Awake thoracoscopic mediastinal biopsy in a teenager: a case report

Abstract

Introduction:

Mediastinal masses are a common pathology encountered by pediatric surgeons. These masses may cause airway compression that precludes the use of general anesthesia; however, pathologic diagnosis may depend upon tissue obtained only through a surgical biopsy. We describe an innovative technique to obtain adequate tissue for diagnosis from an anterior mediastinal mass in the setting of airway compression.

Case presentation:

A 13-year-old child presented with three months of chest pain and weakness. Initial workup with chest x-ray identified a mediastinal mass. A chest computerized tomography (CT) revealed a 14.5 by 9.7 cm anterior mediastinal mass causing tracheal compression. Bone marrow and lymph node biopsies were non-diagnostic, and a three-day trial of oral prednisone (40 mg twice daily) had minimal effect on airway compromise. Prominent vasculature precluded a window for safe percutaneous biopsy or through a Chamberlain approach. The patient was taken to the operating room for an awake thoracoscopic biopsy of the mediastinal mass using intravenous ketamine and local anesthesia. The patient was placed in left lateral decubitus position. A 5-mm trocar was placed in the posterior axillary line with two additional 5-mm trocars triangulated posteriorly. Loss of negative intrathoracic pressure allowed for visualization of the mass. Biopsies were taken using laryngeal biopsy forceps and a chest tube was left in place. The patient was discharged home on the first postoperative day after chest tube removal. The pathology was consistent with classic Hodgkin lymphoma, intermediate risk, Stage IIA. The patient was treated with chemotherapy per the AHOD0031 protocol and continues to be followed by the oncology service.

Conclusion:

Awake, video-assisted thoracoscopic surgery seems to be a feasible option for incisional biopsies in teenagers that have mediastinal tumors causing airway compression precluding the use of general anesthesia.

1. Introduction

Mediastinal masses are commonly encountered by pediatric surgeons. These masses may be associated with tracheal compression, limiting the safe use of general anesthesia due to concern for airway compromise. Less invasive methods of biopsy have been employed for these tumors, including fine-needle aspiration and image-guided percutaneous biopsy. However, these techniques are sometimes associated with inadequate specimens for diagnosis and lower diagnostic yield [1]. Awake, video-assisted, thoracoscopic biopsy has been utilized in adult patients with mediastinal masses with excellent diagnostic yield and low rates of adverse events [2]. These principles have also been applied to pediatric patients undergoing biopsy of thoracic pathologies [3]. We report the use of awake, thoracoscopic biopsy in the case of a 13-year-old child with an anterior mediastinal mass causing significant airway compression. This manuscript was prepared following the CARE guidelines (https://www.care-statement.org).

2. Case presentation

A 13-year-old child with no past medical history presented to the Emergency Department with a three month history of chest pain, fatigue, and dizziness. The child reported associated symptoms of weight loss, night sweats, and left sided scapular pain worsened with inspiration and with elevation of the left arm. Initial workup with chest x-ray identified a mediastinal mass. Chest CT revealed a 14.5 × 9.7 cm anterior mediastinal mass with associated tracheal compression at the level of the carina (Fig. 1). Physical exam was significant for palpable lymphadenopathy in the right axilla. Labs were notable for an elevated white blood cell count of 11.87 × 10³/μL, decreased hemoglobin of 10.6 g/dL, elevated LDH of 315 U/L, and normal uric acid, alpha fetoprotein, and beta-human chorionic gonadotropin. The patient was admitted to the hospital for further work-up. The patient was treated with a course of systemic steroids (oral prednisone, 40 mg twice daily for three days) with minimal effect on the tracheal compression. The child underwent bone marrow and lymph node biopsies that were non-diagnostic. The care team decided that the child required surgical tissue biopsy to establish a diagnosis and guide therapy. The mass had prominent vasculature precluding safe percutaneous image guided biopsy or surgical approach through a Chamberlain procedure (Fig. 1C). The patient was brought to the operating room for an awake thoracoscopic biopsy. Intravenous ketamine and local anesthesia were administered prior to the start of the procedure.

Fig. 1.

CT imaging demonstrating the anterior mediastinal mass in axial (A) and sagittal (B) views with significant airway compression (closed white arrows). (C) Axial CT image demonstrating vasculature in area of Chamberlain procedure (open white arrows).

