Ann Thorac Surg 2005;79:1052-1054
© 2005 The Society of Thoracic Surgeons
Case report
Resection of a Thoracic Duct Lymphangioma Using Video-Assisted Thoracoscopic Surgery
Joseph C. Moran, MD*,a,
Jean-Philippe Bocage, MD, FACSa,
Robert J. Caccavale, MD, FACSa
a Department of Thoracic Surgery and The Minimally Invasive Learning Center, Saint Peter's University Hospital, New Brunswick, New Jersey, USA
Accepted for publication September 18, 2003.
* Address reprint requests to Dr Moran, Department of Surgery, Saint Peter's University Hospital, 254 Easton Ave, New Brunswick, NJ 08901, USA
triathlete70{at}hotmail.com
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Abstract
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Thoracic duct lymphangioma is a rare mediastinal tumor. Most patients are asymptomatic. Symptoms may include dysphagia, dyspnea, cough, or chest pain. Workup may include chest computed tomography or lymphangiography, or both. Surgery should be considered the treatment of choice. We present a 60-year-old man with a 2.4-cm mass in the retro-cardiac space to the right of the esophagus. The patient underwent a thoracoscopic resection of the mass with ligation of the thoracic duct. We conclude that video-assisted thoracoscopic surgery allows for safe evaluation and resection of mediastinal pathology.
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Introduction
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Thoracic duct lymphangioma is an extremely rare benign lesion arising in the mediastinum. This occurs in less than 1% of mediastinal tumors. Most patients are asymptomatic. Surgery should be the treatment of choice for these tumors. We report a case of thoracic duct lymphangioma, which was evaluated and resected by video-assisted thoracoscopic surgery.
A 60-year-old male presented to our office in December 2002. He had a long history of dysphagia and a known mediastinal mass since 1993. There was no history of weight loss. Routine posteroanterior chest roentgenogram showed no abnormality. Computed tomography of the chest and mediastinum revealed a 2.4-cm mass to the right of the aorta and esophagus, with compression of the esophagus (Fig 1). The esophagus was found to be dilatated proximal to the lesion. The density of the lesion on computed tomographic scan was believed to be consistent with a cystic-type structure. The lesion was unchanged in size in comparison with a previous chest computed tomographic scan.
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Fig 1. Preoperative chest computed tomographic scan demonstrates lesion in the right hemithorax adjacent to the esophagus and aorta.
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The patient was brought to the operating room in mid-December 2002. He underwent a right video-assisted thoracoscopic surgery exploration with complete resection of the lesion and ligation of the thoracic duct. The specimen was a thin-walled cyst containing chylous fluid. Final pathology revealed a thoracic duct lymphangioma. There was no evidence of malignancy.
The postoperative course was uneventful. The chest tube was removed in the recovery room after a brief period of observation with no air leaks. The patient was later discharged the same day. The patient was seen in follow-up 1 week later and continues to do well.
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Comment
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Thoracic duct lymphangioma is an extremely rare benign lesion arising in the mediastinum. Carbone [1] first described the lesion in 1892 during a postmortem examination. Fifty-eight years later, Emerson [2] described a supradiaphragmatic thoracic duct cyst in a living patient. This occurs in less than 1% of mediastinal tumors. Ninety percent of tumors develop before 2 years of age, with 10% arising in the superior mediastinum. Least commonly, in less than 10% of cases, lymphangioma may arise in the posterior mediastinum. Those arising in the mediastinum usually develop during childhood but are not discovered until adulthood. The cause of thoracic duct cyst development is unknown. Kausel and colleagues [3] believe that the cyst developed secondary to either a congenital weakness or a structural deficiency within the duct wall[3].
Mediastinal lymphangioma is a benign lesion of proliferating lymphatic vessels categorized into capillary, cavernous, and cystic types. Histologically these lesions frequently contain features of each type making a distinction between them all the more difficult. Lymphangiomas can vary from solid to spongy to predominately cystic lesions. They may contain large unilocular or multilocular cysts. The contents may vary from serous to chylous type fluid. Microscopically the cyst walls may contain smooth muscle and are usually fibrous.
