Tumor-to-thoracic height and width ratios as adjunct imaging markers for preoperative risk stratification in minimally invasive surgery for pediatric mediastinal masses

Selecting the optimal surgical approach for pediatric mediastinal masses is challenging because absolute tumor size does not adequately reflect the available intrathoracic working space in children. This study evaluated whether the tumor-to-thoracic height ratio (TTH) and tumor-to-thoracic width ratio (TTW) are associated with intraoperative complications during minimally invasive surgery (MIS). Sixty-five children who underwent surgical resection of mediastinal masses between 2007 and 2025 were retrospectively reviewed. Fifty-six underwent MIS, and nine underwent open thoracotomy. TTH and TTW were calculated using preoperative chest radiography and computed tomography or magnetic resonance imaging. Associations with intraoperative complications in the MIS group were analyzed, and receiver operating characteristic analysis was performed as an exploratory assessment. Intraoperative complications occurred in five of 56 patients undergoing MIS. Both TTH and TTW were significantly higher in patients with complications than in those without (TTH: 0.51 vs. 0.26, p = 0.004; TTW: 0.67 vs. 0.37, p = 0.005). Positive image-defined risk factors were also more frequent in patients with complications. The area under the curve was 0.894 for TTH and 0.882 for TTW. TTH and TTW may serve as useful exploratory adjunct imaging markers for preoperative risk stratification in pediatric MIS for mediastinal masses.