Pediatric Mediastinal Lymphatic Malformation: Misdiagnosis Analysis and Literature Review

Pediatric Mediastinal Lymphatic Malformation: Misdiagnosis Analysis and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pediatric Mediastinal Lymphatic Malformation: Misdiagnosis Analysis and Literature Review Wen Zhao, siqi Zhang, xinxin qi, songyu Teng, longwei Sun, hongwu Zeng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4260302/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Sep, 2024 Read the published version in BMC Pediatrics → Version 1 posted 10 You are reading this latest preprint version Abstract Objectives Mediastinal cystic lymphatic malformation (MCLM) in children is prone to misdiagnosis as cystic teratoma. We compared the clinical and radiologic features between the two diseases and performed a cross-comparison with previous research focused on adult cases. This study aims to identify characteristic pediatric manifestations for the improvement of diagnostic accuracy. Methods We retrospectively studied clinical and radiology data of 12 cases of MCLM and 20 cases of cystic teratomas confirmed by pathology or intervention biopsy. Clinical characters and radiology features (mass location and morphology, density, component, secondary complication) were recorded and compared. We searched published clinical studies related to MCLM in the past decade. We compared the radiology differences between them. Also, a comparison was made between pediatric MCLM cases in our hospital and MCLM cases from the kinds of literature. Results Group comparison in pediatrics between MCLM and cystic teratomas: There were significant age differences ( p = 0.036), shape ( p = 0.003), DV ( p < 0.001), DR (p < 0.001), calcification ( p < 0.001), fat ( p < 0.001), and typing ( p < 0.001) between the two diseases. MCLM cases from literature: A total of 10 studies with 70 patients were eligible for data extraction. Conclusion The lack of internal fat or irregular morphology with minimal DV suggests the diagnosis of MCLM. In pediatric cases, anterior mediastinal diseases are more likely to extend toward the neck, and the persistence of the thymus can complicate component analysis and increase the risk of misdiagnosis. Thus, MRI evaluation is recommended for pediatric MCLM case assessment. Pediatrics Mediastinum Lymphatic malformation Teratoma Differentiation Figures Figure 1 Figure 2 Figure 3 1.Introduction Mediastinal cystic lymphatic malformation (MCLM) is a benign congenital malformation characterized by the proliferation of well-differentiated lymphatic vessels, typically presenting as polycystic or spongy aggregates. However, the incidence rate of MCLM is extremely low, accounting for only 1% ( 1 ). In children, there is thymus and adipose tissue in the anterior superior mediastinum. In children, there is thymus and adipose tissue in the anterior superior mediastinum. When cystic lymphangioma occurs in this area, it is easy to be misdiagnosed as teratoma. Radiologists usually misinterpreted adipose tissue as a fat component of teratoma ( 1 , 2 ). The treatment strategies for these two tumors differ, with MCLM usually managed through a combination of interventional therapy and surgery, while teratomas are typically treated with surgery alone ( 3 ). Hence, the accuracy of preoperative diagnosis is crucial for clinical surgical decision-making. Due to the extremely low incidence of MCLM, most relevant studies are limited to case reports. Statistical analysis of larger sample sizes is extremely rare, with the largest sample size being 11, and pediatric research was even rarer ( 4 – 6 ). In this study, we retrospectively analyzed the clinical and imaging features of MCLM (n = 12) and mediastinal teratomas (n = 20). We retrospectively studied clinical and radiology data of 12 cases of MCLM and 20 cases of cystic teratomas confirmed by pathology or intervention biopsy ( 7 – 14 ), to identify the key factors for pediatric MCLM diagnosis. This analysis aims to enhance the accuracy of disease diagnosis and assist in making precise clinical decisions regarding treatment. 2.Methods 2.1 Patient selection We retrospectively studied clinical and radiology data of 12 cases of MCLM and 20 cases of cystic teratomas confirmed by pathology or intervention biopsy. These cases were from Shenzhen's children Hospital between January 2011 and December 2023. Cases were further selected based on the following criteria: ( 1 ) diagnostic as MCLM or cystic teratoma; ( 2 ) Chest CT both pre and post contrast before surgical treatment. The exclusion criteria are other types of mediastinal mass lesions or patients with other lung diseases. Thirty-two patients were finally included, with 12 MCLM and 20 cystic teratomas, respectively. This retrospective study was approved by the Institutional Review Board of Shenzhen's children Hospital, and the requirement for informed consent was waived. Institutional ethics review board approval was obtained. 2. 2 CT image acquisition All CT scans were done on GE Optima CT 680 Quantum. Scan parameters were set: tube voltage, 100kV; tube current, 250mA; pitch, 0.984; scanning layer thickness, 5mm; reconstruction layer thickness, 0.625mm. All patients received nonionic contrast material with an iodine concentration of 300 mgI/mL (Iopamiron, Bayer Schering Pharma, Osaka, Japan; or Omnipaque, Daiichi Sankyo, Tokyo, Japan). The injection dose of contrast material was 2 mL/kg body weight, and the speed of injection and the scanning time were personalized according to the child's age, body weight, vein condition, and condition of the child. 2.3 Imaging review All images were evaluated by two senior Chest radiologists with at least 7 years of working experience. The radiologists were blinded to the clinical diagnosis and pathologic outcomes. When two radiologists disagreed, the third one with 20 years of experience gave the final opinion and reached a consensus. The detailed qualitative and quantitative CT indicators were as follows: mass location and morphology (location, short-axis/long-axis ratio, contact surface with heart, shape, margin), density (pre and post-contrast CT Value, the difference value (DV) and ratio (DR) between two CT sequences (using the thymus as reference), component (calcification, fat, cystic variation, septum), classification (sunken, flattened, convex, perfusion), secondary complication (Pleural effusion, pericardial effusion). The typical MRI characteristics of the MCLM and cystic teratoma are exemplified in Fig. 1 and Fig. 2 . 