INTRODUCTION:Although teratomas can occur anywhere in the body, they are found most often in the ovaries, testes, sacrococcygeal region, and mediastinum, in order of decreasing frequency. Mediastinal teratomas with pulmonary involvement are extremely rare. They do not usually produce symptoms and are discovered on screening chest × ray films. We treated two patients with this rare condition, both presenting with massive hemoptysis.
CASE PRESENTATION:Case Report 1This 58-year-old woman presented to the hospital with massive hemoptysis. Her history included repeated admissions for hemoptysis spanning more than 20 years. Over the decades she continued to have hemoptysis and was treated medically, refusing surgery. Most recently, we found an elevated left hemi-diaphragm, destroyed left upper lung lobe, and soft tissue density with cavity formation. Chest computed tomography (CT) also showed bronchiectasis of the anterior segment of the left upper lung lobe, compatible with tuberculosis. During tuberculosis treatment, she coughed up white hair-like material (trichoptysis). Thus, we suspected teratoma. The patient underwent bronchoscopy which revealed hair-like structures within a mass lesion, confirming the diagnosis of teratoma. We resected the ill-defined mass, along with the thymus and left upper lung lobe. Six years after the thoracotomy, the patient is doing well and has had no hemoptysis. Case Report 2A 28-year-old man presented to the hospital due to hemoptysis. He had a long history of hemoptysis beginning at the age of 14 years. From the age of 22 to 28 years, he experienced several episodes of moderate to massive hemoptysis, which he managed with antitussive medications. Most recently, his hemoptysis became unmanageable and he noticed white hairs in the bloody expectorant.Chest radiography demonstrated a mass lesion in the right upper lobe without mediastinal widening. Chest CT revealed a 4.7 × 6.8-cm heterogeneously attenuating mass with a fat component in the right anterior mediastinum, with extension to the right upper lung. Bronchoscopic examination revealed irregular mucosa in the orifice of the anterior segment of the right upper lobe bronchus, and white, hair-like material in the orifice. We performed a right upper lung lobectomy and total excision of the mediastinal tumor and thymus. The microscopic findings revealed a mature teratoma of the anterior mediastinum with involvement of the upper lobe of the right lung. The teratoma was cystic, lined by stratified squamous epithelium, and occasionally by respiratory epithelium, adipose tissue, hair follicles, sweat glands, sebaceous glands, intestinal mucosa, and smooth-muscle bundles in the cyst wall. No signs of malignancy were found. Four years after the surgery, the patient is well and has had no further hemoptysis.
DISCUSSIONS:Mediastinal teratomas with pulmonary involvement are rare. They are recognized most often in adolescence or early adulthood, though occasional cases in older individuals are reported. Most mediastinal teratomas with pulmonary involvement have, for unknown reasons, a predilection for the left upper lobe. Mature mediastinal teratomas are benign, do not infiltrate adjacent organs, and can be resected completely with good results. These tumors are characterized by cysts lined with mature stratified squamous epithelium, and by bronchial and intestinal walls lined with epithelium, also possibly containing various mature tissues. With our patients, hemoptysis was the main symptom and chest radiography and computed tomography showed mass lesions, without widening of the mediastinum. Bronchoscopy revealed hair-like material before a tissue diagnosis was available by surgical biopsy, thus, teratomas were highly suspected.
CONCLUSION:Clinical manifestations of mediastinal teratomas are non-specific, and the unusual nature of the lesion makes its preoperative diagnosis difficult. Chest CT and bronchoscopy are essential examinations. Although teratoma is a rare disease, it should be considered in the differential diagnosis when a patient presents with hemoptysis.
DISCLOSURE:Chi-Chu Chang, No Financial Disclosure Information; No Product/Research Disclosure Information