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doi:10.1510/icvts.2010.253039

Interactive CardioVascular and Thoracic Surgery 12 (2011) 308–310

� 2011 Published by European Association for Cardio-Thoracic Surgery

Case report - Thoracic oncologic

Giant mediastinal teratoma presenting with paroxysmal atrialfibrillation

Christos Asteriou *, Nikolaos Barbetakis , Athanassios Kleontas , Dimitrios Konstantinoua, a a b

Department of CardioThoracic Surgery, Theagenio Cancer Hospital, Al. Symeonidi 2, 54007 Thessaloniki, Greecea

Department of Cardiology, AHEPA University Hospital, S. Kiriakidi 1, 54630 Thessaloniki, Greeceb

Received 27 August 2010; received in revised form 18 October 2010; accepted 25 October 2010

Abstract

Mediastinum is a common site where benign tumors, like teratomas, can develop. Usually, these lesions do not cause any symptoms andthe diagnosis is reached accidentally. As they enlarge they may cause symptoms by compressing the nearby structures of the thorax, mostlythe trachea and the bronchi. Extrinsic compression of the heart or the great vessels appears to be a very rare occurrence. Atrial fibrillationas the first clinical presentation of left atrial compression by a giant mediastinal teratoma is extremely uncommon and very few caseshave been described in the English literature.� 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Mediastinal tumor; Atrial fibrillation; Thoracic surgery

1. Introduction

Mediastinal teratomas account for 10–20% of all medias-tinal tumors w1x. Usually they are located in the anteriormediastinum and occur in young adults. Their origin is fromgerm cells and a wide variety of tissues, such as epithelial,muscle, cartilage, or even teeth, may be discovered insidea teratoma. The physical history of benign teratomas iswell known. Initially, they are asymptomatic, while theygrow very slowly. When they reach a critical size, patientsmay complain for unspecific chest discomfort which some-times is disregarded w2x. Chest X-rays can imply the pres-ence of a mediastinal mass and put the diagnostic algorithmon the right path. In very few cases, teratomas can becomeenormous and compress the adjacent trachea and bronchi.Compression of the heart and the great vessels is extremelyrare. Atrial fibrillation as the first clinical presentation ofleft atrial compression by a huge tumor is considered to bea very unusual occurrence w3x.

2. Case report

A 30-year-old female was admitted to our Institutioncomplaining of dizziness and palpitation during the past45 min. Her medical history was clear. The blood pressurewas 100y60 mmHg, while the pulse examination revealedarrhythmia with 185 beatsymin. The electrocardiogramshowed atrial fibrillation with a rapid ventricular response.The patient received intravenous digoxin and amiodarone.

*Corresponding author. Tel.: q30 2310-898304; fax: q30 2310-029143.E-mail address: asteriouchris@yahoo.gr (C. Asteriou).

Intravenous infusion of 300 mg amiodarone was started for20 min as a loading dose, while 0.5 mg digoxin was usedfor fast digitalism. A maintenance dose of 750 mg amioda-roney24 h combined with 0.25 mg digoxin in a single dosey24 h was decided. Sinus rhythm was restored after onehour. The use of digoxin was no longer necessary and wasceased the next day. However, amiodarone was continued.A chest X-ray revealed a large mass occupying the medias-tinum and an important part of the right hemithorax,pushing the heart to the left (Fig. 1a).

Computed tomography (CT)-scan of the chest showed agiant multilocular lesion measuring 13.5=11.5=15 cmlocated in the upper and middle mediastinum with regularborders (Fig. 1b). Inside the lesion, areas of soft tissue,fluid and fat attenuation, and calcification were describedsuggesting the diagnosis of a mature teratoma. Further CT-scans of the brain and the abdomen were negative, as wasthe bone scanning. The magnetic resonance imaging (MRI)of the chest showed that the large tumor was intenselycompressing the heart and the great vessels, while it waspushing them to the left (Fig. 1c, d). Serum a-fetoproteinand b-human chorionic gonadotropin (b-HCG) levels weremeasured normal.