2.4 Literature review We searched published clinical studies related to MCLM, from PubMed, EMBASE, and Web of Science, between January 2014 and January 2024. Keywords were set as bellowing, (Lymphatic Abnormalities OR Lymphangioma OR Lymphangioma, Cystic) AND diagnosis OR diagnostic imaging OR Differential diagnosis) AND Mediastinal Neoplasms. A search of the lists of references from included studies was also performed. We screened and checked the articles retrieved respectively, according to the predefined inclusion and exclusion criteria. Firstly, the title and abstract of the study were reviewed. Then the full text of potentially eligible studies was scanned swiftly. Finally, the eligible studies were screened by reading the full text carefully. Eligibility criteria were set as follows: ( 1 ) Whether or not an MRI was performed;( 2 ) Whether it spreads to the neck. Disagreement was resolved by discussion, and finally reaching a consensus. 2.5 Statistical methods All tests were performed with Statistical Package for the Social Sciences (SPSS version 22.0 for Windows, SPSS Inc., IBM, Armonk, NY, USA). Continuous variables are described as mean (standard deviation, SD) or median (interquartile range, IQR), and categorical variables are presented as frequencies (%). The independent sample t-test or the Mann–Whitney U-test was used to analyze continuous variables, and the chi-square or Fisher's exact test was used for categorical variables. A p -value of < 0.05 was considered to be statistically significant. 3.Results 3.1 Results of clinical data Table 1 shows a comparison of the clinical characteristics between the two diseases. A total of 32 patients were included in the present study, with 12 MCLM and 20 mediastinal teratomas, respectively. The MCLM dataset consisted of 7 male patients and 5 female patients, and the median age was 1.46 years (IQR, 0.10–5.29). The cystic teratomas dataset consisted of 13 male patients and 7 female patients, and the median age was 4.96 years (IQR, 1.52–11.13). Patients diagnosed with MCLM were younger than teratomas (median age of years 1.46 vs. 4.96, p = 0.036). Table 1 Clinical baseline data on mediastinal lymphangiomas and teratomas in children Type of lesions [n(%)] gender age males females [Year] lymphangioma 12(37.5) 7 5 1.46(0.10–5.29) teratoma 20(62.5) 13 7 4.96(1.52–11.13) p- value — 0.724 a 0.036 b a. Fisher's exact test b. independent sample t-test 3.2 Results of CT features 3.2.1 Qualitative Factors The location of MCLM (5 were in the left anterior mediastinum, 5 in the right anterior mediastinum, and 2 in the posterior mediastinum) was not significantly different from that of teratoma. The shape was considered irregular in ten patients (83.3%) in the group with MCLM outcomes vs. five patients (25%) in those with teratoma outcomes (p=0.033). Calcification is suggestive of a teratoma, but not present in all teratoma (p < 0.001). About the classification, MCLM is mostly perfusion (41.67%), while teratoma tends to be convex (35%), and the difference between the two groups is statistically significant ( p < 0.001). The detailed statistical results are shown in Table 2 . 3.2.2 Quantitative Factors The post-contrast CT value difference of mediastinal lesions with the MCLM was lower than that with the teratoma group, and the difference was statistically significant (mean value of 3.73 vs. 12.31, p < 0.001). The post-contrast CT Value difference ratio of mediastinal lesions with the MCLM was lower than that with the teratoma group, and the difference was statistically significant (mean value of 0.08 vs. 0.25, p < 0.001). The detailed statistical results are shown in Table 2 . Table 2 CT signs of MCLM and teratomas in children CT sign MCLM teratoma P -value Location Anterior mediastinum (leftward) 5 5 0.494 a Anterior mediastinum (rightward) 5 11 Anterior mediastinum (center) 0 2 mediastinum 0 0 posterior mediastinum 2 2 Shape orbicular 2 15 0.003 a irregular 10 5 Short Diameter/Long Diameter (SD/LD) 0.60(0.38–0.93) 0.71(0.48-1.00) 0.096 b The contact surface with the heart 64.59 (37.00-91.70) 68.45(10.23–88.30) 0.659 b Plain CT value 20.89(12.00-28.67) 17.20(11.67-33.00) 0.094 b Pre- and post-contrast difference 3.73(1-6.56) 11.31(5.65–25.30) <0.001 b Enhanced CT difference ratio 0.08(0.02–0.14) 0.25(0.12–0.66) <0.001 b margin clear 10 15 0.683 a blurred 2 5 Cystic variation single capsule 4 8 1 a polycystic 8 12 Septum Yes 7 17 0.092 a No 5 3 Calcification Yes 0 15 <0.001 a No 12 5 Fat Yes 4 20 <0.001 a No 8 0 Classification [17] sunken 3 0 flattened 3 7 convex 1 13 <0.001 a Perfusion 5 0 Pleural effusion Yes 2 9 0.155 a No 10 11 Pericardial effusion Yes 0 4 0.169 a No 12 16 a. Fisher's exact test b. independent sample t-test 3. 3 Results of the literature review A total of 70 articles met the retrieval requirements, followed by the removal of 8 duplicate articles. Finally, a total of 9 studies were included for quantitative analysis. The basic characteristics of the included studies are summarized in Fig. 3 . The present meta-analysis included a total of 2 cases with MRI imaging and 1 case spreading to the neck in patients among them (Table 3 ). Table 3 Imaging features of mediastinal cystic lymphangioma Author Year Number of cases Age Whether or not an MRI was performed Whether it spreads to the neck Stefano Licci 20 2014 1 66Y No No Hiroshi Suehisa 7 2015 1 35Y Yes No Parth Rali 21 2017 1 23Y Yes 1 cases of spreading to the neck Haining Zhou 10 2017 1 69Y No No Malgorzata Szolkowska 22 2019 11 48Y-51Y No No Ana Catarina Dionísio 9 2019 1 36Y No No Kun Zhu 23 2020 1 6Y No No Hira Aslam 14 2022 1 42Y No No Hashan Pathiraja 8 2022 1 16m No No 4.Discussion Among primary tumors of the mediastinum in children, when teratomas undergo cystic transformation, they are not easily differentiated from MCLMs that are independently solitary in the mediastinum. Enhanced CT is the imaging modality of choice for the evaluation and characterization of most mediastinal lesions ( 15 ). Although the final definitive clinical diagnosis of both is currently dependent on pathological findings or interventional diagnostic puncture, enhanced CT examination is of significant value in analyzing the nature of the lesion and evaluating the relationship of adjacent vascular tissue. MCLM is a rare benign disease of the lymphatic system that primarily affects the configuration and function of lymphatic vessels. The development of lymphangiomas is associated with abnormal proliferation of lymphatic tissue, leading to the expansion of lymphatic vessels and local tumor formation. The statistical results of clinical data show that patients with MCLM have a younger age of onset than patients with teratomas, which may be presumed to be related to the fact that MCLM is more likely to burrow and grow and invade adjacent blood vessels, resulting in a greater likelihood of clinical symptoms ( 11 ). Analyzing the composition of the lesion, the presence of intertumoral fat within the anterior mediastinal mass (measured at -40 HU to -120 HU on CT) was highly suggestive of benign teratoma ( 15 – 17 ), similar to the findings of the present study. Although fat-fluid levels and the presence of bone or teeth within the tumor are highly specific for the diagnosis of teratoma, this sign is rare and not of outstanding value for daily clinical use. Therefore, this study proposes that the difference