Oral 4.04: Emergency presentation of mediastinal tumors: a clinicopathological study

Background: Most of the mediastinal tumors in adults present incidentally or with subtle symptoms like chest discomfort, chest pain, exertion dyspnea, or simply shortness of breath. Little is known about the emergency presentation of such tumors. The aim of this study is to evaluate the clinicopathological characteristics of patients with mediastinal tumors who presents acutely to emergency department in a tertiary cancer care center.

Methods: A retrospective review of a prospectively collected database of mediastinal tumors from 2009 till 2015 was analyzed. Demographic data, mode of presentation, presenting symptoms, tumor characteristics, diagnostic procedures, and histology were reported. Data is presented as percentage, mean, and range.

Results: Over the study period, a total of 244 cases of mediastinal mass were collected in the database. Eighteen cases (7%) presented acutely to the emergency department. There were 12 males and 5 females. Two females were pregnant and presented in third trimester. Age ranges from 25 to 72 years with mean age of 58. The main presenting symptoms included: stridor (45%), superior vena cava syndrome (22%), hypotension (11%), tachyarrhythmia (16%), collapse outside the hospital (6%). The diagnosis was established by mediastinoscopy (33%), Chamberlain procedure (44%), incisional biopsy from non-mediastinal site (17%), and Right thoracotomy (6%). One patient presented with stridor and huge posterior mediastinal goiter immediately taken to the operation and the tumor completely resected by a right thoracotomy approach. Due to critical presentation, most patients (61%) had the diagnostic procedure under local anesthesia while awake and the patient is semirecumbent position. All of the mediastinoscopy cases were done under GA in supine position. CT guided biopsy procedure was not used in any patient because either the patient is unstable to go to the radiology suite or the tumor is technically not amenable for such procedure. The anatomic location of these tumors included: anterior mediastinum (88%), middle mediastinum (6%), and posterior mediastinum (6). The tumor size ranges from 7 to 29 cm with a mean of 18 cm. The final pathological diagnosis included: lymphoma (44%), mesenchymal tumors (6%), thymoma (33%), thymic carcinoma (11%), and benign multinodular goiter (6%).

Conclusions: A small, but clinically important, percentage of patients with mediastinal tumors present acutely to the emergency department. Physicians have a wide array of diagnostic procedures that can be safely utilized to diagnose such tumors. Local anesthesia-based procedures can be safely performed to obtain enough tissue for diagnosis. Clinically, these tumors tend to be malignant and larger than the usually incidentally found counterparts, and mainly in the anterior compartment.

Keywords: Mediastinal; neoplams; emergency; clinical