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Primary hyperparathyroidism is a common endocrinology anomaly which involves head and neck region. The diagnosis and treatment of parathyroid adenoma however still remains a challenge. Giant parathyroid adenomas are rare and involve more surgical expertise. Retrospective study was carried in Departments of ENT and Endocrinology, SMS Medical College and Hospital, Jaipur. Records of patients operated between 2010 and 2019 were evaluated and analysed for size and site of parathyroid adenomas, biochemical parameters, intra-operative findings and postoperative course. Tumours with size > 3 cm were termed as giant parathyroid adenomas and this is a rarity in literature. Records of 79 patients were found to be complete. Out of these 9 had giant parathyroid adenomas: 4 left inferior, 2 right inferior, 1 ectopic location (superior mediastinum) and 1 each in left and right superior glands. The size, symptomatology and biochemical parameters are discussed in light of available literature. Giant parathyroid adenomas are a rare entity and their behaviour are same as of non giant parathyroid adenomas. In the view of literature published on pub Med, this is found to be largest case series on parathyroid Adenoma considering size more than 3 cm.

Thymic masses are one of the most common tumors in the anterior mediastinum. Nevertheless, because the thymus originates in the third and fourth pharyngeal pouches and descends into the anterior mediastinum, ectopic thymic tissue may be found anywhere from the angle of the mandible to the superior mediastinum. Ectopic cervical thymoma (ECT) is an extremely rare tumor that originates from ectopic thymic tissue trapped during the migration of the embryonic thymus and is often misdiagnosed as a thyroid tumor or other neck masses. Herein, we report an unusual case of ectopic cervical thymoma associated to myasthenia gravis (MG).

This is a rare case of a 55 year-old immunocompetent female who developed Methicillin sensitive Staphylococcus aureus sternoclavicular septic arthritis. The infection was not limited to the joint space but extended into adjacent bones and superior mediastinum. However the patient was successfully treated without surgical intervention and preservation of joint function was obtained with only intravenous antibiotic therapy.

Mediastinal glomus tumors are rarely recognized, and only seven cases have been reported in the literature. Here, we describe a rare mediastinal glomus tumor and review the characteristics of this rare clinical case. The patient was a 50-year-old female who presented with coughing for 3 months. Her chest computed tomography scan demonstrated a localized tumor in the posterior superior mediastinum. Intraoperatively, we found a longitudinal rupture of the membranous trachea above the carina. We completely resected the tumor and repaired the tracheal rupture under a thoracoscopy using a pedicled muscle flap. The tissue was diagnosed as a mediastinal glomus tumor according to its histological and immunophenotypic characteristics.

Background. Primary hyperparathyroidism is caused by the excessive growth of parathormone secretion, its consequence being hypercalcemia. The parathyroid adenoma is responsible for over half of primary hyperparathyroidism cases. The mandibular tumor can be the initial sign in the case of primary hyperparathyroidism.Case presentation. We present the case of a 33 year old patient with history of a mandibular operated tumor, repetitive pathological fractures and hypercalcemia manifestations. The level of the parathormone at the first measurement indicated a very high value. The parathyroid scintigraphy with 99mTc-MIBI (methoxy-isobutyl-isonitrile) evidenced a high uptake of the tracerin the superior mediastinum, suggestive for an ectopic parathyroid adenoma. The histopathological examination after surgery leads to the diagnosis of parathyroid adenoma. The association between the primary hyperparathyroidism, the mandibular tumour, the clinical history and the nuclear imaging lead to the diagnosis of primary hyperparathyroidism – Jaw tumor syndrome.Conclusion. The hyperparathyroidism-Jaw tumor syndrome has a special clinical importance because of the severe and progressive symptomatology, and because of the risk of developing neoplasia of parathyroid glands, which have a reserved prognosis.

Haemangiomas are most common non-malignant vascular tumours of infancy. Here, we describe an antenatally detected mass over the neck causing compressive respiratory compromise at birth requiring resuscitative measures at birth. The mass showed increased vascularity on Contrast Enhanced Computed Tomography (CECT) with extension upto superior mediastinum. Surgical excision was required following failure to medical measures with steroids and propranolol. Histopathology confirmed it to be a venous haemangioma. This case highlights that these benign lesions may reach large sizes and antenatal detection may help in planning effective delivery and resuscitative measures.

