Resection Of Mediastinal Mass Research Articles

A Rare Cause of Progressive Paresthesias, Cramps, Fasciculations and Weakness in a Collegiate Volleyball Player

HISTORY: A 21 year old female collegiate volleyball player presented with exertional paresthesias involving her cheeks, lips and chest. Her symptoms evolved to include twitching, stiffness and cramping of the thighs and calves, which forced discontinuation of participation in volleyball. She went on to develop upper extremity cramping and abnormal posturing of her hands, even at rest. She noticed symmetric hypertrophy of her calves and quadriceps muscles and increased sweating and salivation. Her cramping and leg stiffness worsened to the point that she needed aid of a walker for ambulation. PHYSICAL EXAMINATION: General medical exam was unremarkable. Her quadriceps and calves seemed abnormally muscular for body habitus. Movements of the upper and lower limbs were slow and stiff with visible cramping of calf and quadriceps muscles with activation. Neurological exam showed diminished reflexes. Strength testing was difficult due to non-painful muscle cramps with isolated testing of muscles. Sensation was normal. DIFFERENTIAL DIAGNOSIS: 1) Myotonia (DM1, DM2)/ Neuromyotonia 2) Diffuse Myopathy 3) Multiple Sclerosis 4) Peripheral Neuropathy TEST AND RESULTS: MRI brain and cervical spine: - No evidence of demyelination, inflammation, or infarction EMG: - Nearly persistent motor unit activity in upper and lower limb muscles with spontaneous, iterative, high frequency discharges consistent with neuromyotonia Laboratory Testing: - Blood tests for hereditary and acquired causes of myotonia/neuromyotonia were inconclusive PET Scan/MRI: - Showed focal, hypermetabolic activity in the thymus with two peripherally enhancing soft tissue nodules FINAL WORKING DIAGNOSIS: Hodgkin’s Lymphoma with presentation of paraneoplastic neuromyotonia (Isaac’s Syndrome) TREATMENT AND OUTCOMES: 1. Intravenous immunoglobulin was poorly tolerated with no clear benefit. 2. Gabapentin and mexiletine were started as membrane stabilizing agents with significant improvement in symptoms. 3. With imaging findings concerning for neoplasm, anterior mediastinal mass resection with total thymectomy was performed. 4. Surgical pathology showed interfollicular Hodgkin’s lymphoma with no abnormality in the thymus. 5. The patient recovered well from surgery, reports 80% improvement in symptoms and is exercising consistently

Timik Malignite İzlenimi Veren Mediastinal Hamartom

Mediastinum is an extremely rare location for hamartoma and according to our knowledge a few case reported in the literature until now. When the imaging modalities demonstrate a mass located in the antero-superior mediastinum compatible with thymoma, the surgical resection remains the mainstay for the treatment. Although, many approaches exist for the resection of these tumors, robotic assisted thoracoscopic surgery is gaining popularity with different surgical components include right versus left side approach, number of incisions and extent of resection. Its technical superiority with excellent exposure and high quality instruments and minimally invasive manner make this approach first option. Herein, we presented a patient who underwent roboticassisted mediastinal mass resection. After resection, interestingly the final pathology was reported as chondroid hamartoma and it was infiltrated with prostatic carcinoma.

Uniportal video-assisted thoracic surgery thymectomy.

A 47-year-old gentleman presented with an incidental discovery of a 2.5-cm anterior mediastinal mass. Following radiological review, the diagnosis of likely thymoma is made and the patient is referred for surgical resection. The patient is currently self-employed and working as a carpenter. He is very concerned about the possibility of having a sternotomy as it would impact on his recovery and return to work. A single port, muscle sparing technique seems the best option for this gentleman. He undergoes surgery and is discharged 2 days later. He is back at work in 2 weeks. Over the past 10 years, video-assisted thoracic surgery (VATS) has replaced median sternotomy for the resection of anterior mediastinal masses, including thymoma. In 1993, the thoracoscopic approach to thymectomy was first reported by Sugarbaker from Boston, as well as a Belgian group (1,2). To date, the VATS approach has become the preferred and standard operation for the treatment of thymic disease. Numerous studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) and is oncologically feasible for noninvasive thymomas as long as en bloc resection of the tumor is achieved (3-5). Most published reports regarding this procedure have focused on the right-sided approach, which has been adopted by most surgeons as the space in the right chest cavity is relatively large, with little interference from the heart, and the superior vena cava acts as an anatomical landmark. The current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paresthesia, and length of hospitalization. Single-port thoracoscopy for mediastinal mass resection is not new. In our early experience with uniportal VATS thymectomy, we adopted the use of a singular access device (SILS port, Covidien) that permits the insertion of three or four instruments, together with CO2 insufflation, through a right-sided single 3-cm incision, without rib spreading.

