Excerpt from Lymphomas, Endocrine, Mesenchymal, and Other Rare Tumors of the Mediastinum

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History of the Procedure: Although the entire field of surgery is an ancient one, successful surgical procedures of the thorax are a relatively recent advancement. Until the era when the airway and ventilation could be controlled artificially, the mediastinum, like other parts of the thorax, was deemed a dangerous area to approach.

A few surgeons in the late 1800s and early 1900s attempted and described surgical approaches to the mediastinum. In 1888, Nassiloff first showed that the esophagus was accessible using a posterior approach. In this time frame, with no ability to manage the airway or to ventilate safely, such a surgical approach had to remain completely extrapleural because perforation of the pleura would result in a fatal pneumothorax.

In 1893, Bastinelli described the removal of an anterior mediastinal dermoid cyst. The procedure required resection of the manubrium, but the patient recovered.

In 1897, Milton wrote extensively on mediastinal surgery using the median sternotomy approach. He tried this approach first on human cadavers, finding that a median sternotomy gave him excellent access to the mediastinum. He then used the same approach to explore the mediastinum of a live goat. Although he did enter the pleural cavity of the animal, Milton was able to perform a tracheostomy and give artificial respiration through it. This support enabled him to explore the mediastinum successfully and allowed the animal to have an uneventful recovery. Milton then described a human case in which he resected most of a tuberculous sternum plus 2 large tuberculous lymph nodes from the mediastinum, successfully avoiding the pleural spaces. This patient did well.

In 1940, Heuer published a monograph on mediastinal tumors. Most of the cases referenced in the monograph were from the 1920s and 1930s, and, in spite of Milton's previously described work, no reference was made to the use of median sternotomy as an acceptable surgical approach to the mediastinum.

Heuer noted that at that time, dermoid cysts and teratomas were the most commonly found tumors of the mediastinum. He also described successful removal of neurogenic tumors from the posterior mediastinum and described several types of thymic tumors.

In 1939, Alfred Blalock reported the first case in which symptoms of myasthenia gravis were completely relieved by removal of a thymic tumor, thus initiating a surgical option in the treatment of that disease.

Wakely and Mulvany described intrathoracic goiters in 1940. The authors divided these lesions into 3 subtypes. These were (1) the "small substernal extension" of a goiter primarily located in the neck; (2) the "partial" intrathoracic goiter for which a large portion, although not all of the goiter, is in the thorax; and (3) the "complete" intrathoracic goiter, for which the entire goiter appears to be within the thorax. Their report indicated that 8-9% of goiters had some intrathoracic component. Of these, more than 80% were of the first type, and only approximately 3% were of the third type.

The first described removal of a parathyroid adenoma from the mediastinum occurred in 1932. This was performed on a patient who had undergone 6 previously unsuccessful surgeries for hyperparathyroidism.

Problem: Any discussion of neoplasms or other masses found within the mediastinum requires delineation of the boundaries .....

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