Thymoma is a rare case presenting in the paediatric age group. Only 30 cases have been reported so far. Our case is a 14 month old female, presented with respiratory distress. CT scan showed gross widening of superior mediastinum with a homogeneous opacity. Immunohistochemistry was suggestive of thymoma. She underwent excision of the thymic mass and is well at present.J Nepal Paediatr Soc 2015;35(1):76-78

Background Surgical stabilization of the sternoclavicular joint (SCJ) is infrequent, and cardiothoracic surgery assistance is often recommended. Patient safety and surgeon efficiency may be improved by greater understanding of the anatomic relationships near the SCJ. The purpose of this study is to determine the distances from the SCJ to critical structures in the superior mediastinum. Materials and methods Distances from the posterior SCJ to adjacent mediastinal structures were recorded using contrast computed tomography scans of 49 consecutive patients. Patient sex, height, body mass index, side, age, and thickness of the sternum and medial clavicle were also recorded. Results The mean distance to the nearest anatomic structure deep to the clavicular region of the SCJ was 6.6 mm and was 12.5 mm for the sternal region. The clavicle was an average thickness of 18 mm, and the sternum was an average thickness of 17 mm. The closest structure was the brachiocephalic vein. An artery was identified as the closest structure in 21.2% of patients. Distance differences between the right and left sides were noted, but sex had no bearing on distance to structures. Conclusion Multiple mediastinal structures are close to the SCJ. The most frequent structure at risk of injury deep to the SCJ is the brachiocephalic vein. Such knowledge may improve patient safety.

Lesions at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children.

A fifty year old male, diagnosed to have an acute retropharyngeal space infection reported two days after his discharge from the hospital with breathing difficulty and rapidly progressive diffuse swelling of the neck. Immediate clinical evaluation failed to localize the exact cause but computed tomography revealed large anterior visceral compartment abscess with recurring retropharyngeal space infection. In this case the involvement of visceral compartment of the neck was a unique presentation. Retropharyngeal space infections are known for their spread to other spaces. However, involvement of visceral compartment is rare. Proximity to visceral vascular space and possibility of spread of infection to superior mediastinum makes visceral space infections a life threatening condition. Deep neck space infections should be observed for extensions beyond the primary site. The role of imaging is indispensable while monitoring these infections. Prompt initiation of definitive treatment can prevent

Background Schwannomas are benign, well-differentiated tumors that originate from Schwann cells. Involvement of the cervical sympathetic nerve is relatively rare. Computed tomography is indispensable for the diagnosis. The treatment is surgical. Histological examination confirms the diagnosis. Horner’s syndrome postoperatively is supportive of the diagnosis. The rarity of giant cervical sympathetic chain schwannoma made the case of our patient interesting to report. Furthermore, our patient’s immense tumor size is very rare, and we could not find any similar report in the literature. Cervical sympathetic chain schwannoma is frequently confused with schwannoma of the vagus nerve on clinical and radiological examination, and its diagnosis can therefore be challenging for clinicians, radiologists, and pathologists. Case presentation We report a rare case of cervical schwannoma in a 40-year-old Moroccan woman who presented with a large parapharyngeal mass. Computed tomography revealed a giant, heterogeneous, well-defined mass measuring 110 × 100 × 147 mm, occupying the right carotid triangle, and descending to the superior mediastinum. Surgical excision with a transcervical approach was done. Histological examination confirmed the diagnosis. The patient’s postoperative course was marked by Horner’s syndrome. Conclusions Cervical sympathetic chain schwannoma is a rare, benign tumor. It should be considered in the differential diagnosis in patients presenting with a lateral neck mass. Surgical exploration must be discussed for a tumor with a large volume.

Castleman's disease is a slowly progressive and rare lymphoproliferative disorder. Here, we report a 55-year-old woman with superior mediastinal Castleman's disease being misdiagnosed for a long term. We found a 4.3 cm mass localized in the superior mediastinum accompanied with severe clinical symptoms. The patient underwent an exploratory laparotomy, but the mass failed to be totally excised. Pathologic examination revealed a mediastinal mass of Castleman's disease. After radiotherapy of 30 Gy by 15 fractions, the patient no longer presented previous symptoms. At 3 months after radiotherapy of 60 Gy by 30 fractions, Computed tomography of the chest showed significantly smaller mass, indicating partial remission. Upon a 10-month follow-up, the patient was alive and free of symptoms.

