), the diaphragm in 1 (4.5%) (a 6 x 6-cm cyst on the left diaphragm), the mediastinum in 1 (4.5%). Thoracic CT scan demonstrated 3 cystic lesions in the mediastinum, the largest measuring 5 x 5 cm), and the heart (intramural) in 1 (4.5%). Echocardiography (Fig 2) and thoracic CT scan (Fig 3) were used for the diagnosis of cardiac hydatid cyst.
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Fig 3. . Computed tomographic scan demonstrating the cardiac hydatid cyst in the same patient as in Figure 2 .
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Before excision of the cysts, a small amount of cystic fluid was aspirated and inactivation was achieved with injection of 10% NaCl into the cystic cavity. Application of sponges with hypertonic saline solution around the incision and in the thoracic cavity was performed routinely.
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Results
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Total excision of the cysts through a thoracotomy was carried out in 18 (82%) of the cases. Operative management is summarized in Table 1. There were no complications except in 1 patient. In this patient with a hydatid cyst in the right oblique fissure, empyema developed (4.5%).
The follow-up period was 1 year, and there were no deaths.
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Comment
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Hydatid cysts can be located in various tissues, although they are mostly seen in the liver and the lung [1, 2]. Radiodiagnostic techniques, dermal test, complementary fixation test, and indirect hemagglutination test can be used for diagnostic purposes. However, the most reliable of these techniques is the radiodiagnostic test [1, 3]. We found that it is possible to establish a satisfactory and reliable diagnosis when conventional roentgenogram is supported with CT scan, ultrasonography, or echocardiography. The intrathoracic location is the most common for hydatid cyst, also known as pulmonary cyst, whereas the chest wall, mediastinal, pericardial, myocardial, fissure, and pleural locations have been reported in the literature as extrapulmonary intrathoracic cysts [4–8]. In our cases, fissure and pleural space were the most common sites among extrapulmonary cysts (72.7%). All of them were attached to the visceral pleura by a thin pedicle. A partial defect in the visceral pleura and undamaged pulmonary parenchymal unity after excision were features that differed from peripherally located hydatid cysts of the lung.
Location of hydatid cysts in the chest wall is rare. Ribs, sternum, or soft tissues of the thoracic wall may become a locus [4]. The rate of overall bone involvement in hydatid disease is 0.9% to 2%, and therefore location in the thoracic cage is less common [9]. In 1 of our cases with costal hydatid cyst, the cyst enlarged in both sides of the rib and took the form of the figure 8. Costal destruction in 2 cases of chest wall location demonstrates that the cyst might enlarge toward the area of least resistance and produce pressure that destroys the bone.
Mediastinal hydatid disease has been reported rarely in the literature [5, 6]. Mediastinal hydatid cysts, which are seen by chance, produce pressure symptoms, as seen in our case. The larger of these cysts had compressed the esophagus of our patient, who suffered from progressive dysphagia.
The diaphragm is another less common site of involvement of hydatid cysts [10]. It usually needs repair after removal of the cyst. In our case, a defect was seen after removal of the cyst, which was located in the left part of the diaphragm, and suturing was performed.
Cardiac cysts differ in symptoms, diagnostic methods, and treatment among intrathoracic extrapulmonary cysts. These patients can present with tachycardia, syncope, and effort dyspnea. Echocardiography and CT scan are the diagnostic methods of choice. Cardiopulmonary bypass must be done for full-thickness myocardial cysts [11]. The cavity occurring after resection of the cardiac cyst in our series was sutured using the capitonnage technique.
Although comparisons between operative and nonoperative (ie, conservative) procedures in the treatment of hydatid cysts are continually being made, many authors have found successful results of operative treatment in large series [1, 4, 11, 12]. Cysts located extrapulmonarily in our series were removed surgically. We do not have experience in the response of cysts in this location to conservative treatment procedures. The fact that there were no deaths and only 1 case of morbidity in these 22 patients suggests that operative treatment is successful.
Hydatid cysts may be located in many different sites, including extrapulmonarily in the thorax, and bearing this in mind will facilitate planning of the surgical procedure.
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Fig 4. . Chest roentgenogram showing a hydatid cyst located in the chest wall. Note costal destruction ( Arrow).
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Footnotes
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Address reprint requests to Dr Ouzkaya, Department of Thoracic and Cardiovascular Surgery, Erciyes University Medical Faculty, 38039 Kayseri, Turkey.
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References
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Abstract
Introduction
