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Turk Gogus Kalp Damar Cerrahisi Dergisi Jan 2024Mediastinal tumors are the most common thoracic tumor in the pediatric population. They include a spectrum of tumors, and most are malignant. These lesions can be... (Review)
Review
Mediastinal tumors are the most common thoracic tumor in the pediatric population. They include a spectrum of tumors, and most are malignant. These lesions can be anatomically and radiologically classified by means of compartments; anterior, middle, and posterior. Symptoms, signs, localization of the tumor, age of the child, and tumor markers are key points of diagnosis. Surgical approaches are typically needed for diagnosis, but sometimes tru-cut needle biopsies may be sufficient. Mediastinoscopy, mediastinotomy, and video-assisted thoracoscopic surgery may be used in the diagnostic workup of mediastinal tumors in children as they are used in adults. Frequently, diagnosis and treatment are both established by means of surgery. Surgery remains the mainstay of treatment of most benign and malignant nonlymphoid tumors. Combined modality of treatment incorporating chemotherapy and radiotherapy is often required in malignant tumors and is associated with high survival rates in these patients.
PubMed: 38584788
DOI: 10.5606/tgkdc.dergisi.2024.25799 -
Healthcare (Basel, Switzerland) Jun 2021A significant part of all neoplasms growing in anterior mediastinum are lymphomas (25%). Achieving a correct diagnosis and a clear definition of a lymphoma's subtype is...
A significant part of all neoplasms growing in anterior mediastinum are lymphomas (25%). Achieving a correct diagnosis and a clear definition of a lymphoma's subtype is crucial for beginning chemotherapy as soon as possible. However, most patients present a large mediastinal mass that compresses vessels and airway, with serious cardiorespiratory repercussions. Therefore, having multiple tools available to biopsy the lesion without worsening morbidity becomes fundamental. Patients enrolled in this study were unfit for a surgical biopsy in general anesthesia and the need to begin chemotherapy as fast as possible prompted us to avoid percutaneous fine needle aspiration to prevent diagnostic failures. Our observational study included 13 consecutive patients with radiological findings of anterior mediastinal mass. Ultrasonography was performed directly in the theatre to mark the lesion and to localize vessels and vascularized neoplastic tissue. Open biopsy was carried out in spontaneous breathing with a laryngeal mask and with short-acting medications for a rapid anesthesia, performing an anterior mediastinotomy. The mean operative time was 33.4 ± 6.2 min and spontaneous respiration was maintained throughout the procedure. No complications were reported. All patients were discharged in the first or second postoperative day after a chest X-ray (1.38 ± 0.5 days). The diagnostic yield of this approach was 100%. With the addition of ultrasonography right before the procedure and with spontaneous breathing, anterior mediastinotomy still represents a useful tool in critical patients that could hardly tolerate a general anesthesia. The diagnostic yield is high, and the low postoperative morbidity allows a rapid onset of chemotherapy.
PubMed: 34205526
DOI: 10.3390/healthcare9060770 -
Annals of Thoracic Medicine Jul 2014Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior... (Review)
Review
Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior mediastinotomy may experience long survival that makes the development of ischemic heart disease throughout their life possible. Therefore, the un-judicial sacrifice of the internal mammary pedicle may deprive them from the benefit to have their internal mammary artery used as a graft in order to successfully bypass severe left anterior descending artery stenoses. We recommend the preservation of the internal mammary pedicle during anterior mediastinotomy, which should be a common message among our colleagues from the beginning of their training.
PubMed: 24987471
DOI: 10.4103/1817-1737.134067 -
Indian Journal of Otolaryngology and... Sep 2017This study aims to evaluate surgical approaches to the management of retrosternal goitre. Between 2004 and 2014, 35 patients (eight males; mean age...
