Eur J Cardiothorac Surg 1998;14:520-522
© 1998 Elsevier Science NL
A case of giant chondrosarcoma of the cricoid cartilage presenting as a superior mediastinal tumour
Philippe Guillema,
Henri Portea,
Marie-Christine Copinb,
Dominique Chevallierc
a Clinique Chirurgicale, Hôpital Albert Calmette, University Hospital, F-59037 Lille, France
b Service d'Anatomie Pathologique, Hôpital Albert Calmette, University Hospital, Lille, France
c Service d'Otorhinolaryngologie, Hôpital Huriez, University Hospital, Lille, France
Received 22 April 1998;
received in revised form 6 July 1998;
accepted 27 July 1998.
Corresponding author. Tel.: +33 3 20444559; fax: +33 3 20444890
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Abstract
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We report the case of a 73-year-old man operated on for a symptomatic superior mediastinal mass which developed from the cricoid cartilage. Through cervicotomy and partial sternotomy, laryngeal subglottic resection allowed complete removal of the tumour. From pathological examination, a benign chondroma was initially diagnosed without any criterion of malignancy. However, subsequent review of the pathological slides showed the lesion to be a low grade chondrosarcoma with an epithelial quota of spindle cells, responsible for the patient's death. This case illustrates the need for resection of presumed cricoid cartilage chondromas because of their potential mediastinal development and associated malignancies.
Key Words: Mediastinum • Neoplasia • Chondrosarcoma • Cricoid cartilage
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Introduction
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Mediastinal masses include a wide variety of tumours which are still a great challenge for physicians, both as regards diagnosis and consecutive appropriate management
[1]. Among these lesions, the most common histological types are lymphomas, thymomas and germ cell tumours
[2]. We report here the case of a giant chondroma of the cricoid cartilage located in the superior mediastinum. As far as we know, such a lesion has never yet been reported in this region.
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Case report
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A 73-year-old man was admitted to our institution for a partially calcified mediastinal mass revealed by chest X-ray substantiated by progressive inspiratory orthopnic dyspnea. Clinical examination revealed laryngotracheal murmur, left anterior and external jugular veins turgescence, dysphonia, and a firm palpable cervical mass on the left side. This mass displaced the thyroid cartilage to the right and moved upwards when the patient swallowed. Its lower limit was not perceptible. The patient had known about this mass for some 15 years, but had never complained about it until the present hospitalization. Cervical and mediastinal CT scan and MRI showed a heterogeneous, partially calcified mass, crossing the thoracic inlet (
Fig. 1
Fig. 2
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Fig. 1. Thoracic CT scan showing a chondrosarcoma of the cricoid cartilage, developed in the superior mediastinum with intra-tumoral calcifications (arrow). The trachea is displaced to the right.
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Fig. 2. Coronal view of cervico-mediastinal MRI showing the chondrosarcoma of the cricoid cartilage, compressing the left brachiocephalic vein (arrow).
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After tracheal intubation with laryngoscopic guidance, surgical exploration was performed in March 1993, by cervicotomy and partial sternotomy. High frequency ventilation was used to maintain ventilatory functions. A large firm mass (10 cm in diameter) was discovered, displacing the left brachiocephalic vein and thyroid isthmus downwards, and stretching the left inferior laryngeal nerve. The left brachiocephalic vein and left inferior laryngeal nerve were dissected after resection of the thyroid isthmus. Consequently, the tumour could be freed from all cervical and mediastinal structures except for the cricoid cartilage. A partial laryngeal subglottic resection including the cricoid cartilage combined with temporary tracheotomy was performed. Overall, macroscopically complete resection of the lesion was achieved, followed by an uneventful postoperative course. Pathological examination showed a 280 g mass, initially described as a chondroma of the cricoid cartilage, without any criterion of malignancy. The tracheotomy was left in place because the patient was lost to the follow-up until the eighth post-operative month, when a recurrent endoluminal laryngeal tumour was diagnosed by laryngoscopy. Pathological examination of biopsies showed a spindle cell carcinoma. Only local laser YAG Co2 destruction of the lesion was performed, because of associated liver metastases. The patient died in June 1994 of general neoplastic spread. Review of the pathological slides of the first lesion demonstrated that the tumour was in fact a low grade chondrosarcoma combined with a focal area of spindle cell carcinoma, which had caused the recurrence.
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Discussion
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Mediastinal masses originate from various tissues
[2]. The reasons for their diversity are both embryological and anatomical: firstly, in the mediastinum, many organs cross in an upward or downward direction during organogenesis, leading to very frequent mediastinal dysembryomas and secondly, a consequent diversity of viscera takes place in the adult mediastinum
[3]. Morphological examinations including chest X-ray, cervical and thoracic ultrasonography, CT scan or MRI supply indications about the histological nature of the lesion
[2]. For example, intratumoral calcifications evoke a diagnosis of chondroma or chondrosarcoma. Furthermore, mottled calcifications (as in our case) may be observed in about 80% of cases
[4], and, when present, are pathognomonic
[5].
Soft tissues neoplasms of the larynx account for about 1% of all laryngeal tumours
[5]
[6]
[7], chondroma being the most frequent histological type. Some authors consider that its frequency has been overestimated
[6], partly because of differential diagnosis with chondrometaplasia
[4] but mainly because of differential diagnosis with low grade chondrosarcoma, as demonstrated by our case
[5]
[6]. It is difficult for the pathologist to be sure of the non-malignant character of these lesions. Consequently, the diagnosis is frequently revised in cases of tumour recurrence
[5]. Laryngeal cartilaginous neoplasia frequently develops from the cricoid cartilage which constitutes 75% of all reported topographies
[7] and explains the frequency of inspiratory dyspnea, since the cricoid cartilage can be considered as the key-stone of the laryngeal airway, assuming lumen permeability
[6].
The thoracic inlet can be traversed by expansive processes of either cervical or thoracic origin. This hiatus is not extensible, and any tumour in this area may be responsible for visceral, nervous or vascular compression, especially if has developed over a long period (about 15 years in our case) and is large (in our case: 10 cm). The lesion's anatomical connections explain the occurrence of dysphonia (stretching of the left inferior laryngeal nerve) and left anterior and external jugular veins turgescence (compression of the left brachiocephalic vein). Surgery of the superior mediastinum can always hold surprises, especially via a limited approach such as cervicotomy. In our case, the surgical approach that combines partial sternotomy and cervicotomy allowed satisfactory exploration of the superior mediastinum and sharp dissection of all vascular and nervous structures. Although the indications of thoracoscopy have expanded to include the surgical management of mediastinal masses
[1]
[8]
[9]
[10], it was not attempted in our patient for obvious reasons including the volume of the tumour, its location and links with the nervous system and the vascular network.
In conclusion, in the present case, the nature of the superior mediastinal mass was exceptional, as it was proved to be a chondrosarcoma of the cricoid cartilage that was misdiagnosed as a chondroma. This case shows that what is assumed to be a chondroma of the cricoid cartilage must be resected because (1) the laryngeal tumour may involve the mediastinum, with clinical and surgical consequences, and (2) pathological results are always liable to produce unpleasant surprises in the form of low grade malignancies justifying the completion of laryngectomy.
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References
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Abstract
Introduction
