Mediastinal tumours

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  • INTRODUCTION MEDIASTINUM is the central compartment in the thoracic cavity between the two lungs Any age group-both sexes (often on routine x ray) (50% are asymptomatic)

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  • ANATOMYAnteriorly : SternumPosteriorly : Thoracic vertebraeSuperiorly : Plane of thoracic inletInferiorly : DiaphragmLaterally : Mediastinal pleura

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  • CROSS SECTION

    Anterior - 1 Middle - 2 Posterior - 3http://mywebpages.comcast.net/wnor/thoraxlesson3.htm

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  • SUPERIOR MEDIASTINUMMUSCLES : Origins of sternohyoid ,sternothyroid,lower ends of longus colliARTERIES : aortic arch,brachiocephalic artery,thoracic portions of left common carotid, and left subclavian arteryVEINS : brachiocephalic vein,upper part of SVC,left highest intercostal veinNERVES : vagus,superficial and deep cardiac plexus,phrenic nerve,left recurrent larnygeal nerveTracheaOesophagusThoracic ductRemains of thymus lymph glands

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  • ANTERIOR MEDIASTINUMLoose areolar tissueSome lymphatic vessels which arise from the convex surface of the liver2 or 3 mediastinal lymph nodes small mediastinal branches of internal mammary arteryThymus

  • MIDDLE MEDIASTINUMPericardiumHeartDescending aortaLower half of SVC and azygous veinsRight and left pulmonary veinsTracheaTrachea BifurcationMain BronchiPhrenic NerveHilar Lymph NodePericardiophrenic vessels

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  • POSTERIOREsophagusVagusSplanchnic nervesThoracic ductThoracic descending AortaAzygos Vein and accessory hemiazygous veinHemi-azygos veinParavertebral Lymph node

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  • CLASSIFICATION - ANATOMICALANTEROSUPERIOR: - Thymic neoplasms - Cysts - Mesenchymal - Lymphomas - Germ cell tumours - Carcinoma - Endocrine MIDDLE:

    - Cysts - Mesenchymal - Lymphomas - Carcinoma POSTERIOR MEDIASTINAL:

    - Neurogenic - Mesenchymal - Cysts - Endocrine

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  • CLASSIFICATION- PATHOLOGICALNEUROGENIC TUMOURS - MOST COMMON : NEUROFIBROMA, NEURILEMOMA, GANGLIONEUROMA, NEUROBLASTOMA, NEUROSARCOMA OTHERS : CHEMODECTOMA, PARAGANGLIOMATHYMOMA - BENIGN, MALIGNANTLYMPHOMA HODGKINSDISEASE , T AND B IMMUNOBLASTIC SARCOMA, SCLEROSING FOLLICULAR CELLGERM CELL TUMOURS- , TERATODERMOID(BENIGN AND MALIGNANT) SEMINOMA, NONSEMINOMA (EMBRYONAL,CHORIOCARCINOMA,ENDODERMAL )

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  • MESENCHYMAL TUMOURS FIBROMA,/FIBROSARCOMA,LIPOMA/ LIPOSARCOMA, LEIOMYOMA/LEIOMYOSARCOMA, RHABDOMYOSARCOMA,MYXOMA, MESOTHELIOMA,XANTHOGRANULOMA, HEMANGIOMA,HEMANGIOENDOTHELIOMA,HEMANGIOPERICYTOMA LYMHANGIOMA,LYMPHANGIOMYOMA,,LYMPHANGIOPERICYTOMA ENDOCRINE INTRATHORACIC THYROID,PARATHYROID ADENOMA/CARCINOMA CARCINOID CYSTS BRONCHOGENIC, PERICARDIAL, ENTERIC, THYMIC, THORACIC DUCT NONSPECIFICGIANT LYMPH NODE HYPERPLASIA CASTLEMAN'S DISEASECHONDROMAEXTRAMEDULLARY HEMATOPOIESIS

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  • Common PathologiesANTEROSUPERIOR MEDIASTINUM - THYMIC NEOPLASM-33% LYMPHOMA-19% GERM CELL TUMOUR-17%MIDDLE MEDIASTINUM - CYSTS-61%,LYMPHOMA-21%POSTERIOR MEDIASTINUM - NEUROGENIC-53%,CYST-32%

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  • CHILDRENPosterior MediastinumMost often benign2/3 of tumors symptomatic

    Neurogenic tumors(40%)Lymphoma(18%)Cysts(18%)Germ cell tumors(11%)Mesenchymal tumors(9%)Thymomas -Rare

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  • ADULTSAnterior MediastinumOften MalignantAges 30 501/3 of tumors are symptomaticNeurogenic tumours(21%)Cysts(20%)Thymomas(19%)Lymphoma(13%)Germ cell tumours(11%)Mesenchymal tumours(7%)Endocrine tumours(6%)

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  • MALIGNANCYAll tumors 25%Per SectionAnterior Superior 59%Posterior 16%Middle 16%

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  • SymptomsChest painDyspneaCoughFeverWeight lossFatigueDysphagiaNight sweats