Troubleshooting thoracoscopic anterior mediastinal surgery: lessons learned from thoracoscopic lobectomy.

Video-assisted thoracoscopic surgery (VATS) lobectomy is safe, oncologically effective, and increasingly utilized for lung cancer resection. Lessons from VATS lobectomy experience can guide the use of a VATS approach to resect mediastinal masses. Exposure and dissection when using VATS to resect anterior mediastinal masses has unique challenges. Several maneuvers acquired from experience with VATS lobectomy can reduce the technical difficulty and often prevent conversion to an open approach. In this troubleshooting guide, we offer 'tips' to both avoid and manage numerous intra-operative technical difficulties that commonly arise during VATS anterior mediastinal procedures. Avoiding an open approach may improve outcomes, although conversion for safety or complete resection can be necessary. Techniques and experiences derived from VATS lobectomy can facilitate VATS resection of mediastinal masses.

Mise en place d’un programme de chirurgie thoracique mini-invasive robot-assistée

Recent publications from North America have shown the benefits of robot-assisted thoracic surgery. We report here the process of setting up such a program in a French university centre and early results in a unit with an average treatment volume. Retrospective review of a single institution database. The program was launched after a 6-month preparation period. From January 2012 to January 2013, totally endoscopic, full robot-assisted procedures were performed on 30 patients (17 males). Median age was 54 [Q1-Q3, 48-63] years and ASA score 2 [1,2]. Operative procedures included thymectomy (9 ; 30%), lobectomy with nodes resection (11 ; 38%), segmentectomy (4 ; 14%), lymphadenectomy (3 ; 10%), Bronchogenic cyst (2, 5%) and posterior mediastinal mass resection (1 ; 3%). No conversion was required. Median blood loss was 50mL [10-100]. Median operating time was 135 min (105-165) including 30 min [20-40] for docking, 90min for robot-assisted operating [70-120] and 15 min [10-15] for lesion extraction. CO2 insufflation was used in 28 cases (93%). Hospital stay was 4 days [4-6] with 6 minor complications (20%) (Grade 1 according to the Clavien-Dindo classification). After a median 4 months follow-up [2-7], all patients were alive and demonstrated a good quality of life. This series suggests that full robotic thoracic procedures are safe and effective treatment for various pathologies, with low morbidity and without a significant learning curve, even in a lower volume centre. This technology should accompany the development of minimally invasive thoracic surgery. The importance of robotic training should be emphasized to optimize procedures and costs.

Controlled Trachea Suspension for Tracheomalacia After Resection of Large Anterior Mediastinal Mass

Tracheomalacia is a disorder of the large airways that is often caused by a large anterior mediastinal mass. This study describes 7 patients who underwent controlled trachea suspension as a surgical intervention to prevent severe tracheomalacia and provide potent relief of airway symptoms. All patients recovered well. The results demonstrate this procedure may be safe and effective for resection of a large mediastinal mass compressing the trachea with collapsed segments.

Complete resection of a giant mediastinal mass following coil embolization: a case report

Complete resection of a giant mediastinal mass following coil embolization: a case report

Percutaneous Recanalization of Occluded Brachiocephalic Vein–Superior Vena Cava Connection After Resection of Mediastinal Mass

A 15-year-old male patient underwent removal of chronic mediastinal histoplasmosis with residual superior vena cava (SVC) stenosis and brachiocephalic vein (BCV) obstruction. He developed significant dizziness following surgery that was attributed to an inability to increase pre-load during

A rare case of necrotic thymoma

The Authors report the case of a patient who underwent resection of a huge anterior mediastinal mass, revealing to be a necrotic thymoma. The patient had been previously submitted to surgical biopsies of the mass yielding non-diagnostic results due to extensive necrosis. A sternotomy was then performed to resect the mediastinal mass originating from the thymus, en-bloc with the mediastinal fat and the apparently infiltrated lung. Histopathology showed a possible cyst/thymoma in massive necrosis, not further definable; revision by a specialized experienced pathologist (J. Rosai) confirmed total mass necrosis and no lung infiltration, thus orientating diagnosis towards a necrotic thymoma and excluding a lymphoblastic lymphoma, with similar histopathological features but more frequent in children or characterized by neoplastic infiltration of surrounding lung. Total body computed tomography (CT) scan and fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/CT, show neither local recurrence, nor distant metastases two years after surgery. In case of anterior mediastinal mass with difficult histopathological diagnosis due to massive necrosis, the hypothesis of a necrotic thymoma should be considered. After radical removal prognosis is generally favourable and no adjuvant treatment is required.

