Giant benign teratoma occupying the left hemithorax with ple
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A 4-year-old female with complete vaccines and without prior pathological prenatal history was admitted and transferred with a diagnosis of pleural effusion from a primary health center where a thoracic drainage tube was placed. She presented a 1-month history of progressive cough, fever, and dyspnea. The physical exam was relevant for thoracic asymmetry, diminished breath sounds, and vocal vibrations in the left hemithorax. A chest X-ray showed total occlusion of the left hemithorax with a deviation of the mediastinum to the right side. A computed tomography (CT) scan showed pectus excavatum and the presence of a large multiloculated mediastinal mass extending to the left pleural space. The mass was heterogeneous containing soft tissue elements, cystic areas and calcification. Laboratory workup was remarkable for mild anemia (hemoglobin 10.2 g/dl), eosinophilia (5.2 cells × 109/l) and elevated alkaline phosphatase. alpha-Fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) were both normal; cancer antigen-125 (CA-125) was elevated (83.3 UI/ml). The initial assessment suggested benign teratoma.

The patient underwent a total resection of the mediastinal mass via a median sternotomy. Given the extension of the teratoma and adhesions to the chest wall, an additional approach with a left anterior thoracotomy was made. Entry into the pleural space was performed through the sixth intercostal space to obtain safe visualization of the cavity and proceed to tumor excision. Many adhesions were found to the thoracic wall, diaphragm and phrenic nerve. Additionally, a nutritional artery depending on left internal mammary artery was discovered with collateral veins draining to brachiocephalic vein. A section of the left internal mammary vessels, dissection of the phrenic nerve, ligation of the nutritional vessel, mediastinal tumor excision, ligation of the thymic vessels and thymectomy was performed.

Thoracic drainage tubes (two) were placed. The mediastinal tumor, excised in block, was red–gray colored, well circumscribed and capsuled with a size of 15 × 15 × 20 cm. Postoperatively, the collapsed left lung was re-expanded, and the patient was extubated on Day 1. The patient recovered from the operation and was discharged on the ninth postoperative day. Preoperative atelectasis of the left lung partially resolved, and the pathological examination revealed a benign mature teratoma with cystic degeneration. Anatomical pathology test showed the presence of glandular epithelial cells concomitant with the presence of cartilage tissue. The histochemistry test revealed CD3(+) CD20(+) TDT(-) CD5(-) cells. Thymic tissue was negative for malignancy; nine lymph nodes showed reactive follicular hyperplasia.