Mediastinal Tumors and Cysts

Sung Chul Hwang, M.D.Dept. of Pulmonary and Critical Care Medicine

Ajou University School of Medicine

Introduction

• Silent in early phase• Mainly cause pressure symptoms• Incidentally discovered by routine x-rays• Specific disease entities according to anatomica

l, and embryologic origin• 50% malignant in children where as 25% in adult

s• Metastatic tumor is the most common tumor

• Pain• Cough• Hemoptysis• SVC syndrome• Hoarseness• Dyspnea• Horner’s syndrome

• Dysphagia• Pleural effusion• Stridor• Myathenia Gravis• Phrenic nerve palsy• Chylothorax

Symptoms and Signs

Diagnosis

• Chest PA & Lateral• Bucky film• Chest CT• Fluoroscopy• Bronchoscopy• Esophagogram

• NAB• Isotope Scanning• Angiography• Thoracotomy• VATS• Medistinoscopy

Common Diseases of the Mediastinum

Thymoma• Anterior and Superior mediastinum• Most common (20%)of mediastinal tumor in adults but rare

ly seen in children• 2/3 is malignant• Equal frequency in males and females • 30 – 50 yrs• Various Classification : Lymphocytic, Epithelial, Spindle Cel

l• 50% are asymptomatic• Associated diseases : MG (35%), PRCA, DiGeroge SD, Car

cinoid, Eaton-Lambert, agammaglobulinemia, myocarditis, thyrotoxicosis, etc

Thymoma (Staging)

• Stage I : contained within an intact capsule

• Stage II: extension through the capsule to surrounding fat, pleura, pericardium

• Stage III : Intrathoracic metastasis• Stage IV: Extrathoracic Metastasis

Thymoma(Treatment)

• Stage I : Surgical resection Recurrence 2-12%

• Stage II & III : Surgery + Radiotherapy• Stage IV : Multimodality Induction ch

emotherapy, surgery + post op Radiotherapy

• 5-year Survival 12 – 54 %, not affected by the presence of Myasthenia Gravis

Thymoma

Thymoma

massCa++

Thymus

Lymphoma

• Metastatic is most common• 5-10% is mediastinal primary• Second moost common Anterior Me

diastinal Mass in Adults• Malignant > Hodgkin’s • Dx: Mediastinoscopy, thoracotomy• NAB : Usually not confirmatory

Hodgkin’s Lymphoma

“mediastinal widening”

Germ Cell Tumors

• Anterior Mediastinal location• Mainly in late teens 15 %of Ant. Med. Tumors in

Adults, 24 % in children• 1/5 is Malignant• Cystic Teratoma(Dermoid Cyst) vs. Solid tumor (T

eratoma)• Solid tumor : 1/3 malignant• Radiosensitive• Teratoma, Malignant teratoma, Seminoma(dysger

minomas)

Teratoma

Teratoma

Teratoma

Teratoma

Substernal Thyroid Tissues

• Develops from cervical goiter or intrathoracic remnants

• Can be diagnosed without biopsy by Radioactive iodine scan

• No treatment unless symptomatic, usually pressure symptoms

Rtrosternal Goiter

Neurogenic Tumors

• Posterior mediastinal location• 1/5 of mediastinal tumor• Originate in neural crest• Ganglioheuroma : most common in the t

extbook• Neurilemmoma – most common in Kore

a : “Dumb bell Tumor”, neural sheath origin

Poosterior Mediastinal Tumor ( Neurillemmoma) )

“Dumb-bell”Tumor

Neurilemmoma(Schwannoma)

Para-ganglioma

Mesenchymal Tumors

• Lipoma, Fibroma, Mesothelioma• Superior or Anterior mediastinal location• Diagnosis with CT scan• May cause Hypoglycemia

Mediastinitis

• Acute : endoscopy complication, Boerhaave’s SD, operation, esophageal rupture, median sternotomy

• Chronic : Tbc, histoplasmosis, silicosis, fibrosing mediastinitis

Fibrosing Mediastinitis

• 20- 40 years• Cough, Dyspnea, or Hemoptysis• Most common cause of Benign SVC syndrome• Almost always remote Histoplasmosis• Plain X-rays may be normal or only minimal ch

anges• Partially calcified Mass on CT is diagnostic

Fibrosing Mediastinitis

F/29 with SVC Syndrome by Histoplasmosis

Fibrosing Mediastinitis

F/29 with SVC Syndrome by Histoplasmosis

Pneumomediastinum

• Spontaneous : mainly in young male adults

• Hamman sign• Present along the Left sternal border• Substernal pain, cough, Dyspnea, Dysph

agia

Pneumomediastinum

Benign Cysts

• Most Common in Middle mediastinum• 20% of mediastinal masses• Less common in Korea• Usually asymptomatic• Bronchogenic cyst(32%), pericardial cyst

(35%), enteric cyst(12%), thymic cyst, and thoracic duct cyst

Pericardial Cyst

• Thin-walled, mesothelial cell lining

• most common in Right C-P angle

• Simple cysts are almost always asymptomatic

• Rare cardiac impingement

Pericardial Cyst (1)

Pericardial Cyst (2)

Bronchogenic Cysts

• 30 - 60% of all mediastinal cysts• Lined by ciliated respiratory epithelium• May contain cartilages or mucous• Communicate with tracheobronchial tree

s• May become infected• Wheezing, dyspnea, recurrent pulmonar

y infections

Bronchogenic Cyst

Bronchogenic Cyst

Aortic Aneurysm

Thymolipoma

Paratracheal Lymphadenopathy

Paratracheal Lymphadenopathy with Tracheal Compression

Paratracheal Lymphadenopathy

Paratracheal Malignant Lymphadenopathy