ratio, using the thymus as a reference base, can more objectively reflect the degree of enhancement of the lesion to better analyze the nature of the internal components. The results showed that the two tumors exhibited statistical differences in this index, with teratoma having a higher difference ratio, indicating a more significant degree of enhancement, presumably due to its more complex and densely packed composition, which is of greater significance in clinical practice. In terms of staging, MCLM tends to be perfusion-type growths, with a tendency to spread along the lax interstitial spaces of the tissue in a "creeping growth", filling the interstitial spaces with plastic changes. Teratomas, on the other hand, tend to be protruding, with inward compression of adjacent tissue structures. In addition, a review of previous adult cases in this study showed that MCLM in children tends to spread to the neck, whereas in adults they are more often limited to the mediastinum ( 18 ). In children, masses located in the neck or anterior mediastinum were found to have vascular malformation components within them, so they were regarded as congenital lesions. In contrast, in adults, the lesions were more often located in the middle or posterior mediastinum, and they mostly consisted of pure fluid cysts, suggesting that they were of acquired origin ( 19 ). This study has several potential limitations. First, it has limitations inherent to the retrospective study design and manual measurement. Second, MRI images were only available for part of our datasets and were consequently excluded from the analysis in this study. These issues need to be further explored in the future. 5.Conclusions In conclusion, the absence of internal fat or irregular morphology with minimal DV suggests a diagnosis of MCLM. In pediatric cases, anterior mediastinal diseases are more likely to extend toward the neck, and the presence of the thymus can complicate component analysis and increase the risk of misdiagnosis. CT imaging and MRI evaluation are recommended for assessing pediatric MCLM cases clinical diagnosis and surgical decision-making. Abbreviations MCLM mediastinal cystic lymphatic malformation DV The difference value DR The different ratio Declarations Availability of data and material s All data analyzed during this study are included in this article. Further enquiries are available upon reasonable request to the correspondence author. Ethics approval and consent to participate The studies involving human participants were reviewed and approved by the Medical Ethics Committee of the Shenzhen Children’s Hospital (NO.2020106). Consent for publication Not applicable Availability of data and material s All data analyzed during this study are included in this article. Further enquiries are available upon reasonable request to the correspondence author. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Sanming Project of Medicine in Shenzhen (SZSM202011005) from Shenzhen Medical and Health Project and the Guangdong High-level Hospital Construction Fund (ynkt2021-zz47). Authors' contributions Wen Zha o : Conceptualization; Methodology; Data Curation; Formal analysis; Writing – original draft; Writing – review or editing. Siqi Zhang: Methodology; Data Curation;Writing – review or editing. Xinxin Qi : Investigation; Formal analysis. Songyu Teng : Investigation; Resources. Longwei Sun : Investigation; Resources. Hongwu Zeng: Funding Acquisition; Supervision; Writing – review or editing. All authors read and approved the final manuscript. Acknowledgements Not applicable References Queiroz-Rodrigues R, Cruz P, Silva AC. Mediastinal Lymphangioma With an Atypical Location in an Adult Patient. Arch Bronconeumol. 2023;59(5):326–7. Saleiro S, Magalhães A, Moura CS, Hespanhol V. Linfangioma cístico do mediastino. Revista Portuguesa Pneumol. 2006;12(6):731–5. Defnet AM, Bagrodia N, Hernandez SL, Gwilliam N, Kandel JJ. Pediatric lymphatic malformations: evolving understanding and therapeutic options. Pediatr Surg Int. 2016;32(5):425–33. Mishra A, Das PP, Goswami D, Malviya A, Saikia MK, Kynta RL et al. Idiopathic Chylous Pericardial Effusion Due to Lymphatic Malformation of Mediastinum. Cureus. 2023. Lim NM, Jang JY, Park JE, Kim S, Kim JH. Lymphatic-Venous Malformation Presenting as a Mediastinal Mass in a 6-Year-Old Boy. J Emerg Med. 2022;63(1):e42–4. Hyvonen H, Salminen P, Kyrklund K. Long-term outcomes of lymphatic malformations in children: An 11-year experience from a tertiary referral center. J Pediatr Surg. 2022;57(12):1005–10. Suehisa H, Ueno T, Sawada S, Yamashita M, Teramoto N. A case of mediastinal cystic lymphangioma. Acta Med Okayama. 2015;69(6):361–3. Pathiraja H, Rasnayake D, Muthukumarana T, de Silva C, Sathkorala W, Gunaratne S et al. A large pericardial cystic lymphangioma presenting as acute-onset respiratory distress in a child: a case report. J Med Case Rep. 2022;16(1). Ana Catarina D, Ricardo G, Eduardo C, Isabel C, José P, Didia L et al. Giant Cystic Mediastinal Lymphangioma. European Journal of Case Reports in Internal Medicine. 2019(Vol 7 No 1). Zhou H, Zhong C, Fu Q, Tang S, Luo Q, Yu L, et al. Thoracoscopic resection of a huge mediastinal cystic lymphangioma. J Thorac Disease. 2017;9(10):E887–9. Cheng AW, Shaul DB, Sydorak RM. Successful thoracoscopic resection of large symptomatic mediastinal lymphatic malformations: Report of 3 cases. J Thorac Cardiovasc Surg. 2015;150(4):e59–60. Jeung M-Y, Gasser B, Gangi A, Bogorin A, Charneau D, Wihlm J-M, et al. Imaging of cystic masses of the mediastinum. Radiographics. 2002;22(suppl1):S79–93. Yang B, Jiang C, Zhang B, Ren Q, Tang T, Xu S, et al. Giant primary cystic mediastinal lymphangioma: A case report. Oncol Lett. 2014;8(3):1246–8. Aslam H, Kamal A, Khan AN, Chaudhary AJ, Ismail R. Solitary Cystic Mediastinal Lymphangioma: A Rare Incidental Case in an Adult Female. Eur J Case Rep Intern Med. 2022;9(9):003295. Biko DM, Lichtenberger JP, Rapp JB, Khwaja A, Huppmann AR, Chung EM. Mediastinal Masses in Children: Radiologic-Pathologic Correlation. Radiographics. 2021;41(4):E1186–207. Molinari F, Bankier AA, Eisenberg RL. Fat-Containing Lesions in Adult Thoracic Imaging. Am J Roentgenol. 2011;197(5):W795–813. Kerpel A, Beytelman A, Ofek E, Marom EM. Magnetic Resonance Imaging for the Follow-up of Treated Thymic Epithelial Malignancies. J Thorac Imaging. 2019;34(6):345–50. Sreedher G, Tadros SS, Janitz E. Pediatric mediastinal masses. Pediatr Radiol. 2022;52(10):1935–47. Aydemir B, Okay T, Imamoglu O, Sahin S, Dogusoy I. Preoperative embolization in mediastinal Castleman's disease. Thorac Cardiovasc Surg. 2010;58(8):496–8. Licci S, Puma F, Sbaraglia M, Ascani S. Primary intrathymic lymphangioma. Am J Clin Pathol. 2014;142(5):683–8. Rali P, Gandhi V, Malik K. Recurring Giant Mediastinal Cystic Lymphangioma. Am J Respiratory Crit Care Med. 2017;196(1):e1–3. Szolkowska M, Szczepulska-Wojcik E, Maksymiuk B, Burakowska B, Winiarski S, Gatarek J, et al. Primary mediastinal neoplasms: a report of 1,005 cases from a single institution. J Thorac Dis. 2019;11(6):2498–511. Zhu K, Gu W, Wang L, Wang J, Tang H, Shen H, et al. A 6-Year-Old Boy With a Mediastinal Mass. Chest. 