Awake thoracoscopic biopsy of anterior mediastinal masses

Anterior mediastinal masses can develop due to a number of conditions, most of which require prompt pathologic diagnosis to initiate appropriate treatment. Diagnosis can be achieved by surgical and non-surgical methods but Video-Assisted Thoracic Surgery (VATS) through general anesthesia is frequently preferred due to its minimal invasiveness and optimal diagnostic yield. One limitation of VATS includes the need for general anesthesia and one-lung ventilation, which can induce life-threatening adverse effects, particularly in patients with bulky masses In order to reduce general anesthesia-related operative risks, we employed a VATS biopsy approach performed by just thoracic epidural or local anesthesia in fully awake, spontaneously ventilating patients. This surgical method allows a wide visual control of mediastinal compartments, an accurate assessment of the disease extension and achievement of multiple biopsy specimens from different sites of the mass, eventually resulting in excellent diagnostic yield. In addition, adequate surgical management of associated intrathoracic conditions including drainage of pleural-pericardial effusions or pleuralpulmonary biopsy is possible when necessary. We believe that this novel and globally less invasive surgical option might thus be included within the framework of the most reliable methods currently available to achieve a rapid diagnosis and adequate surgical management in patients with undetermined anterior mediastinal masses.