Mediastinal tumors in children: a single institution experience

A case of suspected primary mediastinal large B-cell lymphoma: An uncommon cause of sudden death

Primary mediastinal large B-cell lymphoma (PMLBCL) is an aggressive tumor originating from thymic B-cells. Clinically, it presents with general signs such as cough, chest pain and dyspnea. Although these symptoms are not specific, they are severe enough to reveal the disease. We report an autopsy case of a 25-year-old man, with a recent past history of cough and dyspnea, for which he consulted twice the emergency department and no diagnosis was made. He presented to the Emergency Unit, with a sudden onset of a dyspnea followed by a loss of consciousness. He was shortly declared dead after, a medico-legal autopsy was requested. On external examination, no traumatic lesions on the body were found, an important cyanosis of the face and ears, was, however, found. On autopsy, a mediastinal mass was found, measuring 19 cm × 25 cm and weighing 600 g, extending to the infra-hyoid region and to the thoracic cage and infiltrating the pericardium. Trachea had a necrotic mucosa with a partially obstructive lymph node mass. The diagnosis of a primary mediastinal large B-cell lymphoma was suspected based on pathological and immunohistochemical findings. The cause of death was finally attributed to respiratory failure due to this tumor.

A Multidisciplinary Surgical Approach to Mediastinal Masses in Children

The aim of this study is to demonstrate the safety and advantages of a multidisciplinary approach to surgical resection of mediastinal masses in children. Eight patients underwent resection of a mediastinal mass by a team involving both a pediatric general surgeon and pediatric cardiothoracic surgeon. One patient required rapid initiation of cardiopulmonary bypass to complete the tumor resection and repair an aortic injury that occurred when removing adherent tumor from the structure. Perioperative outcomes were excellent for all patients. This series shows that a multidisciplinary surgical approach can be potentially life saving.

Association of anesthetic and surgical risk factors with outcomes of initial diagnostic biopsies in a current cohort of children with anterior mediastinal masses

Background

Diagnostic biopsies of pediatric anterior mediastinal masses (AMMs) are high-risk procedures in which general anesthesia (GA) is traditionally avoided. However, awareness of historically recognized risk factors and corresponding perioperative management have improved over time and may now no longer strictly preclude the use of GA. Therefore, in this study, we examined the association of anesthetic and surgical risk factors and modalities with resulting procedural and survival outcomes in a current patient cohort.

Methods

We retrospectively reviewed charts of 35 children with AMMs who underwent initial diagnostic biopsies between January 2001 and August 2019, and determined tracheal compression and deviation from archival CT scans and procedural and disease outcomes.

Results

Twenty-three (65%) patients underwent GA while 12 (35%) received sedation. Among patients with available CT measurements, 13 of 25 (52%) had >50% anteroposterior tracheal diameter reduction. Patients with >50% anteroposterior tracheal compression received sedation more frequently (p=0.047) and were positioned upright (p=0.015) compared with patients with ≤50% compression, although 4 of 13 and 9 of 12, respectively, still received GA. Intraoperative adverse events (AEs) occurred in four (11.4%) patients: three received GA, and all were positioned supine or lateral. AEs were not associated with radiographic airway risk factors but were significantly associated with morphine and sevoflurane use (p<0.001) and with thoracoscopic biopsies (p=0.035). There were no on-table mortalities, but four delayed deaths occurred (three related to disease and one from late procedural complications).

Conclusions

In a current cohort of pediatric AMM biopsies, patients with >50% anteroposterior tracheal compression were more frequently managed with a conservative perioperative management strategy, though not completely excluding GA. The corresponding reduction in frequency of procedural AEs in this traditionally high-risk group suggests that increased awareness of procedural risk factors and appropriate risk-guided perioperative management choices may obviate the procedural mortality historically associated with pediatric AMM biopsies.

