mediastinal tumors
DESCRIPTION
anatomy,radiological anatomy,epidemology and case presentation of mediastinal tumorsTRANSCRIPT
mediastinummediastinumMade by: Dr. Isha JaiswalMade by: Dr. Isha Jaiswal
Under guidance of: Prof M.L.B BhattUnder guidance of: Prof M.L.B BhattDate:19Date:19thth march 2014 march 2014
IntroductionIntroductionThe The mediastinummediastinum is is the region in the the region in the
chest between the pleural cavities that chest between the pleural cavities that contain the contain the heart and other thoracic heart and other thoracic viscera except the lungsviscera except the lungs
Boundaries Boundaries AnteriorAnterior - sternum- sternum Posterior Posterior - vertebral column and - vertebral column and
paravertebral paravertebral fasciafascia SuperiorSuperior -thoracic inlet -thoracic inlet InferiorInferior - diaphragm- diaphragm Lateral Lateral - parietal pleura- parietal pleura
Sternal Angle
Thoracic inlet
Thoracic oulet
Boundaries of Boundaries of mediastinummediastinum
sternum
Thoracic vertebra
TS: MediastinumTS: Mediastinum
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CS: MediastinumCS: Mediastinum
Divisions of Divisions of mediastinummediastinum
Superior Mediastinum
Posterior Mediastinum
Anterior Mediastinum
Middle Mediastinum
Sternal Angle T4
T5
divided into superior mediastinum and inferior mediastinum by an imaginary line passing through sternal angle anteriorly lower border of 4th thoracic vertebra posteriorly
Mediastinum divisions Mediastinum divisions
Inferior mediastinumInferior mediastinum:: is subdividedis subdivided intointo
Anterior Anterior mediastinummediastinum
Middle Middle mediastinummediastinum
Posterior Posterior mediastinummediastinum
Superior MediastinumSuperior Mediastinum
BoundariesBoundaries Ant: Manubrium sterniAnt: Manubrium sterni Post: T-1 to T-4 Post: T-1 to T-4 Sides: Mediastinal pleuraSides: Mediastinal pleura Sup: Plane of thoracic Sup: Plane of thoracic
inlet at T1inlet at T1 Inf: Imaginary line joining Inf: Imaginary line joining
sternal angle and lower sternal angle and lower border T-4 border T-4
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Superior Superior Mediastinum Mediastinum
It contains:It contains: TracheaTrachea EsophagusEsophagus Blood vessels (large veins Blood vessels (large veins
& arteries) (listed later)& arteries) (listed later) Nerves (listed later)Nerves (listed later) Thoracic ductThoracic duct ThymusThymus Lymph nodes: (listed Lymph nodes: (listed
later)later)
Superior mediastinum Superior mediastinum contentscontents
Blood VesselsBlood VesselsVeins: SVCLt & Rt brachiocephalic veins,
Arteries:Arch of Aorta Brachiocepalic arteryLt Common carotid Lt subclavian artery
Superior Superior Mediastinum Mediastinum
NervesNerves
1.1. Vagus nerveVagus nerve
2.2. Left Recurrent Left Recurrent Laryngeal Laryngeal nerve.nerve.
3.3. Phrenic nerve.Phrenic nerve.
Superior Superior Mediastinum Mediastinum
Lymph nodes: Highest mediastinal Paratracheal Prevascular retrotracheal
Anterior MediastinumAnterior Mediastinum
Lies ant. to pericardiumLies ant. to pericardiumBoundaries:Boundaries:
Anterior: body of sternumPosterior: pericardiumsuperior: imaginary line separating sup. & inf.mediastinumInfreior: diaphragmLateral: mediastinal pleura
Anterior mediastinum: Anterior mediastinum: contains:contains:
a.a. Thymus Thymus glandgland
b.b. Lymph Lymph NodesNodes
c.c. Fat.Fat.