Patient presentation is variable. Some patients may present with symptoms such as dysphagia, dyspnea, cough, or chest pain. Occasionally patients may present with signs of superior vena cava obstruction if the lesion is large enough to impede venous outflow from the head and upper extremities. However, many patients may be completely asymptomatic.
Workup including computed tomographic scan of the chest and chest roentgenogram examination may reveal pleural effusions, hydropneumothorax and mediastinal masses, or both, with or without compression of adjacent structures depending on the location and size of the tumor. Several authors including Tsuchiya and colleagues [4] and Hori and colleagues [5] have touted lymphangiography as the diagnostic test of choice before surgery. Both authors were able to show good results with lymphangiography by being able to delineate thoracic duct pathology. Oshikiri and colleagues [6] reported on magnetic resonance imaging and its usefulness during the patient's preoperative workup for mediastinal lymphangioma.
Surgery should be considered the treatment of choice, primarily in patients who present with a poorly defined mediastinal mass or chylothorax. Several authors including Matsuzoe and colleagues [7] and Anfossi and colleagues [8] have reported on thoracic duct lymphangioma treated by sternotomy and thoracotomy, respectively. At our institution, video-assisted thoracoscopic surgery is used exclusively to evaluate and treat mediastinal pathology.
Our technique for resection involved the following:
- Initial placement of patient in prone position.
- Placement of an appropriate sized broncho-cath endobronchial tube (Mallinckrodt Inc, St. Louis, MO).
- Confirmation of placement through a flexible bronchoscopy and initiation of single lung ventilation.
- Placement of patient in the left lateral decubitus position.
- Creation of four 2-cm incisions (ie, two in the anterior and two in the posterior axillary lines over the fifth and eighth intercostal spaces, respectively).
- Exploration of the thoracic cavity with a 10-mm, zero degree thoracoscope.
- Elevation and division of the mediastinal pleura using a combination of blunt and sharp dissection to expose the lesion.
- Further dissection revealed a saccular lesion in continuity with the thoracic duct. The lesion was not adherent to any adjacent structures.
- Placement of Weck Hem-o-lock clips (Weck Closure Systems Research, Triangle Park, NC) proximal and distal to the lesion.
- Cyst removal after placement in a specimen bag.
- Inspection of the area for any leakage of chyle.
The total operative time for the patient was approximately 55 minutes with an estimated blood loss of only 50 milliliters.
We find that video-assisted thoracoscopic surgery provides excellent visualization and access of the chest with little morbidity and mortality. In the majority of cases, the chest catheters are removed in the recovery room or within the first 24 hours. This translates into shorter hospital stays, less postoperative pain, and reduced hospital costs. Our patient had an uneventful postoperative course and returned to work 1 week later. Postoperative chest roentgenogram 1 week later was clear with no evidence of fluid accumulation.
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References
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- Carbone T. Cisti del dotto toracico (in Italian). J R Acad Med Torino. 1892;40:136–144
- Emerson GL. Supradiaphragmatic thoracic duct cyst. New Engl J Med. 1950;242:575–578
- Kausel HW, Reeve TS, Stein AA, Alley RD, Stranahan A. Anatomic and pathologic studies of the thoracic duct. J Thorac Cardiovasc Surg. 1957;34:631–642
- Tsuchiya R, Sugiura Y, Ogata T, Suemasu K. Thoracic duct cyst of the mediastinum. J Thorac Cardiovasc Surg. 1980;79:856–859[Abstract]
- Hori S, Harada K, Morimoto S, Uchida H, Okumura K. Lymphangiographic demonstration of thoracic duct cyst. Chest. 1980;78:652–654[Abstract/Free Full Text]
- Oshikiri T, Morikawa T, Jinushi E, Kawakami Y, Katoh H. Five cases of lymphangioma of the mediastinum in adult. Ann Thorac Cardiovasc Surg 2001;7:103–5
- Matsuzoe D, Iwasaki A, Hideshima T, Yoshinaga Y, Okabayashi K. Postoperative chylothorax following partial resection of mediastinal lymphangioma: report of a case. Jpn J Surg. 1995;25:827–829
- Anfossi A, Mortola GP, Reboa G. Lymphangioma of the thoracic duct with chylothorax. Int Surg 1974;59:486–8
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Abstract
Introduction