This study aims to evaluate surgical approaches to the management of retrosternal goitre. Between 2004 and 2014, 35 patients (eight males; mean age 67.4 ± 10.9 years) with retrosternal goitre (mainly right-sided in 9, left-sided in 14 and bilateral in 12) underwent surgery. A palpable neck mass was found in 11 (31.4%), stridor in 10 (28.6%) and thyrotoxicosis in 4 (11.4%) cases. 4 (11.4%) patients were asymptomatic. Tracheal compression was detected radiologically in 27 (77.2%) patients with deviation in 18 (51.4%). A collar incision was performed in 34 patients, 6 (17.1%) of whom required additional sternotomy, 1 (2.9%) was assisted by an anterior mediastinotomy. 1 (2.9%) had a right lateral thoracotomy. There was no operative mortality. Transient vocal changes occurred in 3 (8.6%) patients, recurrent laryngeal nerve palsy in 3, atrial fibrillation in 2, and wound complications in 2 (5.7%). Hospital stay ranged from 2 to 12 days (5.5 ± 2.0). Multinodular goitre was found in 33 patients, diffuse goitre in 1 and ectopic thyroid in 1. The average vertical length of goitres in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. The average weight of specimens was 156.3 g in patients with collar incisions and 307.5 g in the sternotomy group. Removal of retrosternal goitre is more commonly performed via a cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the risk of sternotomy. Surgical outcomes are not affected by surgical approach.
PubMed: 28929066
DOI: 10.1007/s12070-017-1151-0 -
Journal of Clinical Medicine Aug 2023(1) Background: The prompt diagnosis of anterior mediastinal lesions is a challenge due to their often being categorized as malignant tumours. Ultrasound-guided...
Ultrasound-Guided Needle Biopsy as an Alternative to Chamberlain's Mediastinotomy and Video-Assisted Thoracoscopic Surgery (VATS) in the Diagnosis of Anterior Mediastinal Neoformations: A Retrospective Analysis.
(1) Background: The prompt diagnosis of anterior mediastinal lesions is a challenge due to their often being categorized as malignant tumours. Ultrasound-guided Transthoracic Core Needle Biopsy (US-TCNB) is an innovative technique that is arousing increasing interest in clinical practice. However, studies in this area are still scarce. This study aims to compare the diagnostic accuracy and complication rate of US-TCNB with those of traditional surgical methods-Anterior Mediastinotomy and Video Assisted Thoracoscopic Surgery (VATS)-in patients with anterior mediastinal lesions. (2) Methods: This retrospective study involved patients evaluated between January 2011 and December 2021 who had undergone US-TCNB at the Interdepartmental Unit of Internal and Interventional Ultrasound, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy. Personal data, diagnostic questions, and technical information concerning the bioptic procedure, periprocedural complications and histological reports were collected. (3) Results: Eighty-three patients were included in the analysis. Histological examination was performed in 78 cases, with an overall diagnostic accuracy of 94.0% (sensitivity 94%; specificity 100%). Only in 5 patients was a diagnosis not achieved. Complications occurred in 2 patients who were quickly identified and properly treated without need of hospitalization. The accuracy of US-TCNB was comparable to the performance of the main traditional diagnostic alternatives (95.3% for anterior mediastinotomy, and 98.4% for VATS), with a much lower complication rate (2.4% vs. 3-16%). The outpatient setting offered the additional advantage of saving resources. (4) Conclusions: a US-guided needle biopsy can be considered effective and safe, and in the near future it may become the procedure of choice for diagnosing anterior mediastinal lesions in selected patients.
PubMed: 37568472
DOI: 10.3390/jcm12155070 -
Case Reports in Anesthesiology 2022Perioperative management of patients with mediastinal masses still poses a challenge for the anesthesiologist, as the use of general anesthesia can be associated with...
Perioperative management of patients with mediastinal masses still poses a challenge for the anesthesiologist, as the use of general anesthesia can be associated with acute perioperative cardiorespiratory impairment resulting from the mass collapsing on the airway or vascular structures. Dexmedetomidine can be used for procedural sedation due to its reversible sedative and anxiolytic properties with dose-dependent effects, while not interfering with ventilatory drive. These features are of particular interest for the perioperative management of patients with large anterior mediastinal masses. In this case, we report our anesthetic management of a 22-year-old male scheduled for anterior mediastinotomy, with a large anterior mediastinal mass, with 50% distal tracheal compression and marked collapse of the superior vena cava and brachiocephalic trunk. In the operation theatre, an infusion of dexmedetomidine was titrated to adequate anesthetic depth while keeping the patient under spontaneous ventilation with oxygen (O) supplementation and local anesthetic infiltration of the surgical site. Mediastinotomy lasted for about 30 minutes, during which the patient maintained appropriate ventilation and hemodynamic stability. No adverse events occurred perioperatively. Diagnostic procedures such as mediastinotomy for tissue biopsy are necessary to achieve a histological diagnosis. High-risk patients may present with severe postural symptoms, stridor, cyanosis, and radiological evidence of more than 50% airway obstruction, tracheal compression with bronchial compression, pericardial effusion, or superior vena cava syndrome. Relaxation of bronchial smooth muscles under general anesthesia increases the risk of airway obstruction. In this case, with the use of dexmedetomidine combined with local anesthetic infiltration, spontaneous ventilation and muscle tone were preserved, decreasing the probability of intraoperative complications. It is our opinion that dexmedetomidine combined with local anesthetic infiltration can be a safe option for procedural sedation in patients presenting with high-risk anterior mediastinal masses for mediastinotomy.
