Case Presentations

Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
Case No. 1
• A 77-year-old man comes to the ED complaining of
the acute onset of dyspnea and presyncope that
occurred 2 hours ago whi...
• His medications include:
 Aspirin, 325 mg daily;
 Lisinopril, 40 mg daily; and
 Verapamil, 360 mg daily.
• On physica...
• Laboratory studies reveal the following:
D-dimer level of 9.57 g/mL (52.40 nmol/L),
Brain natriuretic peptide level of 9...
• CT pulmonary angiogram are shown:
• An echocardiogram is performed, which reveals left ventricular
hypertrophy with normal systolic function. The right vent...
• The patient receives supplemental oxygen and
IV unfractionated heparin (UFH), and is
admitted for close monitoring.
• Tw...
A. Switch to a low-molecular-weight heparin
(LMWH).
B. Insert an inferior vena cava filter.
C. Perform catheter embolectom...
According to ACCP antithrombotic
guidelines published (2008)
• Recommend thrombolytic therapy for all
patients with hemody...
Major contraindications include
• A history of intracranial hemorrhage
• Known intracranial aneurysm or arteriovenous
malf...
Relative contraindications include:
•
•
•
•
•

Recent internal bleeding
Recent surgery or organ biopsy
Uncontrolled hypert...
• This patient has a major and several relative
contraindications, so systemic thrombolysis
would not be the best option (...
• Many experts agree that patients that meet
the following criteria should be considered for
catheter embolectomy:
(1) acu...
Summary
• This patient has massive pulmonary embolism
(PE) (confirmed acute PE with shock and
obvious right ventricular dy...
So the next best step is to:

A. Switch to a low-molecular-weight heparin
(LMWH).
B. Insert an inferior vena cava filter.
...
Thrombolytics in Acute
Pumonary Embolism

Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
The ACCP’s recommendation
classification system:
1 = “recommendation”
2 = “suggestion”
A = based on strong evidence from
r...
Which patients with acute pulmonary embolism
should I treat with systemic thrombolytics?

The ACCP suggests using systemic...
Which patients with acute pulmonary embolism
should I treat with systemic thrombolytics?

ACCP recommends against treating...
Which patients with acute pulmonary embolism
should I treat with systemic thrombolytics?

*However, patients deemed to be ...
How should I treat acute pulmonary embolism
with systemic thrombolytics?

*A short infusion time of 2 hours for systemic
t...
How should I treat acute pulmonary embolism
with systemic thrombolytics?

Randomized trials show that thrombolytics
improv...
How should I treat acute pulmonary embolism
with systemic thrombolytics?
ACCP’s recommendations to provide thrombolytics t...
Catheter-Based Thrombus Removal for the
Initial Treatment of
Patients With PE
In patients with acute PE associated with
hy...
What shall I do with the heparin infusion during
administration of thrombolytic therapy for acute
PE?
*There is no ACCP re...
Recommendations
Contraindications
Saddle PE :that lodges at the bifurcation of the
main pulmonary artery
Multidetector-CT
Findings
• Partial or complete filling defects in lumen of
pulmonary arteries
– Most reliable sign is fil...
Large saddle thrombus with extensive clot burden. Arrows
demonstrating tram-track sign (A), rim sign (B), complete
filling...
Embolic burden scoring system. Schematic of the pulmonary
arterial tree with scores for nonocclusive emboli according to
v...
Thrombotic and Nonthrombotic
Pulmonary Arterial Embolism

