A Case of G.C.
54/F
• With a mediastinal mass
• By: Jessa Christine Surban, MD
• 2nd year resident, Department of General Surgery
• Jon Francis CO, MD
• 1st year resident, Department of General Surgery
Patient’s data
• GC
• 54-year-old, female
• Married
• Bayawan City, Negros Oriental
• Roman Catholic
• Came in for
HPI
Had onset persistent productive cough,
and decided have a consult. No other
symptoms noted. Chest x-ray was done
which revealed a mass on the
mediastinum was then advised to do a
4 years
PTA
CT scan of the chest. CT scan of the
chest was done which revealed a left
superior mediastinal mass measuring 2 x
2 cm as claimed and was then advised
for surgery but due to financial
constraint, she did not comply.
HPI
Patient had another onset of productive
cough. Again, sought consult and a chest
x-ray was again done which revealed that
the was mass increasing in size. Patient
2 year PTA was then referred to a specialist in Cebu
for further work up.
Patient sought consult with the specialist
and was appraised for surgery.
HPI
Onset of pain at the upper back and
shortness of breath associated with body
malaise. No progressive weakness noted.
Sought consult. CT scan of the chest was
2 weeks then performed which revealed a left
PTA superior anterior mediastinal mass
measuring 11.8 x 10 x 6.6 cm with areas of
necrosis and calcifications. Thus advised
for surgery and was subsequently
admitted
CT Scan
Review of Systems
• (-) weight loss
• (-) fever
• (-)dysphagia
• (-) chest pain
• (-) Shortness of breath
• (-) edema
Past Medical History
• (+) hypertensive for 10 years with maintenance
medication of Amlodipine 5mg OD
• Previous surgery includes a subtotal thyroidectomy
(2010)
• Family history of hypertension, diabetes mellitus,
and breast cancer
• Non smoker and an occasional alcoholic beverages
drinker
Physical examination
• gen: awake, alert, not in respiratory distress
• skin: no pallor, no jaundice, warm, moist, good turgor
• HEENT: pink palpebral conjunctivae, no ptosis, moist lips
and tongue
• neck: anterior neck 5 x 5 cm mass, non-movable, firm,
nontender;
• C/L: equal chest expansion, clear breath sounds, (-) rales,
no masses or lympthadenopathies noted
Physical examination
• CVS: distinct heart sounds, (-) murmur
• GI: Flabby, normal bowel sounds, soft, nontender
• GUT: (-) KPS
• Ext: (-) edema, CRT < 2 secs
L R
• Nuero: within normal limits,
5/5 5/5
5/5 5/5
Differential Diagnosis
• Lymphoma
• Thyroid Mass extension
• Germ Cell Tumors
Anterior Mediastinal
Mass to consider
Thymoma
Impression
Course in the wards
Day of Admission
* First Hospital Day (ER level)
1. Admitted as to our department and the department of internal
medicine
2. Placed on diet as tolerated
3. Diagnostic tests were done
4. CP clearance by IM service
5. Contemplated Procedure: video assisted thoracic surgery excision
of mediastinal mass under GETA
Day 1: Pertinent Laboratory
WBC 6.09 Protime 13.4
N 45 Protime con trol 13.2
L 44 % activity 98
INR 1.01
M 9
E 1 Clotting time 10’30”
B 1 Bleeding time 2’45
Hgb 13.2 Creatinine 0.95
Sodium 146
Hct 40.2
Potassium 3.8
plt 195
APTT 33.7
APTT control 31.2
Course in the ward
* Hospital Day 1(ER level)
S: 58-year-old female, with a mediastinal mass, not in respiratory distress, not in pain
O: stable vitals signs, awake , responsive,
A: mediastinal mass, T/C thymoma
Essential hypertension stage 2
P:
Scheduled for video assisted thoracic surgery excision of mass possible open at 8 am
Cefuroxime 1.5 g IVTT on call to OR
Reserve 2 units PRBC for possible OR use
Maintenance medications continued
Labs were taken
Intra-op findings
Intra-op X-ray
Post-op Day 1
* Patient currently awake
responsive, stable vital
signs
* No complaints of pain
* CTT in place
* CTT output 400cc
* CTT attach to thoracic
pump (+) bubbling
noted on expiration.
Post op DAY 2
* Patient currently awake responsive, stable vital signs
* No complaints of pain
* CTT in place
* CTT output 100cc
* CTT attach to thoracic pump (-) bubbling noted on
expiration.
