[size=20px]A two-year old boy develops mild stridor. A chest radiograph reveals a mediastinal mass. Computerized tomography shows a mediastinal lymphatic malformation with medium to large cysts. Which of the following is the best therapeutic intervention for this patient with a cystic mediastinal mass?

 

a observation for resolution of the cysts

 

b aspiration of the largest cyst

 

c excision of the mass

 

d injection of a sclerosing agent

 

e placement of a shunt from the largest cyst to the peritoneum[/size]

D

D

D

C

D

A

C

C

C

D

C

D

Correct answer

D injection of a sclerosing agent

 

The scenario describes a boy with a large symptomatic mediastinal lymphatic malformation (LM). Lymphatic malformations confined to the mediastinum are uncommon and are typically located in the anterior mediastinum. They create symptoms due to their impingement on the airway, lungs or other mediastinal structures. Symptoms can include cough, stridor, dyspnea, dysphagia, hemoptysis, superior vena cava syndrome and Horner syndrome. Infection and collections of chyle can occur in the pleura and pericardium as well. In rare cases, hemorrhage may cause an acute enlargement of a mediastinal hemangioma.

 

The management of these lesions is evolving. Excision of LMs has often been performed. Vital structures are not sacrificed to accomplish a complete resection. The injection of sclerosing agents may also accomplish effective treatment of LMs particularly if they consist of large cysts. Therefore, this would appear to be the first appropriate step in the management of the lesion in the scenario presented. Access to this type of therapy may be limited in some instances. While spontaneous resolution of a LM has been reported it would not typically be expected. The use of a pleural-peritoneal shunt may be successful in resolving chylothorax precipitated by a mediastinal LM. Aspiration alone would not likely be successful in resolving symptoms.

D