KCK Mediastinal Mass

As part of a workup for a chronic cough KCK underwent a chest x-ray and was shocked when the GP revealed that there was a suspicious area in the center of the chest behind the sternum (breast bone).  A PET scan “lit up” and a subsequent referral to a thoracic surgeon came to the conclusion that it was most likely a cancerous tumor.  The possibilities included thymoma (benign), thymus carcinoma (malignant), thyroid or parathyroid neoplasms (benign or malignant), lymphoma, metastatic disease from a distant primary cancer, etc.  The idea that it might be benign was small, and the consideration of an infective process was extremely unlikely.  After undergoing a needle aspiration under local/sedation the results were still not defined as the diagnosis was necrotic debris.  A decision as to whether a head and neck surgeon or a thoracic surgeon should be consulted was considered.  A surgical approach beginning with a neck exploration into the upper mediastinum was recommended with the possibility that an open sternotomy would be required.  The entire mass with necrotic debris was removed from the lower neck incision and the final diagnosis was:  histoplasmosis or Ohio Valley Fever, an infectious process treatable with antibiotics.

Role of Proxy: The Client and proxy discussed, in lay terms, the anatomy, why certain tests were performed, what recommended alternatives were and their risks, expected outcomes, difference between surgical specialties, and what was best for the patient based on his/her desires and fears. With a full discussion the patient felt less anxious and ore confident in the huis/her decision to undergo surgery by the head and neck surgeon.