Mediastinal tumors

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 - diaphragmdiaphragm 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


NervesNerves

1.1. Vagus nerveVagus nerve

2.2. Left Recurrent Left Recurrent Laryngeal Laryngeal nerve.nerve.

3.3. Phrenic nerve.Phrenic nerve.


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

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


Mesenchymal tumors

CYST:• Bronchogenic cyst• Thoracic duct• Meningoceles

Cardiac & pericardial tumors

Tracheal tumors

vascular tumors

Lymphadenopathy• Inflammatory• Granulomatous• sarcoidosis

Posterior mediastinal masses


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



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


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


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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