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Ann Thorac Surg 2004;78:e34
© 2004 The Society of Thoracic Surgeons

Images in Cardiothoracic Surgery

Mediastinal cystic teratoma

Alfredo Cesario, MD*a, Domenico Galetta, MDa, Stefano Margaritora, MDa, Venanzio Porziella, MDa, Pierluigi Granone, MDa

a Department of Surgical Sciences, Division of General Thoracic Surgery, Catholic University, Rome, Italy

* Address reprint requests to Dr Galetta, Surgical Sciences, Thoracic Surgery, Division of General Thoracic Surgery, Catholic University, Largo Agostine Gemelli, 8, Rome 00168, Italy
e-mail: mimgaletta{at}yahoo.com

A 23-year-old man was referred to our department for a symptom-less mediastinal cystic mass.

On computed tomographic scan (Fig 1) the mass measured 16 x 12 x 18 cm. The lesion occupied the entire anterior and left part of the mediastinum and a significant portion of the left hemithorax. Left lung parenchyma was compressed. Hilar and mediastinal structures were compressed and slightly dislocated but no radiologic signs of infiltration were present.



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  		Fig 1.
 
Global spirometry showed a mild reduction in the forced vital capacity in 1 second value that proved to be 2.89 L (81% of the predicted value). Blood gas analysis did not show any anomaly. Blood test analysis did not show any abnormalities. In particular, all the checked tumor markers (carcinoembryonic antigen, tissue polypeptidic antigen, {alpha}-fetoprotein, and ß-human choriogonadotropin) were within the normal range.

The more consistent diagnosis (based on computed tomographic appearance and serological status) was that of a cystic teratoma, and surgery was indicated. Due to the prevalently cystic nature of the mass, a fine needle aspiration cytology was not attempted.

The patient was operated on and a left posterolateral thoracotomy was performed. At opening (Fig 2A), the mass (Fig 2A; open arrow) was confirmed to be occupying the entire anterior, left mediastinum and dislocating the entire left lung (Fig 2A closed arrow). Inflammatory adherence was present among the mass and the lung. After a partial emptying through fine needle aspiration (500 mL of fluid containing sebaceous remnants that strongly suggested a benign nature of the mass) the plan was easily prepared, the lung was retracted, and then the posterior aspect of the mass was bluntly dissected from the delicate surrounding structures (left lung hilum).



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  		Fig 2.
 
Anteriorly, the mass was dissected from the pericardium and the mediastinal pleura, which was opened for better control of the vascular structures in the upper region of the mediastinum (aortic arch, left subclavian artery). The mediastinal pleura was incised laterally to the left phrenic nerve, which was preserved.

Signs of direct infiltration with the structures in contact with the mass were never evidenced, whereas inflammatory adherences were quite common.

The mass was resected en bloc. It weighed 451 g and was 19 cm long at its maximum length, and the diameter was 14.5 x 12 cm (Fig 2B). Once opened its appearance was strongly consistent with our suspicions of a mature cystic teratoma, which was later confirmed on final pathologic examination.

Mediastinal mature cystic teratomas are not very rare; however, in this case it had considerably large dimensions.





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