Neurogenic tumors are the most common type of mediastinal tumor and constitute the majority of neoplasms of the posterior mediastinum. Schwannomas originating from the intrathoracic vagus nerve are extremely rare. The present study describes the case of a 58-year-old man with a large vagal schwannoma in the left superior mediastinum. A large tumor with a round shape was identified in the left superior mediastinum. The tumor originated from and encased the vagus nerve. Using video-assisted thoracoscopic surgery, the tumor was completely excised with amputation of the vagus nerve encased within in the tumor. One year post-surgery, the patient was free of recurrence with no symptoms other than hoarseness.

SUMMARY. Bronchogenic cysts are rare congenital cystic lesions mostly located in the middle and superior mediastinum. Esophageal bronchogenic cysts are extremely rare. We review here 23 cases reported in English in the literature to date of intramural esophageal bronchogenic cyst and their features, including our patient. Although they are extremely rare, intramural esophageal bronchogenic cysts should be kept in mind in the differential diagnosis of benign esophageal lesions. With accurate diagnosis and treatment the prognosis is excellent and serious complications may be prevented.

A 55-year-old man with tracheal adenocarcinoma presented with difficulty in breathing and cough with blood-tinged expectoration. As the patient refused surgery, he was treated with definitive radiotherapy to the neck and superior mediastinum to a total dose of 50 Gy (initially 40 Gy by AP/PA portals followed by 10 Gy with a three-field technique). He showed significant symptomatic relief to radiotherapy and defaulted from further treatment. He remained asymptomatic for 7 years, following which he developed sternal metastases and a local tumour recurrence. This case illustrates that long-term clinical remission can be achieved by radiotherapy alone in this rare histological subtype of tracheal carcinoma.

A method of exposing the posterior and superior mediastinum in video-assisted thoracoscopic surgery (VATS) will be introduced. In the study, all cases underwent two-port VATS as follows: two or three pieces of suture were stitched on the invagination between the visceral and parietal pleura of the posterior or superior mediastinum; the suture was drawn out of the operating port and fixed, so that the lung could be depressed and posterior or superior mediastinum could be exposed very well. This method was performed in 215 cases; there were no operative deaths and all cases recovered. This stitching method to expose the posterior or superior mediastinum can reduce the wound size and decrease the operation time. Additionally, it is simple, practicable and safe.

Summary Juvenile xanthogranuloma (JXG) is the most common form of non-Langerhans histiocytosis in the pediatric population. JXG most typically presents as a subcutaneous nodule. The natural course of the disease is usually spontaneous resolution without treatment. However, there have been case reports of juvenile xanthogranuloma involving the larynx and trachea that required treatment for symptoms of airway obstruction. We describe the first case of juvenile xanthogranuloma involving the superior mediastinum with impingement on the trachea causing airway obstruction.

Retropharyngeal masses are benign or malignant. Because of their location, even the most benign lesion may endanger life by compressing and obstructing the air and/or food passages. Lipomas of the retropharyngeal region are rare; slow-growing tumors that attain a large size before producing symptoms such as dysphagia and dyspnoea. Clinical diagnosis may be difficult. However, computed tomography or magnetic resonance imaging is the investigation of choice and helps in definitive diagnosis pre-operatively, although final histological confirmation is essential. We present the case of a giant lipoma of the retropharyngeal space extending from the nasopharynx to the superior mediastinum causing symptoms of obstructive sleep apnea. The tumor removed surgically and the patient passed an uneventful post-operative period.

Mediastinoscopy has been widely used by thoracic surgeons to evaluate the superior mediastinum since 1959. Large series of mediastinoscopy have been reported with very low morbidity and no mortality. Proper attention to surgical techniques and mediastinal anatomy are essential to maintain the safety of the procedure. Situs inversus totalis is exceedingly rare, but variations in mediastinal anatomy in this group of patients can render the procedure challenging for the thoracic surgeon. A case of mediastinoscopy in a situs inversus patient is presented with emphasis on anatomical variations of the mediastinum and technical pitfalls of the procedure in this rare group.

We report the case of a Hodgkin’s lymphoma presenting as chest pain due to the presence of multiple lymphoadenopathies of the superior mediastinum and a poly-lobated mass in the middle lobe of the right lung. Diagnostic approach and differential diagnosis are discussed.

This text describe through images, how a knife is retrieved from the superior mediastinum.

Digit-assisted thoracoscopic surgery (DATS) is a novel, minimally invasive approach for achieving a superior mediastinal mass, by allowing the surgeon's finger to pass into the superior mediastinum through a suprasternal route. In this study a DATS procedure for a bronchogenic cyst in the superior mediastinum was performed. The procedure worked well for dissecting the tissue around the mass, and thus reduced the effort required to perform the operation. In the current study DATS was found to be superior to the standard technique.