ThymusThymus Located in anterior Located in anterior
mediastinum.mediastinum. Develops from Develops from
endoderm of 3endoderm of 3rdrd pharyngeal pouchpharyngeal pouch
Present in childhood, Present in childhood, involutes in adultsinvolutes in adults
Blood supplyBlood supplyArterial :i nt. Mammary arteries
Venous: internal thoracic veins
Lymphatic drainage: lower cervical, int. Mammary and hilar nodes
Middle MediastinumMiddle MediastinumBoundaries:Boundaries:
Anterior: posterior surface of sternum
Posterior: oesophagus, desc. thoracic aorta, azygous vein
Superior: plane seperating sup.& inf mediastinum
Inferior: diaphragmLateral: mediastinal pleura
Middle MediastinumMiddle MediastinumContents:Contents:
HeartHeart enclosed in pericardium enclosed in pericardium
Arteries:Arteries: Ascending Aorta, Ascending Aorta, Pulmonary trunk with its Lt &Pulmonary trunk with its Lt & Rt branchesRt branches
VeinsVeins: SVC,Pulmonary veins: SVC,Pulmonary veins
Nerves:Nerves: Phrenic, vagus nerve Phrenic, vagus nerve
Bifurcation of Trachea with Bifurcation of Trachea with two principal bronchitwo principal bronchi
Tracheobronchial lymph nodesTracheobronchial lymph nodes
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Posterior MediastinumPosterior Mediastinum Boundaries:Boundaries:
Ant.Ant. Pericardium, Bifurcation of Pericardium, Bifurcation of tracheatrachea
Post.Post. T5 to T12 T5 to T12
sup. sup. Transverse thoracic planeTransverse thoracic plane
Inf. Inf. diaphragmdiaphragm
Sides: Sides: Mediastinal pleuraMediastinal pleura
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Posterior MediastinumPosterior MediastinumContents:Contents: OesophagusOesophagus Arteries Arteries Descending Aorta with Descending Aorta with
its brsits brs VeinsVeins AzygosAzygos Hemizygos Hemizygos Accessory hemizygosAccessory hemizygos Nerves:Nerves: VagusVagus Splanchnic nervesSplanchnic nervesThoracic ductThoracic ductlymph nodeslymph nodes Posterior mediastinal Posterior mediastinal
Trachea: anatomyTrachea: anatomy
LENGTH:10-15 cm
DIAMETER: 2cm in males &1.5 cm in females
Lined by ciliated columnar epithelium
Lower level at T6 on inspiration & T4 on expiration
Made of c shape rings 2 rings per cm The rings make tube convex
anterolateraly Posteriorly the gap is filled by
trachealis muscle.
NERVE SUPPLY:NERVE SUPPLY:
LYMPHATIC DRAINAGELYMPHATIC DRAINAGE Pretracheal Pretracheal paratracheal lymph nodeparatracheal lymph node
PARA SYMPHATHETIC: PARA SYMPHATHETIC: vagus & recurrent vagus & recurrent laryngeal nerves laryngeal nerves ((sensory & secreto-motor sensory & secreto-motor to mucous membrane to mucous membrane motor to trachealis motor to trachealis muscle)muscle)
SYMPHATHETIC: -SYMPHATHETIC: -middle cervical middle cervical ganglion ganglion (vasomotor)(vasomotor)
Blood supplyBlood supplyARTERIAL SUPPLYARTERIAL SUPPLYUpper tracheaUpper trachea
Inferior thyroid arteryInferior thyroid arteryLower partLower part
Branches of the Branches of the bronchial arterybronchial artery
VENOUS DRAINAGE VENOUS DRAINAGE Upper part :Upper part : left brachiocephalic left brachiocephalic
veinveinLower part:Lower part:
Inferior thyroid veinInferior thyroid vein
Radiological antomyRadiological antomy
CHEST X-RAYCHEST X-RAY
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Tracheobronchial anatomyTracheobronchial anatomy
Tracheal Displacement Due to Goiter
Clues to locate mass to Clues to locate mass to mediastinummediastinum
Mediastinal masses : Masses in the lung
not contain air bronchograms mediastinal mass will create
obtuse angles with the lung . Mediastinal lines will be
disrupted
– May contain air bronchograms
– A lung mass abutts the mediastinal surface and creates acute angles with the lung
LEFT: A lung mass abutts the mediastinal surface and creates acute angles with the lung.RIGHT: A mediastinal mass will sit under the surface of the mediastinum, creating obtuse angles with the lung
Cervicothoracic signCervicothoracic sign
The anterior mediastinum ends at the level of the The anterior mediastinum ends at the level of the clavicles.clavicles.
The posterior mediastinum extends much higher.The posterior mediastinum extends much higher.
