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Background CT images and circulating tumor cells (CTCs) are indispensable for diagnosing the mediastinal lesions by providing radiological and intra-tumoral information. This study aimed to develop and validate a deep multimodal fusion network (DMFN) combining CTCs and CT images for the multi-classification of mediastinal lesions. Methods In this retrospective diagnostic study, we enrolled 1074 patients with 1500 enhanced CT images and 1074 CTCs results between Jan 1, 2020, and Dec 31, 2023. Patients were divided into the training cohort ( n  = 434), validation cohort ( n  = 288), and test cohort ( n  = 352). The DMFN and monomodal convolutional neural network (CNN) models were developed and validated using the CT images and CTCs results. The diagnostic performances of DMFN and monomodal CNN models were based on the Paraffin-embedded pathologies from surgical tissues. The predictive abilities were compared with thoracic resident physicians, attending physicians, and chief physicians by the area under the receiver operating characteristic (ROC) curve, and diagnostic results were visualized in the heatmap. Results For binary classification, the predictive performances of DMFN (AUC = 0.941, 95% CI 0.901–0.982) were better than the monomodal CNN model (AUC = 0.710, 95% CI 0.664–0.756). In addition, the DMFN model achieved better predictive performances than the thoracic chief physicians, attending physicians, and resident physicians ( P  = 0.054, 0.020, 0.016) respectively. For the multiclassification, the DMFN achieved encouraging predictive abilities (AUC = 0.884, 95%CI 0.837–0.931), significantly outperforming the monomodal CNN (AUC = 0.722, 95%CI 0.705–0.739), also better than the chief physicians (AUC = 0.787, 95%CI 0.714–0.862), attending physicians (AUC = 0.632, 95%CI 0.612–0.654), and resident physicians (AUC = 0.541, 95%CI 0.508–0.574). Conclusions This study showed the feasibility and effectiveness of CNN model combing CT images and CTCs levels in predicting the diagnosis of mediastinal lesions. It could serve as a useful method to assist thoracic surgeons in improving diagnostic accuracy and has the potential to make management decisions.

Background Video-assisted thoracoscopic surgery (VATS) for a relatively large mediastinal tumor (5.0–10.0 cm) remains controversial. In addition, few studies have focused on comparing different surgical approaches for large mediastinal tumors. Therefore, this study aimed to compare the short-term outcomes between subxiphoid approach VATS, intercostal approach VATS, and traditional sternotomy for large-sized anterior mediastinal tumors. Methods The study consecutively enrolled 159 patients with large-sized anterior mediastinal tumors (5.0–10.0 cm) who received surgery in our hospital between January 2018 and July 2022 (subxiphoid approach VATS: 52 patients, intercostal approach VATS: 70 patients, traditional sternotomy: 37 patients). We analyzed the clinical baseline data, intraoperative and postoperative outcomes, and postoperative complications of all patients. Then the patients were further divided into two groups according to whether there was a peripheral organ (such as pericardium, lung, or left innominate vein) invasion: group A, invasion of the surrounding organ, and group B, no invasion of the surrounding organ. Intraoperative and postoperative outcomes and postoperative complications were also analyzed in group A and group B, respectively. Results In all patients, there were significant differences in blood loss (subxiphoid approach: 33.1 ± 46.0 ml, intercostal approach: 36.9 ± 44.1 ml, sternotomy: 113.0 ± 84.9 ml, P  < 0.001) and duration of postoperative oral analgesics (subxiphoid approach: 3.4 ± 0.9 d, intercostal approach: 3.7 ± 1.4 d, sternotomy: 4.5 ± 1.5 d, P  = 0.002) among the three methods. In group A, there was a significant difference in blood loss (subxiphoid approach: 50.0 ± 67.7 ml, intercostal approach: 90.0 ± 66.6 ml, sternotomy: 157.9 ± 90.2 ml, P  < 0.001) among the three methods. In group B, there were significant differences in the duration of postoperative oral analgesics (subxiphoid approach: 3.2 ± 0.8 d, intercostal approach: 3.7 ± 1.4 d, sternotomy: 4.2 ± 1.1 d, P  < 0.05) and blood loss (subxiphoid approach: 22.5 ± 19.3 ml, intercostal approach: 31.9 ± 38.5 ml, sternotomy: 65.6 ± 44.9 ml, P  < 0.001) between the three methods. There were no significant differences in the postoperative complications. Conclusions VATS is an effective, minimally invasive, and safe procedure for large-sized anterior mediastinal tumors (5.0–10.0 cm) without an invasion of the surrounding organs, and maybe a feasible and secure method for large-sized anterior mediastinal tumors with an invasion of the surrounding organ (such as the pericardium, lung, or left innominate vein). Subxiphoid approach VATS is a less invasive procedure than intercostal approach VATS and traditional sternotomy due to its reduced blood loss and postoperative pain.

