[Feasibility of cardiac surgical techniques for intrathoracic tumors]. / O tselesoobraznosti ispol'zovaniya kardiokhirurgicheskikh tekhnologii pri vnutrigrudnykh opukholyakh.

OBJECTIVE: To analyse safety and expediency of cardiac surgical technologies including cardiopulmonary bypass (CPB) in patients with locally advanced lung cancer and invasive tumors of the mediastinum. MATERIAL AND METHODS: Cardiac surgical techniques and CPB were used in 23 patients (group 1) with locally advanced thoracic tumors between 2005 and 2015. For the same period, there were 22 patients (group 2) who underwent combined surgeries and could have had similar techniques. However, these techniques were not used for various reasons. Mediastinal malignancies and non-small cell lung cancer were diagnosed in 26 (57.8%) and 19 (42.2%) patients, respectively. Invasion of superior vena cava (n=15), aorta (n=13) and pulmonary artery (n=12) was the most common. Lesion of innominate vein (n=8), left atrium (n=6) and innominate artery (n=4) was less common. A total of 21 pneumonectomies were performed (14 in the first group and 7 in the second group). Lobectomy was less common (one patient in each group). Sublobar lung resection was performed in 10 patients (2 patients in the first group and 8 ones in the second group). All resections were total in the first group (R0) that was confirmed by routine morphological examination of resection margins of different organs and vessels. The situation was worse in the second group (R1 in 19 (86.4%) patients, R2 in 3 (13.6%) patients). RESULTS: Total postoperative morbidity was 53.3%, mortality - 8.2%. These values are higher compared to patients undergoing surgical treatment for thoracic malignancies. Incidence of postoperative complications was higher in the first group (16 (69.6%) and 8 (36.4%), respectively). Four patients died in the first group. Sepsis (n=2), acute right ventricular failure (n=1) and acute myocardial infarction (n=1) caused death. There were no lethal outcomes in the second group. Various postoperative complications were diagnosed only in 8 (36.4%) patients. The long-term results were followed-up in 80% of patients. In the first group, 3- and 5-year survival rates were 30.5% and 25%, respectively (median 43.8 months). In the second group, these values were 25% and 2%, respectively (median 24.9 months). Long-term mortality in the second group was caused by progression of malignant process, including local recurrence, after palliative surgery (R1, R2 resection). CONCLUSION: Higher risk of postoperative complications and mortality in patients undergoing on-pump surgery is compensated by significantly better long-term results. Further progress is associated with higher safety of CPB, as well as solving some organizational and educational problems.

Thoracoscopic management of posterior mediastinal neurogenic tumours.

Background: This study describes the surgical technique of thoracoscopic resection of posterior mediastinal neurogenic tumours and reporting the surgical outcomes. Methods: This is a retrospective analysis of 21 patients operated over 7 years in a dedicated thoracic surgery centre. The demographic and post-operative parameters along with complications were recorded and analysed. Results: Twelve patients had right-sided tumours, while 9 had left-sided lesions, and 9 were on the left side. The most common diagnosis was schwannoma (n = 15, 71.42%), followed by neurofibroma (n = 4, 19.04%). The average surgery duration was 104 min (85-135 min), and the mean blood loss was 120 ml (25 ml-250 ml). The average lesion size was 4.8 cm (2 cm-7 cm). Conversion to open procedure was required in one patient. Two patients (14.2%) developed complications. One patient developed Horner's Syndrome and the other developed post-operative lung atelectasis. The median follow-up was 36 months (6-90 months). No recurrence was observed during the follow-up period. Conclusions: Thoracoscopic approach to posterior mediastinal neurogenic tumours is feasible and allows for low morbidity, short hospital stay and superior cosmesis.

Large left innominate vein aneurysm presenting as an anterior mediastinal tumour in a young female.

We report a rare case of large innominate vein aneurysm in a young women clinically presenting with persistent dry cough and retrosternal pressure. Chest X-ray showed a mediastinal widening leading to thoracic computed tomography, MRI, and phlebography. Initial conservative treatment with regular follow-up was performed. Upon aneurysm growth and recurrent pulmonary infection we decided to surgically resect the aneurysm via a minimally invasive approach.

Surgical Removal of an Unusual Massive Mediastinal Tumour Preceded by Interventional Embolisation.

