Case Study

Ruptured thymoma managed via thoracotomy

Asian Cardiovascular & Thoracic Annals 21(6) 744–745 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312470668 aan.sagepub.com

Anand Iyer, Paras Malik, Ramya Krishnan, Gana Kugathasan, Opeyemi Ayobami and Mark Edwards

Abstract Thymomas rarely present with chest pain due to hemorrhage. This could cause shortness of breath if it ruptures into the pleural space, and is best managed surgically. We describe the case of an 83-year-old woman who presented with such symptoms. Computed tomography showed a ruptured mediastinal mass with pleural effusion. She was managed successfully by thoracotomy with excision of the mass and drainage of the effusion. Histopathology revealed a ruptured thymoma with infarction and necrosis.

Keywords Hemothorax, rupture, spontaneous, thymoma, thymus neoplasms

Introduction Thymomas are detected incidentally in the majority of cases. Some patients present with cough, thoracic discomfort, or pain caused by local extension, and others with various symptoms due to an autoimmune disorder.1 Spontaneous bleeding into a thymoma generally occurs into a cyst within, and is very rare.2 If the cyst ruptures, it may lead to hemothorax or hemomediastinum or both, and this is exceedingly rare. We describe a case of spontaneous rupture of a thymoma within the tumor and into the pleural space, causing moderate hemothorax, which was managed by resection of the tumor through a thoracotomy.

Case report An 83-year-old previously well woman presented with severe chest pain. Serial troponin measurements were negative. Chest radiography demonstrated a mediastinal mass, thus a chest computed tomography (CT) scan was performed (Figure 1). This revealed a large mediastinal mass within the anterior mediastinum, with mild extrinsic compression of the superior vena cava and right atrial appendage, and moderate intrinsic compression of the right superior pulmonary vein, as well as a moderate-sized right-sided pleural effusion, features suggestive of a benign mediastinal cystic mass

(pericardial or thymic cyst; Figure 2). On examining the patient and discussing the procedure, it was decided that since she was very stable after her initial episode of chest pain, she should be investigated prior to deciding on surgical management, allowing her time to discuss the options with her family before consenting to surgery. Ultrasound-guided pleural biopsy showed cells of thymic origin, and repeat CT-guided lung biopsy showed the tissue to be of thymic origin. The patient presented again with shortness of breath and chest pain, and underwent a right thoracotomy with excision of the mass and drainage of the hemothorax. The mass was a cystic structure in the anterior mediastinum, which was found to be thick-walled with old hemorrhage and necrosis, intimately associated with the pericardium but well-encapsulated. The pericardium over the superior vena cava and right atrium was opened to facilitate dissection. Histopathology revealed a cystic thymoma that had undergone infarction and necrosis.

Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Australia Corresponding author: Anand P Iyer, Department of Cardiothoracic Surgery, Royal Perth Hospital, Wellington Street, Perth, WA 6000, Australia. Email: [email protected]

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Iyer et al.

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Figure 1. Computed tomography scan showing a mediastinal mass with hemothorax.

usual causes of acute hemomediastinum and hemothorax include chest trauma, rupture of a thoracic aortic aneurysm, or aortic dissection. Spontaneous mediastinal hemorrhage is rare and occurs in 4 clinical settings: as a complication of enlarging mediastinal masses, with transient increases in intrathoracic pressure, with sudden sustained hypertension, and with alterations in hemostasis.4 Preoperative diagnosis can be difficult, but a high index of suspicion combined with timely use of imaging modalities can help to arrive at an early diagnosis. In this case, the patient had an early CT scan that clearly demonstrated a mediastinal mass, and the differential diagnosis was either a thymoma or pericardial cyst. In view of her normal white cell count and drop in hemoglobin, hemorrhage into the cyst was more likely than infection. Due to her stable hemodynamics, she had a work-up for surgery initially. This included a CT-guided biopsy that showed similar findings with some bleeding or hematoma within the tumor. She suffered further chest pain and shortness of breath, thus surgery was performed on an urgent basis. Various approaches have been used for thymectomy. Generally, a partial or complete sternotomy is preferred. In this case, we adopted a thoracotomy approach because the patient was an 83-year-old frail osteoporotic woman, and sternal healing was of concern to us. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest statement None declared.

References

Figure 2. Computed tomography scan showing the same mass with hematoma within it.

The patient did well after surgery, and was eventually discharged.

Discussion Rupture of a thymoma causing hemothorax or hemomediastinum or both is a rare complication of thymoma, with few cases described in the literature.3 The

1. Caplin JL, Gullan RW, Dymond DS, Bradley SM, Hill IM and Banim SO. Hemothorax due to rupture of a benign thymoma. Jpn Heart J 1985; 26: 123–125. 2. Templeton PA, Vainright JR, Rodriguez A and Diaconis JN. Mediastinal tumors presenting as spontaneous hemothorax, simulating aortic dissection. Chest 1988; 93: 828–830. 3. Santoprete S, Ragusa M, Urbani M and Puma F. Shock induced by spontaneous rupture of a giant thymoma. Ann Thorac Surg 2007; 83: 1526–1528. 4. Ellison RT 3rd, Corrao WM, Fox MJ and Braman SS. Spontaneous mediastinal hemorrhage in patients on chronic hemodialysis. Ann Intern Med 1981; 95: 704–706.

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Ruptured thymoma managed via thoracotomy.

Thymomas rarely present with chest pain due to hemorrhage. This could cause shortness of breath if it ruptures into the pleural space, and is best man...
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