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Cystic Thymomas and Thymic Cysts a Review

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Cystic Thymomas and Thymic Cysts a Review Thorax (1967), 22, 408. Cystic thymomas and thymic cysts A Review N. H. DYER' From the London Hospital, E.I Six cases of large thymic cyst are described; five were cystic thymomas and one was non- neoplastic. Two of the thymomas were not only grossly degenerate but showed severe chronic inflammatory change, so that the diagnosis might be missed. The classification of cysts into congenital, inflammatory, and neoplastic groups is discussed. Cystic teratomata of the thymus, lymphatic cysts, and bronchogenic cysts are classed separately since thymic location does not affect their natural history. Cystic thymomas are still not well known clinically, and the literature on the subject is reviewed. It is probable that quite a few non-specific cysts of the anterior mediastinum are of thymic origin. Tumours of the thymus are not as rare as was TABLE I formerly supposed (Brit. med. J., 1963) although MEDIASTINAL TUMOURS AND CYSTS (1950-65) their relative incidence varies greatly in different series of primary mediastinal tumours and cysts Type of Tumour No. and ranges from 7-5% to 43% (Le Roux, 1961). Neurogenous .36 Benign .30 Thymic cysts, however, have received scant atten- Malignant .. 3 most have failed Neuroblastoma.. 3 tion in the literature and reports Teratoma.11 to emphasize the different varieties of the lesion. Benign. 8 Malignant .. 3 In particular, the tendency to gross cyst formation Thymoma .24 which has been Thymic carcinoma 2 in thymomas, long recognized by Thymic cyst 1 pathologists, is often not appreciated by clinicians. Bronchogenic cyst.. 5 Pericardial cyst. 4 When the cystic element predominates the thymic Lymphatic cyst/lymphangioma.2 of the tumour be missed Haemangioma. 2 origin may (Davis, 1956). Gastro-enterogenous cyst.2 Although the clinical diagnosis of thymic cyst Lipoma/liposarcoma.2 Fibroma .. I must ultimately await histological examination, it Hyperplastic mediastinal lymph nodes.1 is hoped that a review of the subject will help the clinician in the differential diagnosis of mediastinal Total .93 masses, especialiy as these cysts do not appear to be as rare as the literature suggests. Two cysts were classified as non-specific. The first MATERIAL was a thin-walled anterior mediastinal cyst which was incised as it could not be mobilized. No material The records of the Institute of Pathology and Depart- was available for histology. The second was situated ment of Thoracic Surgery at the London Hospital in the antero-superior mediastinum and consisted only were examined over the 16-year period from 1950 to of a thin fibrous wall lined by a single layer of 1965. Mediastinal tumours and cysts that were surgi- flattened cells. cally treated during this period were reviewed. All The benign teratomata comprised seven cysts and cases of lymphoma and retrosternal goitre were one solid lesion. Material for histological examination excluded. The different lesions encountered are shown was not available in one, but the cyst contents were in Table I. The tumours classified as neurogenous pathognomonic and the wall was described as being included neurofibroma, ganglioneuroma, and neuri- adherent to the thymus at operation. Five other cysts lemmoma or their malignant counterparts. had normal thymic tissue present either in the cyst wall or immediately adjacent to it, whereas the 'Present address: St. Bartholomew's Hospital, London, E.C.1 remaining cyst had lymphoid tissue resembling 408 Cystic thymomas and thymic cysts 409 thymus, but no definite Hassall's corpuscles were neoplasms from the thymic region are included; they included. The solid tumour and two of the three had a microscopical appearance consistent with malignant teratomata contained no thymic tissue. The thymic carcinoma, but it is recognized that the remaining tumour showed early malignant change and presence of an undifferentiated tumour in -the region thymus was present at its edge. The seven cysts related of the thymus does not imply thymic origin. to the thymus might be classified as thymic cyst but Six 'thymic cysts' are reported in more detail. will not be considered further. They include three large cystic thymomas and one Neither of the two lymphatic cysts was situated in simple cyst with normal thymic tissue in the wall. the anterior mediastinum and so they were not related The remaining two cysts consisted of a calcified to the thymus. A third cyst has been removed since fibrous shell enclosing necrotic debris with a histo- the period of the study and was found to be attached logical pattern believed to be due to massive degenera- to thymus. However, careful histological examination tion in a thymoma. One of these was removed after indicated that the thymus was merely adherent to the 1965 and is not included in Tables I to III. cyst and did not form part of the wall. Of the five bronchogenic cysts reviewed, none was CASE