Ann Thorac Surg 2001;71:370-372
© 2001 The Society of Thoracic Surgeons
Case report
Ruptured thymoma causing mediastinal hemorrhage resected via partial sternotomy
Shinji Shimokawa, MDa,
Shun-ichi Watanabe, MDa,
Koh-ichi Sakasegawa, MDa,
Atsushi Tani, MDa
a Second Department of Surgery and Department of Radiology, Kagoshima University Faculty of Medicine, Kagoshima, Japan
Accepted for publication April 3, 2000.
Address reprint requests to Dr Shimokawa, Second Department of Surgery, Kagoshima University Faculty of Medicine, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
e-mail: simokawa{at}med6.kufm.kagoshima-u.ac.jp
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Abstract
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A case of a ruptured thymoma causing mediastinal hemorrhage and hemothorax that was electively resected by a partial sternotomy approach is presented. This case and others previously reported illustrate that a sudden onset of dyspnea and chest pain accompanied by acute mediastinal widening on chest roentgenogram in a previously healthy patient should suggest the diagnosis of a ruptured thymoma. An upper part sternotomy approach may be as safe and effective as a less invasive surgical procedure in resection of noninvasive thymomas, even if dense tumor adhesion exists.
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Introduction
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Athymoma may present with various symptoms or signs caused by its local extent and an associated systemic or autoimmune disorder. Very rarely a thymoma may rupture spontaneously [1–3]. We report a rare case of a ruptured thymoma causing mediastinal hemorrhage and hemothorax that was electively resected by a partial sternotomy approach as a less invasive surgical procedure.
A 71-year-old previously healthy woman had a sudden onset of chest pain and dyspnea accompanied by mild hypotension. On admission to an outside institution, a chest roentgenogram showed a widened mediastinum. Chest computed tomographic (CT) scans revealed an anterior mediastinal mass within calcification and hemorrhage, mediastinal hemorrhage, bilateral pleural effusion, and a normal aorta and great vessels (Fig 1). She had no abnormality in blood coagulation system. The diagnosis of hemomediastinum and bilateral hemothorax caused by rupture of the anterior mediastinal mass was suspected. Conservative treatment made her stable. The size of the mass and the amount of pleural effusion gradually decreased. She was referred to our department for operation 40 days after the onset. She did not present with any symptoms or signs associated with a systemic or autoimmune disorder. Physical examination was unremarkable. Serum tumor markers showed normal values. A venogram showed normal brachiocephalic veins and superior vena cava. Chest CT scans and magnetic resonance imaging taken before operation revealed the mass, 6 cm in maximum diameter, to be located mainly in the left anterior mediastinum and to reach to the level of the fourth intercostal space inferiorly. A benign teratoma or noninvasive thymoma was suspected.
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Fig 1. A chest computed tomographic scan on admission to an outside institution revealing an anterior mediastinal mass within calcification and hemorrhage, mediastinal hemorrhage, and a normal aorta and great vessels.
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We operated on her by an upper part sternotomy with hemitransection of the sternum to the left fourth intercostal space according to the lateral location and inferior margin of the tumor as a less invasive surgical procedure on January 25, 1999. The previous mediastinal hemorrhage had already been reabsorbed. The mass densely adhering to adjacent structures was carefully dissected. Both bilateral mediastinal pleurae and pericardium adhering to the tumor were partially resected by intention. The tumor (6.0 x 4.5 x 3.5 cm) covered by fibrous capsule was resected completely along with the involved left lobe of the thymus. Hemorrhage was found on the cut surface of the tumor. Frozen section revealed a thymoma and then a total thymectomy was performed. The operating time was 115 minutes. Her postoperative course was uneventful. The final pathologic study revealed a noninvasive, mixed lymphoepithelial type of thymoma. She was discharged from our hospital on the 4th postoperative day with great satisfaction at the cosmetic outcome (Fig 2). On follow-up 8 months after the operation she is free of symptoms without evidence of tumor recurrence.
