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J Thorac Cardiovasc Surg 2003;126:1201-1202
© 2003 The American Association for Thoracic Surgery
Brief communication |
a Ondokuz May
s Unversty, Medical School, Department of Thoracic Surgery, Samsun, Turkey
Received for publication January 21, 2003; accepted for publication April 1, 2003.
* Address for reprints: Ahmet Basoglu, Ondokuz Mays Unversty, Medical School, Department of Thoracic Surgery, Samsun, Turkey
ahmetb{at}omu.edu.tr
Bronchogenic cysts are believed to result from abnormal budding of the tracheal diverticulum between the third and sixth weeks of gestation and consequently may be mediastinal or intrapulmonary in location.1,2
In the adult, bronchogenic cysts are frequently asymptomatic and present as an incidental finding in the chest roentgenogram.1-3 We present a patient with a giant parenchymal bronchogenic cyst that appeared as hydropneumothorax on chest radiograph and CT. The unusual cause and the interesting clinical course of asymptomatic bronchogenic cyst are described.
Clinical summary
A 66-year-old asymptomatic man was found to have a hydropneumothorax on routine chest radiograph for operation of retina decolman (Figure 1). A left tube thoracostomy was performed. Despite tube thoracostomy suction, there was not an air leak, and the chest radiograph showed no pulmonary expansion. Chest CT scan revealed a hydropneumothorax in the left hemithorax (Figure 2). Through a left posterolateral, muscle-sparing thoracotomy, a thin-walled cyst, 18 x 14 cm in diameter with clear fluid, was observed in the upper lobe parenchyma. There was a communication with the tracheobronchial tree, and the cyst was removed completely. The postoperative course was uncomplicated, and the patient was discharged on day 6 and was asymptomatic at the 14-month follow-up. Histopathologic examination showed a cyst lined by pseudostratified respiratory epithelium with only a thin membranous underlining. This histologic feature led to the diagnosis of bronchogenic cyst.
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Bronchogenic cysts account for approximately 5% to 10% of all primary mediastinal masses.4,5 They are found most frequently along the tracheobronchial tree in the mediastinum or within the lung parenchyma.2 Rarely, the cysts have occurred in other locations, including cutaneous and subcutaneous tissues, neck, pericardium, diaphragm, abdomen, and the intramedullary part of the spine.6
Maier7 categorized bronchogenic cysts into 5 groups according to their location: paratracheal, carinal, hilar, paraesophageal, and miscellaneous. The paratracheal, carinal, and hilar groups are usually asymptomatic.5,6 Histopathologically, they are thin-walled masses lined with ciliated respiratory epithelium containing cartilage and bronchial glands. Typically, bronchogenic cysts are smooth and spherical, ranging from 2 to 12 cm in diameter.2,3 In the patient presented here, there was an asymptomatic, giant bronchogenic cyst (18 x 14 cm in diameter) in the upper lobe parenchyma.
Most reported bronchogenic cysts have occurred in pediatric-aged patients, in whom they are often seen in life-threatening emergencies with airway obstruction resulting in atelectasis, air trapping, and respiratory distress. Many bronchogenic cysts are asymptomatic and represent incidental findings on radiograph in adults.1-3 Conversely, more recent series indicate that most adults with bronchogenic cysts ultimately become symptomatic.2,5
Preoperative diagnosis is established primarily by chest radiograph and CT. On radiography, parenchymal bronchogenic cysts are usually sharply defined, solitary, noncalcified, round or oval opacities confined to a single lobe, usually the lower lobe.1,3 CT is very useful in demonstrating the structures. Generally, bronchogenic cysts have homogeneous CT attenuation and water density (0-20 Hounsfield units). On the basis of the radiologic appearance, preoperative diagnoses were accurate in only 10% to 40% of the cases.2,3 The differential diagnoses in such cases can only be made during the operation.
The possibility of malignant degeneration, future symptoms, and recurrence after aspiration has led many surgeons to advocate complete removal by thoracotomy in all patients.2-4 When the cyst cannot be removed completely at thoracotomy, partial excision with de-epithelization may be an alternative.
The bronchogenic cyst in the case we present here is particularly interesting because it was asymptomatic, giant, and presented as hydropneumothorax on chest radiograph. Definitive tissue diagnosis is usually available only after surgical excision. The possibility of bronchogenic cyst should be taken into consideration.
References
This article has been cited by other articles:
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  G. Shanmugam Adult congenital lung disease Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 483 - 489. [Abstract] [Full Text] [PDF]
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