Massive mediastinal tumours are rare in clinical practice and complete surgical resection may be associated with serious complications. Preoperative angiography and embolisation are valuable adjuncts in the management of giant tumours to decrease perioperative blood loss, provide a clear operative field and facilitate complete resection. We report the safe use of preoperative embolisation which facilitated excision via clamshell incision, of a highly vascular massive anterior mediastinal tumour with an unusual final diagnosis.

Detorsion of the Pulmonary Torsion: A Rare Post-thoracotomy Complication.

Pulmonary torsion is a rare but serious condition. Without prompt treatment it progresses to lobar ischaemia, pulmonary infarction and finally fatal gangrene. We present a case of this rare complication in a 61-year-old woman following thoracic operation without involving any lung resection. Careful post-operative clinical observation, chest X-ray and CT scans are crucial for precise diagnosis of lobar torsion. The bedside radiograph provided initial evidence of torsion. Computed tomography scans revealed the presumptive diagnosis of right upper lobe torsion. On exploration, a 70° rotation of the right upper lobe in a clockwise direction was found. The lobar torsion was carefully relieved, and lobar fixation was performed as a prophylaxis against recurrence of this complication. The post-operative period was uneventful. Early recognition and prompt intervention is imperative in order to save the affected lung. Patients with well-developed interlobar fissures may benefit from pulmonary lobe fixation.

Huge Mediastinal Lipoblastoma in a Nine Year-old Boy Successfully Removed Surgically.

A nine year-old boy presented with symptoms of dyspnoea. The chest radiograph and computed tomography scan revealed a large mediastinal tumour. A decision to operate on the patient was made. A huge 2.45 kg mediastinal lipoblastoma was successfully removed from the boy's chest. At three years no evidence of recurrence was found.

A transhiatalis sebészet járatlan ösvényei.

Right-sided spontaneous oesophageal rupture developed two days after left pneumonectomy and vomiting. In this extremely rare emergency, we used a transhiatal approach for primary repair of the rupture, combined with right-sided pleural and mediastinal drainage, gastrostomy and feeding jejunostomy. The seven-day barium meal showed healing of the rupture. It was mandatory that contamination of the pneumonectomized left thoracic cavity during rupture closure as well as a contralateral thoracotomy with its respiratory consequences had to be avoided by all means. Reconstruction and reinforcement (with omentum) of the oesophageal wall was achieved without difficulties, but we did not mobilize the oesophagus to avoid rupture of the left-sided mediastinal pleura. After massive haematamesis, a 68-year-old man was admitted for a huge (8×5 cm) mass in the lower-posterior mediastinum at the right side of the vertebra, seen on CT scan. On the barium meal incarcerated hiatal hernia, secondary short oesophagus and intramediastinally penetrating high lesser curvature ulcer was discovered. To reduce the magnitude of intervention one-stage transhiatal approach was decided. Through enlarged hiatus, dissection of incarcerated and firmly adherent hiatal hernia and of the short oesophagus was done. The following step was the removal of an encapsulated, huge lipomatosus mass from the posterior mediastinum, extending high from behind the vertebra, arising from the lesser curvature of the stomach. The lesser curvature ulcer was excised - sutured and a Toupet type (270 posterior) fundoplication was finally carried out. The follow-up was free from recurrence. This experience suggests that for some particular lower posterior mediastinal or esophageal problems, transhiatal access seems to be a useful alternative of traditional mediastinal approaches.

A rare case of a huge malignant pleural mesothelioma presenting in the posterior mediastinum.

We report a case of a 69-year-old woman with pleural mesothelioma presenting in the posterior mediastinum with a maximum diameter of 25 cm. She had a chronic cough and a pleural effusion was noted on chest X-ray. The examination of the effusion showed high hyaluronic acid levels, and mesothelioma was suspected. A chest computed tomography scan showed a huge mediastinal mass, which caused rapid progression of respiratory failure and compression of the heart. Sufficient tissue samples could not be obtained before death. The patient died approximately 1 month after the initial visit, and a pathological autopsy was performed. The diagnosis of malignant pleural mesothelioma was made. Malignant pleural mesothelioma with a huge posterior mediastinal mass such as in this case is considerably rare; however, it is a rapidly progressing form of the disease and is reported here as an important differential diagnosis for mediastinal tumours.

Rosai-Dorfman disease differentiated from a posterior mediastinal tumour: a case report.

