A 42-year-old female was referred to the outpatient department, with features suggestive of lower respiratory tract infection. Physical examination was unremarkable. She had no history of any cardiac disease or injury to thoracic cage. She had no history of antecedent serious illness. Family history was also non-contributory.\nChest X-ray was done for the workup of respiratory symptoms, which showed abnormal contour and widening of right border of mediastinum (). In chest X-ray, the cervico-thoracic sign and hilum overlay sign were present in posteroanterior (PA) view. Lateral view showed anterior bulging of mediastinum.\nComputed tomography (CT) of thorax was done for further workup in angiographic protocol which was suggestive of aneurysmal ectasia of SVC and patchy consolidation of right lower lobe. Aneurysmal ectasia of SVC measuring 4.5 × 5.5 cm in maximum dilatation and for a length of 8.9 cm without internal thrombosis or dissecting flap was present ( and ). No other vascular anomalies were detected.\nSince CT did not reveal any signs of obstruction, we believe that the SVC aneurysm is primary and can be classified as congenital primary superior vena caval aneurysm (CPSVCA), class 1A as per Abott’s classification (1964) [].
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).