Early clinical outcomes of robot-assisted surgery for anterior mediastinal mass: its superiority over a conventional sternotomy approach evaluated by propensity score matching†

We performed this study to assess early clinical outcomes of robot-assisted surgery for anterior mediastinal mass by comparing results of the robot group with those of the sternotomy group after propensity score matching. Between 2008 and 2012, 145 patients underwent resection of anterior mediastinal mass. Robot-assisted surgery was performed in 37 patients, and conventional surgery by sternotomy in 108 patients. Propensity score matching was done between two groups with variables of age, sex, size of the mass, myasthenia gravis, resection of other organ and pathological diagnosis. Thirty-four patients from the robot group and 34 from the open group were matched, fitting the model. The clinical outcomes of matched groups were compared. In the robot group, mediastinal cyst consisted of 47.1% (16 of 34), thymoma 32.4% (11 of 34), thymic carcinoma 8.8% (3 of 34), thymic hyperplasia 8.8% (3 of 34) and liposarcoma 2.9% (1 of 34). The mean duration of follow-up was 1.11 ± 0.21 and 1.85 ± 0.19 years for the robot and open groups, respectively. There were no mortality or recurrence in both groups during the follow-up. There were no significant differences in operation time, postoperative white blood cell and C-reactive protein increase, maximum visual analogue scale score for pain as well as postoperative intensive care unit care between the two groups. The robot group revealed a lesser number of drains (1.09 ± 0.1 vs 1.41 ± 0.1) and 24-h tube drainage (189.4 ± 20.5 vs 397.6 ± 52.6 ml), lower haemoglobin loss (0.54 ± 0.4 vs 1.35 ± 0.1 g/dl) and haematocrit decrease (1.92 ± 0.5 vs 3.85 ± 0.4%), shorter chest tube days (1.53 ± 0.2 vs 3.06 ± 0.2) and length of hospital stay (2.65 ± 0.2 vs 5.53 ± 0.8) after operation, which were all statistically significant. Although statistically insignificant, there were no postoperative complications in the robot group, but there were 5 (14.7%) in the open group (P = 0.063). In carefully selected patients with relatively smaller sized masses, robot-assisted surgery resulted in excellent early clinical outcomes with lesser tube drainage, lower blood loss, shorter tube days and length of hospital stay without any postoperative complications, compared with the matched open group. Further investigation for long-term clinical outcomes and oncological outcomes is required for a robotic approach. Particularly, long-term follow-up for the local recurrence rate according to the pathological diagnoses is required.

Is a Vessel-Sealing System Useful for Resection of Anterior Mediastinal Mass?

To valuate if the LigaSure (Valleylab, Boulder, Colorado, United States) vessel-sealing system could reduce operative time, intraoperative blood loss, drainage duration, and hospital stay in patients with anterior mediastinal mass undergoing open resection. Forty consecutive patients having resection of anterior mediastinal mass were randomized into two groups according to whether LigaSure was used (n = 20) or not (n = 20). Tumor size, operative time, intraoperative blood loss, chest tube output and duration, length of hospital stay, morbidity, and mortality were prospectively recorded, then intergroup differences were statistically analyzed. Both groups were well matched for age, tumor size, pathologic diagnosis, and incidence of complications. LigaSure significantly reduced operative duration (p < 0.0001) compared with the traditional technique but without leading to any significant reduction in intraoperative blood loss (p = 0.2), chest tube output (p = 0.2) and duration (p = 0.2), and length of hospital stay (p = 0.5). The reduced operative time using LigaSure translates into less exposure to general anesthesia, which is particularly important for patients with myasthenia and potentially reducing cost.

Anterior mediastinal masses resection with cosmetic skin approach.

