Ann Thorac Surg 2006;81:369-370
© 2006 The Society of Thoracic Surgeons
Case report
Supradiaphragmatic Bronchogenic Cyst Extending Into the Retroperitoneum
Won-Min Jo, MD, PhD,
Jae Seung Shin, MD, PhD
*
,
In Sung Lee, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University, Ansan-si, Kyonggi-do, South Korea
Accepted for publication August 13, 2004.
* Address correspondence to Dr Shin, Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University, Gojan-1-dong, Ansan-si, Kyonggi-do, South Korea (Email: jason{at}korea.ac.kr).
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Abstract
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We experienced a case of bronchogenic cyst located on the left lower pleural space extending into the retroperitoneum in a 33-year-old man with left chest pain. Preoperative imaging studies and operative findings showed a broad-based cystic mass on the left lower posterior pleura and diaphragmatic pleura extending into the retroperitoneal region across the diaphragm. Histologic studies proved this mass to be a bronchogenic cyst.
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Introduction
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Bronchogenic cysts are the most common congenital cyst in the mediastinum. Aberrant budding from the ventral diverticulum during embryo development causes these lesions [1]. The most frequently discovered location is the posterior mediastinum. However they are also seen in various sites [2]. The subdiaphragmatic bronchogenic cysts are rare, and they are usually located in the retroperitoneum. They can also attach to or communicate with the gastrointestinal tract [3]. We report herein the case of a supradiaphragmatic bronchogenic cyst extending into retroperitoneum.
A 33-year-old man was admitted as a patient for left chest pain. The patient's symptoms had developed 1 year prior to admittance with a marked increased 1 week prior.
The chest roentgenogram revealed a round soft tissue opacity that obliterated the left hemi-diaphragmatic margin and showed a mild left pleural effusion. Chest and abdominal imaging studies showed approximately an 8-cm sized and high density component contained ovoid heterogeneous mass, broad-based on the left lower posterior pleura and diaphragmatic pleura extending into the retroperitoneum. The retroperitoneal mass was a 2-cm sized low density mass-like lesion in the adrenal area (Fig 1).
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Fig 1. Preoperative imaging of the supradiaphragmatic bronchogenic cyst extending into the retroperitoneum. Chest and abdominal magnetic resonance image shows the broad-based cystic mass in the left lower posterior pleura and diaphragmatic pleura extending into the subdiaphragmatic space, and it is surrounding the fundus of the stomach (arrows).
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We initially suspected this lesion as an extended malignant tumor. However, we could not obtain the satisfactory tissues for preoperative diagnosis through the needle biopsy. Although the bacteriologic examination did not show any cultured bacteria, the aspiratory fluid included some inflammatory cells and many histiocytes.
The operation was conducted using the left posterolateral thoracotomy. We isolated the cyst after removing the adhered dirty tissues. The stalk of the isolated cyst had penetrated the diaphragmatic muscles and extended to subdiaphragmatic regions. Therefore we opened the diaphragm through the thoracic cavity and found the extension of this cyst into the retroperitoneum. The retroperitoneal cyst was dissected and removed using the transdiaphragmatic approach. The cyst was firmly adhered to the retroperitoneum and gastric fundus.
The pleural mass was a 7.5 x 7 x 3 cm cyst with inflammation containing hemorrhagic fluid and the retroperitoneal mass was also a 3 x 2 x 2 cm cystic mass filled with gelatinous fluid. It surrounded the gastric fundus without any communication with the stomach. The inner surface of the cyst was smooth and trabeculated (Fig 2A).
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Fig 2. Gross findings and histologic examination of the bronchogenic cyst. (A) Gross findings of the cross sectioned cyst: the thin-walled cyst is distended with bloody mucinous fluid, and the inner surface is smooth and trabeculated (top). (B) Histologic findings of the cyst. Photomicroscopic findings show a pseudostratified ciliated columnar epithelial cell lined cyst containing smooth muscle and cartilage in the wall (hematoxylin & eosin; x200) (bottom).