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Comment
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The usual causes of acute hemomediastinum and hemothorax include chest trauma, rupture of a thoracic aortic aneurysm, or aortic dissection. Spontaneous mediastinal hemorrhage is rare and occurs in four clinical settings: (1) as a complication of enlarging mediastinal masses, (2) with transient increases in intrathoracic pressure, (3) with sudden, sustained hypertension, and (4) with alterations in hemostasis. Thymomas were not mentioned in the first category [4]. Thymomas, however, should be considered a rare cause of such hemorrhage. To our knowledge, there have been three reports in the literature regarding ruptured thymoma. Caplin and associates [1] reported a case of a 51-year-old man in whom rupture of a benign, predominantly epithelial type of thymoma caused hemothorax and the tumor was resected completely. Templeton and coworkers [2] reported a case of a 63-year-old man in whom a large malignant thymoma causes spontaneous hemothorax simulating aortic dissection. The tumor invaded the pericardium and right atrium and surrounded the great vessels of the aorta. Only biopsy was performed. In these two cases, the tumors had been present for 5 and 4 years, respectively, and emergent operations were required. Fukuse and colleagues [3] reported a case of a 70-year-old man in whom a benign thymoma caused a mediastinal hematoma. In this case, an elective operation was performed by a full median sternotomy with an anterolateral thoracotomy 2 months after the onset. The thymoma was found in the resected cystic tumor by a final careful pathologic examination. In four cases including our own case, a sudden onset of dyspnea and chest pain was the first clinical manifestation and all patients were healthy before the onset. The cause of spontaneous rupture of a thymoma is obscure. An enlargement of a thymoma may cause rupture and subsequently produce hemomediastinum or hemothorax [4]. In the malignant case [2], the rupture may be attributable partly to tumor invasion to adjacent vital structures. Another mechanism, ie, spontaneous intratumor hemorrhage without an enlargement, should be considered in the case reported by Fukuse and colleagues [3] because the diameter of the thymoma was only 7 mm.
Thoracoscopic operation has not been accepted completely for resection of thymomas [5]. As thymomas have a potential malignant behavior, tumor resection accompanied by a total thymectomy is recommended. In addition, sometimes tumor dissection from adjacent structures is required. These factors prevent thoracoscopic resection of thymomas. In our case, dense tumor adhesion to adjacent structures was expected preoperatively because of the previous event of rupture. Partial sternotomy has been advocated only for thymectomy in myasthenia gravis [6]. We believe that full sternotomy is unnecessary for resection of thymomas at least preoperatively diagnosed as noninvasive. A partial sternotomy approach may be safe and effective as a less invasive surgical procedure in resection of noninvasive thymomas, even if dense tumor adhesion exists. This approach can be easily and rapidly extended to a full sternotomy if needed.
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References
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Caplin J.L., Gullan R.W., Dymond D.S., Bradley S.M.O., Hill I.M., Banim S.O. Hemothorax due to rupture of a benign thymoma. Jpn Heart J 1985;26:123-125.[Medline]
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Templeton P.A., Vainright J.R., Rodriguez A., Diaconis J.N. Mediastinal tumors presenting as spontaneous hemothorax, simulating aortic dissection. Chest 1988;93:828-830.[Abstract/Free Full Text]
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Fukuse T., Matsukura T., Nakamura A., Kosaka S., Tamada J. Mediastinal hematoma due to thymomal hemorrhage—a case report. Nippon Kyobu Geka Gakkai Zasshi 1991;39:930-934.[Medline]
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Ellison R.T., III, Corrao W.M., Fox M.J., Braman S.S. Spontaneous mediastinal hemorrhage in patients on chronic hemodialysis. Ann Intern Med 1981;95:704-706.
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Demmy T.L., Krasna M.J., Detterbeck F.C., et al. Multicenter VATS experience with mediastinal tumors. Ann Thorac Surg 1998;66:187-192.[Abstract/Free Full Text]
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Trastek V.F., Pairolero P.C. Standard thymectomy. In: Shields T.W., ed. Mediastinal surgery. Philadelphia: Lea & Febiger, 1991:365-368.
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Abstract
Introduction
