Mediastinal Mass

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Mediastinal Mass

  1. 1. MEDIASTINAL MASSES
  2. 2. Mediastinal Anatomy
  3. 3. Mediastinal Anatomy Anterior thymus, aorta, great veins, lymphatics Middle heart, pericardium, trachea Posterior Esophagus, vagus nerves, thoracic duct, sympathetic chain, azygous venous system
  4. 4. Anterior Mediastinum
  5. 5. Thymoma
  6. 6. Thymoma
  7. 7. Hodgkin’s
  8. 8. Intrathoracic goiter
  9. 9. Anterior Mediastinum Other thymic tumors - carcinomas, carcinoid tumors, lipomas, cysts Germ cell tumors Thyroid tumors Parathyroid adenoma Connective tissue tumors - lipomas, liposarcomas, lymphangiomas, hemangiomas
  10. 10. Middle Mediastinum
  11. 11. Pericardial cyst
  12. 12. Bronchogenic cyst
  13. 13. Middle Mediastinum Thyroid tumor or goiter Tracheal tumors Lymphadenopathy 2/2 infection malignancy idiopathic
  14. 14. Posterior Mediastinum
  15. 15. Posterior Mediastinum Most neurogenic tumors Esophageal tumors Hiatus hernia Neurenteric cysts Unusual: pancreatic pseudocyst, achalasia, extramedullary hematopoiesis
  16. 16. Paraspinal ganglioneuroma
  17. 17. Paraspinal neurilemmoma
  18. 18. Notes Aortic aneurysms can be located in any compartment Anterior masses more likely to be malignant 59% vs. 29% vs. 16%, converse is true in children increased likelihood in 20-40 yo Most common lesions: Children - neurogenic tumors, enterogenous cysts Adults - neurogenic tumors, thymomas, thymic cysts
  19. 19. Signs & Symptoms Hemoptysis, recurrent pulmonary infection (airway compression) Dysphagia (esophageal compression) Paralysis (spinal column involvement) Elevated hemidiaphragm (phrenic nerve damage) Hoarseness (recurrent laryngeal involvement) Horner’s & SVC syndrome (sympathetic ganglion, SVC)
  20. 20. Signs & Symptoms Associated systemic diseases Thymoma = myasthenia gravis, immune deficiency, red cell aplastic anemia Thymic carcinoid tumor = Cushing syndrome Goiter = thyrotoxicosis Parathyroid adenoma = hyperparathyroidism
  21. 21. Imaging CXR -> CT with IV contrast MRI only recommended if pt has contrast allergy or renal failure useful for neurogenic tumors Transesophageal US - posterior lymph nodes Radionuclide scanning 123-I for thyroid, sestamibi for parathyroid, gallium for lymphomas (replaced by FDG-PET)
  22. 22. Labs Goiter -> TFTs Parathyroid adenoma -> Ca, P, PTH Paragangliomas -> urine metanephrines, catecholamines Neurogenic tumors -> homovanillic acid, vanillylmandelic acid Germ cell tumor -> AFP, B-HCG all male pts with anterior mass
  23. 23. Management Excision if likely benign - teratoma, thymoma needle aspiration, VATS, sternotomy/thoracotomy Biopsy lymphoma, germ cell, unresectable malignancy surgical biopsy preferred over needle aspiration Chest wall tumor implantation is a rare complication
  24. 24. Complications Surgical treatment has increased risk of morbidity 2/2 central airway obstruction, greatest in those with: Cardiorespiratory symptoms Evidence of tracheal obstruction Mixed obstructive & restrictive PFTs
  25. 25. The End

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