ThereforeTherefore any mass that remains sharply outlined in any mass that remains sharply outlined in
the apex of the thorax must be posterior the apex of the thorax must be posterior and entirely within the chest, and and entirely within the chest, and
any mass that disappears at the clavicles any mass that disappears at the clavicles must be anterior and extends into neckmust be anterior and extends into neck
See sharp margin
above clavicle
Mass is in posterior mediastinum. because it remains sharply outlined in apex of thorax, indicating that it is surrounded by lung.This particular example is a ganglioneuroma
Thoracoabdominal signThoracoabdominal sign A sharply marginated mediastinal mass seen through A sharply marginated mediastinal mass seen through
the diaphragm must lie entirely within the chest.the diaphragm must lie entirely within the chest.
The posterior costophrenic sulcus extends far more The posterior costophrenic sulcus extends far more caudally than the anterior aspect of the lungcaudally than the anterior aspect of the lung
ThereforeTherefore Any mass that extends below the dome of the Any mass that extends below the dome of the
diaphragm and remains sharply outlined must diaphragm and remains sharply outlined must be in the posterior compartments and be in the posterior compartments and surrounded by lung, andsurrounded by lung, and
Any mass that terminates at dome of Any mass that terminates at dome of diaphragm must be anteriordiaphragm must be anterior
Can you see the
outline of themass below
the diaphragm?
Margin of mass is apparent and below diaphragm, therefore this must be in the middle or posterior compartments where it is surrounded by lungThis example is a ‘Lipoma’
Hilum overlay signHilum overlay sign Principle of hilum overlayPrinciple of hilum overlay An anterior mediastinal mass will overlap the main An anterior mediastinal mass will overlap the main
pulmonary arteries, therefore they will be seen within pulmonary arteries, therefore they will be seen within the margins of the massthe margins of the mass
Hilum can be seen through mass
this must be an anterior mediastinal mass because it overlaps rather than “pushes out” the main pulmonary arteries
This particular example is a thymoma
VASCULAR ANATOMYVASCULAR ANATOMY
At T3 LevelAt T3 Level
At T4 LevelAt T4 Level
At T5 LevelAt T5 Level
At T6 LevelAt T6 Level
MEDIASTINAL TUMORSMEDIASTINAL TUMORSEPIDEMOLOGYEPIDEMOLOGY
Mediastinal malignancies are heterogenous in natureMediastinal malignancies are heterogenous in nature.. most masses (> 60%) are: most masses (> 60%) are:
ThymomasThymomas Neurogenic TumorsNeurogenic Tumors Benign CystsBenign Cysts Lymphadenopathy (LAD)Lymphadenopathy (LAD)
In children the most common (> 80%) are: In children the most common (> 80%) are: Neurogenic tumorsNeurogenic tumors Germ cell tumorsGerm cell tumors Foregut cystsForegut cysts
In adults the most common are: In adults the most common are: LymphomasLymphomas LADLAD ThymomasThymomas Thyroid massesThyroid masses
Mediastinal MassesMediastinal Masses
Compartment % Malignant
Anterosuperior 59
Middle 29
Posterior 16
Mediastinal division
Most common tumors
Anterior-superior thymomamiddle lymphomaposterior Neurogenic
tumors
Anterosuperior Masses Thymus
• Thymoma• Thymic carcinoma• Thymic cyst• Thymic carcinoid• Thymolipoma
Mediastinal Lymphoma• Hodgkin’s Lymphoma• Non-Hodgkin’s Lymphoma
Mesenchymal tumors
Germ Cell Tumor• Seminoma• Non seminomatous Germ Cell
• Embryonal cell carcinoma• Endodermal sinus tumor• Choriocarcinoma
• Teratoma• Mature• Immature
Endocrine tumors• Thyroid tumors• Parathyroid adenoma
Middle mediastinal masses
Mediastinal Lymphoma• Hodgkin’s Lymphoma• Non-Hodgkin’s Lymphoma
Mesenchymal tumors
CYST:• Bronchogenic cyst• Thoracic duct• Meningoceles
Cardiac & pericardial tumors
Tracheal tumors
vascular tumors
Lymphadenopathy• Inflammatory• Granulomatous• sarcoidosis
Posterior mediastinal masses
Mediastinal Lymphoma• Hodgkin’s Lymphoma• Non-Hodgkin’s Lymphoma
Mesenchymal tumors
Neurogenic tumors• Peripheral nerves• Symphathetic ganglia• paraganglia
ENDOCRINE TUMORS
ESOPHAGEAL TUMORS & CYSTS
Tumors of thymusTumors of thymus
ThymomasThymomas Thymic carcinomasThymic carcinomas Thymic lymphomasThymic lymphomas CarcinoidsCarcinoids ThymolipomasThymolipomas SecondariesSecondaries
ThymomaThymoma