Robot-assisted excision of an ectopic parathyroid adenoma in the superior mediastinum was performed in a 57-year-old man. The mass was located by methoxyisobutylisonitrile scan and computed tomography. Identification of the ectopic parathyroid adenoma was facilitated by the 3-dimensional images of the da Vinci robotic system, and resection was achieved using EndoWrist instruments. Robot-assisted excision of parathyroid adenoma located in the relatively inaccessible superior mediastinum proved to be feasible.

Resection of the medial third of the clavicle is a safe and effective surgical approach for exposure of the uppermost portion of the superior anterior and posterior mediastinum for resection of parathyroid adenomata. Two patients underwent this transclavicular approach to resect parathyroid adenomata of the anterior and posterior superior mediastinum following initial negative cervical exploration. One patient had 3 previous operations performed elsewhere resulting in a permanent vocal-cord paralysis. Preoperative localization in both patients included, but was not limited to, Tc-99m sestamibi single-photon emission computed tomography (SPECT), and 1 patient had a positive emission tomography (PET) scan. One adenomata was deep to the left sternoclavicular junction and left sternothyroid muscle, and the other 7 cm caudad in the posterior mediastinum affixed to the thoracic esophagus and thoracic vertebra. There were no major intraoperative or postoperative complications following resection of the medial third of the clavicle; however, 1 patient had a temporary vocal-cord paralysis. Resection of the medial third of the clavicle provides excellent surgical access to parathyroid adenomata located in the uppermost superior anterior mediastinum and the posterior superior mediastinum. Tc-99m sestamibi SPECT and PET images are valuable in the location of such adenomata. In 1 of the patients, PET imaging confirmed the location.

Germ cell, mesenchymal, and thymic tumors of the mediastinum are an uncommon and heterogeneous group of neoplasms. Together they account for less than 25% of mediastinal tumors in childhood. The majority of these tumors are found in the anterior and superior mediastinum, but germ cell tumors and mesenchymal tumors may be located in all compartments. They share a broad range of histological subtypes and clinical behavior, tendency to be large in size, and a requirement for complete surgical excision as the major requirement for successful therapy.

Traditionally, surgical exposure to the larynx, pharynx and trachea has been achieved by lateral, horizontal, or apron incisions. Although these incisions provide excellent surgical exposure, they violate the vertically oriented blood supply to the cervical skin. A single vertical midline incision with limited lateral dissection can provide satisfactory access to the anterior neck without jeopardizing cervical skin perfusion or subsequent carotid artery exposure. We have found this incision useful after preoperative irradiation for total and partial laryngectomy, laryngopharynectomy, and tracheal resection. Superior and inferior extensions provide access to the superior mediastinum and facilitate pharyngostome fashioning and limited neck dissection. We have not observed skin necrosis. Cosmesis and patient acceptance have been excellent.

症例は74歳, 女性.1993年9月胸部X線写真上異常を指摘され, 当院へ紹介された.胸部CT, MRIで, 右前上縦隔に径3cm大の嚢胞性腫瘤を認めた.胸腺嚢胞の術前診断にて, 胸腔鏡による腫瘤摘出術を行なった.病理組織検査では, 腫瘍は一層から数層の中皮様細胞によって内面を覆われ, 明らかな胸腺組織はなかったことからmesothelial cyst と診断された。Mesothelial cyst は先天性嚢胞の1つであり, 2種類に分類されている.嚢胞が心膜に接している時は心膜嚢腫と呼ばれ, それ以外の場所に存在する時は胸膜嚢腫, もしくは狭義のmesothelial cystと呼ばれる.好発性部位は, 心横隔膜角部とされており前上縦隔に発生することは稀である.前上縦隔に発生する嚢胞性病変は術前診断が時として困難であるため, 診断と治療を兼ねて摘出術が行われる.胸腔鏡下手術は従来の開胸術に比べて低侵襲であり, その適応は広がってきている.本症例に対しても胸腔鏡下手術が有用であった.

Sixteen-year-old mentally retarded male patient presented with a giant malignant peripheral nerve sheath tumor (MPNST) on his neck. Surgery was the chosen method of treatment by the help of a neurosurgeon for dissecting the mass from the nerves of the brachial plexus and a thoracic surgeon for removing the mass from the superior mediastinum. A mass of 2 kg in weight was excised gross totally. He had an early recurrence in the second month of the follow-up period despite postoperative irradiation therapy. He died of his disease due to the compression of vena cava superior.

