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RECURRENT THYMIC CARCINOID TUMOR IN A PATIENT WITH MULTIPLE ENDOCRINE NEOPLASIA TYPE 1
Ryan Patrick Cassidy, Lana Schumacher.
Tufts Medical Center, Boston, MA, USA.
Background: We present a rare case of recurrent thymic carcinoid tumor in a patient with multiple endocrine neoplasia type 1 and highlight the intraoperative technical challenges and decision-making required during redo sternotomy with significant vascular involvement.
Case Report: We report the case of a 67-year-old male with multiple endocrine neoplasia type 1 who previously underwent resection of a thymic carcinoid tumor via median sternotomy one decade earlier. His initial operation included en bloc resection with a small cuff of pericardium and reconstruction using Gore-Tex mesh; pathology confirmed thymic carcinoid tumor. Ten years later he presented with exertional dyspnea, shortness of breath, and cough. Computed tomography demonstrated a large mass involving the anterior and middle mediastinum with mass effect on the superior vena cava (SVC) and right atrium. Multidisciplinary evaluation by thoracic surgery, radiation oncology, and interventional radiology was performed. Magnetic resonance imaging did not demonstrate vascular invasion.Given the degree of mediastinal compression and progressive cardiopulmonary compromise, surgical debulking was recommended prior to planned radiation therapy. A redo median sternotomy was planned, with preemptive placement of femoral arterial and venous sheaths in anticipation of potential cardiopulmonary bypass (CPB). Upon entry into the chest, a large bilobed anterior mediastinal mass was encountered, densely adherent to the pericardium and SVC, with obliteration of normal tissue planes. Despite preoperative imaging suggesting the absence of vascular invasion, safe mobilization of the mass from the SVC was not feasible. A controlled venotomy was therefore performed to facilitate complete resection.Repair of the venotomy required initiation of CPB. Intraoperative transesophageal echocardiography revealed severe right atrial compression, and the patient exhibited hemodynamic instability consistent with obstructive shock during induction and early dissection. Following resection, there was immediate and marked improvement in hemodynamics.
Conclusion: This case underscores the rarity of recurrent thymic carcinoid tumor in patients with multiple endocrine neoplasia type 1, while highlighting the technical challenges of redo mediastinal surgery, the limitations of preoperative imaging in assessing vascular involvement, and the importance of multidisciplinary collaboration.
LEGEND: Large mediastinal mass with SVC and right atrial compression
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