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Thymoma Presenting as a Thoracic Mass in a Parturient
Abstract Number: SU-26
Abstract Type: Case Report/Case Series
Introduction: Thymic tumors in pregnancy are considered extremely rare, given the 0.1% incidence of cancers diagnosed in pregnancy. We present a case of a large right mediastinal thymoma in a parturient.
Case Presentation: A 25-year-old G3P2 at 14 5/7 weeks EGA presented with intermittent RUQ abdominal pain, non-productive cough and 2-pillow orthopnea. Exam revealed thyromegaly and decreased breath sounds over the right hemithorax. SpO2 was 99% on room air. Chest x-ray revealed a large right pleural effusion and lobular mass. MRI revealed a 19 cm lobulated mixed solid and cystic mass within the right hemithorax with mass effect on the right lung and diaphragm, abutting and possibly invading the pleural space and mediastinum. The patient had an IR ultrasound guided biopsy; cytology was consistent with thymoma. At 15 6/7-weeks EGA she underwent surgical resection of the mass. Day of surgery she reported new symptoms of fatigue, SOB and palpitations. She received a thoracic epidural pre-operatively as well as an arterial line prior to induction. She was placed in a semi-recumbent position and slowly induced with midazolam, fentanyl, and sevoflurane. After adequate ventilation was confirmed, propofol was administered and she was intubated with a left double lumen tube. A right internal jugular TLC was placed and the operation proceeded with a right thorocosternotomy and complete resection of the mass. The patient remained hemodynamically stable and tolerated the procedure well. Estimated blood loss was 350 mL. She was transferred to the surgical ICU and extubated 6 hours later. Fetal heart tones were confirmed pre and post-operatively. Postoperative course was uneventful and the patient was discharged on POD 6. She delivered a healthy female infant at term.
Discussion: Managing a large intrathoracic tumor in a parturient presents several unique challenges. Although parturients are considered a ‘full stomach’ and at risk for aspiration, we chose to maintain spontaneous ventilation and proceed slowly with induction to ensure adequate ventilation and oxygenation, given the risk of airway compromise due to acute obstruction far exceeded the risk of pulmonary aspiration. Maintenance of adequate perfusion, ventilation, and oxygenation is imperative to ensure fetal well-being. Coordination of care between thoracic surgery, maternal fetal medicine, and obstetric anesthesia were instrumental to this patient’s successful outcome.