A multilocular thymic cyst (MTC) is a rare mediastinal tumor with multiloculated cyst-like structures in the anterior mediastinum. This tumfor is associated with inflammatory diseases, including human immunodeficiency virus (HIV) infection. The present study reports a case of MTC detected during coronavirus disease 2019 (COVID-19) treatment in an adult who was tested HIV positive. An anterior mediastinal tumor was incidentally detected on computed tomography in a 52-year-old man with a 20-year history of HIV infection on the 9th day of COVID-19. The patient was asymptomatic with no notable physical findings. Magnetic resonance imaging revealed a 28-mm bilocular cyst. Robot-assisted thoracoscopic tumor resection was performed. Pathological examination showed that the cyst was lined with squamous or cuboidal epithelium, and the cystic lesion wall was mainly composed of thymic tissue with follicular hyperplasia. Based on these findings, the patient was diagnosed with MTC. To date, only 15 MTC cases have been reported in patients with HIV, and the majority of cases showed HIV infection-related symptoms such as lymphoid interstitial pneumonia and parotid gland enlargement. The present case was atypical for an HIV-related MTC because it did not involve HIV infection-related symptoms, suggesting the possibility for an alternative etiology such as COVID-19. Further reports on MTC development in patients with COVID-19 are required to elucidate the relationship between MTC and COVID-19.

OBJECTIVES The application of video-assisted thoracoscopic surgery (VATS) for relatively large mediastinal tumours (≥5.0 cm) has been a subject of debate, and few studies have investigated the subxiphoid approach VATS in different tumour size categories. The study aims to compare the efficacy of the subxiphoid approach VATS for achieving curative outcomes based on tumour size categories (<3.0, 3.0–4.9 and 5.0–10.0 cm). METHODS A total of 165 patients with anterior mediastinal tumours who underwent surgery at our hospital between January 2018 and July 2022 were consecutively enrolled, categorized according to tumour size—group A (<3.0 cm): 58, group B (3.0–4.9 cm): 70 and group C (5.0–10.0 cm): 37. Clinical baseline data, intraoperative and postoperative outcomes, and postoperative complications were analysed. RESULTS The study revealed significant differences in operation time among the 3 groups (group A: 103.4 ± 36.1, group B: 106.4 ± 35.2, group C: 127.4 ± 44.8; P < 0.05) as well as in the volume of drainage (group A: 273.3 ± 162.0, group B: 411.9 ± 342.6, group C: 509.7 ± 543.7; P < 0.05). However, no differences were seen in blood loss, drainage duration, postoperative hospital stay and duration of postoperative oral analgesics. Additionally, the incidence of postoperative complications did not exhibit significant differences across these groups. CONCLUSIONS Subxiphoid approach VATS is considered a feasible and safe surgical method for large-sized anterior mediastinal tumours (5.0–10.0 cm) with no invasion to the surrounding tissues and organs. The management of mediastinal tumours necessitates a comprehensive approach, combining surgical intervention, radiation therapy and chemotherapy, tailored to the tumour type and stage [1, 2].

