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Giant mediastinal thymolipoma mimicking teratoma

Giant mediastinal thymolipoma mimicking teratoma

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A young female presented to us with chest complaints of 10 months duration. Imaging was done which revealed fat attenuation mass lesion in the mediastinum occupying both Accepted hemithoraces. Provisional differential diagnosis of giant teratoma, mediastinal thymoli-poma, large pleural lipoma or a pulmonary lesion with effusion was kept. Patient under-went surgery, mass was resected and the patient discharged in good condition.

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Page 1: Giant mediastinal thymolipoma mimicking teratoma

Giant mediastinal thymolipoma mimicking teratoma

Page 2: Giant mediastinal thymolipoma mimicking teratoma

Case Report

Giant mediastinal thymolipoma mimickingteratoma

Binit Sureka a,*, Yatish Agarwal b

a Senior Resident, Department of Radiodiagnosis, VM Medical College & Safdarjung Hospital, New Delhi, Indiab Professor, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi

a r t i c l e i n f o

Article history:

Received 8 November 2013

Accepted 27 January 2014

Available online 12 March 2014

Keywords:

Thymolipoma

Imaging

Mediastinal

a b s t r a c t

A young female presented to us with chest complaints of 10 months duration. Imaging was

done which revealed fat attenuation mass lesion in the mediastinum occupying both

hemithoraces. Provisional differential diagnosis of giant teratoma, mediastinal thymoli-

poma, large pleural lipoma or a pulmonary lesion with effusion was kept. Patient under-

went surgery, mass was resected and the patient discharged in good condition.

Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Thymolipomas are rare mediastinal tumors composed of

mature adipose tissue intermixed with benign thymic tissue

arising from thymus gland. This tumor accounts for only a

small percentage of mediastinal masses. It has a clinical

importance as early diagnosis and complete surgical excision

is curative.

2. Case report

A 30-year-old female presented with complaints of gradually

increasing dyspnea, cough and tightness in chest of 10

months duration. General and neurological examination was

normal. Hemograms and sputum examination were normal.

Pulmonary function tests revealed mixed obstructive and

restrictive type of pattern. Chest skiagram revealed

homogenous opacities in bilateral mid and lower zones pre-

dominantly in central regions silhouetting the cardiac borders

with blunting of bilateral costophrenic and cardiophrenic

angles [Fig. 1]. Based on the chest radiograph and clinical

history of the patient, possibilities of the lesion arising from

either mediastinum, pulmonary or pleura were kept in the list

of differentials. So a contrast-enhanced computed tomogra-

phy (CECT) of chest was performed. It revealed a relatively

well marginated fat attenuation mass measuring

19� 21� 18 cmwith thin strands of hyperdensities suggestive

of fibrous septa in both sides of hemithorax [Fig. 2]. No calci-

ficationwas seen. Superiorly themass had continuity with the

thymus, and inferiorly themasswas reaching upto the level of

bilateral hemi diaphragms causing mild flattening of both the

diaphragm [Fig. 3]. No cervical or intraabdominal extension of

themass lesion was seen. Nomass effect or thrombosis of the

mediastinal vessels was seen. Passive compressive atelectasis

of basal segments of bilateral lungs was noted. The patient

underwent surgery (left postero-lateral thoracotomy), which

* Corresponding author. Tel.: þ91 9013082292.E-mail address: [email protected] (B. Sureka).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier .com/locate/apme

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http://dx.doi.org/10.1016/j.apme.2014.01.0110976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

Page 3: Giant mediastinal thymolipoma mimicking teratoma

revealed a massive mediastinal fatty-attenuation mass with

scattered fibrous components within themass. No vascular or

pleural invasion was noted. Pathological examination of

resected specimen revealed that the tumor was predomi-

nantly composed of lobules of mature adipose tissue inter-

mixed with septa of thymic tissue containing abundant

Hassall’s corpuscles and was consistent with the diagnosis of

mediastinal thymolipoma. The mass weighed 2900 g.