After a median sternotomy was carried out, the giantmass was found in front of the bifurcation of the tracheaextending almost from the right lateral thoracic wall tothe pericardium, compressing the left atrium (Fig. 2a). Thetumor was dissected very carefully, to prevent penetration.Dissection from the pericardium of the left atrium wasdifficult because of the strong adhesions. The tumorweighed 983 g and its largest diameter was 15 cm (Fig.2b). The postoperative period was uneventful, while no

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Fig. 1. Giant mediastinal teratoma. (a) Chest X-ray showing a large mass occupying the mediastinum and an important part of the right hemithorax, pushingthe heart to the left. (b) Chest CT-scan revealing a giant multilocular lesion measuring 13.5=11.5=15 cm located in the upper and middle mediastinum withregular borders. The compression of the heart by the large mass is obvious. (c) Chest MRI (transverse section) showing accurately the anatomical relationbetween the tumor and the heart. (d) Chest MRI (coronary section). The tumor’s size as well as the compression of the heart and the great vessels is easilyrecognized. CT, computed tomography; MRI, magnetic resonance imaging.

recurrence of atrial fibrillation was noticed. Intravenousinfusion of amiodarone in the maintenance dose was con-tinued until the third postoperative day (POD), when anoral dose was started (one tablet twice a day). The patientwas discharged on the seventh POD, continuing the oraluse of amiodarone in the aforementioned dose for 10 moredays. For the next month, the patient received oral amio-darone once daily and then stopped. The pathologicalexamination confirmed the diagnosis of a benign matureteratoma. Eight months after the operation the patient isfree of any symptom including recurrence of the atrialfibrillation.

3. Discussion

The first case of mediastinal teratoma was described in1823. Since then, a variety of atypical presentations havebeen reported. They are usually diagnosed due to theircomplications. Compression of the adjacent organs,because of the tumor’s enlargement is the most common

complication w4x. Perforation of the pleural cavity, pericar-dial sac, compression of the trachea and bronchi, as wellas invasion of the lung tissue and massive hemoptysis, havealso been reported, although malignancy is rare.

Arrhythmias are not a common clinical expression ofmediastinal lesions. To the best of our knowledge, very fewcases have been reported in the English literature. Com-pression of the left atrium by a large mass is a conditionwhich obviously has the potential for a catastrophic hemo-dynamic derangement. It is of crucial importance that thefirst clinical manifestation of the mass was the suddenparoxysm of atrial fibrillation, which was probably due tomechanical stretching of the atrial myocardial fibers w3x.

Diagnostic assessment of mediastinal tumors is performedwith plain chest X-rays, followed-up by chest CT. Teratomausually appears as a well-circumscribed anterior mediasti-nal mass. CT accurately estimates the density of all inclu-ded tissues, such as soft tissue (in virtually all cases), fluid(88%), fat (76%), calcification (53%) and teeth, which areconsidered specific image findings w5x. MRI is a very valua-

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Fig. 2. Giant mediastinal teratoma. (a) The large mass is almost dissectedfrom the adjacent mediastinal structures. Strong adhesions to the pericar-dium of the left atrium are the only obstacle before excising completely thetumor (not shown). (b) Surgical specimen. Its largest diameter was 15 cmand it weighed 983 g.

ble tool in detecting the anatomical relations to the media-stinal and the hilar structures, like vessels and airways.Serum a-fetoprotein and b-HCG levels must be measuredif a teratoma is suspected. An abnormal level of one orboth markers is diagnostic.

The treatment of choice for benign mediastinal teratomasis surgical excision. Median sternotomy is a very commonapproach, although many authors suggest that lateral tho-racotomies which are performed from the side of tumorthat has more extension offer a significant advantage w2,6x.

Although benign teratomas usually cause mild symptoma-tology, in some cases they can provoke serious symptomsw7x. Compression of the heart and the great vessels canlead to an emergency situation. Atrial fibrillation as thefirst clinical expression is very rare and of special interest,because it suggests that a benign tumor can be the reasonfor life-threatening situations.

References

w1x Wu TT, Wang HC, Chang YC, Lee YC, Chang YL, Yang PC. Maturemediastinal teratoma: sonographic imaging patterns and pathologiccorrelation. J Ultrasound Med 2002;21:759–765.

w2x Takeda S, Miyoshi S, Ohta M, Minami M, Masaoka A, Matsuda H. Primarygerm cell tumors in the mediastinum: a 50-year experience at a singleJapanese institution. Cancer 2003;97:367–376.

w3x Parambil JG, Gersh BJ, Knight MZ, Krowka MJ, Ryu JH. Bronchogeniccyst causing atrial fibrillation by impinging the right inferior pulmonaryvein. Am J Med Sci 2006;331:336–338.

w4x Wagner RB. The history of mediastinal teratoma. Chest Surg Clin N Am2000;10:213–222,xi.

w5x Zisis C, Rontogianni D, Stratakos G, Voutetakis K, Skevis K, Argiriou M,Bellenis I. Teratoma occupying the left hemithorax. World J Surg Oncol2005;3:76.

w6x Allen MS. Presentation and management of benign mediastinal terato-mas. Chest Surg Clin N Am 2002;12:659–664,vi.

w7x Golash V. A giant anterior mediastinal teratoma presenting as orthopneaand dysphagia in an adult. J Thorac Cardiovasc Surg 2005;130:612–613.