Downloaded 513 times
Uploaded byYuvaraj Karthick
Mediastinal tumours
The document provides information on tumors and masses located in the mediastinum. It begins with an overview of the anatomy of the mediastinum and then describes the various pathologies that can occur in each compartment, including the most common tumor types seen in children and adults. For some of the major tumor types such as thymomas, neurogenic tumors, and germ cell tumors, it provides details on characteristics, clinical presentation, diagnostic evaluation, and treatment approaches. The document emphasizes that surgical resection is the main treatment for most mediastinal masses but chemotherapy and/or radiation are also used as adjuvant therapies for malignant tumors.
More Related Content
Similar to Mediastinal tumours
Mediastinal tumours
- 2. INTRODUCTION MEDIASTINUM isthe central compartment in the thoracic cavity between the two lungs Any age group-both sexes (often on routine x ray) (50% are asymptomatic)
- 3. ANATOMY • Anteriorly :Sternum • Posteriorly : Thoracic vertebrae • Superiorly : Plane of thoracic inlet • Inferiorly : Diaphragm • Laterally : Mediastinal pleura
- 5. CROSS SECTION Anterior- 1 Middle - 2 Posterior - 3 http://mywebpages.comcast.net/wnor/thor axlesson3.htm
- 6. SUPERIOR MEDIASTINUM MUSCLES: Origins of sternohyoid ,sternothyroid,lower ends of longus colli ARTERIES : aortic arch,brachiocephalic artery,thoracic portions of left common carotid, and left subclavian artery VEINS : brachiocephalic vein,upper part of SVC,left highest intercostal vein NERVES : vagus,superficial and deep cardiac plexus,phrenic nerve,left recurrent larnygeal nerve Trachea Oesophagus Thoracic duct Remains of thymus lymph glands
- 7. ANTERIOR MEDIASTINUM Looseareolar tissue Some lymphatic vessels which arise from the convex surface of the liver 2 or 3 mediastinal lymph nodes small mediastinal branches of internal mammary artery Thymus
- 8. MIDDLE MEDIASTINUM Pericardium Heart Descending aorta Lowerhalf of SVC and azygous veins Right and left pulmonary veins Trachea Trachea Bifurcation Main Bronchi Phrenic Nerve Hilar Lymph Node Pericardiophrenic vessels
- 9. POSTERIOR Esophagus Vagus Splanchnic nerves Thoracic duct Thoracic descending Aorta Azygos Vein and accessory hemiazygous vein Hemi-azygos vein Paravertebral Lymph node
- 12. CLASSIFICATION - ANATOMICAL ANTEROSUPERIOR: -Thymic neoplasms - Cysts - Mesenchymal - Lymphomas - Germ cell tumours - Carcinoma - Endocrine MIDDLE: - Cysts - Mesenchymal - Lymphomas - Carcinoma POSTERIOR MEDIASTINAL: - Neurogenic - Mesenchymal - Cysts - Endocrine
- 13. CLASSIFICATION- PATHOLOGICAL • NEUROGENICTUMOURS - MOST COMMON : NEUROFIBROMA, NEURILEMOMA, GANGLIONEUROMA, NEUROBLASTOMA, NEUROSARCOMA OTHERS : CHEMODECTOMA, PARAGANGLIOMA • THYMOMA - BENIGN, MALIGNANT • LYMPHOMA – HODGKINSDISEASE , • T AND B IMMUNOBLASTIC SARCOMA, SCLEROSING FOLLICULAR CELL • GERM CELL TUMOURS- , TERATODERMOID(BENIGN AND MALIGNANT) SEMINOMA, NONSEMINOMA (EMBRYONAL,CHORIOCARCINOMA,ENDODERMAL )
- 14. • 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 NONSPECIFIC • GIANT LYMPH NODE HYPERPLASIA – CASTLEMAN'S DISEASE • CHONDROMA • EXTRAMEDULLARY HEMATOPOIESIS
- 15. Common Pathologies • ANTEROSUPERIORMEDIASTINUM - THYMIC NEOPLASM-33% LYMPHOMA-19% GERM CELL TUMOUR-17% • MIDDLE MEDIASTINUM - CYSTS-61%,LYMPHOMA-21% • POSTERIOR MEDIASTINUM - NEUROGENIC-53%,CYST-32%