The objective of this study was to describe a cosmetic skin incision for resection of large anterior mediastinal masses, and to review our experience with this technique. From 1999 to 2010, 55 patients with a diagnosis of large anterior mediastinal masses underwent "goblet"-shaped skin incision with midline sternotomy. The complications, mortality, details of surgery, and duration of hospital stay were observed from review. Patients were monitored via follow-up for a duration of one year after surgery. The mean hospital stay was nine days. Wound complications of infection were observed in one patient. There were no other complications, such as hematoma formation, necrosis of skin flap, split or infection of the sternum. No related mortality was recorded within the 30-day postoperative period. All of the patients verbalized the benefits of this technique, particularly the possibility of wearing open-collared clothing, as a result of the cosmetic chest wall and a camouflaging scar below the angle of Louis. At the follow-up periods, 52 of the patients were found to be well. Three patients did not complete follow-up at our facility. Our primary experience with this procedure proved it was safe. The technique allows excellent access to the mediastinum and complete removal of large anterior mediastinal masses that are complicated with adjacent midline cardiovascular structures. This technique also provides a better cosmetic result than the standard vertical incision.

Navigating the Pathway to Robotic Competency in General Thoracic Surgery

Although robotic technology has addressed many of the limitations of traditional videoscopic surgery, robotic surgery has not gained widespread acceptance in the general thoracic community. We report our initial robotic surgery experience and propose a structured, competency-based pathway for the development of robotic skills. Between December 2008 and February 2012, a total of 79 robot-assisted pulmonary, mediastinal, benign esophageal, or diaphragmatic procedures were performed. Data on patient characteristics and perioperative outcomes were retrospectively collected and analyzed. During the study period, one surgeon and three residents participated in a triphasic, competency-based pathway designed to teach robotic skills. The pathway consisted of individual preclinical learning followed by mentored preclinical exercises and progressive clinical responsibility. The robot-assisted procedures performed included lung resection (n = 38), mediastinal mass resection (n = 19), hiatal or paraesophageal hernia repair (n = 12), and Heller myotomy (n = 7), among others (n = 3). There were no perioperative mortalities, with a 20% complication rate and a 3% readmission rate. Conversion to a thoracoscopic or open approach was required in eight pulmonary resections to facilitate dissection (six) or to control hemorrhage (two). Fewer major perioperative complications were observed in the later half of the experience. All residents who participated in the thoracic surgery robotic pathway perform robot-assisted procedures as part of their clinical practice. Robot-assisted thoracic surgery can be safely learned when skill acquisition is guided by a structured, competency-based pathway.

Thoracic Techniques: Robotic Thymectomy for Thymoma

The traditional approach to resection of anterior mediastinal masses has been via sternotomy. This approach has been associated with an average length of stay of 4–5 days, sternal precautions for 6 weeks, a visible scar, and in some cases, long term discomfort. Although some surgeons have attempted VATS resection of thymomas and other anterior mediastinal masses, we have found that a robotic assisted resection, with its enhanced vision (due to the 10× magnification) and endowrist movements, are ideal for the compact space of the anterior mediastinum [1]. Herein, we describe our technique of total thymectomy for thymoma, highlight some adjunctive techniques, discuss the results of robotic thymectomy, and identify the controversies around robotic resection for thymoma.

Challenging posterior mediastinal mass resection via a minimally invasive approach with neurological monitoring†

We report a novel surgical strategy for the resection of a rare type of posterior mediastinal tumour in a young patient. A melanotic schwannoma arose from the left thoracic sympathetic chain, adjacent to the origin of the artery of Adamkiewicz. Successful excision of this tumour via a minimally invasive approach without arterial or spinal cord injury was possible with the aid of neurological monitoring using spinal-evoked potentials.

Cardiopulmonary Bypass Assisted Resection of Mediastinal Masses

We report a recurrent solitary fibrous tumor of the mediastinum that was encircling the right pulmonary artery. The resection of the tumor with the involved right pulmonary artery segment and sequential graft reconstruction of the vessel was facilitated by the use of cardiopulmonary bypass. We review the indications, management, and outcomes of cardiopulmonary bypass for the resection of mediastinal masses.