Case discussion
Mediastinal Mass
Epidemiology
• Mediastinal malignancies are heterogenous in nature
• Most Masses(>60%) are
• Thymomas
• Neurogenic Tumors
• Benign Cyst
• Lymphadenopathy
• In Children (>80%)
• Neurogenic Tumor
• Germ Cell Tumors
• Foregut Tumors
• In Adults, the most common are
• Lymphomas
• LAD
• Thymomas
• Thyroid Mass
Mediastinal Mass
Compartment % Malignant Most common tumors
Anterosuperior 59% Thymoma
Middle 29% Lymphoma
Posteriro 16% Neurogenic Tumors
Anterosuperior Mass
• Thymus
• Germ Cell Tumor
• Thymoma
• Seminoma
• Thymic Carcinoma
• Non Seminamtous Germ Cell
• Thymic cyst
• Teratoma
• Thymic carcinois
• Thymolipoma
• Endocrine Tumors
• Lymphoma
• Hodgkins Lymphoma
• Thyroid tumors
• Non Hodgkins Lymphoma • Parathyroid adenoma
THYMOMA
• Most common primary anterior
• equal between male and female, in age more than
40 years
• Most patients are asymptomatic
• Half of patients have associated sydromes:
• Myasthenia gravis
• Hypogammaglobulinemia
• Pure red cell aplasia
• Originates within the epithelial cells of the thymus
• There is no clear histologic distinction between
benign and malignant thymomas
• Malignant thymomas is determined by the
invasiveness of the tumor to adjacent structures
within the mediastinum
• 15 year survival is 12.5% (inVasive) 47% (non
Invasive)
• Clinical Presentation:
• Chest pain
• Cough
• dyspnea
• Fine Needle Aspiration and Biopsy
• Is only indicated if patient presents with atypical
features or is found to have invasive tumor and
is under consideration for induction therapy
STAGE DEFINITION TREATMENT
I Encapsulated Complete surgical
tumor with no excision
gross or
microscopic
invasion
II Macroscopic Complete surgical
invasion into the excision and
mediastinal fat or postoperative
pleura or radiotherapy to
microscopic decrease the
invasion into the incidence of local
capsule recurrence
III Invasion of the Complete surgical
pericardium, great excision and
vessels, or lung postoperative
radiotherapy to
decrease the
incidence of local
Chemotherapy
• cisplatin/vincristine/doxorubicin/cyclophosphamide
Multidisciplinary approach
• Three cycles- cyclophosphamide,
doxurobucin,cisplatin, prednisone
• Surgical Resection
• Postoperative Radiation
• Consolidation Chemotherapy
Thymic Carcinomas
• More common in men, usually in 40
• More aggressive with higher propensity for capsular invasion
• Early local invasion, widespread lymphatic and hematogenous
metastases
• Clinically, patients present initially with tussis, dyspnea, pleuretic
chest pain, phrenic nerve palsy, or superior vena cava syndrome
• 80% have invasion into adjacent structures in mediastinum
• 40% may have mediastinal lymphadenopathy
• Distant metastases to regional lymphatics, bone, liver, kidney and
lung
Lymphomas
• Most common anterior mediastinal mass in
children second most common in adult
• 5-10% of patients lymphoma present with primary
mediastinal mass
• Primary mediastinal lymphoma represent 10-20%
of primary mediastinal masses are usually in
anterosuperior compartment
• Clinical presentation
• Fever,
• Night sweats
• Weight loss
• Pain dyspnea
• Stridor
• SVC syndrome
Mediastinal Germ Cell Tumors
• Primary extragonadal germ cell tumors comprise 2-
5% of all GCTS
• Approximately 2/3 occur in mediastinum
• The mediastinum is the most common site of
primary extragonadal GCT in young adults
• Represent 10-15% of adult anterosuperior
mediastinal tumors
• They presumably arise from germ cells that along
the urogenital ridge during embryonic
development
• Three Types
• Teratoma
• Seminoma
• Non seminamatous Germ Cell Tumor
Medaistinal Teratomas
• Most common GCT
• 3 types
• Mature: benign , well differentiated
• Immature: contains > 50% immature, may recur
or meatstasize
• Malignant: a mature teratoma that contains
focus of carcinoma, sarcoma or malignant GCT
Medaistinal Seminomas
• Represents 40% of malignancy mediastinal GCTs
• Afflicts Caucasian men in 20s-30s
• Only rarely represent a metastatic lesion from a
testicular primary tumor, but testicular USG is
usually performed to rule this out
• AFP is normal, elevated beta HCG
Clinical Presentation
• Presentation
• Slow Growing tumor, usually symptomatic at diagnosis
• Commonly presents with chest pain, dyspnea, cough and
weight loss
• Presents infrequently with SVC syndrome
• Bulky, lobulated, homogenous mass, no calcifications
• Usually not invasive, but many have metastasized to
regional lymph nodes, lung and/ or bone by the time of
diagnosis
Mediastinal Non Seminomatous GCT
• Worse prognosis
• Occur in men in the 20-40 age group
• 20%
• Have Klinefelter’s Syndrome
Clinical Presentation
• Incidental Discovery- most common
• 50% of all medaistinal maas are asymptomatic
• 80% of mass are benign
• If with symptoms more than half are malignant
• Chest pain
• Cough
• Hemoptysis
• Pleural effusion
• Dysphagia
• Pericarditis
• Superior Vena Cava Syndrome
Diagnostics
• Chest Radiograph (posteroanterior and lateral)
• Computed Tomography
• Magnetic Resonance Imaging