- 16. CHILDREN Posterior Mediastinum Most often benign 2/3 of tumors symptomatic Neurogenic tumors(40%) Lymphoma(18%) Cysts(18%) Germ cell tumors(11%) Mesenchymal tumors(9%) Thymomas -Rare
- 17. ADULTS Anterior Mediastinum Often Malignant Ages 30 – 50 1/3 of tumors are symptomatic Neurogenic tumours(21%) Cysts(20%) Thymomas(19%) Lymphoma(13%) Germ cell tumours(11%) Mesenchymal tumours(7%) Endocrine tumours(6%)
- 18. MALIGNANCY All tumors25% − Per Section Anterior Superior 59% Posterior 16% Middle 16%
- 19. Symptoms Chest pain Dyspnea Cough Fever Weight loss Fatigue Dysphagia Night sweats
- 20. Clinical Features SVCsyndrome Myasthenia gravis, Immune deficiency, Aplastic anemia - Thymoma Sympathetic ganglion - Horner’s Syndrome In late stages : Diaphragmatic palsy Pleural Effusion Haemorrage (Erosion of major vessels)
- 21. Malignant Tumors Invasion Structure Tracheobronchial tree and lungs Esophagus Superior Vena Cava Pleura and Chest Wall Intrathoracic nerves
- 22. CLINICAL MANIFESTATIONS OFANATOMIC COMPRESSION OR INVASION BY NEOPLASMS OF THE MEDIASTINUM Vena caval obstruction Pericardial tamponade Congestive heart failure Dysrhythmias Pulmonary stenosis Tracheal compression Esophageal compression Vocal cord paralysis Postobstructive pneumonitis Horner's syndrome Phrenic nerve paralysis Chylothorax Chylopericardium Spinalcord compressive syndrome Pancoast's syndrome
- 23. DIAGNOSTIC EVALUATION Historyand Physical examination Radiology - Standard chest films ,Barium swallow, Fluroscopy ,Arteriography,Venography, CT,MRI,USG,Myelography Radioisotope scanning Serology Endoscopy Bronchoscopy Needle aspiration and biopsy Operative procedures – Mediastinoscopy, Mediastinotomy Thoracotomy
- 24. ULTRASTUCTURAL CHARACTERISTICS OF MEDIASTINALTUMOURS Carcinoid : Dense core granules,fewer tonofilaments and desmosomes Lymphomas : Absence of junctional attatchments and epithelial features Thymoma : Well formed desmosomes ,bundles of tonofilaments Germ cell : Prominent nucleoli ,even chromatin, scant desmosomes, rare tonofilaments Neuroblastoma :Neurosecretory granules ,synaptic endings
- 25. Treatment Thoracotomy andremoval If malignant - Adjuvant therapy like radiotherapy & chemotherapy Sternotomy - Sup. and ant.tumours
- 26. • Thymic cancersrequire 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.
- 27. THYMOMAS Most commontumour of the anterosuperior mediastinum in adults Fifth to Sixth decade Both sexes are equally affected
- 29. Types HISTOLOGY: Epithelialcell - Poor prognosis Lymphocytic Mixed Spindle - Better prognosis 50% THYMOMAS ARE MALIGNANT
- 30. Clinical features: ASYMPTOMATIC50% 30 - 40% ASSOCIATED WITH MYASTHENIA GRAVIS Chest pain Dysphagia Dyspnoea SVC obstruction
- 31. Modified Masaoka clinicalstaging of thymoma Stage Definition I Macroscopically and microscopically completely encapsulated IIA Microscopic transcapsular invasion IIB Macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium III Macroscopic invasion into neighboring organs (ie, pericardium, great vessels, or lung) IVA Pleural or pericardial dissemination IVB Lymphogenous or hematogenous metastasis
- 32. 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
- 34. Treat myasthenia- Neostigmine Thymectomy IS BENEFICIAL in: Disease < 5yrs Myasthenia without thymoma In young females Treatment
- 35. Surgical removalof 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.