3. Discussion

Mediastinal thymolipomas are rare, benign, slow-growing

tumors of the antero-superior mediastinum containing an

admixture of thymic parenchyma and mature adipose tissue.

The term “thymolipoma”was first used by Hall in 1949.1 These

tumors represent 2%e9% of all thymic neoplasms.2,3 Mean age

of presentation is 22 years without sex predilection.2 Most

Fig. 1 e Chest X-ray postero-anterior (PA) view showing

homogenous opacities in bilateral mid and lower zones

predominantly in central regions silhouetting the cardiac

borders with blunting of bilateral costophrenic,

cardiophrenic angles.

Fig. 3 e Coronal reformatted CT thorax showing continuity

of mass with the superior mediastinum and no

intraabdominal extension.

Fig. 2 e Axial CECT thorax showing a relatively well marginated fat attenuation mass containing thin strands of

hyperdensities suggestive of fibrous septa in mediastinum and both sides of hemithorax with passive segmental

atelectasis.

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patients are asymptomatic, and detected incidentally. Symp-

toms such as cough, dyspnea, arrhythmias, chest tightness

and chest pain may occur secondary to the displacement of

mediastinal structures. Associations with myasthenia gravis,

cystic lymphangioma, aplastic anemia and Graves disease are

known.2 These tumors may be mistaken for cardiomegaly,

diaphragmatic elevation, pleural or pericardial tumor, peri-

cardial effusion, consolidation, atelectasis, or sequestration

on chest radiographs.4 On CT, thymolipomas appear as pri-

marily fatty tissue mixed with linear whorls of soft-tissue

attenuation and have continuity with the superior medias-

tinum along the anatomical location of thymus. The sharp

borders of the lesion delineate a well-defined capsule, with no

invasion of surrounding structures. On T1-weighted Magnetic

Resonance (MR) imaging, mass follows fat signal.5

Differentials of fat containing lesions are lipoma, lip-

osarcoma, mediastinal lipomatosis, teratoma, diaphragmatic

hernias, extramedullary erythropoiesis, lipoid pneumonia,

lipoblastoma, cardiac liposarcomas.2,6 Demonstration of

continuity of mass with thymus on coronal images clinches

the diagnosis.7

In conclusion, mediastinal thymolipomas are rare thymic

neoplasms. Chest radiographs which do not conform to a

particular site of origin or lacking correlation with the clinical

and radiograph findings, should be evaluated by a contrast-

enhanced CT scan.

Conflicts of interest

The author has none to declare.

r e f e r e n c e s

1. Hall GF. A case of thymolipoma with observations on apossible relationship to intrathoracic lipomata. Br J Surg.1949;36:321e324.

2. Gaerte SC, Meyer CA, Winer-Muram HT, Tarver RD, Conces DJ.Fat-containing lesions of the chest. Radiographics.2002;22:S61eS78.

3. Takamori S, Hayashi A, Tayama K, Ohtsuka S, Hiraki H,Shirouzu K. Thymolipoma associated with myasthenia gravis.Scand Cardiovasc J. 1997;31:241e242.

4. U�gras‚ N, Akyıldız EU, Unal N, Bayram AS. An incidental uniquemediastinal mass in an asymptomatic young patient:thymolipoma. Tuberk Toraks. 2013;61:78e80.

5. Aghajanzadeh M, Alavi A, Pourrasouli Z, Aghajanzadeh G,Massahnia S. Giant mediastinal thymolipoma in 35-year-oldwomen. J Cardiovasc Thorac Res. 2011;3:67e70.

6. Molinari F, Bankier AA, Eisenberg RL. Fat-containing lesions inadult thoracic imaging. AJR. 2011;197:W795eW813.

7. Rosado-de-Christenson ML, Pugatch RD, Moran CA,Galobardes J. Thymolipoma: analysis of 27 cases. Radiology.1994;193:121e126.

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