PresentationPresentation Most common primary anterior Most common primary anterior
mediastinal tumormediastinal tumor M=F, most >40M=F, most >40 Most patients are asymptomaticMost patients are asymptomatic Half of patients suffer have associated Half of patients suffer have associated
parathymic syndromesparathymic syndromes• myasthenia gravismyasthenia gravis• hypogammaglobulinemiahypogammaglobulinemia• pure red cell aplasiapure red cell aplasia
1/3 have chest pain, cough or dyspnea on 1/3 have chest pain, cough or dyspnea on presentationpresentation
Myasthenia gravis occurs in 30-50% of pts Myasthenia gravis occurs in 30-50% of pts with thymoma. Hypogammaglobulinemia with thymoma. Hypogammaglobulinemia occurs in 10% of pts with thymomaoccurs in 10% of pts with thymoma
Pure red cell aplasia occurs in 5%, but Pure red cell aplasia occurs in 5%, but thymoma occurs in 50% of pts with red cell thymoma occurs in 50% of pts with red cell aplasiaaplasia
ThymomaThymoma
lobulated mass in the anterior lobulated mass in the anterior mediastinum mediastinum
thymomathymoma
Invasive thymomaInvasive thymoma Encasement of Encasement of
mediastinal mediastinal structures, structures, infiltration of fat infiltration of fat planes, and an planes, and an irregular interface irregular interface between the mass between the mass and lung and lung parenchyma, are parenchyma, are highly suggestive highly suggestive of invasion. of invasion.
Pleural thickening, Pleural thickening, nodularity, or nodularity, or effusion generally effusion generally indicates pleural indicates pleural invasion by the invasion by the thymoma thymoma
Thymic CarcinoidThymic Carcinoidcarcinoid tumors (neuroendocrine tumors) of the thymus are very carcinoid tumors (neuroendocrine tumors) of the thymus are very
rare, rare, accounting for <5% of all neoplasms of the anterior mediastinum.accounting for <5% of all neoplasms of the anterior mediastinum. They originate from the normal thymic Kulchitsky cells, which They originate from the normal thymic Kulchitsky cells, which
belong to the amine precursor uptake and decarboxylation belong to the amine precursor uptake and decarboxylation (APUD) group (APUD) group
PresentationPresentation men aged 30 to 50 years men aged 30 to 50 years (male/female ratio: 3:1)(male/female ratio: 3:1) Rarely associated with carcinoid syndromeRarely associated with carcinoid syndrome Associated endocrine abnormalities: Cushing’s syndrome due Associated endocrine abnormalities: Cushing’s syndrome due
to ectopic ACTH or MENto ectopic ACTH or MEN 73% have regional lymph node and/or distant osteoblastic bone 73% have regional lymph node and/or distant osteoblastic bone
metsmets
Thymic carcinoid tumor in a 22-year-old man with a 3-month Thymic carcinoid tumor in a 22-year-old man with a 3-month history of a persistent dry cough. history of a persistent dry cough.
Contrast-enhanced CT scan shows a heterogeneously Contrast-enhanced CT scan shows a heterogeneously enhancing thymic mass . enhancing thymic mass .
PET image shows intense FDG uptake by the massPET image shows intense FDG uptake by the mass
Thymic CarcinomaPresentation
•M>F, 40s
•Thymic carcinomas are less common than thymomas, more aggressive with a higher propensity for capsular invasion
•Early local invasion, widespread lymphatic and hematogenous metastases
•Clinically, patients present initially with tussis, dyspnea, pleuritic chest pain, phrenic nerve palsy, or superior vena cava syndrome
80% of patients with thymic carcinoma may have radiographic evidence of invasion into adjacent structures in the mediastinum
40% may have evidence of mediastinal lymphadenopathy
•Distant metastases to regional lymphatics, bone, liver, kidney, and lung are a common clinical feature
Thymic CarcinomaThymic Carcinoma
Thymic Thymic carcinomas carcinomas behave more behave more aggressively than aggressively than invasive invasive thymomas and thymomas and are more likely to are more likely to metastasize to metastasize to distant sites distant sites
Thymic LymphomasThymic LymphomasLymphoma is the Lymphoma is the
most common most common cause of an cause of an anterior anterior mediastinal mass mediastinal mass in children and in children and the second most the second most common cause of common cause of an anterior an anterior mediastinal mass mediastinal mass in adults. in adults.
