Video-Assisted Thoracoscopic Resection of a Large Anterior Mediastinal Mass
Pediatric mediastinal masses pose a challenging case for the
pediatric surgeon due to narrow working space and a concentration of vital structures
in the area. Mediastinal masses are typically diagnosed on chest radiograph in
a child presenting with dyspnea, cough, fever, and/or general malaise, though a
large proportion of mediastinal masses are diagnosed as incidental findings on
chest radiographs obtained for other reasons. After initial diagnosis, the mass
can be further characterized via ultrasound, CT scan, or MRI. The differential
diagnosis for mediastinal masses in children is broad and includes neoplastic
and non-neoplastic processes. The location of the mass (anterior, middle, or
posterior mediastinum) helps to narrow the differential diagnosis. The most
common neoplasm of the mediastinum is lymphoma found in all compartments of the
mediastinum, followed by neurogenic tumors (ganglioneuroma,
ganglioneuroblastoma, neuroblastoma), fou nd primarily in the posterior
mediastinum. Thymomas and germ cell tumors (i.e., seminomas and teratomas) are
most commonly found in the anterior mediastinum [1]. With the exclusion of
lymphomas, which respond to chemotherapy and/or radiotherapy, all mediastinal
masses in children should be resected when feasible [2].
When resection is indicated, current surgical management of pediatric
mediastinal masses relies primarily on open resection via median sternotomy or
posterolateral thoracotomy depending on the anatomical extent of the mass [2].
However, based on a growing body of literature suggesting that a minimally
invasive approach is both feasible and safe in appropriately selected adult
patients, some pediatric surgeons have adopted video-assisted thoracoscopic
surgery (VATS) for resection of mediastinal tumors in children [3, 4]. There is
still significant hesitation among pediatric surgeons to employ VATS for
resection of mediastinal tumors due to lack of familiarity with the technique
and close proximity to vital structures. This video aims to provide a basic
framework for VATS resection of anterior mediastinal tumors.
References
[1] Franco A, Mody NS, Meza MP. Imaging evaluation of
pediatric mediastinal masses. Radiologic clinics of North America
2005;43(2):325-53.
[2] Tovar JA. chapter 25 - MEDIASTINAL TUMORS. In: Holcomb GW, Murphy JP,
Ostlie DJ, editors. Ashcraft's Pediatric Surgery (Fifth Edition). Philadelphia:
W.B. Saunders; 2010, p. 322-9.
[3] Marshall MB, DeMarchi L, Emerson DA, Holzner ML. Video-assisted
thoracoscopic surgery for complex mediastinal mass resections. Ann Cardiothorac
Surg 2015;4(6):509-18.
[4] Sato T, Kazama T, Fukuzawa T, Wada M, Sasaki H, Kudo H, et al. Mediastinal
tumor resection via open or video-assisted surgery in 31 pediatric cases:
Experiences at a single institution. Journal of pediatric surgery
2016;51(4):530-3.
