[Management of anterior mediastinal masses in adults]

Clinical evaluation of the impact of mediastinal tumour size on the subxiphoid approach video-assisted thoracoscopic surgery

OBJECTIVES

The application of video-assisted thoracoscopic surgery (VATS) for relatively large mediastinal tumours (≥5.0 cm) has been a subject of debate, and few studies have investigated the subxiphoid approach VATS in different tumour size categories. The study aims to compare the efficacy of the subxiphoid approach VATS for achieving curative outcomes based on tumour size categories (<3.0, 3.0-4.9 and 5.0-10.0 cm).

METHODS

A total of 165 patients with anterior mediastinal tumours who underwent surgery at our hospital between January 2018 and July 2022 were consecutively enrolled, categorized according to tumour size-group A (<3.0 cm): 58, group B (3.0-4.9 cm): 70 and group C (5.0-10.0 cm): 37. Clinical baseline data, intraoperative and postoperative outcomes, and postoperative complications were analysed.

RESULTS

The study revealed significant differences in operation time among the 3 groups (group A: 103.4 ± 36.1, group B: 106.4 ± 35.2, group C: 127.4 ± 44.8; P < 0.05) as well as in the volume of drainage (group A: 273.3 ± 162.0, group B: 411.9 ± 342.6, group C: 509.7 ± 543.7; P < 0.05). However, no differences were seen in blood loss, drainage duration, postoperative hospital stay and duration of postoperative oral analgesics. Additionally, the incidence of postoperative complications did not exhibit significant differences across these groups.

CONCLUSIONS

Subxiphoid approach VATS is considered a feasible and safe surgical method for large-sized anterior mediastinal tumours (5.0-10.0 cm) with no invasion to the surrounding tissues and organs.

Efficacy of contrast-enhanced ultrasound-guided percutaneous core needle biopsy in anterior mediastinal masses

OBJECTIVE

To evaluate the efficacy and safety of percutaneous core needle biopsy (PCNB) using ultrasound (US)-guided and contrast-enhanced ultrasound (CEUS)-guided procedures for anterior mediastinal masses (AMMs).

METHODS

In total, 284 consecutive patients (166 men, 118 women; mean age, 43.0 ​± ​18.4 years) who underwent PCNB for AMMs were enrolled. Patients were divided into the US-guided group (n ​= ​133) and the CEUS-guided group (n ​= ​151). PCNB was performed using a core needle (16-gauge or 18-gauge). Internal necrosis, diagnostic yield, and diagnostic accuracy were compared between the two groups.

RESULTS

The predominant final diagnosis of the cases in this study was thymoma (29.7%), lymphoma (20.5%), thymic carcinoma (13.3%), and germ cell tumour (13.3%), respectively. There was no significant difference in patient age, sex, number of percutaneous biopsies, or display rate of internal necrosis on conventional US between the two groups. The rate of internal necrosis of the lesions was significantly higher after contrast agent injection (72.2% vs. 41.7%; P ​< ​0.001). The CEUS-guided group had a higher diagnostic yield than the US-guided group (100% vs. 89.5%, P ​< ​0.001). There was no significant difference between the diagnostic accuracy of the CEUS-guided and US-guided groups (97.3% vs. 97.4%; P ​= ​1.000). None of the patients experienced adverse reactions or complications after US-guided or CEUS-guided PCNB.

CONCLUSIONS

CEUS-guided PCNB can improve the diagnostic yield by optimizing the biopsy procedure.

Dyspnoea, thoracic pain and fever in a young caucasian female: A case report

INTRODUCTION

The diagnostic approach to patients with mediastinal pathology is not always simple and an improper diagnostic work-up can lead to significant diagnosis delay.

PRESENTATION OF CASE

We report on the case of a young woman who was admitted to the Emergency Department complaining of thoracic pain, dyspnoea, fever and productive cough. The physical examination showed a painful swelling over the sternum's upper left margin, which had become evident 4 months earlier. A Computer Tomography showed the presence of a retrosternal oval lesion (5.5 x 4 cm) infiltrating the thoracic wall and showed the presence of discretely enlarged mediastinal lymph nodes in several mediastinal stations.

DISCUSSION

The Multidisciplinary Team decided to perform an ultrasound-guided biopsy of the retrosternal mass that showed an inflammatory pattern, whereas microbiology tests proved negative. The lack of improvement with medical therapy (non steroideal anti-inflammatories and antibiotics) and the clinical suspicion of malignancy led us to perform a surgical biopsy of the mass that finally proved to be diagnostic for Hodgkin's lymphoma.

