and Resection: Anesthetic Techniques and Perioperative Concerns

The patient was a 39-year-old man, on active duty in the Navy, with no significant past medical history who pre-sented to the emergency department in mid-October with a 1 month history of progressive dyspnea with exertion and right shoulder pain. The dyspnea had progressed from mild dyspnea to shortness of breath occurring with minimal ambulation and shipboard activities. A chest X-ray was performed in the emergency department, which showed an elevated right hemidiaphragm and a large right-sided mediastinal mass, which was then confirmed by chest CT scan. The mass initially measured 9.4 cm × 7.8 cm × 9.8 cm and demonstrated mass effect and severe narrowing of the right superior pulmonary vein. The tracheobronchial struc-tures were widely patent at that time. Testicular ultrasound was negative for testicular neoplasm, although patient history was significant for an undescended testicle on the right until 3 years prior. Lab studies were only significant for an elevated α-fetoprotein level of 225.6 ng/mL (normal 0-15 ng/mL). The remaining labs, including B-HCG, were normal. The patient was referred to the oncology service, and the differential diagnosis initially included germ-cell tumor (GCT), lymphoma, and thymoma. There were no palpable superficial lymph nodes on exam, so the patient was scheduled for a CT scan–guided biopsy of the mass. Pulmonary function tests (PFTs) in the upright and supin