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The microscopic findings showed a pseudostratified ciliated columnar epithelial cell-lined cyst containing smooth muscle and cartilage in the wall (Fig 2B). Therefore this cyst was proved to be a bronchogenic cyst.
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Comment
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Bronchogenic cysts originate from an accessory lung bud of the primitive foregut after the third week of embryonic life. These lesions are eventually found in the posterior mediastinum. However, in rare cases the cyst may separate completely from its origin and as a result it may be found in such unusual sites as the skin, subcutaneous tissue, and retroperitoneum [3–5]. Retroperitoneal bronchogenic cysts are also found in rare cases [4, 5]. It is hypothesized that the abnormal lung bud of the primitive foregut migrates to the abdomen before the fusion of the pleuroperitoneal membrane [6].
In our case, we postulated that a part of the usual bronchogenic cyst tissue may have subsequently migrated before the fusion of the diaphragm's components at the end of the sixth week of embryonic life, and it was then pinched off [2]. As a result this bronchogenic cyst was located and grew in a different region.
Although many of the bronchogenic cysts were discovered accidentally, some patients complain of various pains in the affected region, and the size of the cyst has a tendency to grow with time [7].
Retroperitoneal bronchogenic cysts are apt to be misdiagnosed as a pancreatic cyst, an adrenal tumor, or a metastatic tumor, as in our case.
The diagnosis can be confirmed by histologic examination. The bronchogenic cysts are ciliated columnar epithelial cell-lined cysts, and their wall often contain cartilage and bronchial mucous glands [8].
Although the treatment of asymptomatic bronchogenic cysts remains a controversial issue, many authors recommend surgical resection even in patients with asymptomatic disease because of possible development of symptoms and complications, such as infection, misdiagnosed malignant tumors, and so forth [7, 8].
Infection is a well-known complication in bronchogenic cysts, and the morbidity and mortality rate of surgery to remove an infected cyst is higher than that for an uncomplicated cyst [7]. Furthermore, carcinoma and fibrosarcoma have been reported to arise from benign-appearing bronchogenic cysts [7].
We report herein a case of supradiaphragmatic bronchogenic cyst extending into the retroperitoneum. It was a very interesting clinical case and it may be the first time such a case has been presented in the literature.
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References
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- Haddon MJ, Bowen A. Bronchopulmonary and neurenteric forms of foregut anomaliesImaging for diagnosis and management. Radiol Clin North Am 1991;29(2):241-254.[Medline]
- Itoh H, Shitamura T, Kataoka H, et al. Retroperitoneal bronchogenic cystreport of a case and literature review. Pathol Int 1999;49(2):152-155.[Medline]
- Foerster HM, Sengupta EE, Montag AG, et al. Retroperitoneal bronchogenic cyst presenting as an adrenal mass Arch Pathol Lab Med 1991;115(10):1057-1059.[Medline]
- Reichelt O, Grieser T, Wunderlich H, et al. Bronchogenic cysta rare differential diagnosis of retroperitoneal tumors. Urol Int 2000;64(4):216-219.[Medline]
- Haddadin WJ, Reid R, Jindal RM. A retroperitoneal bronchogenic cysta rare cause of a mass in the adrenal region. J Clin Pathol 2001;54(10):801-802.[Abstract/Free Full Text]
- Menke H, Roher HD, Gabbert H, et al. Bronchogenic cysta rare cause of a retroperitoneal mass. Eur J Surg 1997;163(4):311-314.[Medline]
- Coselli MP, de Ipolyi P, Bloss RS, et al. Bronchogenic cysts above and below the diaphragmreport of eight cases. Ann Thorac Surg 1987;44(5):491-494.[Abstract]
- Ingu A, Watanabe A, Ichimiya Y, et al. Retroperitoneal bronchogenic cysta case report. Chest 2002;121(4):1357-1359.[Abstract/Free Full Text]
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Abstract
Introduction
