European Journal of Cardiovascular Medicine

Mediastinal masses are a heterogeneous group of lesions located in the mediastinum, a central thoracic compartment containing vital structures such as the heart, great vessels, trachea, and esophagus. They can be congenital, benign, or malignant and are commonly classified according to location: anterior, middle, or posterior mediastinum [1,2]. Even small lesions can cause significant symptoms due to compression of adjacent structures, leading to respiratory distress, cardiovascular compromise, or dysphagia [3,4].

Accurate preoperative assessment with imaging modalities like computed tomography (CT) or magnetic resonance imaging (MRI) is essential for diagnosis, surgical planning, and risk stratification [5]. Surgical excision is the mainstay of treatment for symptomatic or potentially malignant masses. Approaches include open thoracotomy, sternotomy, or minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS), depending on tumor size, location, and involvement of surrounding structures [6,7].

Despite advancements, mediastinal masses continue to pose perioperative challenges, including airway obstruction and cardiovascular complications [4,8]. Prospective data on immediate postoperative outcomes, complications, and hospital stay remain limited, especially in the Indian context [9]. This study aims to evaluate surgical management and immediate outcomes of patients with mediastinal masses at a tertiary care center in India, including demographics, tumor characteristics, surgical approach, postoperative complications, and hospital stay [10].

The study aims to evaluate the surgical management and immediate outcomes of mediastinal masses in patients operated at a tertiary care centre, with respect to tumor size, anatomical localization, histopathology, and surgical approach. The objectives include analyzing the surgical strategies employed according to mass size, location, histopathological diagnosis, and procedural complexity, as well as assessing immediate postoperative outcomes. Key perioperative parameters considered are duration of surgery, extubation time, postoperative hospital stay, chest tube drainage duration, intraoperative challenges, and both postoperative complications and mortality.

Study type: Prospective, observational study

Study place:  Department of Cardio Thoracic & Vascular Surgery, Institute of Post Graduate Medical Education & Research and Seth Sukhlal Karnani Memorial hospital Kolkata

Study population: All patients with mediastina mass admitted in CTVS Department, Institute of Post Graduate Medical Education & Research and Seth Sukhlal Karnani Memorial hospital Kolkata.

Study period: One and Half Year (August 2023-February 2025)

Sample size: 40 Patients with Mediastinal Mass

Study variables:

• Age Group (Years)
• Tumour Type
• Recurrence
• Recurrence and Histopathological Diagnosis
• Mortality and Histopathological Diagnosis

Inclusion criteria

All patients presenting with Mediastinal mass and posted for surgery.

Exclusion criteria

• previous thoracic surgery
• Hemodynamically unstable patients.
• Patients below 12 years of age.
• Patients managed non-surgically (medical management or radiotherapy only)
• Recurrent mediastinal tumors

Statistical analysis:

Data from the study were analyzed using SPSS software, with continuous variables (e.g., age, liver enzyme levels) expressed as mean ± SD and compared using t-tests or Mann–Whitney U tests. Categorical variables (e.g., gender, CBD stones, and complications) were presented as frequencies and percentages, and compared using Chi-square or Fisher’s exact tests. Diagnostic accuracy (sensitivity, specificity, PPV, NPV, and accuracy) was calculated for MRCP-first and EUS-first strategies, using ERCP/intraoperative findings as the reference. Kaplan-Meier analysis may be used for time-to-intervention comparisons. A p-value < 0.05 was considered significant.

Table 1: Distribution based on Age Group (n=40)

Table 2: Distribution based on Tumour Type (n=40)

Table 3: Distribution based on Recurrence (n=40)

Table 4: Association between Recurrence and Histopathological Diagnosis (n = 40)

Table 5: Association between Mortality and Histopathological Diagnosis (n = 40)

Figure 1: Distribution based on Tumour Type (n=40)

Figure 2: Association between Mortality and Histopathological Diagnosis (n = 40)

In our study, the distribution of patients according to age group was as follows: 5 patients (12.8%) were in the 14–30 years age group, 14 patients (35.9%) were in the 31–45 years age group, and 21 patients (51.3%) were in the 46–60 years age group. The mean age of the study population was 42.1 ± 10.6 years.

In our study, out of 40 patients, 38 patients (94.9%) had benign mediastinal tumors, while 2 patients (5.1%) had malignant tumors.

In our study, recurrence was observed in 2 patients (5.1%), while 38 patients (94.9%) did not have any recurrence during the follow-up period.

In our study, recurrence occurred in 2 patients (100.0%) with Schwannoma. No recurrence was observed in 2 patients (5.3%) with Bronchogenic cyst, 2 patients (5.3%) with Esophageal Duplication Cyst, 1 patient (2.6%) with Neurofibroma, 4 patients (10.5%) with Teratoma, 2 patients (5.3%) with Thymic carcinoma, 13 patients (34.2%) with Thymic Hyperplasia, 1 patient (2.6%) with Thymolipoma, and 12 patients (31.6%) with Thymoma. The association between histopathological diagnosis and recurrence was statistically significant (p = 0.01).

In our study, all patients with Bronchogenic cyst (2 patients, 5.3%), Esophageal Duplication Cyst (2 patients, 5.3%), Neurofibroma (1 patient, 2.6%), Schwannoma (3 patients, 7.9%), Teratoma (4 patients, 10.5%), Thymic carcinoma (2 patients, 5.3%), and Thymolipoma (1 patient, 2.6%) survived. Mortality was observed in 1 patient (7.7%) with Thymic Hyperplasia (out of 13 patients) and 1 patient (8.3%) with Thymoma (out of 12 patients). The association between histopathological diagnosis and mortality was not statistically significant (p = 0.996).

