1. Mediastinal Masses 2010 WOFAPS Meeting George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. Diseases in the Mediastinum Infection Tumors – Benign/Malignant Lympadenopathy Cysts Lymphangioma

3. Symptoms Severe Respiratory Distress Asymptomatic

4. Anatomic Divisions of the Mediastinum

5. Regionalization Anterior Mediastinum Middle Mediastinum Posterior Mediastinum Teratoma, Thymus Ectopic Thyroid Adenopathy Bronchogenic Cysts Esophageal Duplication Cysts Neurogenic Tumors Esophageal Duplication Cysts > > >

6. Imaging Studies CT (IV, Oral contrast) MRI (esp. posterior mediastinal lesion) Contrast esophagram Technetium – 99m pertechnetate scan

7. Imaging Studies Contrast esophagram

8. Anterior Mediastinum 1.Lymphoma (50% of all mediastinal lesions) 2.Teratoma 3.Germ cell tumors 4.Cystic hygromas 5.Thymic lesions

9. Anterior Mediastinum Lymphoma Usually older child  Hodgkin’s – 14 yrs  Non-Hodgkin’s – 9 yrs  Often have other symptoms and other adenopathy  Frequently have airway compromise

10. Anterior Mediastinum Airway Compromise Tracheal collapse on induction of anesthesia Look diligently for extrathoracic approach & local anesthesia  Cervical adenopathy  Pleural effusion  Bone marrow examination  Needle biopsy often obtains inadequate tissue, esp. in Hodgkin’s  ? Short course steroids or radiation followed by thoracoscopic biopsy or mini-thoracotomy

11. Middle Mediastinum < 2 yrs: Remnants of embryonic foregut (trachea & esophagus) Pericardial cysts Lymphadenopathy

12. Middle Mediastinum Esophageal Duplication Cyst Adjacent to or embedded in wall of esophagus Can have respiratory or GI epithelium May either obstruct or erode through esophageal wall Thoraco-abdominal duplications: orginate near duodenum & jejunum and expand to middle mediastinum (gastric mucosa & vertebral anomalies) Bronchogenic Cyst Can be adjacent to or far away from bronchogenic structures Usually have respiratory epithelium Can be large and cause respiratory symptoms

13. Thoracoscopy Technique Baseball diamond concept for location of instrument sites Convert if difficult

14. Thoracoscopy Single lung ventilation

15. Bronchogenic Cyst

16. Lateral Decubitus Position

17. Bronchogenic Cyst

19. Mediastinal Lymphadenopathy

20. Lateral Decubitus Position

21. Thoracoscopic Biopsy Mediastinal Lymphadenopathy

22. Esophageal Duplication

24. Posterior Mediastinum Ganglioneuroma Ganglioneuroblastoma Neuroblastoma

25. Posterior Mediastinum Neuroblastoma Very good prognosis, especially Stage I & II * Paraplegia implies compression of spinal cord (MRI & urgent laminectomy)

26. Neurogenic Tumor

30. Thoracoscopic Operations Children’s Mercy Hospital (2000-2007) DiagnosticNo. of Patients Wedge biopsy of solitary lung lesions37 Biopsy and excision of mediastinal masses26 Wedge biopsy of diffuse parenchymal disease15 Evaluation of penetrating thoracic trauma1 Total79 Therapeutic Pleural decortication for empyema79 Exposure for scoliosis26 Bullae resection for pneumothorax25 Lobectomy9 Repair of esophageal atresia and fistula8 Evacuation of hemothorax and pleural effusion3 Repair of bronchopleural fistula1 Total151 IPEG 2007 J LAST 18:131-135, 2008

31. Thoracoscopy Pearls & Pitfalls Single lung ventilation, if possible Keep dissection as close to the wall of a foregut duplication cyst to avoid entry into an adherent structure (esophagus, bronchus) Aspirate large cystic mass, if necessary Place bougie in esophagus to identify its location If common wall of duplication left intact, it is imperative to remove mucosal lining

32. www.cmhcenterforminimallyinvasivesurgery.com