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Ann Thorac Surg 2003;75:568-569
© 2003 The Society of Thoracic Surgeons

Case report

Mediastinal talcoma masquerading as thymoma

Zahoor Ahmed, MDa, Joseph B. Shrager, MDa*

a Section of General Thoracic Surgery, Division of Cardio-thoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

Accepted for publication August 22, 2002.

* Address reprint requests to Dr Shrager, General Thoracic Surgery, Hospital of the University of Pennsylvania, 4 Silverstein, 3400 Spruce St, Philadelphia, PA 19104, USA.
e-mail: jshrag{at}mail.med.upenn.edu


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We report a young woman with a large, calcified anterior mediastinal mass discovered 18 months following a left talc pleurodesis. The lesion was evaluated and treated as the thymoma or teratoma that it appeared to be, with excision by a transcervical approach. Pathologic examination revealed a giant talc granuloma. Awareness of such a possibility following talc pleurodesis may allow surgeons to avoid unnecessary mediastinal exploration, and its occurrence suggests that talc administration simultaneous with mechanical pleurodesis should be avoided.


   Introduction
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Pleurodesis is often performed in cases of spontaneous pneumothorax or nonresolving pleural effusion. Talc has been reported to be the most reliable chemical agent for creating pleurodesis [1] by inducing a vigorous sterile inflammatory process. Although complications ranging from benign granuloma formation to pneumonitis and acute respiratory distress syndrome (ARDS) have been reported following the intrapleural administration of talc [2], the material continues to be widely used. We report a new "complication" of intrapleural talc – the formation of a calcified mass in the anterior mediastinum masquerading as an anterior mediastinal neoplasm. This "talcoma" required resection by a transcervical approach for diagnosis and treatment.

A 43-year-old woman was referred to us for persistent left-sided, burning thoracic pain in a neurogenic distribution suggesting that it was related to a left video thoracoscopic (VATS) procedure performed at an outside institution approximately 18 months previously. She had been taking oral narcotics continuously since the procedure, and she had also tried nonsteroidal antiinflammatory medications without significant relief. On questioning, the patient, who was otherwise in good health, reported that she had suffered a spontaneous pneumothorax on the left at that time, and that she had undergone the surgery because of persistent air leak and pneumothorax. She had no knowledge of precisely what procedure had been performed within her chest, and we were unable to locate an operative note from the previous procedure because the surgeon had retired and the hospital record had been lost.

The patient had a remote smoking history but no other significant past medical history. Her physical examination was unremarkable except for moderate to severe hyperaesthesia anterior to the VATS port sites as far as the midline, as well as what appeared to be pain-induced weakness in her left upper extremity. A chest computed tomogram (Fig 1) had been ordered by the referring physician in the hope that it might prove helpful in our evaluation of the patient’s pain, but he had not reviewed it at the time of the patient’s visit with us. Interestingly, the scan showed a 2.1 by 1.9 cm calcified mass in the anterior mediastinum consistent with a thymoma or a germ cell tumor.



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  		Fig 1. Computed tomographic image showing a 2.1- by 1.9-cm calcified mass.

 
For management of the patient’s apparent intercostal neuralgia, we referred her to a pain specialist for diagnostic injection of a local anesthetic, followed by possible neuroablation. In further workup of the incidental anterior mediastinal mass, we obtained serum {alpha}1-fetoprotein and ß-hCG levels. As these were in the normal range, we recommended and performed excision of the mass along with the thymus gland through a transcervical approach. Intraoperatively we did note that the mass was more adherent to anterior chest wall than a typical noninvasive thymoma would be. However, no technical difficulties were encountered. To our surprise, pathologic examination of the excised tumor demonstrated it to represent a giant talc granuloma with granulomatous giant cell reaction to polarizable, crystalline foreign material. The patient was discharged home on the day of the surgery and recovered uneventfully.


   Comment
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Chemical pleurodesis is a reasonably effective method of managing nonresolving spontaneous pneumothoraces or pleural effusions. Various substances, including tetracycline, doxycycline, talc powder or slurry, silver nitrate, nitrogen mustard, bleomycin, autologous blood, and scores of others have been utilized to achieve this objective. Responses to these chemicals range from innocuous, desirable changes like pleural inflammation to fatal complications such as ARDS [2, 3]. Although the age of the patient, safety profile of the material, and disease process initiating the pleural space pathology may determine the choice of the chemical agent used, most surgeons have adopted talc as the preferred agent.

Talc may be used as a slurry, in which case it is generally instilled through tube thoracostomy, or in its dry, powdered form that is usually used during thoracoscopy. In either form it may generate some degree of pneumonitis [2], which is usually limited to the periphery of the lungs. This limited inflammatory change helps in achieving sound pleural symphysis but does not appear to produce fibrothorax or hemothorax as may occur with tetracycline derivatives [4]. Talc has also been found to be disseminated throughout the body after intrapleural instillation, and this systemic absorption may be the cause of the reported cases of ARDS [2]. The various talc preparations in use differ markedly in their physical characteristics. It has been suggested that variation in the size of the particles and the presence of impurities may determine the incidence of complications [5].

In the patient reported here, the radiographic appearance of the anterior mediastinal mass suggested thymoma or teratoma and pushed our hand to perform surgical excision. Although there have been scattered reports of large talc granulomas in the literature, nothing of this size and in this location has been previously described. The possibility of a talc-related mass did not even enter our differential diagnosis. Further, we had no personal clinical experience that would suggest such a possibility. Even if we had obtained a clear history of the patient having undergone a talc pleurodesis, we would nevertheless have recommended surgical excision. We speculate, in retrospect, that vigorous mechanical pleurodesis before talc insufflation at the time of her thoracoscopy might have created a path of entry in the anterior mediastinum where a sufficient volume of talc was then deposited that subsequently developed into a huge foreign body granuloma.

The knowledge that a large, granulomatous pseudotumor of this sort may develop following talc pleurodesis should prove of use to thoracic surgeons and their patients. In some circumstances such knowledge may avert the need for invasive procedures carried out for diagnosis or therapy of these masses. Further, the occurrence of such a large mediastinal talcoma suggests that talc and mechanical pleurodesis should perhaps not be combined.


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 Abstract
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 References
 

  1. Bresticker M.A., Oba J., LoCicero J., 3rd, Greene R. Optimal pleurodesis: a comparison study. Ann Thorac Surg 1993;55:364-366.[Abstract]
  2. De Milanez C., Jose R., Vargas F.S., et al. Thoracoscopy talc poudrage: a 15-year experience. Chest 2001;119:801-806.[Abstract/Free Full Text]
  3. Brant A., Eaton T. Serious complications with talc slurry pleurodesis. Respirology 2001;6:181-185.[Medline]
  4. Light R.W., Wang N.S., Sassoon C.S.H., Gruer S.E., Vargas F.S. Comparison of the effectiveness of tetracycline and minocycline as pleural sclerosing agents in rabbits. Chest 1994;106:577-582.[Abstract/Free Full Text]
  5. Ferrer J., Villarino M.A., Tura J.M., Traveria A., Light R.W. Talc preparations used for pleurodesis vary markedly from one preparation to another. Chest 2001;119:1901-1905.[Abstract/Free Full Text]



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