An 84-year-old female and a 76-year-old female with retropharyngeal hematoma are reported. Both patients visited our hospital because of dyspnea and dysphagia following neck injury. In both patients, the hematoma developed in the retropharyngeal space from the cranial base to the superior mediastinum. The first case underwent in emergent tracheostomy, and was fed with a nasogastric tube. Her hematoma regressed spontaneously in about two weeks. The second case did not need a tracheostomy, but required intravenous hyperalimentation, and her hematoma disappeared itself in about 25 days.

The objective was to evaluate approaches to the anterior and posterior superior mediastinum to facilitate resection of mediastinal thyroid disease as a retrospective review. The setting was a head and neck surgery referral center and the participants were 53 patients with mediastinal thyroid disease. A suprasternal approach was used in 27 patients, resection of the medial third/half clavicle in 15 patients, a median sternotomy in 6 patients, a combination of median sternotomy/clavicle resection in 4 patients, and a resection of the manubrium sterni in 1 patient. The outcome measures were satisfactory operative exposure with lack of complications. The results were excellent exposure with minimal morbidity and no operative/postoperative mortality. These approaches yielded excellent exposure of the anterior and posterior superior mediastinum without the necessity of unilateral or bilateral thoracotomy.

We report a case of epithelioid hemangioendothelioma arising from the left brachiocephalic vein in the anterior superior mediastinum of a 41-year-old man. The tumor was resected by local excision using a novel approach, the "hemi-plastron window" technique. The patient had an uneventful postoperative course and no recurrence of tumor 28 months after surgical treatment. We describe this surgical approach and discuss its advantage for cervicothoracic tumors.

Atraumatic spontaneous posterior dislocation of the sternoclavicular joint (SCJ) is an extremely rare event. Only three recorded cases exist in the literature, and they are poorly documented and without roentgenographic confirmation. Spontaneous posterior dislocation of the SCJ occurred in an active 50-year-old woman without any known underlying pathology. Closed reduction attempted five days later was unsuccessful, and the patient was treated conservatively with short-term modification of activity. The patient is asymptomatic and followed carefully one year postdislocation. A review of the literature discloses a 25% complication rate involving the vital structures of the superior mediastinum after posterior dislocation of the SCJ. Because of this high complication rate, a thoracic or vascular surgeon must be available should closed or open reduction become necessary.

Symptomatic primary hyperparathyroidism is still predominant form in developing countries. Sumit Shukla et al. (2008) Most of these lesions are usually less than 2 cm in diameter with serum calcium levels between 11 to 13 mg/dl. Our case had 3.9 × 2 × 1.7 cm non palpable right inferior parathyroid adenoma extending into superior mediastinum, serum calcium 17 mg/dl and vomiting as presenting symptom a case report.

Central venous pressure measurement, prolonged intravenous nutrition, massive and rapid fluid replacement, infusion of hypertonic and cytotoxic solutions, and the use of percutaneous pacemakers have all made catheterization of the great veins of the neck and superior mediastinum a common hospital procedure. A detailed knowledge of the internal jugular, subclavian and brachiocephalic veins is therefore of considerable importance – especially their surface markings and the position of adjacent structures which may inadvertently be damaged in these procedures.

We describe a case of necrotizing fasciitis, involving the oral floor, neck, and superior mediastinum, that was secondary to pericoronitis of a wisdom tooth. It was accompanied by sepsis, candidiasis, and disseminated intravascular coagulation. The patient, a 70-year-old man, visited our hospital for trismus and swallowing pain, and was immediately hospitalized because of marked swelling of the neck. A CT scan revealed gas fluid from the oral floor to the mediastinum. He required a skin graft and training in mouth opening and neck expansion as well as drainage and administration of antibiotics for treatment. Five months later he was discharged.

Thymomas are usually found in the superior mediastinum and sternotomy is the standard approach for resection. We report a case of a male patient with a giant left-sided thymoma, nearly fulfilling the whole hemithorax. Due to the sheer size of the tumor and its location in the anterior-inferior mediastinum, we performed a lateral approach for thymectomy. On resection the specimen measured 18 x 16 x 12 cm. Histology revealed a mixed stage I thymoma. The patient is doing well 36 months after resection and has no signs of recurrence. In literature, a significant increase in the risk of recurrence for thymomas >8 cm is reported.