The patient was placed in the left lateral decubitus position and three trocars were placed in the right chest with a 5 mm trocar in the posterior axillary line and two additional 5 mm trocars triangulated posteriorly (Fig. 2A). Trocar insertion caused collapse of the lung due to loss of negative intrathoracic pressure, allowing for adequate visualization of the mediastinal mass (Fig. 2B; video 1). The pleura overlying the mass was opened with hook electrocautery. A laryngeal biopsy forceps was used to obtain several biopsies (Fig. 2C). Manual pressure and an absorbable hemostatic agent provided hemostasis. We placed a chest tube that was removed on postoperative day 1 and the child was discharged home that day. The pathology identified classic Hodgkin lymphoma, intermediate risk, Stage IIA. The child was treated with chemotherapy per the AHOD0031 protocol. The patient is currently being followed by the oncology team.

Fig. 2.

(A) The patient was positioned in left lateral decubitus position and a 5 mm port was placed in the 5th intercostal space in the anterior axillary line (represented by red dot) to accommodate the thoracoscope, with two additional 5 mm ports triangulated posteriorly (blue dots). Thoracoscopic image of the anterior mediastinal mass viewed from the right chest (B) (closed white arrow) and biopsy of the mass using laryngeal biopsy forceps (C).

3. Discussion

Mediastinal masses in children are not uncommon but may present a diagnostic challenge. Anterior mediastinal masses include thymoma, teratoma, thymic cysts, lymphatic malformations, lipoma, leukemia, lymphoma, and germ cell tumors [4,5]. Diagnostic certainty is critical to providing appropriate treatment given that in children, 70–75 % of these masses are malignant [5]. Previous evaluations of percutaneous image-guided core-needle biopsy for mediastinal masses in adults have shown variable results, with diagnostic yield ranging from 77 % to 96 % [1,6-8]. While image-guided percutaneous biopsy provides a less invasive option, alternative procedures such as thoracoscopic biopsy must be undertaken when percutaneous biopsy is unsuccessful in providing a diagnosis.

Additionally, tumor mass effect may compress critical structures, including the trachea or major blood vessels, leading to airway compromise and hemodynamic instability [5,9]. Children with significant tracheobronchial compression, often defined as more than 1/3 decrease in luminal area, are at significant risk of complete airway obstruction under general anesthesia [10]. Tracheal and vascular compression in combination with respiratory symptoms in children with mediastinal masses are indicators of an increased risk of general anesthesia complications, and avoiding general anesthesia is recommended in this cohort [11]. These studies describe the use of ketamine, local anesthesia [3], epidural catheter, or intercostal block for sedation and analgesia in awake patients undergoing thoracoscopic biopsy [2].

In the setting of a patient with significant airway compression from a large mediastinal mass, contingency planning for complications such as bleeding or airway compromise is essential. This patient population is at high risk for sudden decompensation with changes in positioning, sedation, or positive pressure ventilation [10]. To limit these risks, this procedure was performed under local anesthesia with the patient awake and breathing spontaneously. Avoiding general anesthesia in this patient reduced the risk of muscle relaxation that could further exacerbate airway collapse. In the event of severe bleeding requiring conversion to thoracotomy, all instruments and personnel required for open surgery were immediately available. The anesthesia team was prepared for urgent awake fiberoptic intubation in the lateral decubitus position, and rigid bronchoscopy equipment was on standby. The perfusion team was notified in advance in the case that emergent extracorporeal membrane oxygenation (ECMO) became necessary. A multidisciplinary, coordinated approach is necessary to ensure patient safety in this high-risk situation. This case underscores the importance of preparing for the physiologic challenges imposed by large mediastinal masses.

The use of awake, video-assisted thoracoscopic biopsy has shown to be safe in adult patients with mediastinal masses, and authors report excellent diagnostic yield of 100 % in their cohort [2]. Previous reports have described similar practices of awake, thoracoscopic biopsy in pediatric patients with thoracic pathology [3]. However, there is a paucity of literature describing the use of awake thoracoscopic biopsy for mediastinal masses in pediatric patients. The current report demonstrates that this technique may be safely utilized in pediatric patients with airway compression who cannot undergo general anesthesia for surgical biopsy.

4. Conclusion

The use of awake, video-assisted thoracoscopic biopsy of a mediastinal mass in the pediatric population is a viable option in the setting of airway compression and diagnostic uncertainty after exploring all less invasive alternatives.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.epsc.2025.103078.