P019: WHAT THE TEETH? CASE OF LARGE POSTERIOR MEDIASTINAL TERATOMA
Kalina Nedeff, MD1; Jessica Reyes, MD1; Brian Cheung, MD1; Javier Kaplan, MD2; Naaman Abdullah, MD2; 1Kendall Regional Medical Center; 2Aventura Hospital and Medical Center
Introduction/Background: 36-year-old male with no reported medical history presented with complaints of left sided chest discomfort and shortness of breath.
Chest X-ray demonstrated elevated left hemidiaphragm and left base opacity with small left effusion and basilar atelectasis. CT Chest revealed a multiloculated soft tissue density arising from the mediastinum, extending into the left chest with locules of fluid and areas of calcification and fat interspersed. Transthoracic Echocardiogram showed extrinsic cystic mass pressing on left ventricle laterally, normal systolic function, no wall motion or valvular abnormalities.
Methods: The decision was made to undergo surgical excision once medical and cardiac clearances were obtained. An arterial line was inserted preoperatively; the patient was given midazolam for anxiolysis and transported to operating room. General anesthesia was induced intravenously with fentanyl, lidocaine, propofol and rocuronium, and maintained with sevoflurane. The airway was secured with a double lumen tube, verified with bronchoscope. Patient was repositioned and left lung deflated. Upon surgical exploration, 13 x 12 x 7 cm tumor was found to occupy more than half of the left chest cavity with bulk coming from posterior mediastinum. The tumor was extracted, chest tubes inserted and chest wall closed. Patient was spontaneously breathing and met criteria for extubation after appropriate reversal from neuromuscular blockade. He was successfully extubated and remained in the operating room for observation. Excessive output from chest tubes was noted, prompting intervention. The patient was subsequently re-intubated, transfused 1 unit packed red blood cells and underwent re-exploration to ascertain hemostasis. Chest tubes were exchanged and patient was transported to the ICU intubated.
Results: Pathology was consistent with a large, mature teratoma, revealing a multicystic mass containing mucinous fluid, yellow greasy material and hair, as well as a bony area with pieces of teeth. There was no evidence of atypical or malignant differentiation.
Discussion: Mature teratomas are germ cell tumors that most frequently occur in the gonad and have their origin from multipotential primitive germ cells during embryogenesis. The most common location of extragonadal germ cell tumors is the anterior mediastinum, although rare. Patients with mediastinal masses may present with cardiorespiratory problems, which may be exacerbated until general anesthesia. Symptoms, if present, are usually secondary to compression, such as shortness of breath, respiratory distress, chest pain, or superior vena cava syndrome. Effusions, pneumothorax and cardiac tamponade may be seen. Profound hypotension seen under general anesthesia is likely secondary to enhanced compression due to changes in pressure gradients and smooth muscle relaxation. Invasive blood pressure monitoring and immediate availability of blood products is recommended, as well as possible central venous access or cardiopulmonary bypass. Complications may arise at any point in the perioperative period and close hemodynamic monitoring is warranted.
1. Shameem, Mohammad et al. Mature mediastinal teratoma in adult. Respiratory Medicine CME 3 (2001) 116-117.
2. P. Slinger (ed.), Principles and Practice of Anesthesia for Thoracic Surgery, 201 DOI 10.1007/978-1-4419-0184-2_14.