Awake video-assisted thoracoscopic biopsy in complex anterior mediastinal masses

Anterior mediastinal masses can develop from a wide spectrum of pathologic conditions, most of which are malignant in nature and require prompt diagnosis for immediate initiation of the appropriate treatment. Clinical pictures can be variable and complicated by associated intrathoracic conditions requiring surgical management such as pleural and pericardial effusions or nodules (complex anterior mediastinal masses). We have used a single-trocar video-assisted thoracoscopic surgery (VATS) approach using thoracic epidural or sole local anesthesia in awake patients. Advantages of awake VATS biopsy include avoidance of all potential adverse effects related to the use of general anesthesia, wide visual control of mediastinal sampling, and accurate assessment of the disease extent with the possibility of obtaining multiple biopsy specimens from different sites of the mass and a diagnostic yield of 100%. This novel and less invasive surgical option might thus be included within the framework of most reliable methods currently available to manage patients with undetermined anterior mediastinal masses.