INTRODUCTION: Granular cell tumors are rare neoplasms primarily of neuroendocrine origin. They account for only 0.5% of soft tissue tumors. They most commonly occur in the head and neck region, with less than 10% of cases involving the respiratory tract. Due to their low prevalence, granular cell tumors are easily mistaken for more common tumors. This case highlights the presentation, diagnosis, and management of a patient with these rare tumors using a multidisciplinary approach.CASE PRESENTATION: A 41-year-old African American female smoker presented with atypical chest pain and dyspnea. Associated symptoms included fevers, chills, fatigue, cough productive of green sputum, and a 20 pound unintentional weight loss. She was hemodynamically stable with excellent oxygen saturation on room air. Physical exam was remarkable for slightly diminished breath sounds over the lower right lung field. CT chest demonstrated right hilar lymphadenopathy and a bulky, heterogenous 5.9 x 6.1 x 5.6 cm mass in the posterior medial right lower lobe. Bronchoscopy revealed several yellow, lobulated endobronchial lesions located in the right upper and lower lobes. Biopsies were obtained from both locations, resulting in PASþ, S100þ, and SOX10þ stains. Fine needle aspiration (FNA) of hilar and mediastinal adenopathy was performed via endobronchial ultrasound (EBUS) and was negative for malignancy. The combined morphologic and immunohistochemical findings were determined to be consistent with a granular cell tumor.The case was presented at the hospital center's multidisciplinary thoracic conference with a recommendation for formal surgical evaluation. Cardiothoracic surgery performed a right video-assisted thoracoscopic surgery (VATS) exploration and second biopsy of the right upper lobe mass, with pathology again consistent with granular cell tumor. Definitive treatment for this patient concluded with a right pneumonectomy.DISCUSSION: Granular cell tumors are rare, slow growing tumors presenting most often in the head and neck region. Persons in their 4th-6th decade of life are most commonly affected, with an increased incidence in African American females. When pulmonary involvement occurs, granular cell tumors may present as an endobronchial lesion or small solitary lung mass less. Diagnosis requires tissue acquisition and immunohistochemical staining. Granular cell tumors are typically benign, with a malignancy rate of less than 3%. There is little evidence to support the use of chemoradiation in treatment of these tumors. Surgical resection offers the best therapeutic option for curative treatment.CONCLUSIONS: Granular cell tumors are rarely occurring pulmonary neoplasms with a lack of standardized management recommendations. This case illustrates a multidisciplinary approach to identification, evaluation, and management of these rare neoplasms.

CORRESPONDENCE MEDICIOSH 589 but he is ultimately left in a far worse condition for radical surgical treatment or for the administration of thiouracil. The profession should in my opinion avoid using iodine altogether, except as part of the preparation for operation. The late Cecil Joll, whom I assisted for many years, strongly deprecated its all too common and thoughtless use. To embark on thyroid surgery without serving a long apprenticeship is wrong, as the hazards encountered are many. Joll himself often said that he assisted at some thousand-odd operations for goitre before undertaking one himself. Linnell et al. rightly consider the importance of good anaesthesia, without which the operation may be one of extreme difficulty in the most capable hands. All would-be thyroid surgeons should not fail to read Rowbotham's book Anaesthesia in Operations for Goitre (Blackwell, Oxford, 1945), for therein lies much sound guidance and wisdom. Lastly the cooperation of physician, surgeon, ear, nose, and throat surgeon, and anaesthetist is the ideal before the final decision as to the best form of treatment is made. Let us not forget that many thousands of sufferers from goitre and its complications have obtained lasting relief from a well-planned and skilfully executed operation.-I am, etc., Aylesbury.

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INTRODUCTION: Thymomas and thymic carcinomas are rare tumors of the anterior mediastinum. We present a case of a thymoma incidentally discovered on chest imaging. CASE PRESENTATION: A 74 year old female was admitted to the hospital with decompensated heart failure. Initial workup included plain films of the chest which showed new multifocal left upper lobe opacities. Computed tomography (CT) of the chest without contrast obtained to better characterize these infiltrates showed a new 5-6cm anterior mediastinal mass.CT guided core biopsy of the mass showed variable-sized islands of epithelial cells within a fibrous stroma with rare scattered lymphocytes and total absence of normal thymic tissue. Extensive immunohistochemical staining suggested a diagnosis of thymoma. Acetycholine receptor antibodies were negative.The patient underwent median sternotomy and thymectomy with total apparent removal. Pathology showed a type A thymoma, T1a N0 M0, with some transcapsular invasion into the mediastinal fat.The patient was scheduled to undergo postoperative radiation therapy.DISCUSSION: Thymomas may be incidentally seen on chest imaging, and patients may present with symptoms due to the presence of a mass in the thorax or to paraneoplastic phenomenon such as myasthenia gravis (MG) which is present in up to half of patients with thymomas.Imaging of mediastinal masses with CT or MRI is key in determining resectability. MG should be ruled out in patients with anterior mediastinal masses given its high prevalence in thymic neoplasms and the implications MG has on anesthesia. The World Health Organization (WHO) morphologically classifies thymomas based on their compositions of epithelial and lymphoid cells. Tumors with high spindle cell density or lymphoid density have a better prognosis than those with high epithelioid density. Our patient had a type A thymoma, comprised mostly of spindle cells with few scattered lymphocytes. However, the prognosis of thymic neoplasms is mostly dependent on their TNM stage and resectability. Prognosis is excellent for local, resectable tumors; however, 10 year survival in metastatic disease is about 47%. Postoperative radiation therapy is indicated in most thymic neoplasms aside from cases with no capsular invasion. Chemotherapy with or without immunotherapy may be indicated in metastatic disease or partially resectable/unresectable tumors. CONCLUSIONS: Thymic neoplasms often present as incidentalomas. Multidisciplinary medical and surgical teams are needed to manage thymic cancer. It is often a resectable disease, frequently causes paraneoplastic phenomena, is amenable to radiation and systemic therapies, and has a widely variable prognosis.

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