2020;158(6):e317–21. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Sep, 2024 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 05 Aug, 2024 Reviews received at journal 26 Jul, 2024 Reviewers agreed at journal 23 Jul, 2024 Reviews received at journal 07 Jul, 2024 Reviewers agreed at journal 24 Jun, 2024 Reviewers invited by journal 24 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Editor invited by journal 14 Apr, 2024 Submission checks completed at journal 14 Apr, 2024 First submitted to journal 12 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4260302","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":291049327,"identity":"fe4a784b-68c4-40b8-8b3a-2e0a149ed395","order_by":0,"name":"Wen Zhao","email":"","orcid":"","institution":"Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Zhao","suffix":""},{"id":291049328,"identity":"6dea4dcb-b1b4-4669-9c28-af9ea467d39d","order_by":1,"name":"siqi Zhang","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"siqi","middleName":"","lastName":"Zhang","suffix":""},{"id":291049329,"identity":"feecfd97-6dac-405d-92d6-238f1231a2a6","order_by":2,"name":"xinxin qi","email":"","orcid":"","institution":"Shenzhen's children hospital","correspondingAuthor":false,"prefix":"","firstName":"xinxin","middleName":"","lastName":"qi","suffix":""},{"id":291049330,"identity":"65c3e0d7-7556-4889-bb45-1b6a45b31c3b","order_by":3,"name":"songyu Teng","email":"","orcid":"","institution":"Shenzhen's children hospital","correspondingAuthor":false,"prefix":"","firstName":"songyu","middleName":"","lastName":"Teng","suffix":""},{"id":291049331,"identity":"05b75d0d-8fb9-4b62-9792-463d56392e7f","order_by":4,"name":"longwei Sun","email":"","orcid":"","institution":"Shenzhen's children hospital","correspondingAuthor":false,"prefix":"","firstName":"longwei","middleName":"","lastName":"Sun","suffix":""},{"id":291049332,"identity":"a7ab066d-1475-42a2-85f4-e56878325ccd","order_by":5,"name":"hongwu Zeng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACAziLvbHxwQfStPAcbjacQZoWifQ2aQ5itJizdyc+rvhjkycf+bBBmoHBTk63gYAWy56zmw3P8KQVG95ObDAuYEg2NjtAyGE3crdJNkgcTtw4O7EheQbDgcRtRGjZ/rPB4H/ixpkHGw7zEKllG2NDwoHE+RKMjc3EaTlzdrNkw4HkxA08ic2MMwyI8cvx3o0fG/7YJc5vP/78x4cKOzmCWhB6wSoNCKhCAfINpKgeBaNgFIyCEQUATBRJncaMhq8AAAAASUVORK5CYII=","orcid":"","institution":"Shenzhen's children hospital","correspondingAuthor":true,"prefix":"","firstName":"hongwu","middleName":"","lastName":"Zeng","suffix":""}],"badges":[],"createdAt":"2024-04-13 03:59:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4260302/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4260302/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-024-05069-3","type":"published","date":"2024-09-28T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55009241,"identity":"92040ed2-0539-4c2f-893b-0d92247244c2","added_by":"auto","created_at":"2024-04-19 19:12:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1693289,"visible":true,"origin":"","legend":"\u003cp\u003eCT and pathologic picture of a patient with MCLM. The patient, a 5-year-old male, presented with a mediastinal lymphangioma mass. CT scans revealed uniform density within the mass with multiloculated cystic lesions (Figure A). The enhanced CT scan showed no intensification in the cystic part, with evidence of septal-like alterations and mild enhancement in the septa (Figure B). Pathological examination displayed cystic walls composed of proliferated fibrous tissue, focal hemorrhage, and a single layer of flat epithelial overlay in local foci (Figure C).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4260302/v1/22f2cd4d80906de33ae7b3d4.png"},{"id":55010386,"identity":"39e1201f-7111-4682-99f9-0d1b5da78fd4","added_by":"auto","created_at":"2024-04-19 19:20:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2269213,"visible":true,"origin":"","legend":"\u003cp\u003eCT and pathologic picture of a patient with mediastinal teratoma. The patient, an 11-year-old male, presented with a mediastinal teratoma. CT scans revealed uneven density within the mass, with evidence of fat and calcification (Figure A). The enhanced CT scan showed no enhancement in the cystic part, with segmentation-like changes and mild enhancement in the septum (Figure B). Pathological examination displayed matured tissues of three germinal origins, including keratinized compound squamous epithelium, hair follicles, and sebaceous glands in the ectodermal layer; fibrofatty tissue in the mesoderm; and ciliated columnar epithelium in the endodermal layer (Figure C).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4260302/v1/1c53586566d5da06c05b14b4.png"},{"id":55009243,"identity":"810f7246-6d04-436f-8a2f-eddf7aca2704","added_by":"auto","created_at":"2024-04-19 19:12:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2114996,"visible":true,"origin":"","legend":"\u003cp\u003eLiterature Search and Inclusion-Exclusion Flowchart.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4260302/v1/c4fcf3484c75f07ee51047d8.png"},{"id":65628444,"identity":"b239d7df-828a-4fae-b6c3-a3964e8d9df3","added_by":"auto","created_at":"2024-09-30 16:19:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10739326,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4260302/v1/930eadb3-dfe0-4426-81ff-df02a4cdd454.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pediatric Mediastinal Lymphatic Malformation: Misdiagnosis Analysis and Literature Review","fulltext":[{"header":"1.Introduction","content":"\u003cp\u003eMediastinal cystic lymphatic malformation (MCLM) is a benign congenital malformation characterized by the proliferation of well-differentiated lymphatic vessels, typically presenting as polycystic or spongy aggregates. However, the incidence rate of MCLM is extremely low, accounting for only 1% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In children, there is thymus and adipose tissue in the anterior superior mediastinum. In children, there is thymus and adipose tissue in the anterior superior mediastinum. When cystic lymphangioma occurs in this area, it is easy to be misdiagnosed as teratoma. Radiologists usually misinterpreted adipose tissue as a fat component of teratoma (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The treatment strategies for these two tumors differ, with MCLM usually managed through a combination of interventional therapy and surgery, while teratomas are typically treated with surgery alone (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Hence, the accuracy of preoperative diagnosis is crucial for clinical surgical decision-making.