cancers of the head and neck, abdomen, and pelvis can cancers of the head and neck, abdomen, and pelvis can involve the thymus via lymphatic pathways involve the thymus via lymphatic pathways
Metastatic Metastatic disease to the disease to the thymus in a 10-thymus in a 10-year-old boy 2 year-old boy 2 years after years after diagnosis of diagnosis of alveolar alveolar rhabdomyosarcorhabdomyosarcoma of the thigh. ma of the thigh.
Secondary Tumors of the Thymus
Mediastinal lymphomaMediastinal lymphoma
Primary Mediastinal Primary Mediastinal LymphomaLymphoma
5-10% of patients with lymphoma present 5-10% of patients with lymphoma present with primary mediastinal lesionswith primary mediastinal lesions
Primary mediastinal lymphoma represents Primary mediastinal lymphoma represents 10-20% of primary mediastinal masses in 10-20% of primary mediastinal masses in adults and are usually in the adults and are usually in the anterosuperior compartmentanterosuperior compartment
Usually present with fever, weight loss and Usually present with fever, weight loss and night sweatsnight sweats
Pain, dyspnea, stridor, SVC syndrome due Pain, dyspnea, stridor, SVC syndrome due to mass effects are uncommonto mass effects are uncommon
Primary Mediastinal Primary Mediastinal LymphomaLymphoma
Two TypesTwo Types Primary Mediastinal Hodgkin’s Primary Mediastinal Hodgkin’s
LymphomaLymphoma Primary Mediastinal Non-Hodgkin’s Primary Mediastinal Non-Hodgkin’s
LymphomaLymphoma• Poorly differentiated lymphoblasticPoorly differentiated lymphoblastic• Diffuse lymphocyticDiffuse lymphocytic• Primary Mediastinal B-cell LymphomaPrimary Mediastinal B-cell Lymphoma
Primary Mediastinal Hodgkin’s Primary Mediastinal Hodgkin’s LymphomaLymphoma
PresentationPresentation Incidental mediastinal mass on chest xray Incidental mediastinal mass on chest xray
is 2nd most common presentation after is 2nd most common presentation after asymptomatic lymphadenopathyasymptomatic lymphadenopathy
Mass is usually large, rarely causes Mass is usually large, rarely causes retrosternal chest pain, cough, dyspnea, retrosternal chest pain, cough, dyspnea, effusions or SVC syndromeeffusions or SVC syndrome
Bimodal age distribution Bimodal age distribution ““B” symptoms: fever, weight loss (>10% B” symptoms: fever, weight loss (>10%
body wt in 6 months), night sweatsbody wt in 6 months), night sweats Generalized pruritus presentGeneralized pruritus present
A chest CT exam shows the mass to extend from the neck to the diaphragm, compressing the tracheal and left mainstem bronchus leading to left lower lobe atelectasis. The chest wall mass is partially eroding the sternum.Dx:Lymphoma, Hodgkin, Anterior Mediastinal, Sternal Involvement
Two contiguous slices from an enhanced chest CT exam show a homogenous, solid, anterior mediastinal mass and a large right pleural effusion.
Dx-LymphomaNon-Hodgkin, Anterior Mediastinal
Mediastinal Germ Cell Mediastinal Germ Cell TumorsTumors
Primary extragonadal germ cell tumors Primary extragonadal germ cell tumors comprise 2% to 5% of all germ cell comprise 2% to 5% of all germ cell tumors tumors
Approximately two thirds of these Approximately two thirds of these tumors occur in the mediastinum tumors occur in the mediastinum
The mediastinum is the most common The mediastinum is the most common site of primary extragonadal germ cell site of primary extragonadal germ cell tumors in young adults tumors in young adults
Represent 10-15% of adult Represent 10-15% of adult anterosuperior mediastinal tumorsanterosuperior mediastinal tumors
they presumably arise from germ cells that they presumably arise from germ cells that migrate along the urogenital ridge during migrate along the urogenital ridge during embryonic development .embryonic development .
