Video-Assisted Thoracic Surgery Excision of Mediastinal Hemangioma
Alexander PH Chan, MRCS,
Randolph HL Wong, FRCS,
Innes YP Wan, FRCS,
Michael KY Hsin, FRCS,
Malcolm J Underwood, FRCS,
Anthony PC Yim, FRCS
Division of Cardiothoracic Surgery Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong Shatin, Hong Kong SAR, China
Malcolm J Underwood, MD, Tel: +852 2632 2629, Fax: +852 2637 7974, Email: mjunderwood{at}surgery.cuhk.edu.hk, Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China.
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ABSTRACT
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A 62-year-old woman with a middle mediastinal hemangioma was successfully treated using a video-assisted thoracic surgery approach facilitated by segmental rib resection, despite an initial radiological study that showed encasement by the surrounding great vessels. Pathological examination confirmed a cavernous hemangioma. This approach offers potential resection in difficult cases of mediastinal tumor.
Key Words: Hemangioma • Cavernous • Mediastinal Neoplasms • Thoracic Surgery • Video-Assisted
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INTRODUCTION
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Tumors of the middle mediastinum often impose great clinical challenges in terms of diagnosis and treatment. Acquisition of a tissue diagnosis is especially difficult because of close proximity to the great vessels, heart, and visceral organs. A posterolateral thoracotomy is arguably the most painful surgical incision, and hitherto has been the standard access to approach these tumors. We describe a case of middle mediastinal hemangioma that was successfully treated using a video-assisted thoracic surgery (VATS) approach facilitated by segmental rib resection.
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CASE REPORT
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A 62-year-old woman with unremarkable medical history was found to have a middle mediastinal mass during investigations for dizziness. Computed tomography of the thorax with contrast showed a 6.8 x 4.5 x 5.9-cm isodense middle mediastinal tumor posterior to the trachea and both main bronchi, invading through an aortopulmonary window. There was eccentric patchy strong enhancement compatible with vascular attenuation. No definite feeding vessel to the tumor was noted (Figure 1
). Positron-emission tomography showed a hypermetabolic middle mediastinal tumor with a standard uptake value of 3.14 and no focally hypermetabolic lesions elsewhere. As tissue diagnosis is essential to guide further management, we offered VATS exploration for biopsy and trial excision of the lesion. The patient was placed in a full right decubitus position with the table flexed at 30° between the level of the nipples and the umbilicus, to open the upper intercostal spaces. We used a 30° lens to avoid torquing of the telescope.1 Resection of a 3-cm segment of the left 4th rib was performed. Intraoperatively, the mass was observed to be lobulated with cystic and solid components. Trial aspiration of the mass showed altered blood, suggestive of recent hemorrhage. We decided to adopt VATS exploration facilitated by segmental rib resection, as previously described by our group.2 With this approach, bidigital palpation and blunt dissection are permitted, and the tumor could be freed from the left main bronchus, descending thoracic aorta, left main pulmonary artery, esophagus, and vertebral body. The specimen was excised en bloc (Figure 2). The patient was discharged after a good recovery on the 3rd day after the operation, with minimal pain. On histological examination, the tumor was noted to be formed by dilated interconnected vascular spaces lined with cytologically benign endothelium. Most of the spaces were of a cavernous type with fibrous septa. The resection margin was clear, and there was no evidence of malignancy. These findings confirmed hemangioma.
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Figure 1. Axial contrast computed tomography showing the well-defined mediastinal tumor (grey arrow), measuring 6.8 x 4.5 x 5.9 cm, with 40.4 Hounsfield units. There was no definite enhancement of the major portion of the mass. The carina (white arrow) was displaced anteriorly and right laterally by the mass.
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Figure 2. (A) Intraoperative photograph showing the mixed cystic and solid mediastinal mass (white arrow) that was dissected from the surrounding major vessels and delivered en bloc with an intact capsule. (B) Complete excision of the mediastinal mass was ensured, with the left vagus nerve secured (black arrow).
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DISCUSSION
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Hemangiomas are benign highly vascularized tumors that can involute with time. Their occurrence in the mediastinum is rare, with an incidence of less than 0.5% of all mediastinal tumors.3 Mediastinal hemangiomas affect all age groups, but 50% of cases occur in patients <20 years of age. Symptoms are nonspecific, such as chest pain, breathlessness, and back pain. Rarely, dysphagia, superior vena cava syndrome, and neurologic symptoms can result from a direct pressure effect or invasion of the intraspinal canal.3,4 Hemangiomas are classified as capillary, cavernous, or venous types, according to the size of their vascular spaces. Cavernous and capillary hemangiomas are the predominant clinical types; whereas venous hemangiomas are extremely rare.4 Cavernous hemangiomas do not spontaneously regress, unlike their capillary counterpart. Surgical interventions are often necessary for cavernous hemangiomas as they could cause local pressure on vital structures including the great vessels, major airways, and lung parenchyma. They have also been implicated in thrombocytopenia, microangiopathic hemolytic anemia, and coagulopathy.4 In such cases, aggressive therapy is clearly warranted as the mortality rate is high when the tumors are left untreated. Complete surgical excision when feasible constitutes the mainstay of treatment because partial excision is associated with an increased risk of postoperative bleeding.5
Thus far, only 125 well-documented cases of mediastinal hemangioma had been reported, and these were located in either the anterior or posterior mediastinum. A VATS approach to anterior and posterior mediastinal tumors has been used often, but a posterolateral thoracotomy is still the standard approach to middle mediastinal tumors.6,7 As demonstrated in our case, VATS with segmental rib resection extends the range of patients who could benefit from minimal access surgery. Using this approach, the advantages of a standard thoracotomy with digital palpation and dissection are maintained. At the same time, well-illuminated intrathoracic images are vividly presented to the operating surgeon, allowing best judgment to be made. We have had a conversion rate of less than 10% after adopting this approach. This strategy is useful for experienced VATS surgeons dealing with difficult cases, as well as for beginner VATS surgeons learning complex VATS procedures. We believe this approach may lead to wider acceptance of VATS major pulmonary resection among the thoracic surgical community.
Segmental rib resection has been proved to be an important means of allowing manual palpation and dissection without converting to a full thoracotomy in difficult thoracic cases. In our unit, we routinely perform VATS exploration of mediastinal tumors for both biopsy and trial excision. As demonstrated in this case, despite radiological features of possible vascular involvement, complete excision is still feasible using a VATS technique with segmental rib resection.
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REFERENCES
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- Yim AP. VATS major pulmonary resection revisited—controversies, techniques, and results. Ann Thorac Surg 2002;74:615–23.[Abstract/Free Full Text]
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- Cohen AJ, Sbaschnig RJ, Hochholzer L, Lough FC, Albus RA. Mediastinal hemangiomas. Ann Thorac Surg 1987;43:656–9.[Abstract/Free Full Text]
- Moran CA, Suster S. Mediastinal hemangiomas: a study of 18 cases with emphasis on the spectrum of morphological features. Hum Pathol 1995;26:416–21.[Medline]
- Rodriguez Paniagua JM, Casillas M, Iglesias A. Mediastinal haemangiomas [Letter]. Ann Thorac Surg 1988;45:583.[Medline]
- Sugerbaker DJ. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653–6.[Abstract/Free Full Text]
- Naunheim KS. Video thoracoscopy for masses of posterior mediastinum. Ann Thorac Surg 1993;56:657–8.[Abstract/Free Full Text]
Asian Cardiovasc Thorac Ann 2009;
17:522-524
© 2009 by SAGE Publications
DOI: 10.1177/0218492309348634
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ABSTRACT
INTRODUCTION