\u003c/p\u003e \u003cp\u003eDue to the extremely low incidence of MCLM, most relevant studies are limited to case reports. Statistical analysis of larger sample sizes is extremely rare, with the largest sample size being 11, and pediatric research was even rarer (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In this study, we retrospectively analyzed the clinical and imaging features of MCLM (n\u0026thinsp;=\u0026thinsp;12) and mediastinal teratomas (n\u0026thinsp;=\u0026thinsp;20). We retrospectively studied clinical and radiology data of 12 cases of MCLM and 20 cases of cystic teratomas confirmed by pathology or intervention biopsy (\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), to identify the key factors for pediatric MCLM diagnosis. This analysis aims to enhance the accuracy of disease diagnosis and assist in making precise clinical decisions regarding treatment.\u003c/p\u003e"},{"header":"2.Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patient selection\u003c/h2\u003e \u003cp\u003eWe retrospectively studied clinical and radiology data of 12 cases of MCLM and 20 cases of cystic teratomas confirmed by pathology or intervention biopsy. These cases were from Shenzhen's children Hospital between January 2011 and December 2023. Cases were further selected based on the following criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) diagnostic as MCLM or cystic teratoma; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Chest CT both pre and post contrast before surgical treatment. The exclusion criteria are other types of mediastinal mass lesions or patients with other lung diseases. Thirty-two patients were finally included, with 12 MCLM and 20 cystic teratomas, respectively. This retrospective study was approved by the Institutional Review Board of Shenzhen's children Hospital, and the requirement for informed consent was waived. Institutional ethics review board approval was obtained.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2. 2 CT image acquisition\u003c/h3\u003e\n\u003cp\u003eAll CT scans were done on GE Optima CT 680 Quantum. Scan parameters were set: tube voltage, 100kV; tube current, 250mA; pitch, 0.984; scanning layer thickness, 5mm; reconstruction layer thickness, 0.625mm. All patients received nonionic contrast material with an iodine concentration of 300 mgI/mL (Iopamiron, Bayer Schering Pharma, Osaka, Japan; or Omnipaque, Daiichi Sankyo, Tokyo, Japan). The injection dose of contrast material was 2 mL/kg body weight, and the speed of injection and the scanning time were personalized according to the child's age, body weight, vein condition, and condition of the child.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Imaging review\u003c/h2\u003e \u003cp\u003eAll images were evaluated by two senior Chest radiologists with at least 7 years of working experience. The radiologists were blinded to the clinical diagnosis and pathologic outcomes. When two radiologists disagreed, the third one with 20 years of experience gave the final opinion and reached a consensus. The detailed qualitative and quantitative CT indicators were as follows: mass location and morphology (location, short-axis/long-axis ratio, contact surface with heart, shape, margin), density (pre and post-contrast CT Value, the difference value (DV) and ratio (DR) between two CT sequences (using the thymus as reference), component (calcification, fat, cystic variation, septum), classification (sunken, flattened, convex, perfusion), secondary complication (Pleural effusion, pericardial effusion). The typical MRI characteristics of the MCLM and cystic teratoma are exemplified in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Literature review\u003c/h2\u003e \u003cp\u003eWe searched published clinical studies related to MCLM, from PubMed, EMBASE, and Web of Science, between January 2014 and January 2024. Keywords were set as bellowing, (Lymphatic Abnormalities OR Lymphangioma OR Lymphangioma, Cystic) AND diagnosis OR diagnostic imaging OR Differential diagnosis) AND Mediastinal Neoplasms. A search of the lists of references from included studies was also performed.\u003c/p\u003e \u003cp\u003eWe screened and checked the articles retrieved respectively, according to the predefined inclusion and exclusion criteria. Firstly, the title and abstract of the study were reviewed. Then the full text of potentially eligible studies was scanned swiftly. Finally, the eligible studies were screened by reading the full text carefully. Eligibility criteria were set as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Whether or not an MRI was performed;(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Whether it spreads to the neck. Disagreement was resolved by discussion, and finally reaching a consensus.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical methods\u003c/h2\u003e \u003cp\u003eAll tests were performed with Statistical Package for the Social Sciences (SPSS version 22.0 for Windows, SPSS Inc., IBM, Armonk, NY, USA). Continuous variables are described as mean (standard deviation, SD) or median (interquartile range, IQR), and categorical variables are presented as frequencies (%). The independent sample t-test or the Mann\u0026ndash;Whitney U-test was used to analyze continuous variables, and the chi-square or Fisher's exact test was used for categorical variables. A \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 was considered to be statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3.Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Results of clinical data\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows a comparison of the clinical characteristics between the two diseases. A total of 32 patients were included in the present study, with 12 MCLM and 20 mediastinal teratomas, respectively. The MCLM dataset consisted of 7 male patients and 5 female patients, and the median age was 1.46 years (IQR, 0.10\u0026ndash;5.29). The cystic teratomas dataset consisted of 13 male patients and 7 female patients, and the median age was 4.96 years (IQR, 1.52\u0026ndash;11.13). Patients diagnosed with MCLM were younger than teratomas (median age of years 1.46 vs. 4.96, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical baseline data on mediastinal lymphangiomas and teratomas in children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of lesions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e[n(%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003egender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003efemales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[Year]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elymphangioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.46(0.10\u0026ndash;5.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eteratoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20(62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.96(1.52\u0026ndash;11.