Rosai-Dorfman disease presenting solely with intrathoracic lesions is exceptionally rare. Herein, we report the case of a 53-year-old man presenting with a posterior mediastinal tumour. Computed tomography revealed a 7-cm soft tissue shadow in the posterior mediastinum. Positron emission tomography-computed tomography demonstrated a high maximum standardized uptake value of 10.35 in the tumour, with no evidence of lymph node or other organ involvement. Serum marker levels were within the normal range. Thoracoscopic surgery was performed to obtain a biopsy for a definitive diagnosis and treatment planning. Postoperative histological findings revealed a diffuse infiltration of eosinophilic histiocytes, lymphocytes, and plasma cells. Immunohistochemical analysis indicated positivity for S-100 protein, oct-2, and cyclin D1 in these histiocytes. Consequently, the patient was diagnosed with Rosai-Dorfman disease and is currently asymptomatic, undergoing regular monitoring without treatment as an outpatient. The absence of characteristic findings, such as bilateral cervical lymphadenopathy, posed challenges in preoperative diagnosis.

Robotic portal resection for mediastinal tumours: a prospective observational study.

BACKGROUND: To demonstrate the effectiveness and feasibility of robotic portal resection (RPR) for mediastinal tumour using a prospectively collected database. METHODS: Data from 73 consecutive patients with mediastinal tumours who underwent RPRs were prospectively collected from August 2018 to April 2023. All patients underwent chest and abdominal enhanced computed tomography (CT) and preoperative multidisciplinary team (MDT) discussion. The patients were stratified into two groups based on tumour size: Group A (tumour size < 4 cm) and Group B (tumour size ≥ 4 cm). General clinical characteristics, surgical procedures, and short outcomes were promptly recorded. RESULTS: All of the cases were scheduled for RPRs. One patient (1/73, 1.4%) was switched to a small utility incision approach because of extensive pleural adhesion. Two patients (2.8%) converted to sternotomy, however, no perioperative deaths occurred. Most of the tumours were located in the anterior mediastinum (51/73, 69.9%). Thymoma (27/73, 37.0%) and thymic cyst (16/73, 21.9%) were the most common diagnoses. The median diameter of tumours was 3.2 cm (IQR, 2.4-4.5 cm). The median total operative time was 61.0 min (IQR, 50.0-90.0 min). The median intraoperative blood loss was 20 mL (IQR, 5.0-30.0 ml), and only one patient (1.4%) experienced an intraoperative complication. The median length of hospital stay was 3 days (IQR, 2-4 days). Compared with Group A, the median total operative time and console time of Group B were significantly longer (P = 0.006 and P = 0.003, respectively). The volume of drainage on the first postoperative day was greater in group B than in group A (P = 0.013). CONCLUSION: RPR is a safe and effective technique for mediastinal tumour treatment, which can expand the application of minimally invasive surgery for the removal of complicated mediastinal tumours.

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.

Mediastinal epithelioid inflammatory myofibroblastic sarcoma with the EML4-ALK fusion: A case report and literature review.

Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is an aggressive subtype of inflammatory myofibroblastic tumour which rarely affects the chest cavity. We, for the first time, report a case of mediastinal EIMS with the EML4-ALK fusion. A young woman presented to our hospital with cough, chest tightness and shortness of breath. Computed tomography (CT) showed a mixed attenuation soft-tissue mass in the right middle and upper mediastinum. Negative results were obtained from bronchoscopy forceps biopsy and endobronchial ultrasound-guided transbronchial fine needle aspiration. CT-guided percutaneous biopsy was finally performed. However, due to the rapidly progressed EIMS that compressed the trachea and right main bronchus, the patient died of respiratory failure 1 day before diagnosis. EIMS progresses rapidly, and an early diagnosis is important. For mediastinal EIMS, CT-guided percutaneous biopsy may be useful. Next-generation sequencing of blood may be instructive to EIMS patients who are intolerant to invasive biopsy.

EPIPERICARDIAL FAT NECROSIS.

Introduction: Epipericardial fat necrosis (EFN) is a relatively rare benign disease that causes acute chest pain. Case Description: A woman in her 20s presented with acute left shoulder and epigastric pain. One day before presentation, she had visited a cardiologist and an acute coronary syndrome had been ruled out. The pain worsened with deep inspiration. Chest computed tomography (CT) showed a soft-tissue attenuation lesion containing a fatty centre located in the epipericardial fat at the left cardiophrenic angle. Hence, EFN was diagnosed and the pain was resolved with loxoprofen. The lesion had disappeared on a follow-up chest CT scan. Discussion: EFN is a rare benign disease that causes acute chest pain. Approximately 70-90% of EFN cases are misdiagnosed by clinicians as other diseases. Conclusion: In patients with acute chest pain, the correct diagnosis of EFN avoids unnecessary invasive investigations and reassures patients. LEARNING POINTS: Patients with epipericardial fat necrosis typically present with acute pleural chest pain without any associated symptoms.Characteristic CT findings of the encapsulated fatty pericardial lesion with a surrounding inflammatory reaction are key for the diagnosis of epipericardial fat necrosis.The correct diagnosis of epipericardial fat necrosis in patients with acute chest pain reassures them and avoids unnecessary invasive investigation.