This article describes a case of cervicothoracic giant cell tumor expanding into the superior mediastinum treated by total spondylectomy. A 42-year-old-man presented with back pain and paraparesis. Magnetic resonance imaging revealed the collapse of the T2 vertebral body. The spinal cord was severely compressed by the tumor mass. The tumor had spread from T2 to the mediastinum, so that the tumor was in contact with many vital structures. To resect the tumor completely, total spondylectomy from T1 to T3 was performed through a combined anterior-posterior approach. The tumor was dissected from the vital structures using an anterior low cervical approach and splitting one-third of the sternum. En bloc vertebral resection from Th1 to Th3, including the tumor pseudocapsule, was possible through a posterior approach. The tumor around the nerve roots or dura was resected piece by piece since it was possible to separate the capsulated tumor from the dura. Splitting one-third of the sternum allowed separation of the tumor from the anterior vital structures, under direct vision. This allowed en bloc vertebral resection of the tumor that had spread to the mediastinum from T2 and in the craniocaudal direction from T1 to T3. Although giant cell tumor is benign, it can be locally aggressive. Complete excision of a giant cell tumor is the best treatment option even for the cervicothoracic spine, to protect the vital structures or neural function.

A case of a tentorial meningioma with atypical histological features invading the transverse sinus and extending along the internal jugular vein up to the superior mediastinum is described. This report illustrates one of the many ways meningiomas spread beyond the cranial cavity and the difficulty in managing such a problem.

Trans-cervical resection of posterior mediastinal goiters is usually very difficult, requiring a high thoracotomy. Until recently, using conventional video-assisted thoracoscopic surgery to resect such tumors has been technically difficult and unsafe. By virtue of 3 dimensional visualization, greater dexterity, and more accurate dissection, the Da Vinci robot, for the first time, enables a completely minimally invasive approach to the posterior superior mediastinum.

An abnormal origin of the left common carotid artery from the initial portion of the brachiocephalic trunk was found in the superior mediastinum in a 81-year-old Caucasian male cadaver during dissection practice. We report on the exact morphology of that variant that is appeared in an incidence of 0,2% in the literature. We discuss the relative literature and pay attention on the significance of such a variation for clinicians in its recognition and protection.

(CHEST 2008; 133:1508–1511) A 37-year-old woman presented with a sudden onset of right-sided chest pain and dyspnea the day after she underwent an abdominal hysterectomy for excessive menstrual bleeding. The pain was constant and worsened with breathing. Medical history was significant for a splenectomy following a motor vehicle accident at the age of 9 years. She had a 20–pack-year history of smoking. A pulmonary embolism was suspected. Multidetector-row spiral CT of the chest showed compression atelectasis of the basal segments of the right and left lower lobes but no pulmonary embolism. Unexpectedly, a well-circumscribed, homogeneously enhanced mediastinal nodule 15 mm in diameter was seen in the anterior superior mediastinum (Fig 1, left, A). With analgetic treatment, she was discharged free of symptoms on the seventh postoperative day. At the following visit to the Department of Pulmonary Diseases, she denied any complaints. Physical examination and laboratory findings were unremarkable. In addition to the known mediastinal nodule (Fig 1, left, A), conventional contrastenhanced chest CT revealed the presence of a pleural nodule 5 mm in diameter located anterolaterally in the left hemithorax (Fig 1, right. B). The patient underwent video-assisted thoracoscopic surgery. The mediastinal nodule seen on CT correlated with a reddish pedunculated nodule closely adherent to the left superior mediastinum (Fig 2, left, A). Several other, smaller pleuralbased lesions with a similar appearance were noted (Fig 2, right, B). The mediastinal nodule was resected and sent for pathologic examination (Fig 3). The other lesions were left intact.

All thoracic surgeons must have an extensive knowledge of the anatomy of the neck, because cervical approaches are used on an almost daily basis to access the cervical trachea, upper esophagus, and superior mediastinum. In addition to basic and scholarly knowledge of anatomy, they also must understand the anatomic relationships among the neck, the mediastinum, and both pleural spaces. Indeed, such knowledge forms the basis for the diagnosis and management of many aspects of pulmonary, mediastinal, and esophageal pathologies.

Hepatocellular carcinoma (HCC) is common in Taiwan. Recently, extrahepatic metastases have developed more frequently in patients due to prolonged survival rates to which improved diagnostic and treatment methods have contributed. We present here a case of a 46-year-old man with an unusual metastasis to the superior mediastinum causing Pancoast syndrome eight months after a right hepatic lobectomy for HBV-related HCC. Early detection and prompt treatment of paraspinal metastasis are important to relieve symptoms and prevent permanent loss of neurological functions.