Interactive Cardiovascular and Thoracic Surgery 3:11-13(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Carcinosarcoma as a primary mediastinal tumor
Ahmet Sami Bayrama,*,
Bulent Ozdemirb,
Fatma Aydinerc and
Sümeyye Gullulub
a Thoracic Surgery Department, Medical Faculty of Uludag University, Gorukle-Bursa, Turkey 16059
b Cardiology Department, Medical Facuty of Uludag University, Gorukle-Bursa, Turkey 16059
c Pathology Department, Medical Faculty of Uludag University, Gorukle-Bursa, Turkey 16059
* Corresponding author. Tel.: +90-224-4429166; fax: +90-224-4428698
asbayram2{at}yahoo.com
Received June 28, 2003;
received in revised form August 5, 2003;
accepted August 26, 2003
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Abstract
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Carcinosarcoma is a rare, biphasic and malignant tumor having a mixture of carcinoma and sarcoma containing differentiated mesenchymal elements. It may occur in such diverse locations as the uterus, breast, thyroid, lung, and upper gastrointestinal system. However, to date a primary mediastinal carcinosarcoma has not been reported in the literature.
Key Words: Mediastinal tumors; Carcinosarcoma
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1. Introduction
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Mediastinal masses are categorized as either anterior, middle, or posterior based on their location on the lateral chest roentgenogram [1]. Mediastinal tumors show wide variability in histological classification and the frequencies of certain neoplasms differ in adults and children [2]. Carcinosarcoma is a rare, biphasic and malignant tumor having a mixture of carcinoma and sarcoma containing differentiated mesenchymal elements. It may occur in such diverse locations as the uterus, breast, thyroid, lung, and upper gastrointestinal system [3,4]. However, up to date a primary mediastinal carcinosarcoma has not been reported in the literature. So, we thought it might be of value to present our case with a primary mediastinal carcinosarcoma.
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2. Case report
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This report deals with a 42-year-old patient with chest pain on the left side of the sternum. The pain he described was not suggestive of angina pectoris, and not clearly associated with exertion. On chest postero-anterior (PA) X-ray, the aorta-pulmonary window was obliterated with an opacity that might probably represent a tumoral mass (Fig. 1a). In order to evaluate cardiac and paracardiac areas, an echocardiographic examination was done. On parasternal long axis view a 4x3-cm paracardiac mass adjacent to the left atrium was noticed (Fig. 1c). The walls and the cavities of the heart were normal. The computerized tomography (CT) showed a mediastinal mass occupying the aortapulmonary window (Fig. 1d). Since the tumor was not suitable for fine needle aspiration the patient was operated for diagnostic and therapeutic purposes.
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Fig. 1 (a) Paracardiac mass (red arrow) on posteroanterior lung graphy; (b) mass (red arrow) on the lateral graphy; (c) mass (red arrow) on EKO; (d) mass (red arrow) on the CT.
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He was operated and the tumor was removed via mid-sternotomy. The tumor was not in relation with the structures in the aortapulmonary window but adhesions to the mediastinal adipose tissue were noticed. The mass was removed with the mediastinal adipose tissue. The patient was discharged on the 5th day without complication. The pathological examination of the biopsy material was consistent with carcinosarcoma (Fig. 2a–d). The biopsy results confirmed carcinosarcoma and evaluation by abdominal and cranial computerized tomography was not able to show any tumoral mass and the final diagnosis was primary mediastinal carcinosarcoma. The patient had chemotherapy four times and the patient is at 6th month of follow-up without evidence of recurrence.
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Fig. 2 (a) Pathology photograph of carcinosarcoma with sitoceratine; (b) with vimentine 200x; (c) with hemotoxileneosine 200x; (d) with hemotoxileneosine 400x.
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3. Discussion
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Mediastinal masses are categorized as either anterior, middle, or posterior based on their location on the lateral chest roentgenogram. Although overlap exists, this division greatly aids the clinician in narrowing the differential diagnosis. In most cases, the evaluation of a mediastinal mass noted on a chest roentgenogram should start with a spiral CT of the chest.
In general a mediastinal mass is recognized by a standard chest radiograph. A simple but highly efficient diagnostic evaluation by a medical history, physical examination, laboratory tests and computerized tomographic (CT) scan will allow us to cover the hidden part of the iceberg. In general these patients require further invasive diagnostic evaluation. Most of the non-lymphatic mediastinal tumors require surgery even if they are benign, preoperative invasive diagnostic procedures do not worth taking additional risks [1].
Mediastinal tumors show wide variability in histological classification and the frequencies of certain neoplasms differ in adults and children. In adults thymomas are the most seen tumors of mediastinum in some series. In pediatric patients neurogenic tumors are seen more commonly [2].
Mediastinal tumors have high probability of being malignant and 25–49% malignancy rates are reported [5,6]. Due to this high malignancy rate, diagnostic steps must not be full of details and therapy must be started as soon as possible.
The diagnostic approach in these patients mostly includes diagnostic mediastinoscopy with biopsy and thoracotomy, the former being more frequent [7]. Magnetic resonance imaging (MRI) and computed tomography (CT) are important imaging modalities for the non-invasive characterization of cardiac and paracardiac masses [8].
Carcinosarcoma is a rare, biphasic and malignant tumor having a mixture of carcinoma and sarcoma containing differentiated mesenchymal elements, such as malignant cartilage, bone, and skeletal muscle. It may occur in such diverse locations as the uterus, breast, thyroid, lung, and upper gastrointestinal system [3,4].
In the gastrointestinal canal (GIC), they are most frequently seen in the esophagus [3,9]. The histogenesis of biphasic tumors is not clear. Some researchers have argued that a primary carcinoma stimulates excessive stromal proliferation, resulting in a carcinosarcoma [4]. Other researchers, however, are of the opinion that the spindle cell component reflects anaplasia within the carcinoma [3,9].
In general carcinosarcoma being a mixed tumor can be localized in a wide variety of areas in the body and can originate from various organs including the lungs, organs of the gastrointestinal and the genitourinary systems. However, up to date a primary mediastinal carcinosarcoma has not been reported in the literature.
doi:10.1016/S1569-9293(03)00201-9
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References
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Abstract
1. Introduction