- 36. RETROSTERNAL GOITRE >50 % goitre below the suprasternal notch. PRIMARY : rare (1%) - SECONDARY : common
- 37. PRIMARY Arises fromectopic 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
- 38. TYPES Substernal 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 pressure Intrathoracic goitre: neck is normal
- 39. CLINICAL FEATURES SYMPTOMS : Dyspnoea Cough and stridor Dysphagia SIGNS : Engorgement of neck veins and superficial veins on the chest wall Lower border is not seen on inspection and not felt on palpation
- 40. PEMBERTON'S SIGN: is positive Percussion :dull note over sternum Can be nodular,toxic or malignant Rarely – recurent larygeal nerve palsy
- 41. INVESTIGATIONS Chest X-ray CT scan and MRI is diagnostic
- 43. TREATMENT Surgical removal Commonly through incision in neck Large goitre or malignant type median sternotomy is required rarely Radiodine therapy is not not accepted Stridor –due to compression of tracheobronchial tree it is very dangerous, as often it is not possible to clear airway either by intubation or tracheostomy Surgical removal should be complete : recurrence – very difficult to operate
- 44. Neurogenic tumors Neurofibroma,Neurilemmoas Melanotic schwannoma Ganglioneuromas Chemodectoma Pheochromocytomas BenignMalignant Neurofibrosarcomas Ganglioneuroblastoma Neuroblastomas Malignant chemodectoma Malignant Pheochromocytoma
- 45. Neurilemmomas Most common Arises fromthe Schwann cells of the nerve sheath Well encapsulated X-ray :dense homogenous mass in the posterior mediastinum Surgical excision
- 46. Neurofibromas Arises from thenerve sheath and nerve fibres Poorly encapsulated Treatment : Difficult to excise due to its infiltrating nature Multiagent chemotherapy due to aggressive nature
- 48. Ganglioneuromas Originates from sympatheticchain Composed of ganglionic cells and nerve fibres More common in children Mostly asymptomatic Usual location is paravetebral region INVESTIGATION: X ray- well marginated lesion on anterolateral aspect of spine TREATMENT: surgical resection
- 49. Neuroblastomas Usually seen amongyoung children Most poorly differentiated tumor Arising from the sympathetic nerves Highly invasive tumor 75% -children clinical feature is fever cough diarrhea vomiting At time of presentation – pain,neurological defects,Horners syndrome,respiratory distress ataxia -lymph node metastasis Metastasis to spinal cord Investigation : CT,MRI,radionucleide imaging Treatment : Radiotherapy and chemotherapy
- 51. Germ cell tumors BenignMalignant Seminomatous Non seminomatous Choriocarcinomas Embryonal carcinomas Mixed tumors Teratocarcinomas Yolk sac carcinomas.
- 52. LAB STUDIES Beta human chorionic gonadotropin Alpha-fetoprotein IMAGING Chest radiography CTscan of the chest and mediastinum DIAGNOSTIC PROCEDURES Transthoracic needle biopsy Cervical mediastinoscopy and substernal extended mediastinoscopy Anterior mediastinotomy Video-assisted thoracoscopy Sternotomy and thoracotomy
- 53. TERATOMA isthe commonest. Symptoms: usually asymptomatic, cough, dyspnoea and chest pain can occur. Investigations : Chest Xray, CT, MRI Treatment: complete surgical excision and chemotherapy. SEMINOMA: 25- 50% of GCT Men 20- 40 yrs Symptoms: dysnoea, substernal pain, weakness, gynaecomastia, SVC syndrome Investigations: chest Xray, CT, Treatment: radiotherapy
- 54. Non Seminoma: Embryonal cell carcinoma, endodermal thymus tumours, choriocarcinoma, yolk sac tumours with multiple cellular components. Symptoms: chest pain, hemoptysis, cough, fever, wt loss, gynaecomastia Investigation: AFP, beta HCG are increased. Treatment: chemotherapy with bleomycin, etoposide and cisplatin If there is residual tumour then = surgery
- 55. Lymphomas Commonly situated inanterior mediastinum Commonest Hodgkin's lymphomas Common in 40-60 yrs Non Hodgkin’s affects any age. Symptoms: fever, wt loss, night sweats, compressive symtoms like pain, dyspnoea, wheezing, SVC syndrome and pleural effusion. Investigations : x-ray , CT scan, cervical lymph node biopsy Treatment: Combination chemotherapy Surgery not usually done.
- 56. Vascular and Lymphatics Hemangiomas Lymphangiomas Haemangimyomas Lymphangimyomas Commonestis lymphangioma(cystic hygroma) Seen in ant mediastinum
- 57. Mediastinal cysts Primary cyst Pericardialcyst Bronchogenic cyst Enteric cyst Thymic cyst
- 58.