Cervical Thoracic Duct Cysts

Abstract

T horacic duct cysts are uncommon entities that most commonly occur in the abdominal and thoracic segments of the thoracic duct; the rarest reported location is the cervical segment. The first case of a cervical thoracic duct cyst was reported in 1964, 1 and a review of the literature that was published in 1999 identified only 10 such cases. 2 We describe a patient with a thoracic duct cyst, review the relevant literature, and discuss the characteristics, treatment, and diagnosis of these lesions. REPORT OF A CASEA previously healthy 41-year-old man presented with a 2-year history of a progressively enlarging left supraclavicular mass. There were no symptoms associated with the mass. The patient's medical history was noncontributory except for the excessive use of tobacco and alcohol. Examination of his neck revealed a partially mobile, globular, nontender mass in the left supraclavicular fossa that measured approximately 5 cm in diameter. The mass was nonpulsatile and compressible. The findings of the rest of the head and neck examination were unremarkable. A computed tomographic scan of the neck and chest with contrast revealed a nonenhancing, fluid-filled 4ϫ3 cm mass in the left supraclavicular fossa that was partially compressing the left internal jugular vein (Figure 1). There was no evidence of adenopathy. The mass, which was exposed through a neck crease incision placed in the lower part of the left side of the neck, appeared to be cystic in consistency and was located above the clavicle immediately proximal to the junction of the thoracic duct and the internal jugular and subclavian veins. The cyst was connected to the internal jugular vein by 2 small tubular pedicles, which were carefully divided between liga-tures before excision of the mass. The partially aspirated contents, which appeared milky, were sent for analysis. The neck incision was closed over a suction drain that was removed the next day, and the patient was discharged from the hospital. There were no postoperative complications. Analysis of the fluid that was aspirated intraoperatively revealed a triglyceride level of 817 mg/dL (9.22 mmol/L). Pathologic examination showed an ovoid unilocular cyst whose wall was composed of fibrous tissue and smooth muscle, with adipose tissue and lymphoid aggregates on its outer surface. The luminal surface had focal areas covered by a single layer of flat cells (Figure 2), which stained positively with immunohistochemical markers for CD31, CD34, factor VIII, and keratin. No staining was present with epithelial membrane antigen or calretinin. This pattern of immunoreactivity is consistent with endothelial or lymphatic cells. The histologic sections, pattern of immunoreactivity, and high triglyceride level support the diagnosis of a thoracic duct cyst. COMMENTThe thoracic duct enters the left side of the neck posterior to the inominate artery and arches 3 to 4 cm above the clavicle. It lies anterior to the vertebral vessels, sympathetic trunk, and thyrocervical trunk and empties into the left internal jugula...

Lymphocoele of the thoracic duct: a cause of left supraclavicular fossa

“…Both congenital weakness in the thoracic duct wall and acquired degenerative process from inflammation have been proposed as causative mechanisms. Trauma has also been suggested as the underlying aetiology [7][8][9]. In the present case, no history of trauma was identified.…”

“…In the present case, no history of trauma was identified. It is worth noting that obstruction by ligation of the thoracic duct does not result in cystic dilatation [5,7].…”

“…It also has a very unique composition and so aspirate should be sent for both cytological and biochemical analysis to consolidate the diagnosis. In lymph (or chyle), lymphocytes are the predominant cell type with T-lymphocytes making up the majority of the count [7,8]. Occasional macrophages, neutrophils and epithelial cells may be present.…”

“…The protein content of lymph is relatively high, particularly in relation to its albumin content. Most striking, however, is the high concentration of triglycerides (and chylomicrons), which makes biochemical analysis both essential and confirmatory [7,8]. In this way, surgery and the potential complications thereof, such as a chylous fistula or leak, can be averted.…”

“…Unless the cyst is symptomatic or cosmetically displeasing to the patient, conservative management is generally advocated for lymphocoeles of the thoracic duct so as to avoid the potential complications outlined. Nevertheless, there are reports of surgical excision in the literature [5,[7][8][9].…”