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep-\u003c/em\u003evalue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.724\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.036\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003ea. Fisher's exact test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eb. independent sample t-test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Results of CT features\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Qualitative Factors\u003c/h2\u003e \u003cp\u003eThe location of MCLM (5 were in the left anterior mediastinum, 5 in the right anterior mediastinum, and 2 in the posterior mediastinum) was not significantly different from that of teratoma. The shape was considered irregular in ten patients (83.3%) in the group with MCLM outcomes vs. five patients (25%) in those with teratoma outcomes (p=0.033). Calcification is suggestive of a teratoma, but not present in all teratoma (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). About the classification, MCLM is mostly perfusion (41.67%), while teratoma tends to be convex (35%), and the difference between the two groups is statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The detailed statistical results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Quantitative Factors\u003c/h2\u003e \u003cp\u003eThe post-contrast CT value difference of mediastinal lesions with the MCLM was lower than that with the teratoma group, and the difference was statistically significant (mean value of 3.73 vs. 12.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The post-contrast CT Value difference ratio of mediastinal lesions with the MCLM was lower than that with the teratoma group, and the difference was statistically significant (mean value of 0.08 vs. 0.25, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The detailed statistical results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCT signs of MCLM and teratomas in children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT sign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMCLM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eteratoma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior mediastinum (leftward)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.494\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior mediastinum (rightward)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior mediastinum (center)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emediastinum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eposterior mediastinum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eorbicular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eirregular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShort Diameter/Long Diameter (SD/LD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.60(0.38\u0026ndash;0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.71(0.48-1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.096\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe contact surface with the heart\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.59 (37.00-91.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.45(10.23\u0026ndash;88.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.659\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlain CT value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.89(12.00-28.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.20(11.67-33.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre- and post-contrast difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.73(1-6.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.31(5.65\u0026ndash;25.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhanced CT difference ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.08(0.02\u0026ndash;0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25(0.12\u0026ndash;0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emargin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.683\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eblurred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCystic variation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esingle capsule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epolycystic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.092\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification \u003csup\u003e[17]\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esunken\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eflattened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003econvex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.155\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePericardial effusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.169\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea. Fisher's exact test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eb. independent sample t-test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003e3. 3 Results of the literature review\u003c/h3\u003e\n\u003cp\u003eA total of 70 articles met the retrieval requirements, followed by the removal of 8 duplicate articles. Finally, a total of 9 studies were included for quantitative analysis.\u003c/p\u003e \u003cp\u003eThe basic characteristics of the included studies are summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The present meta-analysis included a total of 2 cases with MRI imaging and 1 case spreading to the neck in patients among them (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImaging features of mediastinal cystic lymphangioma\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhether or not an MRI was performed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWhether it spreads to the neck\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStefano Licci\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHiroshi Suehisa\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParth Rali\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 cases of spreading to the neck\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaining Zhou\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalgorzata Szolkowska\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48Y-51Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAna Catarina Dion\u0026iacute;sio\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKun Zhu\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHira Aslam\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHashan Pathiraja\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4.Discussion","content":"\u003cp\u003eAmong primary tumors of the mediastinum in children, when teratomas undergo cystic transformation, they are not easily differentiated from MCLMs that are independently solitary in the mediastinum. Enhanced CT is the imaging modality of choice for the evaluation and characterization of most mediastinal lesions (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Although the final definitive clinical diagnosis of both is currently dependent on pathological findings or interventional diagnostic puncture, enhanced CT examination is of significant value in analyzing the nature of the lesion and evaluating the relationship of adjacent vascular tissue.