The Hematological Differential Diagnosis of Mediastinal Masses

Mediastinal masses commonly present in children and may pose diagnostic challenges, particularly with limited sampling. This article aids the pathologist by reviewing the hematologic differential diagnosis of a pediatric mediastinal mass, along with ancillary testing useful for rendering the correct diagnosis. A review of the more common lymphomas is presented, including classic Hodgkin lymphoma, T-lymphoblastic leukemia/lymphoma, and primary mediastinal (thymic) large B-cell lymphoma, along with brief mentions of less common entities such as gray zone lymphoma and thymoma as well as non-neoplastic conditions such as benign cysts and infections.

Epidemiology of childhood malignant mediastinal masses and clinical factors associated with intensive care unit admission: A Singapore experience

AIM

Majority of mediastinal masses in children are malignant. These masses are complex to manage as they have a risk of compression to surrounding structures. Many of these children have to be managed in the intensive care unit (ICU). Hence we sought to evaluate the local epidemiology of malignant mediastinal masses in children and their clinical presentation, and identified factors associated with ICU admission so that at-risk patients may be identified early.

METHODS

This study is a retrospective review of institutional case records of 56 children below 18 years of age from 2000 to 2015 with a malignant mediastinal mass. We collected data on their presenting symptoms, clinical signs, radiological investigations, treatment and correlated these factors with admission to our ICU.

RESULTS

Lymphoma was most common diagnosis, comprising 37 children (66.0%). There were 6 patients with neuroblastoma (10.7%), 3 patients with germ-cell tumour (5.4%) and 10 patients with T-cell acute lymphoblastic leukaemia (17.9%). Overall, 21 patients (37.5%) had to be admitted to the ICU. Almost all patients (98.2%) were symptomatic on presentation, of which lymphadenopathy was the most common (69.6%). Factors that are significantly associated with ICU admission are stridor, pericardial effusion and need for pleural drainage.

CONCLUSIONS

Malignant mediastinal masses in children in our institution range from leukaemias and lymphomas to germ cell tumours and neuroblastomas, of which almost all are symptomatic. These children have a risk of cardiorespiratory collapse and many of them require intensive care. We identified factors that are associated with ICU admission, with the aim of early intervention of at-risk cases.

Prediction of respiratory collapse among pediatric patients with mediastinal tumors during induction of general anesthesia

PURPOSE

Fatality resulting from respiratory collapse (RC) during general anesthesia (GA) induction in children with mediastinal tumors has been reported. We explored potentially useful parameters for predicting the risk of RC based on objective imaging results.

METHODS

We retrospectively reviewed the records of 31 patients (median age: 4years; range: 4months-15years) with mediastinal tumors treated between 2000 and 2015. Comparing those with RC under GA induction to those without (RC group vs. non-RC group), we analyzed a variety of factors that might predict respiratory obstruction during GA induction, including our new parameter, the standardized tumor volume (STV), which is adapted from the formula for the volume of an ellipsoid.

RESULTS

All eight patients in the RC group had large tumors in the anterior mediastinum, including lymphoma, teratoma, and germ cell tumor. The mean STV value of the RC group was significantly larger than that of the non-RC group (3.6±1.4 vs. 1.4±1.0, p=0.006). Using an STV cut-off value of 2.5, the sensitivity and specificity for predicting RC under GA induction were both 0.86, making STV more useful than previously reported risk factors.

CONCLUSION

Anterior mediastinal tumors in children can often cause airway obstruction under GA induction. Measuring STV can help predict the respiratory risk during GA among pediatric patients with anterior mediastinal tumors.

LEVEL OF EVIDENCE

III.

