Safe diagnostic management of malignant mediastinal tumors in the presence of respiratory distress: a 10-year experience

Abstract

Background: The fundamental treatment for patients with pediatric malignant mediastinal tumors is chemotherapy. Therefore, accurate diagnosis is essential for selecting the appropriate chemotherapeutic regimen. However, malignant mediastinal tumors occasionally cause respiratory distress, and biopsies under general anesthesia are dangerous for such patients as invasive mechanical ventilation can aggravate airway obstruction caused by mass effect. In this study, we reviewed our 10-year diagnostic experience to evaluate the efficacy of our practices and confirm a safe diagnostic protocol for future patients. Methods: We retrospectively reviewed medical records of children with malignant mediastinal tumors diagnosed at Nagoya University Hospital from 2007 to 2018 who demonstrated respiratory distress. Respiratory distress included dyspnea, massive pleural effusion, wheezing, and hypoxemia owing to tumors. Data on sex, age at onset, primary symptoms, location of tumor, management strategy (especially the method of diagnosis and definitive diagnosis), clinical course, prognosis during the acute phase (within 3 months from the onset of respiratory symptoms), and long-term outcome were collected. Results: Twelve pediatric patients met the review criteria. There were seven anterior mediastinal tumors and five posterior mediastinal tumors. All anterior mediastinal tumors were diagnosed via bone marrow smear, thoracentesis, or core needle biopsy while maintaining spontaneous breathing. Regarding posterior tumors, two patients were diagnosed via a core needle biopsy and lymph node excisional biopsy under spontaneous breathing. Two cases were initially diagnosed solely using tumor markers. One patient with severe tracheal compression underwent tumor resection with extracorporeal membrane oxygenation stand-by. No patient died of diagnostic procedure-related complications. Conclusions: In 11 of the 12 cases reviewed, safe and accurate tumor diagnosis was accomplished without general anesthesia. A diagnostic strategy without general anesthesia considering the tumor location proved to be useful.

Resection of a Posterior Mediastinal Mass in a 4-Year-Old Child Complicated by Difficult Airway Management and Emergent Use of Extracorporeal Membrane Oxygenation

“…13 A few case reports describe the anesthetic management of posterior mediastinal mass resection in adults. 3,[7][8][9]15,16,[23][24][25][26]27 A single-center experience of 5 patients 28 and a handful of case reports 5,17,29,30 describe the symptoms, management, and complications associated with posterior mediastinal masses in pediatric patients. Based on these pediatric case reports, clinical presentation, management, and potential complications vary.…”

“…Patients aged 3 to 14 years present with dyspnea 5,29 (may be positional), 29 cyanosis, 17 fever, 5,30 or pneumonia, 30 only occasionally causing airway compression. [28][29][30] The majority of the cases requiring surgical resection were performed through open thoracotomy. 5,17,29,30 Two cases proceeded with ECMO standby but ultimately was not utilized.…”

“…5,17,29,30 Two cases proceeded with ECMO standby but ultimately was not utilized. 28,29 Because of the heterogeneity of the aforementioned presentation and management found in the limited literature, there is no consensus on the management of posterior mediastinal masses, especially in the pediatric population. While there are no guidelines on a common anesthetic management for posterior mediastinal masses, the anesthetic approach has been well studied for anterior mediastinal masses and could potentially be applied to posterior masses.…”

“…If the patient is deemed to be at risk for severe cardiopulmonary complications, general anesthesia should be avoided and diagnosis can potentially be established through tumor markers or local-only anesthesia should be utilized if possible for diagnostic biopsy. 13,28 Tumor burden can be decreased through chemotherapy and/or radiation therapy, 12,13 and it is the fundamental treatment for pediatric patients with malignant mediastinal tumors. 28 If the decision is made to undergo general anesthesia, the patient should be induced in a position of minimum symptomatology 15 with the head of bed elevated to minimize deleterious effects of supine positioning.…”

“…13,28 Tumor burden can be decreased through chemotherapy and/or radiation therapy, 12,13 and it is the fundamental treatment for pediatric patients with malignant mediastinal tumors. 28 If the decision is made to undergo general anesthesia, the patient should be induced in a position of minimum symptomatology 15 with the head of bed elevated to minimize deleterious effects of supine positioning. 13 Due to frequent involvement of the bronchial tree in mediastinal masses, difficult airway management should be anticipated in all patients.…”