\u003c/p\u003e \u003cp\u003eMCLM is a rare benign disease of the lymphatic system that primarily affects the configuration and function of lymphatic vessels. The development of lymphangiomas is associated with abnormal proliferation of lymphatic tissue, leading to the expansion of lymphatic vessels and local tumor formation.\u003c/p\u003e \u003cp\u003eThe statistical results of clinical data show that patients with MCLM have a younger age of onset than patients with teratomas, which may be presumed to be related to the fact that MCLM is more likely to burrow and grow and invade adjacent blood vessels, resulting in a greater likelihood of clinical symptoms (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnalyzing the composition of the lesion, the presence of intertumoral fat within the anterior mediastinal mass (measured at -40 HU to -120 HU on CT) was highly suggestive of benign teratoma (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), similar to the findings of the present study. Although fat-fluid levels and the presence of bone or teeth within the tumor are highly specific for the diagnosis of teratoma, this sign is rare and not of outstanding value for daily clinical use. Therefore, this study proposes that the difference ratio, using the thymus as a reference base, can more objectively reflect the degree of enhancement of the lesion to better analyze the nature of the internal components. The results showed that the two tumors exhibited statistical differences in this index, with teratoma having a higher difference ratio, indicating a more significant degree of enhancement, presumably due to its more complex and densely packed composition, which is of greater significance in clinical practice.\u003c/p\u003e \u003cp\u003eIn terms of staging, MCLM tends to be perfusion-type growths, with a tendency to spread along the lax interstitial spaces of the tissue in a \"creeping growth\", filling the interstitial spaces with plastic changes. Teratomas, on the other hand, tend to be protruding, with inward compression of adjacent tissue structures.\u003c/p\u003e \u003cp\u003eIn addition, a review of previous adult cases in this study showed that MCLM in children tends to spread to the neck, whereas in adults they are more often limited to the mediastinum (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In children, masses located in the neck or anterior mediastinum were found to have vascular malformation components within them, so they were regarded as congenital lesions. In contrast, in adults, the lesions were more often located in the middle or posterior mediastinum, and they mostly consisted of pure fluid cysts, suggesting that they were of acquired origin (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study has several potential limitations. First, it has limitations inherent to the retrospective study design and manual measurement. Second, MRI images were only available for part of our datasets and were consequently excluded from the analysis in this study. These issues need to be further explored in the future.\u003c/p\u003e"},{"header":"5.Conclusions","content":"\u003cp\u003eIn conclusion, the absence of internal fat or irregular morphology with minimal DV suggests a diagnosis of MCLM. In pediatric cases, anterior mediastinal diseases are more likely to extend toward the neck, and the presence of the thymus can complicate component analysis and increase the risk of misdiagnosis. CT imaging and MRI evaluation are recommended for assessing pediatric MCLM cases clinical diagnosis and surgical decision-making.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eMCLM \u0026nbsp;\u0026nbsp;\u003c/strong\u003emediastinal cystic lymphatic malformation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDV\u003c/strong\u003e\u0026nbsp; The difference value\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDR\u003c/strong\u003e\u0026nbsp; The different ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data analyzed during this study are included in this article. Further enquiries are available upon reasonable request to the correspondence author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies involving human participants were reviewed and approved by the Medical Ethics Committee of the Shenzhen Children\u0026rsquo;s Hospital (NO.2020106).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data analyzed during this study are included in this article. Further enquiries are available upon reasonable request to the correspondence author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Sanming Project of Medicine in Shenzhen (SZSM202011005) from Shenzhen Medical and Health Project and the Guangdong High-level Hospital Construction Fund (ynkt2021-zz47).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWen\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Zha\u003c/strong\u003e\u003cstrong\u003eo\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Conceptualization; Methodology; Data Curation; Formal analysis; Writing \u0026ndash; original draft; Writing \u0026ndash; review or editing.\u0026nbsp;\u003cstrong\u003eSiqi\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Zhang:\u003c/strong\u003e Methodology; Data Curation;Writing \u0026ndash; review or editing.\u0026nbsp;\u003cstrong\u003eXinxin Qi\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Investigation; Formal analysis.\u0026nbsp;\u003cstrong\u003eSongyu Teng\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Investigation; Resources.\u0026nbsp;\u003cstrong\u003eLongwei Sun\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Investigation; Resources. \u003cstrong\u003eHongwu Zeng:\u003c/strong\u003e Funding Acquisition; Supervision; Writing \u0026ndash; review or editing.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eQueiroz-Rodrigues R, Cruz P, Silva AC. Mediastinal Lymphangioma With an Atypical Location in an Adult Patient. Arch Bronconeumol. 2023;59(5):326\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaleiro S, Magalh\u0026atilde;es A, Moura CS, Hespanhol V. Linfangioma c\u0026iacute;stico do mediastino. Revista Portuguesa Pneumol. 2006;12(6):731\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDefnet AM, Bagrodia N, Hernandez SL, Gwilliam N, Kandel JJ. Pediatric lymphatic malformations: evolving understanding and therapeutic options. Pediatr Surg Int. 2016;32(5):425\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra A, Das PP, Goswami D, Malviya A, Saikia MK, Kynta RL et al. Idiopathic Chylous Pericardial Effusion Due to Lymphatic Malformation of Mediastinum. Cureus. