A 52-year-old man was referred to our hospital for assessment of a suspicious mass that was detected on a chest radiography during a routine health check. He denied symptoms, including chest pain, hoarseness, hemoptysis, cough, dry cough, and dyspnea. He was a nonsmoker and had no exposure to any environmental fumes or dust.\nPhysical examination revealed normal breathing sounds in both lung fields. Laboratory findings were within normal limits. In these examinations, hematology test results and biochemistry test results were within regular levels. Plain chest computed tomography (CT) displayed a circumscribed soft tissue mass that was located in the anterior mediastinum, measuring 2.1 × 1.4 cm (Figure A). Contrast-enhanced CT showed a demarcated soft tissue mass with no calcification and marginal enhancement (Figure B). The lesion was suspected to be a thymoma rather than a vascular neoplasm before surgery.\nAs a diagnosis was not established through imaging, surgery was scheduled. We approached the tumor, which was removed by thymectomy using video-assisted thoracic surgery (VATS) rather than a median sternotomy. The thymectomy was performed in the lateral decubitus position, utilizing a three-port, right-sided VATS approach under general anesthesia administered through a double-lumen endotracheal tube. Three entry ports were made at the third and sixth intercostal spaces of the right posterior axillary, midaxillary, and midclavicular lines. The camera was introduced via trocar through the lower port at the sixth intercostal space of the midaxillary line. The operative procedure involved removal of the entire thymus gland including the anterior mediastinal fat, with careful attention to preservation of the phrenic nerve and control of thymic venous tributaries draining into the left brachiocephalic vein. There was no invasion into adjacent structures. After careful attention to hemostasis, a chest tube was placed to drain the pleural cavity, and the right lung was reinflated under direct vision. Macroscopically, examination of the resected specimen showed an encapsulated tumor measuring 2.2 × 1.2 × 0.8 cm in the thymus that could be palpated as a soft nodule. The cut surface seemed to have some fresh blood and the soft tissue was taupe, and no phlebolith was discerned in the center. Histopathologically, it was diagnosed as a cavernous hemangioma consisting essentially of a large number of dilated vessels with a single layer of endothelial cells with no signs of atypia or mitosis. Most of the channels contained red blood cells in the cavity (Figure ). No tumor tissue was detected at the surgical margin.\nThe postoperative course was ordinary. The patient was discharged 3 days after the operation with no complication. He has been followed up for 8 months without evidence of recurrence.
A 73-year-old female presented as an outpatient from her primary care physician for a CT of the thorax, abdomen, and pelvis to evaluate a reportedly stable abdominal aortic aneurysm. Pertinent past medical history revealed a left supraclinoid internal carotid artery aneurysm, a stable infrarenal abdominal aortic aneurysm, systemic lupus erythematous/rheumatoid arthritis overlap syndrome, smoldering IgG lambda myeloma, chronic kidney disease (stage II), hyperparathyroidism, and a cerebral infarction in the right posterior cerebral artery territory in 2009. Findings on the CT of the thorax demonstrated a fusiform superior vena cava (SVC) aneurysm measuring 5.9 × 4.4 × 6.1 cm (anterior-posterior × transverse × craniocaudal). No thrombus was noted within the SVC aneurysm (). The aneurysm was first partially visualized in 2007 on a cervical spine CT, and since that time it had remained stable on annual follow-up CTs.\nThe patient's course between 2007 and the most recent study in 2016 included an extensive rheumatologic and hematologic workup, including a temporal artery biopsy in 2015. Pathology revealed intimal hyperplasia with focal internal membrane disruption, but no features of granulomatous vasculitis were identified.\nThe etiology of the SVC aneurysm in this patient is uncertain. Potential causes in this patient include autoimmune disease (RA/SLE), which seems unlikely. Pathology did not reveal any convincing evidence of vasculitis. The arterial aneurysms are also felt to be unrelated as the patient has significant atherosclerotic disease. While an iatrogenic cause is possible, a chart review did not elicit any complications relating to prior hemodialysis catheter placement. Therefore, we surmised that the SVC aneurysm was likely idiopathic.\nThis patient did not receive any anticoagulation to prevent thrombus formation within the SVC aneurysm, and no repair was ever attempted. For the six years during which the patient was under observation at our institution, an SVC thrombus or sequela of an embolus originating from the SVC has never been observed. While the patient had a cerebral infarct in 2009, there was no evidence of right to left circulatory shunt. The observatory management of the SVC aneurysm in this patient stands in contrast with the majority of the cases found in the literature. Most patients were treated prophylactically for theoretical complication.