Background The purpose of this study was to compare the perioperative efficacy and safety of da Vinci robot-assisted thoracoscopic surgery (RATS) for treating anterior mediastinal tumors through the subxiphoid and lateral thoracic approaches under the anesthesia of nontracheal intubation (i.e., laryngeal mask airway). Methods We retrospectively analyzed the clinical data of 116 patients with anterior mediastinal tumors treated by RATS under laryngeal mask anesthesia completed by the same operator in the Department of Thoracic Surgery, Gansu Provincial People’s Hospital, from October 2016 to October 2022. There were a total of 52 patients including 24 males and 28 females, with an average age of 45.40±4.94 years, in the subxiphoid approach (subxiphoid group). On the other hand, there were a total of 64 patients including 34 males and 30 females, with a mean age of 46.86±5.46 years in the lateral thoracic approach (lateral thoracic group). Furthermore, we have detailedly compared and analyzed the operating time, intraoperative bleeding, and total postoperative drainage in the two groups. Results All patients in both groups successfully completed resection of the anterior mediastinal tumor without occurring perioperative death. Compared with the lateral thoracic group, the subxiphoid group has more advantages in terms of total postoperative drainage ( P =0.035), postoperative drainage time ( P =0.015), postoperative hospital stay ( P =0.030), and visual analog scale (VAS) pain on postoperative days 2 ( P =0.006) and 3 ( P =0.002). However, the lateral thoracic group has more advantages in the aspect of docking time ( P =0.020). There was no statistically significant difference between the two groups in terms of operative time ( P =0.517), total operative time ( P =0.187), postoperative day 1 VAS pain score ( P =0.084), and postoperative complications ( P =0.715). Conclusion The subxiphoid approach of RATS under laryngeal mask anesthesia is safe and feasible for resecting anterior mediastinal tumors. Compared with the lateral thoracic approach, the subxiphoid approach has advantages in terms of rapid postoperative recovery and postoperative patient pain, and patient acceptance is also higher and thus is worth promoting in hospitals where it is available.

Background Teratoma is the second most common mediastinal neoplasm, but malignant transformation in mature teratomas is uncommon, and cases of carcinoid tumor with teratoma are described in only a few studies. In addition, multilocular thymic cyst associated with mature mediastinal teratoma is also a rare entity. There have been no reports of case with the coexistence of these three pathological lesions. Case presentation The patient was a 24-year-old man who was referred to our hospital due to a 2-day history of left shoulder pain, a feeling of severe chest tightness and high fever. Pre-operative computed tomography (CT) showed a large, fluid-filled and well-demarcated multilocular cyst in the anterior to superior mediastinum measuring up to 12 cm in size. Contrast-enhanced CT also revealed that the tumor contained a solid component with slight contrast enhancement and spotty wall-thickening septation. Therefore, cystic thymoma, thymic cyst, cystic teratoma, or germ cell tumor with an inflammatory reaction were considered as differential diagnoses. The patient underwent tumor extirpation under median sternotomy. The pathological diagnosis was multilocular thymic cyst with mature teratoma including carcinoid tumor (Grade 2) in the mediastinum. Conclusions The relationship between thymic cyst, teratoma and carcinoid tumor is unclear at present; therefore, further research is needed to clarify the relationship between these entities. In this report, we present a case of multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum that was detected by complete surgical resection.

Abstract Introduction: Neurogenic tumours are the most common tumours of the posterior mediastinum and account for 75% of the tumours in this region. Till recently, open transthoracic approach has been the standard of care for their excision. Thoracoscopic excision of these tumours is being commonly employed because of lesser morbidity and shorter hospital stay. The robotic surgical system offers a potential advantage over conventional thoracoscopy. We herein report our technique and surgical outcomes of excision of posterior mediastinal tumours using the Da Vinci Robotic Surgical System. Materials and Methods: We retrospectively reviewed 20 patients who underwent Robotic Portal-Posterior Mediastinal Tumour (RP-PMT) Excision at our centre. The demographic data, clinical presentation, characteristics of the tumour, operative and post-operative variables including, total operative time, blood loss, conversion rate, duration of the chest tube, hospital stay and complications were noted. Results: Twenty patients underwent RP-PMT Excision and were included in the study. The median age was 41.2 years. The most frequent presentation was chest pain. Schwannoma was the most common histopathological diagnosis. There were two conversions. The total operative time was 110 min with an average blood loss of 30 mL. Two patients developed complications. The postoperative hospital stay was 2.4 days. With a median follow-up of 36 months (6-48 months), all except patients are recurrence-free, except the patient with malignant nerve sheath tumour who developed local recurrence. Conclusion: Our study demonstrates the feasibility and safety of robotic surgery for posterior mediastinal neurogenic tumours with good surgical outcomes.

