Fibrosing mediastinitis is caused by a proliferation of fibrous tissue in the mediastinum with encasement of mediastinal viscera and compression of mediastinal bronchovascular structures.
Pulmonary hypertension (PH) is a severe complication of
fibrosing mediastinitis caused by extrinsic compression of the pulmonary arteries and/or veins.We have conducted a retrospective observational study reviewing clinical, functional, hemodynamic, radiological characteristics, and outcome of 27 consecutive cases of PH associated with
fibrosing mediastinitis diagnosed between 2003 and 2014 at the French Referral Centre for PH.Fourteen men and 13 women with a median age of 60 years (range 18-84) had PH confirmed on right heart catheterization. The causes of
fibrosing mediastinitis were
sarcoidosis (n = 13),
tuberculosis-
infection confirmed or suspected (n = 9), mediastinal irradiation (n = 2), and idiopathic (n = 3). Sixteen patients (59%) were in NYHA functional class III and IV. Right heart catheterization confirmed moderate to severe PH with a median mean pulmonary artery pressure of 42 mm Hg (range 27-90) and a median cardiac index of 2.8 L/min/m (range 1.6-4.3). Precapillary PH was found in 22 patients, postcapillary PH in 2, and combined postcapillary and precapillary PH in 3. Severe extrinsic compression of pulmonary arteries (>60% reduction in diameter) was evidenced in 2, 8, and 12 patients at the main, lobar, or segmental levels, respectively. Fourteen patients had at least one severe pulmonary venous compression with associated
pleural effusion in 6 of them. PAH
therapy was initiated in 7 patients and
corticosteroid therapy (0.5-1 mg/kg/day) was initiated in 3 patients with
sarcoidosis, with 9 other being already on low-dose
corticosteroids. At 1-year follow-up, 3 patients had died and among the 21 patients evaluated, 3 deteriorated, 14 were stable, and only 4 patients with
sarcoidosis improved (4 receiving
corticosteroids and 1 receiving
corticosteroids and PAH
therapy). Survival was 88%, 73%, and 56% at 1, 3, and 5 years, respectively.We found no clear clinical improvement with the use of specific PAH
therapy.
Corticosteroid therapy may be associated with clinical improvement, in some patients with
fibrosing mediastinitis due to
sarcoidosis. Although never performed for this indication,
lung transplantation may be proposed in eligible patients with severe PH and
fibrosing mediastinitis.