PubMed: 35237452
DOI: 10.1155/2022/3519003 -
Journal of Thoracic Disease Dec 2020Pathologic diagnosis of thymic tumors (TTs) can be made by surgical or nonsurgical procedures. About 20% of TTs had been diagnosed by pretreatment biopsy methods while... (Review)
Review
Pathologic diagnosis of thymic tumors (TTs) can be made by surgical or nonsurgical procedures. About 20% of TTs had been diagnosed by pretreatment biopsy methods while the rest had gone to surgery for diagnosis and treatment. However, in the last two decades there was an increase in pretreatment procedures for optimal management of locally advanced or metastatic TTs. Pretreatment tissue diagnosis of a noninvasive TT is not a standard option but is required if there is suspect or atypical clinical presentation and imaging, an invasive tumor requiring a nonsurgical approach or preoperative chemotherapy or chemo-radiotherapy, strong possibility of lymphoma or unclear differential diagnosis between lymphoma or other solid tumor by imaging studies, or suspicion of a metastatic lesion. In surgical diagnosis anterior mediastinotomy, video-assisted thoracic surgery or mediastinoscopy can be chosen for invasive TTs whereas total resection is performed for small, noninvasive tumors. Nonsurgical diagnosis can be made by transthoracic fine or core needle biopsies (TTFNA, TTCNB), conventional bronchoscopy, endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or medical thoracoscopy depending on procedural amenability according to tumor extension. TTFNA and TTCNB have been the most frequently used nonsurgical methods. However, there is an upward trend in using conventional bronchoscopy, EBUS-TBNA, EUS-FNA and medical thoracoscopy recently. To increase the diagnostic performance of these procedures in TTs, recommendations are (I) obtaining histologic specimens, (II) combining smears or liquid based cytology preparations and cell blocks, (III) obtaining multiple sufficient samples, (IV) combining histologic and cytologic specimens, (V) performing morphologic, immunohistochemical and molecular analyses on all specimens, (VI) using rapid onsite evaluation for cytologic specimens, (VII) correlating pathologic, clinical and radiologic findings, (VIII) consulting experienced pathologists.
PubMed: 33447450
DOI: 10.21037/jtd-2019-thym-14 -
International Journal of Surgery Case... Aug 2022Anterior mediastinal masses are rare conditions that can become symptomatic through compression of the airways and vascular structures. Fatal or severe complications can...
INTRODUCTION AND IMPORTANCE
Anterior mediastinal masses are rare conditions that can become symptomatic through compression of the airways and vascular structures. Fatal or severe complications can occur during anesthesia and surgery. With this review we aim to describe the state of the art in peri-anesthetic management of mediastinal tumors, which we illustrate with a clinical case.
PRESENTATION OF CASE
We report a case of a young female patient suffering from a large anterior mediastinal mass that underwent an open biopsy after intercostal nerve blocks (INB) in six consecutive right intercostal spaces (2nd to 7th). A right anterior mediastinotomy was performed and an excellent analgesic effect was achieved. The patient was awake and did not experience significant pain or cough, having received paracetamol 1 g and returned home later in the day. The diagnosis of non-Hodgkin's lymphoma was later confirmed.
DISCUSSION
Our review showed that anesthesia for mediastinal masses' resection or open biopsy is rare and prone to severe complications. Such complications are more important in children, patients in supine position, under general anesthesia and already symptomatic prior to the procedure. INB presents some advantages against paravertebral block (PVB) and thoracic epidural anesthesia (TEA), is easier to reproduce and has a shorter learning curve. Airway stenting with a rigid bronchoscope can be an alternative.
CONCLUSION
Multilevel medial axillary line INBs are safer and easier to reproduce than PVB, have less hemodynamic repercussion than TEA and can, therefore, be preferable for open anterior mediastinal biopsies or small masses resection.
PubMed: 35907298
DOI: 10.1016/j.ijscr.2022.107461