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 58 years-old man presented at our emergency room with fever, cough and left thoracic pain. His past medical history was unremarkable. Blood test showed WBC and C-reactive protein elevation. He had started antibiotics therapy and, given the persistence of symptoms, CT scan was performed showing lower left pneumonia. Incidentally, a 2.5 cm mass was found in the upper anterior mediastinum, with positive contrast enhancement and a 5 mm vessel arising from left brachio-cephalic vein (, ). Because of size and position fine needle aspiration nor anterior mediastinotomy were performed. Radiologic features were consistent with thymoma that usually appears as an ovoid or lobulated, smooth, well-marginated mass, projecting over the mediastinum typically protruding unilaterally, therefore patient underwent (1) neurologic evaluation that excluded myasthenia (2) PET/CT scan that showed the absence of any pathological uptake. However, thymoma was felt to remain a diagnostic possibility and patient was referred for radical surgery, with particular attention to abnormal vascularization. He underwent left thoracoscopy and, in spite of extreme attention, during pleural dissection between mediastinum and sternum, a sudden massive bleeding occurred (about 1,500 cc) requiring emergency conversion to median sternotomy. It was then clear that the bleeding came from tumor and not from brachiocephalic vein or its branches, as initially thought. After controlling the bleeding, we removed the mass but it was necessary to sacrifice the left laryngeal nerve.\nIntra-operative emergency required significant blood transfusions and precautionary transfer in intensive care for 24 h. The patient eventually made a complete recovery. We only recorded transitory dysphonia as in case of laryngeal nerve paralysis. At specimen analysis, the cut surface seemed to have some fresh blood and the soft tissue was taupe with multifocal thrombosis in various stages of organization up to phlebolithes. Histopathologically, it was diagnosed a residual thymic tissue surrounded by lipomatous hyperplasia with venous malformation 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. Margins were free. Definitive histology was a 7 cm fatty specimen enclosing a 2.5 cm in size mass diagnostic for residual thymus associated with venous vascular malformation (ISSVA classification, 2008).