When laparoscopy for fertility preservation prior to gonadotoxic treatment of an anterior mediastinal mass is a dilemma: A case report

INTRODUCTION: The management of anterior mediastinal masses is a challenge for anesthesiologists. Recommendations for their management in the context of diagnostic or curative surgery are well described. The added risk of laparoscopic surgery for fertility preservation has however never been discussed in the literature. PRESENTATION OF CASE: We present the case of a 32-year-old female patient with a large malignant anterior mediastinal mass. She was referred for anesthesia evaluation before laparoscopic ovarian tissue harvesting as part of fertility preservation prior to gonadotoxic treatment. The patient presented dyspnea at rest. Chest computed tomography revealed a tracheal deviation and a partial obstruction of the left mainstem bronchus. Transthoracic echocardiography showed a pericardial effusion. Proceeding to high risk anesthesia for a non-curative surgery in a patient with a highly symptomatic mass was considered unacceptable and the procedure was postponed. The patient received a single cycle of neoadjuvant chemotherapy. Clinical and radiological improvement were shown after this single dose and laparoscopic surgery was performed under general anesthesia without complications. CONCLUSION: In the context of an anterior mediastinal mass and fertility preservation a thorough benefit-risk analysis must be undertaken before non-curative laparoscopic surgery. In case of severe symptoms, surgery should be postponed until the patient’s condition improves after the minimum necessary chemotherapy treatment. So far it is impossible to say whether the risk exceeds the expected benefit in this difficult situation. Further studies need to be conducted in this area.