Case Report
Informed written consent was taken from the patient for the publication.
A 53-year old female patient presented to us with a provisional
diagnosis of hiatus hernia, which was detected incidentally on a CECT
chest and whole abdomen while she was being evaluated for fibroid
uterus. Outside, CECT chest and abdomen was reported as hiatus hernia
with herniation of omental fat through widened hiatus with heterogeneous
lobulated lesion within herniated omental fat; in addition there was
significant left pleural effusion with passive atelectasis of the left
lung. Patient was asymptomatic from hiatus hernia per se. As the
diagnosis was in question, we re-evaluated the CT images with in-house
radiologist. On re-evaluation, it appeared to be a large well-defined
posterior mediastinal mass approximately 8x8 cm in dimension in left
hemithorax in left paraspinal region, abutting on the descending
thoracic aorta (DTA) with preserved fat planes (?liposarcoma) (Figure
1A, 1B). The mass showed intense enhancement on contrast imaging (Figure
1C). CT- guided biopsy of the mass was reported on histopathology as
possibly inflammatory myofibroblastic tumour. No malignant cells were
detected on diagnostic pleural aspiration.
After evaluating resectability of the mass, patient was taken up for
excision via left posterolateral thoracotomy. Intra-operatively, a large
lobulated mass, approximately 10x10x8 cm in dimension, firm in
consistency occupying the paraspinal aspect of left hemithorax was
detected. It was adherent to DTA with feeder vessels arising from DTA.
The mass was densely adherent to the parieties and to left
hemidiaphragm. On intraoperative assessment, it appeared to be a
malignant tumour. The mass was gently dissected free from DTA after
ligating feeder vessels, necessitating application of partial cross
clamp for short duration to control bleeders from DTA. Mass was
mobilised from left hemidiaphragm and parieties by combination of blunt
and sharp dissection. Approximately 700 ml of straw coloured pleural
fluid was aspirated. Left lung was completely normal and away from the
mass.
Postoperative period was uneventful and patient was discharged in stable
condition on 5th post operative day (POD). The cut section of the
operative specimen showed well-defined tumour surrounded by fatty tissue
on other end (Figure 2). On HPE of the excised mass, it showed
characteristic onion-skin pattern of lymphoid follicles (concentric
layer of lymphocytes surrounding an atrophic germinal centre) and was
diagnosed as CD, hyaline vascular variant (Figure 3A, 3B).