Awake thoracoscopic mediastinal biopsy in a teenager: a case report

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.

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.

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.