Robot-assisted thoracoscopic surgery for mediastinal tumours in children: a single-centre retrospective study of 149 patients.

OBJECTIVES: The purpose of this retrospective study was to summarize our experience in performing robot-assisted thoracoscopic surgery (RATS) for mediastinal tumours in children to investigate its safety and feasibility. METHODS: This retrospective study involved 149 patients with mediastinal tumours who were hospitalized in the Department of Thoracic Surgery of Beijing Children's Hospital, Capital Medical University, and underwent RATS for tumour resection from March 2021 to November 2022. Information on patient age, weight, tumour size, surgical incision selection, operative time, intraoperative bleeding, intraoperative complications, length of hospital stay, rate of conversion to thoracotomy and follow-up conditions were summarized. RESULTS: All 149 surgeries were successfully completed with no cases of mortality. There were 77 male and 72 female patients, with a mean age of 5.9 years (range: 6 months-16 years, 8 months) and a mean weight of 23.6 kg (8.0-72.0 kg). The mean maximum tumour diameter was 5.5 cm (2.0-12.0 cm), the mean operative time was 106.7 min (25.0-260.0 min), the mean intraoperative bleeding volume was 11.3 ml (1.0-400.0 ml) and the mean hospital stay was 7.2 days (4.0-14.0 days). All patients recovered well with no cases of tumour recurrence or mortality during the postoperative follow-up period (3-23 months). CONCLUSIONS: RATS is safe and feasible to apply in children with mediastinal tumours who are >6 months of age and weigh more than 8 kg in terms of short-term outcomes, but longer-term follow-up is needed to fully evaluate the benefits. For cases that are associated with greater surgical difficulty and risk, a comprehensive surgical plan should be fully prepared in advance of surgery.

Clinico-Pathological and Radiological Spectrum of Mediastinal Masses in a Tertiary Care Center: A Cross-Sectional Study.

Introduction The phrase "mediastinal mass" refers to a mass within the mediastinum. About 50% of all mediastinal masses, including teratoma, thymoma, lymphoma, and thyroid illness, are anterior mediastinal tumors. Data on the mediastinal mass in India are relatively sparse, especially in this region, compared to those from other countries. Mediastinal masses are very infrequent lesions that might occasionally present a diagnostic and therapeutic challenge to the doctor. The current study describes the socio-demographic characteristics, symptoms, diagnosis, and location of mediastinal mass among the study participants. Methodology We carried out a retrospective, cross-sectional study in a tertiary care center in Chennai for three years. We included patients with an age above 16 years who visited the tertiary care center in Chennai during the study period. We included all patients with a mediastinal mass diagnosed by CT scan, with or without signs and symptoms of mediastinal compression. Patients under the age of 16 and those with insufficient data were both excluded from the study. As per the universal sampling technique, we included all the patients who met the eligibility criteria during the study period (three years) as study subjects. By using the hospital records, we collected all data about the patients like socio-demographic data, presenting complaints, past history, x-ray findings, and co-morbidities. Similarly, we recorded blood parameters, pleural fluid parameters, and histopathological reports from the laboratory register. Results The mean age of the study participants was 41.11 years, with a high proportion of patients belonging to the age group of 21 to 30 years. Over 70% of the study participants were male. Only about 54.5% of the study participants had symptoms because of a mediastinal mass. The most common local symptom felt by the patients was dyspnea, followed by a dry cough. Weight loss was the most common symptom for the patients. Most study participants (47.7%) had seen a doctor within one month of the onset of symptoms. About 4.5% of the patients had pleural effusion, as diagnosed by x-ray. Most of the study participants had a mass in the anterior mediastinum, followed by the posterior mediastinum. Most of the participants (15.9%) had non-caseating granulomatous inflammation suggestive of sarcoidosis.  Conclusion The most common tumor found in our study was lymphoma, which was followed by non-caseating granulomatous disease and thymoma. Anterior compartments are most commonly involved. We observed the most common presentation in the third decade of life with a male to female ratio of 2:1, with dyspnea being the most common symptom, followed by a dry cough. Our study found 4.5% of the patients had pleural effusion as a complication.

