A multidisciplinary collaborative model based on single-port\nthoracoscopy for the treatment of giant mediastinal lymph node hyperplasia: a\ncase report
The reporting of the present case conforms to the CARE guidelines.\n A 30-year-old male patient was admitted to our hospital because of chest\ntightness after exercise of 1 month’s duration. He had been diagnosed with chronic\nhepatitis B >10 years earlier, for which he was taking entecavir. His hepatitis B\nvirus DNA titre was within the normal range. Computed tomography (CT) revealed a\nwell-defined mass in his right upper mediastinum that was compressing his superior\nvena cava (). Subsequent CT thoracic aortic angiography demonstrated that the\nmediastinal mass was mainly supplied by the brachiocephalic trunk, and more\nspecifically, most of the large and tortuous vessels surrounding the mass originated\nfrom the right subclavian artery (). Using arteriography of the thoracic aorta and subclavian\nartery, we determined that the bilateral branches of the subclavian artery and the\nT3 and T4 intercostal arteries were the main supply arteries. His two distal\nintercostal arteries, right internal mammary artery and left thyrocervical trunk\nwere embolised (),\nbut we were unable to successfully embolise the right subclavian artery branch\nbecause of its narrow lumen.\nSurgery was scheduled for the day after the arteriography. A double-lumen\nendotracheal tube was placed and the patient was positioned in the left lateral\ndecubitus position. Single-lung ventilation was applied, and a 4-cm long incision\nwas made in the fourth intercostal space along a right anterior axillary line.\nVia single-port thoracoscopy, we disconnected the thin\nnutritive vessels by ultrasonic scalpel and coagulation hook, gradually freed up the\nthicker branches connecting to the mass and clamped these using vascular clips, and\nfinally removed the tumour completely. Because the mass was hard and lacked the\nflexibility of lung tissue, we could not remove it via a\nnormal-length incision. Therefore, to avoid the mass rupturing, we extended the\nincision appropriately. The mass was 7 × 5 × 4 cm in size (), and was later confirmed to be\nhyaline vascular Castleman disease by postoperative haematoxylin and eosin-staining\n(),\nimmunohistochemistry, and in situ hybridisation (ISH) (). However,\nimmunostaining for human herpesvirus (HHV)-8 and ISH for Epstein–Barr virus (EBV)\nwere both negative, which is consistent with the findings of most previous studies\nthat neither HHV-8 nor EBV is involved in hyaline vascular CD.\nIn addition to the vascular embolism, acute normovolaemic haemodilution and\nautologous blood transfusion were also used. After the induction of anaesthesia and\nbefore the surgical incision was made, blood was slowly drawn from the left jugular\nvein of the patient and an equal amount of balanced salt solution was simultaneously\nprovided via a peripheral vein until the haemoglobin concentration\nhad decreased from 167 g/L to 130 g/L. Blood reinfusion was performed when the\nsurgical wound had stopped haemorrhaging. A precise thoracoscopically-guided\nintercostal nerve block was performed. The entire procedure lasted ∼1 hour, and the\ntotal blood loss was ∼200 ml. The patient was discharged on the third postoperative\nday, when he demonstrated an absence of cough, haemothorax, chylothorax, and severe\npain. During the following year there were no complications or recurrence.