Mediastinal masses in children: experience with 120 cases

Primary mediastinal malignancies are rare tumors and can originate from any mediastinal organ or tissue such as thymic, neurogenic, lymphatic, germinal, or mesenchymal. The authors reviewed all cases of primary pediatric mediastinal masses diagnosed over a 25-year period to determine the pattern of presentation, the histology, and the outcome of the surgical treatment. In this study, 120 primary pediatric mediastinal mass cases diagnosed between 1985 and 2011 are retrospectively evaluated according to their age, sex, symptoms, anatomical location, surgical treatment, and histopathological evaluation. The median age of the patients was 5.8 years. There were 34 benign and 86 malign tumors. Thirty patients were asymptomatic. Common symptoms in the patients were cough, dyspnea, fatigue, fever, abdomen pain, back pain, and neurological symptoms. According to their origins, they were presented as neurogenic tumors (38.3%), lymphomas (18.3%), undifferentiated sarcomas (15%), germ cell tumors (7.5%), and the other tumors (22%) thymic pathologies, lymphangiomas, rhabdomyosarcomas, lipomas, hemangiomas, and Wilms' tumor. Complete resection of the tumor was performed in 86 patients, partial resection of the tumor was the intervention in 11 patients. In 23 patients, biopsy was undertaken. Because of the high incidence of asymptomatic or nonspecific presentation such as the upper airway disease, the presentation of a mediastinal mass in children may be challenging. Neurogenic tumors or lymphomas are indicating surgery, if possible complete resection, for both benign and malignant conditions. Although surgery is the mainstay of therapy for most mediastinal tumors, an experienced multidisciplinary approach is necessary.

US-guided percutaneous needle biopsy of anterior mediastinal masses in children

BACKGROUND

Anterior mediastinal masses in children are clinically challenging, requiring prompt histological diagnosis.

OBJECTIVE

The purpose of this study was to review the experience with US-guided percutaneous core needle biopsy (PCNB) of anterior mediastinal masses in children, particularly with respect to safety and diagnostic accuracy.

MATERIALS AND METHODS

We retrospectively reviewed the clinical presentation, imaging, sedation approach, procedural details and pathology results of US-guided PCNB of mediastinal masses that occurred during an 8-year period (2001-2008). Complications were graded and pathology was categorized into four groups based on adequacy and diagnostic yield.

RESULTS

32 US-guided PCNBs were performed on 32 children, mean age 12 years (range 18 months to 17 years), mean weight 48 kg (range 11.5 to 109 kg, median 49 kg). A coaxial US-guided technique was used, with a mean of 8.2 passes and a mean 7.6 cores obtained (range 2-15). There were no major complications. The biopsies were adequate in volume and quality of specimens in 29/32, and 25/32 were diagnostic. PCNB was diagnostic in all cases of non-Hodgkin disease.

CONCLUSIONS

Experience with anterior mediastinal masses suggests that US-guided PCNB can be considered a viable, safe and accurate method of reaching a diagnosis in the pediatric population.

Therapeutic application of helium-oxygen and mechanical ventilation in a child with acute myelogenous leukemia and airway obstruction

Children with mediastinal masses can have a variety of disparate clinical presentations, including chest pain, superior vena cava syndrome, Horner syndrome, pericardial effusion, and cardiac tamponade. Nonetheless, respiratory symptoms are present in 80% of children at presentation and are the most common presenting symptom. Management of respiratory failure due to mediastinal masses is challenging because intubation-with the accompanying sedation and paralysis-is likely to worsen the respiratory failure. For this reason, any new treatments for this condition are welcome. We report the case of an intubated 2-year-old girl with respiratory failure from a mediastinal mass who was successfully weaned from mechanical ventilatory support through the use of a 70%:30% helium-oxygen admixture (heliox). We then review mediastinal masses and the biophysical rationale for use of heliox in airway narrowing.

Extracorporeal membrane oxygenation (ECMO) initiation without intubation in two children with mediastinal malignancy

We report the cases of two children presenting with severe airway compromise secondary to a mediastinal malignancy managed with extracorporeal membrane oxygenation without intubation. Results are presented on the use of ECMO as a primary means of stabilizing a pediatric patient with a critical mediastinal mass, thus providing another management strategy for this difficult situation.

Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths

Asphyxia, not an uncommon cause of sudden death, may result from numerous etiologies. Foreign-body aspiration and strangulation are 2 extrinsic causes. Airway obstruction may also be caused by laryngeal edema, asthma, infection, or anaphylaxis. Chronic causes of asphyxia include musculoskeletal diseases (eg, muscular dystrophy, amyotrophic lateral sclerosis), neurologic disorders (eg, myasthenia gravis, multiple sclerosis), respiratory disease (eg, emphysema, chronic bronchitis), or tumors. The manner of death in cases of asphyxiation may be natural, accidental, homicide, or suicide. For the death investigator, determining the cause and manner of death can often be quite challenging. We report here 2 cases of an esophageal fibrovascular polyp causing sudden asphyxial death, review of the literature, and discussion of other differential diagnoses in the case of asphyxial death.

Oncological emergencies in the pediatric intensive care unit

The overall 5-year survival rate of children with cancer has now reached 77%, an increase of about 45% in the past 25 years. Newer therapies, including hematopoietic cell transplantation and cutting edge chemotherapeutics evolving in the form of molecular and biological cell targeted agents, are being researched and developed and are responsible for the change in survival rates over time. Also, despite the national trend toward hospice and palliative care, children with chronic and life threatening illnesses, continue to die in the hospital setting, often in the intensive care unit. Previous studies of children with complications of cancer and its therapy document poor outcomes among those who do require intensive care. These trends are changing, however, currently leaving a hopeful, optimistic view of the outcome in children with cancer complications admitted to the pediatric intensive care unit. It is imperative that nurses and intensive care staff understand pediatric cancer and its potential emergent consequences in order to respond to the symptoms of life threatening events.

Life-threatening airway obstruction secondary to mass in children-a preventable event?

OBJECTIVES

To investigate the management of children with life-threatening airway obstruction from large mediastinal masses.

METHODS

Review of the medical records of children with mediastinal masses and severe airway obstruction who were admitted to a multidisciplinary pediatric intensive care unit.

RESULTS

Eight patients with 12 life-threatening events were identified. Five events (in 4 patients) occurred before hospital admission, and 3 patients had more than 1 choking episode. Five patients underwent cardiorespiratory resuscitation (2 before admission), and 2 underwent emergency endotracheal intubation because of severe airway obstruction; the eighth patient could not be weaned off the ventilator until the mediastinal mass was resected. Median time from appearance of the initial symptoms to diagnosis was 8.5 days, and median time from the onset of alarming signs to admission was 2 days.

CONCLUSIONS

Severe airway obstruction in children with an anterior mediastinal mass is not rare and can lead to complete obstruction, requiring cardiorespiratory resuscitation. Physician awareness and preparedness for respiratory complications are essential for proper management of children with mediastinal masses.

Life-threatening presentation of mediastinal neoplasms: report on 7 consecutive pediatric patients

BACKGROUND

Cases of respiratory failure at presentation in children with anterior mediastinal malignancies can be very challenging for clinicians. Seven consecutive children presenting with superior mediastinal syndrome are reported needing urgent critical care approach.

PATIENTS AND METHODS

Seven children (age range from 0.8 to 14 years; mean, 4.5 years) suffered from critical mediastinal neoplasms. Clinical presentation, laboratory findings, treatment, and outcome are discussed.

SETTING

a tertiary-care 6-bed medical and surgical pediatric intensive care in a university hospital. Interventions included emergency management, resuscitation and intensive care admission, and diagnostic and therapeutic procedures.

RESULTS

All cases showed a respiratory compromise and underwent ventilatory and/or cardiovascular support. Two patients needed renal replacement therapy. Pediatric Intensive Care Unit discharge was achieved in all patients.

CONCLUSIONS

Critical or extreme presentation of mediastinal neoplasms does not preclude a good clinical outcome: an intensive care approach is essential to allow patient recovery and effective antineoplastic therapy administration.

Imaging Evaluation of Pediatric Mediastinal Masses

Mediastinal masses in children are a heterogeneous group of asymptomatic to potentially life-threatening congenital, infectious, or neoplastic lesions that can present complex diagnostic and therapeutic dilemmas. This article presents the imaging features of the common mediastinal masses seen in the pediatric population. Classification of the masses is performed according to the traditional mediastinal compartment model, consisting of the anterior, middle, and posterior mediastinum. This scheme facilitates differentiation of the variety of disorders.