In our series of 40 patients with mediastinal tumours, the mean age was 42.1 ± 10.6 years, with the majority (51.3 %) in the 46‑60 yr age group, 35.9 % in the 31‑45 yr age group and 12.8 % in the 14‑30 yr age group. This age‑distribution is broadly in line with prior studies of adult mediastinal masses, which have shown peak incidence in the 30–50 year age range. For example, a Brazilian series found that more than half of all patients were aged 20–49 yrs. [11] Similarly, a retrospective series of 94 patients found a mean age of ~33.9 ± 18.9 yrs. [12] Thus our dataset appears consistent with the middle adult age predominance, and the relatively small number in the younger age group is acceptable in this context. In our cohort, 38/40 (94.9 %) had benign and only 2 (5.1 %) had malignant mediastinal tumours. That confirms the predominance of benign lesions in certain mediastinal series. Indeed, many authors report a majority of lesions as benign: e.g., one review reports that more than two‐thirds of mediastinal masses in adults are benign, though this varies by location (anterior vs posterior) and patient age. [13] A recent single‐centre adult study found 71.9 % benign lesions. [14] Thus our high benign proportion is within the recognised spectrum—albeit somewhat higher than many series in which malignant lesions are more common in the anterior compartment. In our study, recurrence occurred in 2 patients (5.1 %), both of whom had schwannoma (100 % of the Schwannoma subgroup), and no recurrences were seen in other histologic types (bronchogenic cyst, esophageal duplication cyst, neurofibroma, teratoma, thymic carcinoma, thymic hyperplasia, thymolipoma, thymoma). The association between histopathologic diagnosis and recurrence was statistically significant (p = 0.01). Several published reports on mediastinal tumours and specifically on thymic epithelial tumours (TET) provide perspective on recurrence risk. For example, a large review of 235 TETs found an overall recurrence rate of 10.7 % (25/235). [15] In that study the recurrence rate rose substantially with more advanced stage: e.g., 1.5 % in stage I, 7.5 % in IIA, 3.1 % in IIB, 30 % in III, 80 % in IVA. A separate study of 305 thymoma resections noted a recurrence rate of 13.4 % (41/305) and found that completeness of resection, WHO histologic subtype and tumour size (≥8 cm) were significant on univariate analysis, though only stage (Masaoka) remained independent. [16] In a more general review of TETs it was emphasised that recurrence occurred in 5–50 % of patients depending on stage and follow‑up length. [17] In our study, the relatively low recurrence of 5.1 % may reflect the predominance of benign lesions (which by definition have lower recurrence risk) and possibly favourable resection completeness or follow‑up duration. Moreover, the fact that both recurrences occurred in a neurogenic benign tumour subtype (schwannoma) suggests that even lesions classically regarded as benign may warrant longer vigilance, particularly when surgical margins are uncertain or there are atypical features.Regarding the survival/mortality outcomes, in our study survival was observed in all patients with bronchogenic cyst (2 patients, 5.3 %), esophageal duplication cyst (2 patients, 5.3 %), neurofibroma (1 patient, 2.6 %), schwannoma (3 patients, 7.9 %), teratoma (4 patients, 10.5 %), thymic carcinoma (2 patients, 5.3 %) and thymolipoma (1 patient, 2.6 %). Mortality occurred in one patient (7.7 %) with thymic hyperplasia (out of 13 patients) and one patient (8.3 %) with thymoma (out of 12 patients). The association between histopathological diagnosis and mortality was not statistically significant (p = 0.996). Published series on TETs underscore that overall survival is quite favourable for early stage, completely resected tumours: a study of 136 thymomas reported 5‑year survival of 71 %, 10‑year of 56 %, 15‑year of 44 % and thymoma‑related mortality of ~14 %. [18] Another large series of 235 patients found overall survival rate of 94.4 % (median follow‑up ~105 months), and only 13 disease/treatment‑related deaths.  The relatively low mortality in our series aligns with the expectation for benign lesions or early stage malignant tumours; the non‐significant association between histopathology and mortality may reflect the low number of death events (n=2) limiting statistical power. It may also reflect that many benign mediastinal tumours in adults carry an excellent prognosis. For example, it is well documented that benign mediastinal cysts and neural tumours, once completely resected, have excellent outcomes. [19] Thus our findings are consonant with the literature.The finding that recurrence occurred exclusively in schwannoma merits special comment. Schwannomas (nerve‐sheath tumours) of the posterior mediastinum are typically benign with low recurrence risk if completely excised; however, incomplete resection, tumour size, or capsule violation may increase recurrence risk. Although the studies of posterior mediastinal neurogenic tumours are fewer than those of thymic epithelial tumours, the literature supports that benign posterior lesions have excellent prognosis. For instance, in a paediatric series of 51 mediastinal masses (84.3 % benign) no recurrences were reported for benign neural tumours in the follow‑up. [20] The statistically significant association in our series (p=0.01) between histology and recurrence suggests that histologic subtype indeed matters even for benign mediastinal lesions; this is consistent with broader oncologic principles and warrants emphasising in the discussion.

The study demonstrates that benign mediastinal tumors are more common than malignant ones and generally have excellent outcomes. Recurrence is uncommon and is largely associated with specific histopathological subtypes, whereas mortality is low and not significantly influenced by tumor type. Histopathological classification plays an important role in predicting recurrence risk, while overall survival remains favorable for most patients. Complete surgical excision remains the cornerstone of management, and long-term follow-up is essential, particularly for subtypes prone to recurrence.

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