The embryologic urogenital ridge extends The embryologic urogenital ridge extends from C6 to L4 and after malignant from C6 to L4 and after malignant transformation of displaced germ cells, transformation of displaced germ cells, explains the development of primary germ explains the development of primary germ cell tumors outside the gonadscell tumors outside the gonads
Mediastinal Germ Cell Mediastinal Germ Cell TumorsTumors
Mediastinal Germ Cell Mediastinal Germ Cell TumorsTumors
Three typesThree types TeratomaTeratoma SeminomaSeminoma Nonseminomatous Germ Cell TumorNonseminomatous Germ Cell Tumor
Mediastinal TeratomasMediastinal Teratomas
Most common mediastinal germ cell tumorMost common mediastinal germ cell tumor Three types:Three types:
• Mature: benign, well-differentiatedMature: benign, well-differentiated• Immature: contains >50% immature Immature: contains >50% immature
components, may recur or metastasizecomponents, may recur or metastasize• Malignant: a mature teratoma that contains a Malignant: a mature teratoma that contains a
focus of carcinoma, sarcoma or malignant GCTfocus of carcinoma, sarcoma or malignant GCT
Mature TeratomaMature Teratoma Occurs in children and young adultsOccurs in children and young adults Usually asymptomatic, but if large enough, Usually asymptomatic, but if large enough,
may cause chest pain, dyspnea, cough or may cause chest pain, dyspnea, cough or other symptoms of mediastinal compressionother symptoms of mediastinal compression
Contains derivatives of all three primitive Contains derivatives of all three primitive germ layers includinggerm layers including• Ectoderm: teeth, skin, hairEctoderm: teeth, skin, hair• Mesoderm: cartilage and boneMesoderm: cartilage and bone• Endoderm: bronchial, intestinal and pancreatic Endoderm: bronchial, intestinal and pancreatic
tissuetissue Expectoration of hair (trichoptysis) is rare Expectoration of hair (trichoptysis) is rare
but pathognomonicbut pathognomonic
Dx Teratoma, Anterior Mediastinal
CT exam show a low density mass in the anterior mediastinum with irregular walls with calcium in it.
Mediastinal SeminomaMediastinal Seminoma
Represents 40% of malignant mediastinal Represents 40% of malignant mediastinal GCTsGCTs
Afflicts Caucasian men in 20s-30sAfflicts Caucasian men in 20s-30s Only rarely represents a metastatic lesion Only rarely represents a metastatic lesion
from a testicular primary tumor, but testicular from a testicular primary tumor, but testicular USG is usually performed to rule this outUSG is usually performed to rule this out
If any other germ cell tumor histology is If any other germ cell tumor histology is identified in the tumor, it is treated as a mixed identified in the tumor, it is treated as a mixed NSGCTNSGCT
AFP normal, AFP normal, -HCG may be elevated in 10%-HCG may be elevated in 10%
Mediastinal SeminomaMediastinal SeminomaPresentationPresentation Slow growing tumor, usually symptomatic at Slow growing tumor, usually symptomatic at
diagnosisdiagnosis Commonly presents with chest pain, Commonly presents with chest pain,
dyspnea, cough, weight lossdyspnea, cough, weight loss Presents infrequently with SVC syndromePresents infrequently with SVC syndrome Bulky, lobulated, homogeneous mass, no Bulky, lobulated, homogeneous mass, no
calcificationscalcifications Usually not invasive, but many have Usually not invasive, but many have
metastasized to regional lymph nodes, lung metastasized to regional lymph nodes, lung and/or bone by the time of diagnosisand/or bone by the time of diagnosis
Mediastinal Mediastinal Nonseminomatous Germ Nonseminomatous Germ
Cell TumorsCell Tumors Five TypesFive Types
• Embryonal cell carcinomaEmbryonal cell carcinoma• Endodermal sinus tumor: elevated AFPEndodermal sinus tumor: elevated AFP• Choriocarcinoma: elevated Choriocarcinoma: elevated -HCG -HCG • Malignant TeratomaMalignant Teratoma• MixedMixed
Mediastinal Mediastinal Nonseminomatous Germ Nonseminomatous Germ
Cell TumorsCell Tumors NSGCTs of the mediastinum have a worse NSGCTs of the mediastinum have a worse
prognosis than mediastinal seminomas or prognosis than mediastinal seminomas or teratomasteratomas
Occur in men in the 20-40 age groupOccur in men in the 20-40 age group 20% of patients also have Klinefelter’s 20% of patients also have Klinefelter’s
