Minimally invasive robotic-assisted excision of an aortopulmonary mediastinal paraganglioma

Tracheobronchomalacia vs Excessive Dynamic Airway Collapse

Tracheobronchomalacia (TBM) is a frequently under-recognized condition that often coexists with other chronic respiratory diseases. The diagnosis of excessive central airway collapse requires consideration by the physician. Dynamic computed tomography scan of the chest and awake dynamic bronchoscopy are critical to establishing a diagnosis of TBM. Patients with severe TBM are candidates for tracheobronchoplasty. Multidisciplinary evaluation of patients with TBM has the potential benefit derived from shared decision-making to ensure patient optimization, prehabilitation, periprocedural care and posttreatment recovery, rehabilitation, and follow-up. Robotic tracheobronchoplasty is safe and improves pulmonary function tests and quality of life in patients with severe TBM.

Combined left thoracoscopic and median sternotomy approach to resect aortopulmonary mediastinal paraganglioma following feeding artery embolization: a case report

Background

Aortopulmonary mediastinal paragangliomas are rare. Complete resection of the tumor is desirable regardless of tumor size in view of the risk of sudden death induced by adjacent organ compression and poor prognosis after partial resection or untreated observation. Due to the hypervascularity of the tumor, the risk of intraoperative bleeding is significant, and cardiopulmonary bypass is often required for complete resection.

Case presentation

The patient was diagnosed as having bilateral carotid body tumors and supposedly an aortic body tumor at the age of 43 and eventually underwent resections of bilateral carotid body tumors at the age of 52. The pathology of the carotid body tumors was compatible with paraganglioma on both sides. A familial succinate dehydrogenase subunit D mutation was subsequently identified. Five years later, a contrast-enhanced computed tomography scan showed an enlarged tumor of 45 mm in size in the aortopulmonary mediastinum. Based on the previously known genetic mutation, the tumor was thought to be a paraganglioma. After confirming with an endocrinologist that the aortic body tumor was non-functional, radiologists performed preoperative embolization of the feeding vessels. Subsequently, a surgical team consisting of thoracic and cardiovascular surgeons resected the aortic body tumor using a video-assisted small left thoracotomy approach combined with a median sternotomy approach. The procedure was completed without cardiopulmonary bypass or blood transfusion. The patient was discharged home on postoperative day 9 uneventfully.

Conclusions

After conduction of preceding interventional embolization of multiple feeding vessels, we employed a video-assisted thoracoscopic surgical approach to dissect the aspects of the tumor adjacent to the esophagus, descending thoracic aorta, and left pulmonary artery, followed by a median sternotomy approach to dissect the other aspects of the tumor adjacent to the ascending aorta, aortic arch, right pulmonary artery, and trachea. There have been no reports on scheduled preoperative embolization of feeding vessels to an aortopulmonary mediastinal paraganglioma. Multidisciplinary approach was effective for complete resection of this challenging rare mediastinal tumor.

Paraganglioma fed by the circumflex artery

Mediastinal paragangliomas are rare neuroendocrine tumours and usually identified incidentally. Surgical excision remains the mainstay of treatment. Due to their location, anatomical relations, and highly vascular nature, surgical excision can be challenging. We present such a case, where the blood supply arose directly from the circumflex coronary artery and cardiopulmonary bypass was used to aid complete surgical excision.