REPORTS related to the thymus. Three were attached to major bronchi, whereas the other two were related to CASE 1 A man aged 44 was referred to hospital after oesophagus and situated in the posterior mediastinum. a shadow had been discovered on chest radiography The four pericardial cysts all lay in the right at a routine medical examination. He was asympto- cardiophrenic angle, and microscopy revealed no matic, and physical examination revealed no abnormal attached thymic tissue, although one cyst had lym- signs. Haemoglobin was 17-0 g./ 100 ml., but white cell phoid foci in its wall. and differential counts and E.S.R. were normal. An Thymic tumours were separated by their macro- E.C.G. indicated slight left axis deviation. Chest scopical descriptions into solid, cystic, and necrotic radiography demonstrated an oval mass in the region groups (Table II). No detailed histological classifica- of the right side of the heart (Fig. 1), which was shown to lie in close association with the heart shadow on tomography. Pulmonary function tests, TABLE II which included measurements of ventilation and lung MACROSCOPICAL APPEARANCES OF THE THYMIC volumes, were normal. TUMOURS Thoracotomy was performed on 19 August 1964. A lobulated cyst with a thin translucent wall was loosely Appearance No. attached to the pericardium but was not adherent to Solid 13 the lung or other mediastinal structures and was not Solid with multiple cysts . 6 obviously related to the thymus. It was excised and Up to 0-5 cm. diam. ... 2 Up to 1-5 cm. diam.....3 the patient made a complete recovery. Including cysts > 1-5 cm. diam. 1 The cyst measured 10x9x7 cm. and was uni- Solid with areas of necrosis or haemorrhage 3 Minute ... 2 locular, containing opaque yellow fluid and refractile Up to 1-5 cm.diamI.. globules. On one area of the wall there was a raised Predominantly cystic.4 polypoid mass, 4-5 x 3-5 x 1*5 cm., the cut surface of Total ..26 which revealed soft, friable, pink-grey tissue contain- ing minute cysts (Fig. 2). The remainder of the wall was trabeculated and four small nodules up to 05 cm. diameter were also present. Microscopical exam- tion was attempted, a thymoma being regarded as a ination of the polypoid tissue revealed a lympho- tumour containing varying admixtures of lymphocytes epithelioma of the and epithelial cells (Seybold, McDonald, Clagett, and thymus (Fig. 3) containing lakes of Good, 1950). if eosinophilic fluid. The rest of the wall was fibrous However, spindle cells dominated the with areas of cholesterol clefts, foamy macrophages, picture this was recorded (Table III). A 'granulo- and haemosiderin matous thymoma' was regarded as a lymphoma and but contained no calcium. excluded after Two review. undifferentiated malignant Comment An asymptomatic cyst was situated in the antero-inferior mediastinum, and its nature was not TABLE III certain until histological examination had been made. MICROSCOPICAL CLASSIFICATION OF THE THYMIC TUMOURS AND ITS RELATIONSHIP TO CYST FORMATION CASE 2 A woman aged 21 developed myasthenic OF ANY SIZE symptoms three months prior to admission and these gradually worsened in spite of neostigmine methyl- Type of Tumour Total No. No. Cystic sulphate therapy. Examination showed ptosis and Lympho-epithelioma .. 21 9 weakness of the face, palate, and limbs. There were Spindle cell ..3 no abnormal signs in the chest. Haemoglobin and Undifferentiated malignant 2 Nil white cell counts were normal. The chest radiograph Total 26 10 showed an abnormal cardiac contour due to super- imposition of a thymic tumour. 410 N. H. Dyer .... .......................... FIG. 1. Case 1. Chest radiograph showing cyst at right cardio- phrenic angle. XA .. FIG. 2. Case 1. Cut surface ofcyst showing thin trans- lucent wall and single solid nodule. FIG. 3. Case 1. Lyinpho-epithelioma. H. and E. x400. Cystic thymomas and thymic cysts 411 A course of high-voltage radiotherapy was given and thymectomy was performed on 23 April 1955. The normal site of the thymus was occupied by a mass of fibrotic fat and the tumour was finally located far out in the left pleural cavity, where its extreme mobility made it difficult to palpate. It had drawn the entire thymus downwards and was situated in its lower pole. The gland remained attached to the superior mediastinum only by its vascular pedicle and two horns. Excision resulted in immediate improvement in the myasthenia. The tumour was not invasive, measured 95x 55 x 45 cm., and consisted of a capsule 05 cm. thick which enclosed a large cavity containing grey-white, pink, and amber material. At the lower pole there was a grey solid area 15 cm. in diameter containing small vesicles. Microscopy revealed a lympho- epithelioma in which epithelial cells predominated (Fig. 4), forming a lattice-work between cysts con- taining eosinophilic fluid and sometimes haemorrhagic material. A few flecks of calcium were present. Comment The presence of myasthenia led to the detection of a paracardiac shadow that was not immediately obvious.
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