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  • Clinical Features SVC syndromeMyasthenia gravis, Immune deficiency, Aplastic anemia - ThymomaSympathetic ganglion - Horners SyndromeIn late stages : Diaphragmatic palsyPleural EffusionHaemorrage (Erosion of major vessels)

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  • Malignant Tumors Invasion StructureTracheobronchial tree and lungsEsophagusSuperior Vena CavaPleura and Chest WallIntrathoracic nerves

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  • CLINICAL MANIFESTATIONS OF ANATOMIC COMPRESSION OR INVASION BY NEOPLASMS OF THE MEDIASTINUMVena caval obstruction Pericardial tamponadeCongestive heart failureDysrhythmiasPulmonary stenosisTracheal compressionEsophageal compressionVocal cord paralysisPostobstructive

    pneumonitis Horner's syndrome

    Phrenic nerve paralysis

    Chylothorax

    Chylopericardium

    Spinalcord compressive

    syndrome

    Pancoast's syndrome

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  • DIAGNOSTIC EVALUATION History and Physical examination Radiology - Standard chest films ,Barium swallow, Fluroscopy ,Arteriography,Venography, CT,MRI,USG,Myelography Radioisotope scanning SerologyEndoscopy Bronchoscopy Needle aspiration and biopsy Operative procedures Mediastinoscopy, Mediastinotomy Thoracotomy

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  • ULTRASTUCTURAL CHARACTERISTICS OF MEDIASTINAL TUMOURSCarcinoid : Dense core granules,fewer tonofilaments and desmosomesLymphomas : Absence of junctional attatchments and epithelial featuresThymoma : Well formed desmosomes ,bundles of tonofilamentsGerm cell : Prominent nucleoli ,even chromatin, scant desmosomes, rare tonofilamentsNeuroblastoma :Neurosecretory granules ,synaptic endings

  • Treatment Thoracotomy and removal If malignant - Adjuvant therapy like radiotherapy & chemotherapy Sternotomy - Sup. and ant.tumours

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  • Thymic cancers require surgery, followed by radiation or chemotherapy. Types of surgery include thoracoscopy (a minimally invasive approach), mediastinoscopy (minimally invasive) and thoracotomy (a procedure performed through an incision in the chest). Lymphomas are recommended to be treated with chemotherapy followed by radiation. Neurogenic tumors found in the posterior (back) mediastinum are treated surgically.

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  • THYMOMAS Most common tumour of the anterosuperior mediastinum in adults Fifth to Sixth decade Both sexes are equally affected

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  • Types HISTOLOGY: Epithelial cell - Poor prognosis Lymphocytic Mixed Spindle - Better prognosis

    50% THYMOMAS ARE MALIGNANT

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  • Clinical features: ASYMPTOMATIC 50% 30 - 40% ASSOCIATED WITH MYASTHENIA GRAVIS Chest pain Dysphagia Dyspnoea SVC obstruction

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  • Modified Masaoka clinical staging of thymoma

    StageDefinitionIMacroscopically and microscopically completely encapsulatedIIAMicroscopic transcapsular invasionIIBMacroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardiumIIIMacroscopic invasion into neighboring organs (ie, pericardium, great vessels, or lung)IVAPleural or pericardial disseminationIVBLymphogenous or hematogenous metastasis

  • Investigations

    Chest Xray : Lateral view - Opacity in mediastinum Mediastinoscopy & biopsy. Tensilon Diagnostic test : Injecting 10mg edrophonium chloride iv. Myasthenia is relieved within 1 min temporarily CT scan

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  • Treat myasthenia - Neostigmine

    Thymectomy IS BENEFICIAL in: Disease < 5yrs Myasthenia without thymoma In young females

    Treatment

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  • Surgical removal of the tumor is the preferred treatment. Surgery is often the only treatment required for stage I tumors. Treatment of thymoma often relieves the symptoms caused by paraneoplastic syndromes. Stages II, III, and IV thymomas are often treated with surgery and some form of adjuvant therapy.

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  • RETROSTERNAL GOITRE > 50 % goitre below the suprasternal notch. PRIMARY : rare (1%) -SECONDARY : common

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  • PRIMARY Arises from ectopic thyroid tissue from mediastinum. It gets it blood supply from mediastinum itself,not from the neck.Not related to existing thyroid tissue in the neck

    SECONDARY

    Extension from an enlarged thyroid from the neck Arises from lower pole of a nodular goitre usually. Commonly seen in short neck or obese individuals Nodule gets drawn into the superior medistinum due

    To negative intrathoracic pressure

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  • TYPESSubsternal type : part of the nodule is palpable in the lower neck Plunging goitre : an intrathoracic goitre is occasionally forced into the neck by increased intrathoracic pressureIntrathoracic goitre: neck is normal

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  • CLINICAL FEATURES SYMPTOMS :Dyspnoea Cough and stridorDysphagiaSIGNS :Engorgement of neck veins and superficial veins on the chest wallLower border is not seen on inspection and not felt on palpation

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  • PEMBERTON'S SIGN : is positivePercussion :dull note over sternumCan be nodular,toxic or malignantRarely recurent larygeal nerve palsy

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  • INVESTIGATIONSChest