Background The artery of Adamkiewicz (AKA) provides the major blood supply to the lower two-thirds of the spinal cord. As the AKA typically arises from a left posterior intercostal artery at the levels between 9 and 12th thoracic vertebrae, injury of the AKA during thoracic surgery such as resection of a lower paravertebral tumor may cause serious neurological complications. Robot-assisted thoracic surgery (RATS) has several advantages over video-assisted thoracic surgery including three-dimensional and high-definition view with high image magnification and reduced restriction in movement of surgical instruments. Here, we present a case of a left paravertebral ganglioneuroma originating from the sympathetic trunk. Whereas both tumor-feeding arteries and the AKA arose from the 9 th intercostal artery, complete tumor resection with preserving the AKA was achieved by RATS. Case presentation A 15-year-old girl admitted for surgery for a posterior mediastinal tumor. Chest computed tomography showed a well-circumscribed 8.0 cm tumor adjacent to 8–11th thoracic vertebrae and the descending aorta. Contrast-enhanced CT and angiography revealed that the AKA arose from the left 9 th intercostal artery that ran between the tumor and the vertebrae and that tumor-feeding arteries also arose from the same intercostal artery. RATS was performed with the left intercostal approach using the da Vinci Xi system (Intuitive Surgical, Mountain View, CA). The tumor originating from the sympathetic trunk was completely resected with preserving the sympathetic trunk and the AKA. Postoperative course was uneventful without any adverse event, such as neurological complications. The final pathological diagnosis of the tumor was ganglioneuroma. Conclusions RATS is a useful surgical approach for removal of a mediastinal tumor with preserving surrounding organs or tissues, such as the AKA.

This study aimed to determine the optimal position and port placement during robotic resection for various mediastinal tumors. For anterior mediastinal tumors, total or extended thymectomy is commonly performed in the supine position using the lateral or subxiphoid approach. Although it is unclear which approach is better during robotic thymectomy, technical advantages of subxiphoid approach are beneficial for patients with myasthenia who require extended thymectomy. Partial thymectomy is performed in the supine position using a lateral approach. Superior, middle, and posterior mediastinal tumors are resected in the decubitus position using the lateral approach, whereas dumbbell tumor resection, which requires a posterior approach, can be performed in the prone position. The position and port placement should be chosen depending on the size, location, and aggressiveness of the tumor. In this study, we describe how to choose which of these different robotic approaches can be used based on our experience and previous reports.

Background： Transesophageal echocardiography （TEE） is a well-established method for detecting and diagnosing heart tumors. In contrast, its role in assessing the presence, growth and evidence of malignant tumors originating from mediastinal sites remains unclear. The aim of this study was to compare the diagnostic impact of TEE and transthoracic echocardiography （TTE） for determining the localization, growth and malignancy of adult mediastinal tumors （MTs）. Methods： In a prospective and investigator-blinded study, we evaluated 144 consecutive patients with MT lesions to assess the diagnostic impact of TEE and TTE for detecting the presence of tumors spreading both inside and outside of the heart and for determining infiltration and invasion using pathological examination results as a reference. Results： All tumor lesions were diagnosed and carefully evaluated by biopsy. Biopsy revealed malignant tumors in 79 patients and benign tumors in 65 patients. When compared to histological findings, TEE predicted malignancy from the presence of tumors spreading both inside and outside of the heart and from infiltration and invasion in 49/79 patients （62.0%）. TTE predicted malignancy in only 8/79 patients （10.1%, P 〈 0.005）. TEE visualized tumor lesions in 130 patients （90.3%） while the TTE visualized tumor lesions in 110 patients （76.4%） and was less effective at detecting MT lesions （P 〈 0.001 ）. TTE and TEE could detect anterior MTs and adequately verified MTs （P 〉 0.05）： TEE detected medium MTs better than TTE （P 〈 0.001 ）. Conclusions： TEE is effective and superior to TTE for predicting the localization and growth of MTs as well as for accessing evidence of tumor malignancy. TTE and TEE were able to detect anterior MTs; TEE was able to detect medium MT better than TTE.