Sara Fernandes, MD
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Sara Fernandes, MD1; José Estevão-Costa, MD, PhD2; Nuno Farinha, MD3; Ana Catarina Fragoso, MD, PhD2; 1Department of Pediatric Surgery - Centro Hospitalar Universitário São João; 2Department of Pediatric Surgery - Centro Hospitalar Universitário São João. Faculty of Medicine, Porto University.; 3Pediatric Oncology Department - Centro Hospitalar Universitário São João
Thymus experiences multiple physiologic, morphologic and topographic changes with time that interfere with the interpretation of imaging findings and with the diagnosis of pathologic alterations.
An asymptomatic 6-year old girl was referred with the evidence of a paracardiac mass. Computed tomographic scanning revealed a thymic hyperplasia and an expectant attitude was initially adopted but the persistent finding of mediastinal enlargement lead to further investigation. A magnetic resonance imaging has shown a paracardiac mass, raising the possibility of a massive thymic hyperplasia, not excluding the diagnosis of a thymoma. Surgical removal was decided and performed by thoracoscopy. The patient was discharged in the second postoperative day. The histological analysis has revealed a complete exeresis of a B2a thymoma.
Although rare, thymomas may present an uncertain biological behavior and a complementary treatment may be necessary if the surgical removal is incomplete.
Intended audience: Healthcare professionals and clinicians.
Hello. This video shows the minimally invasive resection of a mediastinal mass that ultimately lead to diagnosis. An asymptomatic 6-year-old girl was diagnosed with an incidental finding of paraicardic mass on X-ray by the age of 2. Back then, the CT scan showed timeic hyperplasia and an expectant attitude was decide. By the age of 5, the X-ray still showed mediastinal enlargement, and the girl was referenced to pediatric surgery consultation. An MRI was ordered and showed a large paracardiac mass with approximately 6 centimeters. The radiologic findings raised suspicion on a massive thymic hyperplasia, but not excluding the diagnosis of a thymoma. Surgical removal was decided and performed by thoracoscopy. A right-sided approach was decided and the patient was positioned on a 30 degree semi-supine position. Three ports of 5 millimeter were inserted in these positions. At the first inspection of the thoracic cavity, a large mass was promptly identified with well defined borders. The phrenic nerve was identified for anatomical reference. The mediastinal pleura is opened with a vessel sealing device, and the dissection of the mass from the pericardium begins. Moving upwards, the upper pole of the thymus gland is dissected from the vascular structures. Here we can see the blunt dissection of the mass from the inominate vessels. And here we see the separation from the pericardium and the superior vena cava. The right thic vessels were isolated on the superior pole. And then ligated with the vessel sealing device. The cervical thymus was grasped and pulled cordially. And finally, the upper pole is released. The extraction of the surgical piece was accomplished with extension of the thoracic incision and then pulling it out with a clamp. This is the macroscopic aspect of the piece of resection. The final inspection for hemostasis showed no bleeding or other immediate complications. The patient was admitted on the intensive care unit for surveillance in the first day. The chest drain was removed on the first post-operative day, and the patient was discharged home in the next day. The histological analysis has revealed a complete exeresis of a B a thymoma. Since the resection was complete, no additional treatment was necessary, and the patient remains on clinical and imageological follow-up. Thank you
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