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim NM, Jang JY, Park JE, Kim S, Kim JH. Lymphatic-Venous Malformation Presenting as a Mediastinal Mass in a 6-Year-Old Boy. J Emerg Med. 2022;63(1):e42\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHyvonen H, Salminen P, Kyrklund K. Long-term outcomes of lymphatic malformations in children: An 11-year experience from a tertiary referral center. J Pediatr Surg. 2022;57(12):1005\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuehisa H, Ueno T, Sawada S, Yamashita M, Teramoto N. A case of mediastinal cystic lymphangioma. Acta Med Okayama. 2015;69(6):361\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePathiraja H, Rasnayake D, Muthukumarana T, de Silva C, Sathkorala W, Gunaratne S et al. A large pericardial cystic lymphangioma presenting as acute-onset respiratory distress in a child: a case report. J Med Case Rep. 2022;16(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAna Catarina D, Ricardo G, Eduardo C, Isabel C, Jos\u0026eacute; P, Didia L et al. Giant Cystic Mediastinal Lymphangioma. European Journal of Case Reports in Internal Medicine. 2019(Vol 7 No 1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou H, Zhong C, Fu Q, Tang S, Luo Q, Yu L, et al. Thoracoscopic resection of a huge mediastinal cystic lymphangioma. J Thorac Disease. 2017;9(10):E887\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng AW, Shaul DB, Sydorak RM. Successful thoracoscopic resection of large symptomatic mediastinal lymphatic malformations: Report of 3 cases. J Thorac Cardiovasc Surg. 2015;150(4):e59\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeung M-Y, Gasser B, Gangi A, Bogorin A, Charneau D, Wihlm J-M, et al. Imaging of cystic masses of the mediastinum. Radiographics. 2002;22(suppl1):S79\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang B, Jiang C, Zhang B, Ren Q, Tang T, Xu S, et al. Giant primary cystic mediastinal lymphangioma: A case report. Oncol Lett. 2014;8(3):1246\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAslam H, Kamal A, Khan AN, Chaudhary AJ, Ismail R. Solitary Cystic Mediastinal Lymphangioma: A Rare Incidental Case in an Adult Female. Eur J Case Rep Intern Med. 2022;9(9):003295.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiko DM, Lichtenberger JP, Rapp JB, Khwaja A, Huppmann AR, Chung EM. Mediastinal Masses in Children: Radiologic-Pathologic Correlation. Radiographics. 2021;41(4):E1186\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolinari F, Bankier AA, Eisenberg RL. Fat-Containing Lesions in Adult Thoracic Imaging. 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Recurring Giant Mediastinal Cystic Lymphangioma. Am J Respiratory Crit Care Med. 2017;196(1):e1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSzolkowska M, Szczepulska-Wojcik E, Maksymiuk B, Burakowska B, Winiarski S, Gatarek J, et al. Primary mediastinal neoplasms: a report of 1,005 cases from a single institution. J Thorac Dis. 2019;11(6):2498\u0026ndash;511.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu K, Gu W, Wang L, Wang J, Tang H, Shen H, et al. A 6-Year-Old Boy With a Mediastinal Mass. Chest. 2020;158(6):e317\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pediatrics, Mediastinum, Lymphatic malformation, Teratoma, Differentiation","lastPublishedDoi":"10.21203/rs.3.rs-4260302/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4260302/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eMediastinal cystic lymphatic malformation (MCLM) in children is prone to misdiagnosis as cystic teratoma. We compared the clinical and radiologic features between the two diseases and performed a cross-comparison with previous research focused on adult cases. This study aims to identify characteristic pediatric manifestations for the improvement of diagnostic accuracy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively studied clinical and radiology data of 12 cases of MCLM and 20 cases of cystic teratomas confirmed by pathology or intervention biopsy. Clinical characters and radiology features (mass location and morphology, density, component, secondary complication) were recorded and compared. We searched published clinical studies related to MCLM in the past decade. We compared the radiology differences between them. Also, a comparison was made between pediatric MCLM cases in our hospital and MCLM cases from the kinds of literature.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGroup comparison in pediatrics between MCLM and cystic teratomas: There were significant age differences (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036), shape (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), DV (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), DR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), calcification (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), fat (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and typing (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between the two diseases. MCLM cases from literature: A total of 10 studies with 70 patients were eligible for data extraction.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe lack of internal fat or irregular morphology with minimal DV suggests the diagnosis of MCLM. In pediatric cases, anterior mediastinal diseases are more likely to extend toward the neck, and the persistence of the thymus can complicate component analysis and increase the risk of misdiagnosis. Thus, MRI evaluation is recommended for pediatric MCLM case assessment.\u003c/p\u003e","manuscriptTitle":"Pediatric Mediastinal Lymphatic Malformation: Misdiagnosis Analysis and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 19:12:07","doi":"10.21203/rs.3.rs-4260302/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-06T03:47:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-26T16:06:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201950127655211275023902739262236174764","date":"2024-07-24T01:42:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-08T02:25:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79029318620153163398633454316896153284","date":"2024-06-25T01:22:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-24T14:02:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-19T14:20:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-14T17:32:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-14T17:29:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-04-13T03:56:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f64d0934-11bc-40b0-a6e2-c4b5709f95c0","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:14:13+00:00","versionOfRecord":{"articleIdentity":"rs-4260302","link":"https://doi.org/10.1186/s12887-024-05069-3","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2024-09-28 15:57:40","publishedOnDateReadable":"September 28th, 2024"},"versionCreatedAt":"2024-04-19 19:12:07","video":"","vorDoi":"10.1186/s12887-024-05069-3","vorDoiUrl":"https://doi.org/10.1186/s12887-024-05069-3","workflowStages":[]},"version":"v1","identity":"rs-4260302","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4260302","identity":"rs-4260302","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}