A 50-year-old female patient presented with the incidental finding of an anterior mediastinal mass on chest radiography during a routine health examination in October 2020. No related subjective symptoms were reported and the physical examination showed no abnormalities. Contrast-enhanced computerized tomography (CT) of the chest showed a 4.8 × 4.6 cm anterior mediastinal mass with significant homogenous enhancement after injection of the contrast (mean CT values before and after contrast injection were 38 and 115 HU, respectively), suggesting a diagnosis of Castleman's disease, but not excluding thymoma ().\nThe patient underwent surgical resection of the anterior mediastinal mass under a thoracoscopic approach. After the intubation of the single lumen tube with a bronchial obstruction balloon, single lung ventilation on the contralateral side was performed under general anesthesia. The patient was placed in the lateral position with a retroversion of 30°. The operation was performed via a single-utility port: the endoscopic port was a 1-cm incision at the 6th intercostal space in the midclavicular line, and the utility port was a 3-cm incision at the 4th intercostal space along the anterior axillary line. Intraoperatively, the anterior mediastinal mass was determined to be an aneurysm originating from the left innominate vein. Through careful surgical manipulations and adequate exposure of the operative field, the root of the aneurysm was fully dissected and ligated, and then the root vessel was divided with a cutter closure (). Postoperative pathology confirmed the diagnosis of left innominate vein aneurysm. The patient experienced an uneventful postoperative course. The thoracic drainage tube was removed on postoperative day 1 after chest X-ray imaging showed complete re-expansion of the lung, with no obvious pneumothorax or hydrothorax. She was discharged from the hospital on postoperative day 2. At her 6-month follow-up, the patient did not report any specific discomfort.
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).