Ann Thorac Surg 2002;73:633-635
© 2002 The Society of Thoracic Surgeons
Case report
Preoperative diagnosis of a paraesophageal bronchogenic cyst using endosonography
Li Lin Lim, MRCPa,
Khek Yu Ho, MD*a,
Peter Min Goh, FRCSb
a Department of Medicine, National University Hospital, Singapore, Singapore
b Department of Surgery, National University Hospital, Singapore, Singapore
Accepted for publication June 28, 2001.
* Address reprint requests to Dr Ho, Department of Medicine, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
e-mail: mdchoky{at}nus.edu.sg
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Abstract
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Preoperative diagnosis of paraesophageal bronchogenic cysts is difficult, and its management remains controversial. We describe the case of an incidental paraesophageal bronchogenic cyst, suspected preoperatively with endoscopic ultrasound and established intraoperatively by thoracoscopic inspection. Surgical treatment was achieved by cyst excision using a needlescopic technique. Endoscopic ultrasound seems to be the preoperative diagnostic test of choice for paraesophageal bronchogenic cysts.
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Introduction
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Bronchogenic cysts are one of the most common bronchopulmonary malformations. Definitive diagnosis is difficult preoperatively. Despite improved imaging modalities, including computed tomography (CT) and magnetic resonance imaging, the intramural and extramural relationship of lesions around the gastrointestinal tract and the possibility of solid tumors cannot always be clearly defined. We report the case of a paraesophageal bronchogenic cyst, suspected preoperatively with endoscopic ultrasound (EUS) and established intraoperatively by thoracoscopic inspection and needlescopic excision of the cyst.
A 40-year-old Japanese man, previously well, had an incidental mediastinal mass on chest radiography. A CT thorax (Fig 1)
revealed a 3.8 x 2.6-cm mass closely related to the carina and posterior wall of the proximal aspect of the right main bronchus, at the azygoesophageal recess. Differential diagnoses included a bronchogenic cyst, duplication cyst, esophageal leiomyoma, pleural fibroma, and lymphadenopathy.
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Fig 1. Thoracic computed tomographic scan revealing mediastinal mass (arrow) closely related to the carina and posterior wall of the proximal aspect of the right main bronchus.
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Endoscopic ultrasound examination using an echoendoscope with switchable frequencies of 7.5 to 12 MHz (Olympus GF-UM200, Olympus Co. Ltd, Singapore), demonstrated a 3.8 x 2.1-cm anechoic, well-circumscribed oval lesion, consistent with a cyst (Fig 2),
located outside the esophageal wall, at 28 cm to 32 cm from the gum level and separate from the right bronchus. Preoperative diagnoses were a paraesophageal bronchogenic cyst or esophageal duplication cyst.
At a planned thoracoscopic removal, a cyst next to the esophagus in the subcarinal region was seen. Surgery was performed with the patient in the left lateral position using double lumen general anesthesia. The right lung was collapsed. Three needlescopic ports, one 3 mm for the camera and two 2 mm for the operating instruments were inserted in the third, fifth, and seventh intercostal spaces in the posterior axillary line. Vision was provided by a 3-mm optic and three-chip charged couple device camera (Karl Storz Co, Ltd, Tübingen, Germany). On locating the cyst, yellowish milky fluid contents were aspirated. The cyst wall was excised using cautery and 2-mm needlescopic scissors. The lung was inflated under vision. No chest tubes were inserted. Skin puncture wounds were closed with steristrips without suture.
Histology showed a cuboidal epithelium lined cyst wall, which contained cartilage and few bronchial glands. The pathologic diagnosis was consistent with a bronchogenic cyst. The patient was discharged 2 days after the thoracoscopy and remains well.
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Comment
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Bronchogenic cysts mostly originate in the mediastinum, with a smaller percentage in the lung parenchyma. Different imaging techniques are used to make the diagnosis preoperatively. CT shows the cystic nature of the mass. However, if the cyst is infected or high in protein and calcium content, its density may fall into the solid tissue range which increases diagnostic uncertainty [1]. Moreover, CT is unable to differentiate paraesophageal cysts from intramural esophageal cysts, as neither of them enhance with contrast. CT suggested the presence of a bronchogenic cyst in our patient, but could not exclude a solid mass nor confidently assess the intramural or extra-esophageal location of the lesion. Magnetic resonance imaging is sensitive for detecting fluid-filled tissue. However, many bronchogenic cysts contain large amounts of proteinaceous material, thus producing high signal T1-weighted intensity images, making differentiation from fatty lesions difficult. EUS has revolutionalized the diagnosis of mediastinal masses [2]. As in our case, EUS clearly distinguishes cystic from solid masses, as well as defines the intra–extramural extent of lesions. It is thus very useful in the preoperative diagnosis of paraesophageal bronchogenic cysts. EUS is a very safe procedure with a low complication rate. Among 37,915 cases of upper gastrointestinal EUS reported in the literature, there were only 19 major complications (0.05%) with no mortality [3].
Management of asymptomatic bronchogenic cysts remains controversial. Most advocate surgical excision due to the high complication rate of subsequent infection, rupture, or hemorrhage, and occasional reports of malignant degeneration [4]. Alternatives to surgical excision include transbronchial needle aspiration and transesophageal needle aspiration, but these techniques are likely to be associated with cyst recurrence [5].
Thoracoscopic surgery is a recent less invasive option to resection via thoracotomy [6]. The technique entails minimal entry to the chest offering benefits for benign mediastinal tumor patients. In our case, thoracoscopy allowed excellent cyst visualization, facilitating precise and complete needlescopic excision. While recognizing that minimally invasive surgery may turn out to be insufficient treatment, it contributed to his short and uneventful postoperative recovery. In summary, preoperative diagnosis of paraesophageal bronchogenic cysts is difficult, but EUS seems to be the diagnostic test of choice.
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Acknowledgments
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The authors thank Jimmy So, FRCS, from the Department of Surgery, National University Hospital, Singapore.
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References
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Martinod E., Pons F., Azorin J., et al. Thoracoscopic excision of mediastinal bronchogenic cysts: results in 20 cases. Ann Thorac Surg 2000;69:1525-1528.[Abstract/Free Full Text]
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Abstract
Introduction