syndromesyndrome
Tracheal tumorsTracheal tumors
Extremely rare tumors.Extremely rare tumors. Comprise of 0.1 to 0.4 %of all diagnosed Comprise of 0.1 to 0.4 %of all diagnosed
malignanciesmalignancies Two types: squamous cell carcinoma M:F=3:1 Two types: squamous cell carcinoma M:F=3:1
Age:6Age:6thth decade decade
adenoid cystic carcinomas M:F=1:1 adenoid cystic carcinomas M:F=1:1 younger ageyounger age
Clinical feature: cough, dysnoea, dysphagia,stridor Clinical feature: cough, dysnoea, dysphagia,stridor hemoptysis, dysphoniahemoptysis, dysphonia
Clinical presentation of Clinical presentation of mediastinal massmediastinal mass
Clinical PresentationClinical Presentation
Asymptomatic massAsymptomatic mass Incidental discovery – most commonIncidental discovery – most common 50% of all mediastinal mass are asymptomatic50% of all mediastinal mass are asymptomatic 80% of such mass are benign80% of such mass are benign More than half are malignant if with More than half are malignant if with
symptomssymptoms
Clinical PresentationClinical Presentation 11 Effects on Compression or invasion of Effects on Compression or invasion of adjacent tissuesadjacent tissues Chest painChest pain, from traction on mediastinal mass, tissue , from traction on mediastinal mass, tissue invasion, or bone erosion is commoninvasion, or bone erosion is common CoughCough, because of extrinsic compression of the , because of extrinsic compression of the trachea or bronchi, or erosion into the airway itselftrachea or bronchi, or erosion into the airway itself Hemoptysis, hoarseness or stridorHemoptysis, hoarseness or stridor Pleural effusion, invasion or irritation of pleural spacePleural effusion, invasion or irritation of pleural space Dysphagia, invasion or direct invasioin of the Dysphagia, invasion or direct invasioin of the esophagusesophagus Pericarditis or pericardial tamponadePericarditis or pericardial tamponade Right ventricular outflow obstruction and cor Right ventricular outflow obstruction and cor pulmonapulmonalele
Clinical PresentationClinical Presentation
22 Effects on Compression of nerves Effects on Compression of nerves Hoarseness, invading or compressing the Hoarseness, invading or compressing the
nerves recurrent laryngeal nerve nerves recurrent laryngeal nerve Horners syndrome, involvement of the Horners syndrome, involvement of the
sympathetic gangliasympathetic ganglia Dyspnea, from phrenic nerve involvement Dyspnea, from phrenic nerve involvement
causing diaphragmatic paralysiscausing diaphragmatic paralysis Tachycardia, secondary to vagus nerve Tachycardia, secondary to vagus nerve
involvemenTinvolvemenT
Clinical PresentationClinical Presentation Superior vena cavaSuperior vena cava
Vulnerable to extrinsic compression and obstruction Vulnerable to extrinsic compression and obstruction because it is thin walled and its intravascular because it is thin walled and its intravascular pressure is low.pressure is low.
Superior vena cava syndromeSuperior vena cava syndrome Results from the increase venous pressure in the Results from the increase venous pressure in the
upper thorax , head and neck upper thorax , head and neck characterized by dilation of the collateral veins in the characterized by dilation of the collateral veins in the
upper portion of the head and thorax and edema upper portion of the head and thorax and edema oand phlethora of the face, neck and upper torso, oand phlethora of the face, neck and upper torso, suffusion and edema of the conjunctiva and cerebral suffusion and edema of the conjunctiva and cerebral symptoms such as headache, disturbance of symptoms such as headache, disturbance of consciousness and visual distortionconsciousness and visual distortion
Bronchogenic carcinoma and lymphoma are the Bronchogenic carcinoma and lymphoma are the most common etiologiesmost common etiologies
Clinical PresentationClinical Presentation
Systemic symptoms and syndromesSystemic symptoms and syndromes Fever, anorexia, weight loss and other non Fever, anorexia, weight loss and other non
specific symptoms of malignancy .specific symptoms of malignancy .
Mediastinal mass: pre Mediastinal mass: pre treatment evaluationtreatment evaluation
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