CONCLUSIONS

Mediastinal masses with an aggressive behavior, should always be considered to be potentially malignant. Surgical biopsy, sometimes, can be the only way to correctly diagnose the pathological process, especially in the case of Hodgkin's lymphoma in which few diagnostic cells (Reed-Sternberg cells) are generally embedded in an abundant inflammatory background tissue.

Massive thymic hyperplasia in an adult: A rare case report and literature review

INTRODUCTION

Massive thymic hyperplasia is an extremely rare disorder, with fewer than 60 cases reported so far. Majority of the previous cases occurred in neonates, infants, and older children.

PRESENTATION OF CASE

A man was found to have an anterior mediastinal mass without any symptoms at 30 years of age. Operation was done successfully. The mass measured 112 mm × 191 mm × 184 mm and weighed 2141 g. Histological and immunohistochemical findings further confirmed the diagnosis of massive thymic hyperplasia. The complication of postoperative chylothorax occurred, which has not been previously reported in MTH. After undergoing conservative treatment, the patient finally recovered.

DISCUSSION

This is the first case of massive thymic hyperplasia reported in an adult (defined as ≥ 18 years old). Chylothorax is one of the potentially fatal complications. However, we carried out effective treatments, which are educational and clinically interesting to surgeons and clinicians.

CONCLUSION

Although not previously reported, massive thymic hyperplasia could also be found in adults. The main treatment for massive thymic hyperplasia is surgical removal. Good clinical effects on post-thymectomy chylothorax are available after undergoing conservative treatment.

[Which surgery for mediastinum tumor: Experience of the Department of thoracic surgery of CHU Hassan II of Fès]

INTRODUCTION

Tumors of the mediastinum are a heterogeneous group of dysembryoplatic and neoplastic diseases essentially with different prognoses and therapeutic. These tumors develop slowly and remain long asymptomatic in 40-50% of cases. The purpose of our work is to bring the result of surgical management in diagnostic and therapeutic of principal mediastinum tumors framework.

PATIENTS AND METHOD

We reviewed retrospectively the records of 68 patients in our training, between January 2009 and December 2013, for tumor of the mediastinum in the diagnostic framework and or therapy.

RESULTS

There were 37 men and 31 women with a mean age of 37 years with extremes ranging from 11 to 73 years and 77.94% had an age between 11 and 50. In 39 patients, surgery had a diagnostic purpose (2 benign tumors and 37 malignancies including 27 cases of lymphomas). Curative surgery was performed in 34 patients, dominated by the tumors of thymic origin in 15 cases. Conventional surgery had involved 32 patients. The surgical approach was a total vertical sternotomy in 14 patients, in 17 patients was posterolateral thoracotomy and a left anterior thoracotomy in 1 patient. Video assisted thoracic surgery had been done in 3 patients under resection of a pleuropericardique cyst. Overall mortality was 4.41 percent. It is a death at D17 of the postoperative (thymoma with myasthenia) following a myasthenic crisis requiring a tracheotomy. A patient operated on for invasive thymoma developed myopathy and died at D44 of the postoperative following a difficulty of weaning. Another patient had a thymoma B3 benefited from 6 courses of neoadjuvant chemotherapy and then a thymectomy had presented a respiratory distress with bilateral pleural effusion, death at D10 of the postoperative by septic shock following a nosocomial infection.

CONCLUSION

Tumors of the mediastinum are infrequent, discovered more often by chance. The main prognostic factor is the completeness of tumor resection without taking the break. Conventional surgery always keeps a place in our context, despite the advent of minimally invasive surgery.

[Chamberlain biopsy is not necessary when mature teratoma is evident on imagery]

INTRODUCTION

Mature teratoma represents 60 % of germinal cells tumours of the mediastinum. Most patients with these tumours are asymptomatic, so the neoplasms are usually discovered by accident during routine chest X-ray examination. They have specific and almost pathognomonic radiological features. However, patients can be symptomatic and may present with chest, back, or shoulder pain; dyspnoea; fever; pleural effusion; cough; and bulging of the chest wall.

CASE REPORT

We report the case of a young woman presenting with a giant mediastinal mature teratoma compressing the left lung. The patient was admitted for dyspnoea and non productive cough. The chest X-ray showed a mediastinal mass and a chest computed tomography scan revealed a heterogeneous pluritissular mass lesion of the mediastinum. Complete surgical removal is the treatment of choice for mature cystic teratomas, with optimal results and an acceptable surgical risk. This approach allows confirmation of the diagnosis and is the only way to rule out the presence of malignancy. Surgical biopsy by the Chamberlain method is therefore not strictly necessary.

DISCUSSION

When chest X-ray and a computed tomography scan show specific radiological features of teratoma, a complete resection should be undertaken if the patient is fit for surgery. This will confirm the anatomico-pathological diagnosis, exclude the presence of malignant cells and it represents the treatment of choice of mature teratomas.