A successful case of robot-assisted thoracic surgery for apical thoracic schwannoma.

The thoracic apex is a narrow and complicated area with nerves and vessels, making it difficult to secure a visual field and perform surgical operations. Robot-assisted surgery enabled good visibility and highly flexible forceps manipulation, we were able to perform minimally invasive and safe thoracic apical tumour resection.

Lambert-Eaton myasthenic syndrome with primary thymic marginal zone B-cell lymphoma: A case report.

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune paraneoplastic syndrome with proximal muscle weakness, that often complicates small cell lung cancer. It is known that neurological symptoms do not improve with malignancy treatment alone in many LEMS patients, therefore treatment is often difficult. Since Lambert-Eaton myasthenic syndrome is a rare disease with a frequency of about 1/100 that of myasthenia gravis, there are only a few case reports on malignancy complications other than small cell lung cancer. We report a LEMS patient in his 40s who was found to have an anterior mediastinal mass. We performed surgical resection and confirmed the diagnosis of primary thymic marginal zone B-cell lymphoma by pathological diagnosis using immunostaining. Thymectomy and malignant lymphoma treatment with rituximab had no effect on neurological symptoms. The neurological symptoms improved only after we provided comprehensive care with the haematology, neurology, and rehabilitation department.

Resection of a capillary haemangioma using robotic-assisted thoracic surgery: A case report.

Capillary haemangioma is a rare condition that is difficult to diagnose preoperatively because of its rarity and nonspecific imaging findings. In this report, we describe a case of capillary haemangioma diagnosed by robot-assisted thoracic surgery (RATS). A 72-year-old man was incidentally found to have an anterior mediastinal tumour on chest computed tomography. The preoperative imaging findings were indicative of thymoma, and surgical treatment by RATS was selected. The intraoperative findings suggested that the tumour was a haemangioma originating from the pericardiophrenic vein. The pathological findings revealed a well-defined tumour with capillaries in a vascular-like structure and some thrombus formation. The pathological diagnosis was capillary haemangioma. The patient was discharged unaided at 7 days postoperatively and no recurrence was observed at 16 months postoperatively.

Full subcostal subxiphoid robotic-assisted radical thymectomy: preclinical cadaveric study for optimizing patient positioning, table settings, and port configuration.

Robotic subxiphoid transthoracic thymectomy showed several surgical advantages. Nevertheless, the intercostal insertion of trocars may lead to nerve injury with enhanced post-operative pain. Moreover, the dissection of peri-diaphragmatic mediastinal fat may result challenging, in particular on left side, where the presence of the heart precludes the optimal visualization. We describe a preclinical cadaveric study of a novel full subcostal robotic-assisted technique to overcome these limitations. A total subcostal robotic-assisted radical thymectomy was evaluated on a cadaver model using the da Vinci Xi system. The exploratory procedure was divided in two steps: (a) dissection of the thymus gland, except the left mediastinal epi-diaphragmatic fat pad; (b) dissection of the left diaphragmatic mediastinal fat pad avoiding heart compression while perfectly visualizing the left phrenic nerve. Five different setups were explored based on camera and trocars insertions, patient's positioning and table's settings. Both the tasks were accomplished using the novel technique. The subxiphoid insertion of the camera and the position of two robotic arms about 8 cm distally on the subcostal made the most part of mediastinal dissection straightforward. Left peri-diaphragmatic fat pad can be better visualized and dissected positioning the camera in the left subcostal port shifting the instruments on the right side. This may permit a better control of the left phrenic nerve reducing heart compression. Full subcostal robotic-assisted thymectomy resulted feasible in cadaveric model. Clinical trial should be performed to confirm the translational use of this novel technique and the speculated advantages in living model.

Diffuse large B-cell lymphoma with cardiac invasion diagnosed using transesophageal ultrasound-guided bronchoscopic aspiration.

Transesophageal ultrasound-guided bronchoscopic aspiration (EUS-B-FNA) allowed for minimally invasive and simultaneous diagnosis and evaluation of the degree of invasion by echocardiography. EUS-B-FNA may be useful for the evaluation and diagnosis of tumours with cardiac invasion.