Ten-year experience of mediastinal robotic surgery in a single referral centre

The aim of this study was to report a single referral centre experience in the exeresis of mediastinal lesions with robotic surgical system. The outcomes of all patients were retrospectively investigated with special regard to myasthenic and thymomatous patients. From February 2001 to December 2010, 69 patients (30 males, 39 females), with a mean age of 55.4 years (range 20-81), underwent robotic surgery for treatment of mediastinal lesions. There were 39 thymectomies, 13 paravertebral neurogenic tumour removals, 9 pleuropericardial cyst removals, 3 teratoma excisions, 4 lymphonodal removals and 1 enterogenous cyst excision. Operative time, conversion rate, morbidity and mortality were analysed. There were no intra-operative complications, and no mortality. The mean operative time was 124.3 min (range 45-240). Conversion to open surgery occurred in three cases (4.3%). All post-operative complications (7.2%) were conservatively treated. The mean post-operative stay was 4.3 days (range 3-10). For the myasthenic patients (mean follow-up of 18 months), the Myasthenia Gravis Foundation of America change in status resulted improved in 18 (90%) patients and unchanged in 2 (10%) patients. In cases of thymoma, the pathological analysis revealed Masaoka stage I (seven cases), IIA (three cases), IIB (two cases) and III (one case). No disease recurrence occurred at a mean follow-up of 16 months. Our experience suggests that the surgical system was safe in performing mediastinal mass resection, with low morbidity and conversion rate. The robotic system proved useful, especially in a tiny space such as the mediastinum, and appeared to be an effective treatment for myasthenia gravis and for early-stage thymoma.

India ink artifact on ECG-gated SSFP sequences predicts resectability of tumours invading the mediastinum

Summary Cardiac SSFP sequences can be used for the resectability assessment of advanced mediastinal tumors: the presence of India Ink artifact between tumor and structures predicts tumor resectability. Background In tumours invading the mediastinum the identification of a resection plane between the mass and neighbouring critical structures may be doubtful on CT scans. Steady State Free Precession (SSFP) Magnetic Resonance (MR) sequences can show reciprocal sliding between structures, and a peculiar signal drop-out in voxels that contain both water and fat: the India Ink artifact. We tested if SSFP sequences can improve differentiation between contact and infiltration of mediastinal structures. Methods Sites of contact between tumour and mediastinal structures on preoperative CT scans were individually assessed. 3 orthogonal stacks of SSFP sequences were acquired after contrast administration. Absence of infiltration was defined as the presence of India Ink artifact at the the tumour-structure interface. Surgical findings (presence or absence of a resection plane) were reported postoperatively for each site. Results 14 patients (9 males and 5 females, age 23-72) were preoperatively assessed by CT and MR. 6 patients had lung cancer, 6 thymoma, 1 sarcoma and 1 germ cell tumor. 69 contact sites were identified by preoperative CT scans. Surgical procedures were: pneumonectomy 5, mediastinal mass resection 5, extrapleural pneumonectomy 1, and exploratory thoracotomy 1. The negative predictive value was 0.94, positive predictive value 0.80, sensitivity 0.91, specificity 0.86, and accuracy 0.88. Complete resection was always successfully carried out based on MRI findings. In one case MR correctely anticipated non resectability. Conclusions In patients with advanced mediastinal tumours and doubtful preoperative CT scan, SSFP-MR allows for an accurate selection and surgical planning of complex resections.

Single-Port Thymectomy Through an Infrasternal Approach

We report a surgical procedure in which a port and devices designed for single-incision endoscopic surgery are employed for thymectomy through an infrasternal approach. As this single-port thymectomy procedure can be performed through a single 3.5-cm incision in the abdominal region usually concealed under clothes, it is esthetically excellent and is among the least invasive thymectomy procedures because no sternal incision is applied and no intercostal nerve is injured. Investigation of the safety of this procedure and long-term therapeutic outcomes for myasthenia gravis and anterior mediastinal tumors is necessary.

Robotic surgery for mediastinal tumors

BACKGROUND: The surgical approach to mediastinal tumors has changed during the last two decades. Median sternotomies and thoracotomies have been replaced in part by minimally invasive procedures. Aim of this review is to highlight applications of a robotic-assisted approach in mediastinal tumor surgery. METHODS: Review of the current literature. RESULTS: A robotic approach for thymectomy, anterior mediastinal mass resection, pericardial cyst resection, diagnostic sampling of enlarged lymph nodes in the middle mediastinum, resection of benign neurogenic tumors in the posterior mediastinum and esophageal procedures was shown to be feasible. Postoperative outcomes as well as the contraindications and limitations of a robotic approach are discussed. CONCLUSIONS: For appropriate indications minimal invasive surgery with a surgical robot can safely be performed for tumors in the anterior, middle, and posterior compartments of the mediastinum.