When should a pediatric patient with an unexplained chest mass be referred to surgery?

When to Refer a Pediatric Patient with an Unexplained Chest Mass to Surgery

A pediatric patient with an unexplained chest mass should be referred to a pediatric surgeon immediately upon discovery, as a high proportion of chest wall and mediastinal masses in children are malignant and require prompt evaluation and potential surgical intervention. 1, 2

Immediate Surgical Referral Criteria

Age-Based Mandatory Referral

• All patients ≤5 years of age with chest masses must be referred to a pediatric surgeon, as this is the established age cutoff for mandatory pediatric surgical specialist involvement 1, 3
• Patients with medical conditions that increase operative risk (congenital heart disease, preterm birth) require pediatric surgeon management regardless of age 1, 3

Clinical Presentation Requiring Urgent Referral

• Any palpable chest wall mass warrants immediate surgical consultation, as chest wall tumors in children carry significant malignancy risk 2
• Masses presenting with pain or respiratory distress require emergent evaluation 2
• Mediastinal masses with signs of superior mediastinal obstruction (large volume pleural effusion, absence of acute fever, evidence of lymphadenopathy) require urgent but cautious surgical approach, as general anesthesia poses significant risk of sudden death 1

Diagnostic Workup Prior to Surgical Referral

Initial Imaging Sequence

• Chest radiography should be obtained first to define location and morphology 1, 4
• CT chest with contrast is the primary cross-sectional imaging modality for most mediastinal masses and should be performed to characterize the lesion and assess for invasion 1, 4
• MRI is preferred over CT for posterior mediastinal masses or suspected vascular lesions, as it provides superior soft tissue contrast for detecting chest wall invasion and neurovascular involvement 1, 4

Critical Imaging Findings That Mandate Surgical Consultation

• Evidence of invasion across tissue planes, into large blood vessels, or chest wall involvement indicates higher probability of incomplete resection and directs surgical planning versus neoadjuvant therapy 1
• Solid masses require tissue diagnosis, as the differential includes Ewing's sarcoma/PNET, rhabdomyosarcoma, osteosarcoma, neurogenic tumors, and teratomas 2, 5, 4

Surgical Approach Algorithm

Biopsy Strategy

• Initial incisional biopsy is performed in most cases due to the significant risk of malignancy in pediatric chest masses 2
• The type of biopsy should be selected based on mass size, location, relation to airways, complication risk, and available expertise 1
• For suspected malignancy with mediastinal obstruction, only small volume aspiration (5 mL) for diagnostic purposes should be performed, avoiding general anesthesia/sedation 1

Definitive Surgical Management

• Robotic or thoracoscopic resection is safe and effective for solid mediastinal masses, with operative times averaging 113 minutes and short hospitalization (1.4 days average) 6
• Initial chemotherapy may be administered before resection for malignant small round cell tumors and osteosarcoma to decrease tumor size, vascularity, and friability, facilitating surgical resection 2
• Cure requires successful local control combined with adjuvant chemotherapy, particularly challenging in children presenting with metastases 2

Common Pitfalls to Avoid

• Do not delay surgical referral while pursuing extensive imaging workup—once a chest mass is identified on initial CT, immediate pediatric surgeon consultation should occur 1, 2
• Do not assume benign pathology based on imaging alone—80% of mediastinal masses in children are lymphoma, thymic enlargement, teratomas, foregut cysts, or neurogenic tumors, but malignancy rates are high and tissue diagnosis is essential 4, 2
• Avoid general anesthesia for large volume fluid aspiration in patients with suspected mediastinal malignancy and superior obstruction, as this carries significant mortality risk 1
• Do not refer to general surgeons for children ≤5 years—these patients require pediatric surgeons who have completed 5-year general surgery residency plus 2-year pediatric surgery fellowship 1, 3

Special Considerations

• Infants and children with solid malignancies should be cared for from the outset by a pediatric surgeon and pediatric medical oncology specialist as part of a multispecialty team 1
• Minimally invasive procedures (thoracoscopy) in infants and children should be performed by a pediatric surgeon trained in these techniques 1
• Seriously injured children with chest trauma should be stabilized locally then transferred to a pediatric trauma center with pediatric surgical specialists 1