By

Gamal Rabie Agmy , MD , FCCP

Professor of Chest Diseases ,A...
Acute Pulmonary Embolism
Saddle PE :that lodges at the bifurcation of the main
pulmonary artery
Multidetector-CT
Findings
• Partial or complete filling defects in lumen of
pulmonary arteries
– Most reliable sign is fil...
Large saddle thrombus with extensive clot burden. Arrows
demonstrating tram-track sign (A), rim sign (B), complete
filling...
Acute pulmonary embolism and deep venous thrombosis (DVT) in a 48-year-old woman. (a) Contrast
material–enhanced pulmonary...
Acute pulmonary embolism in a 41-yearoldwoman. Coronal gadolinium-enhanced threedimensional pulmonary MR angiogram shows a...
Embolic burden scoring system. Schematic of the pulmonary
arterial tree with scores for nonocclusive emboli according to
v...
Helical CT Findings in Chronic PTE
Cardiac abnormalities
Right ventricular enlargement
Right atrial enlargement
Thrombi in...
Septic Pulmonary Embolism
Septic pulmonary embolism in a 28-year-old intravenous drug abuser with human
immunodeficiency v...
Hydatid Embolism
Fat Embolism
Amniotic Fluid Embolism
Tumor Embolism
Air Embolism
Talc Embolism
Cement (Polymethylmethacrylate) Embolism
Iodinated oil embolism
Miscellaneous Foreign Body Embolism
Case No. 2
• History of exposure to asbestos more than 45
years ago.
• He had long-standing bilateral pleural plaques,
upper lobe nod...
• A 72-year-old man is seen for evaluation of
hemoptysis.
• He had a 14-year history of rheumatoid
arthritis (RA) previous...
• He denied any fever, sweats, chills, or weight
loss and stated that his chronic respiratory
symptoms were stable.
• His ...
• His spirometry revealed an FEV1 of 2.49 L
(78% of predicted) and an FVC of 2.98 L (71%
predicted), with an FEV1/FVC of 0...
• Bronchoscopy revealed some old blood in the
left upper lobe but no active bleeding or
endobronchial lesions were seen.
•...
Which is the best-recommended therapy at the
present time?
A. Bronchial artery embolization.
B. Itraconazole.
C. Surgical ...
• The CT scan reveals a left upper lobe cavity
with a mass inside, highly suggestive of a
fungus ball.
• Preferred therapy...
• For patients who are considered poor
operative candidates, a number of alternative,
to surgery exist.
• These include br...
• Inhaled, intracavitary, and endobronchial
instillations of antifungal agents have been
tried in small numbers of patient...
• There are some older reports on the use of
radiation therapy or corticosteroids to control
hemoptysis, but neither affec...
• A fungus ball, or mycetoma, is the saprophytic
colonization of a preexisting parenchymal cavity.
This cavity may be due ...
• The most common fungus causing a mycetoma is
Aspergillus, hence, the use of the term aspergilloma,
but other fungal spec...
• CT scanning usually shows an intracavitary
mass, as in this patient, often with an air
crescent sign.
• Treatment of cho...
• Poor prognostic factors includes:
1. The severity of the underlying lung disease.
2. Increasing size or number of lesion...
Surgical resection revealed
classic fungus ball (fig-1)

containing numerous fungal organisms on staining (Fig 2), some of...
• An aortic erosion from the Aspergillus cavity
was also found and repaired.
So........
The best-recommended therapy at the present
time?
A. Bronchial artery embolization.
B. Itraconazole.
C. Surgica...
Spectrum of Pulmonary
Aspergillosis

Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
Pulmonary Aspergillosis
Pulmonary aspergillosis can be subdivided into
five categories:
(a) saprophytic aspergillosis (asp...
Saprophytic Aspergillosis (Aspergilloma)
*Saprophytic aspergillosis (aspergilloma) is characterized
by Aspergillus infecti...
Saprophytic Aspergillosis (Aspergilloma)
*Although patients may remain asymptomatic, the most
common clinical manifestatio...
Saprophytic Aspergillosis (Aspergilloma)
Saprophytic Aspergillosis (Aspergilloma)
Hypersensitivity Reaction (Allergic
Bronchopulmonary Aspergillosis)
*Allergic bronchopulmonary aspergillosis is seen most
...
Allergic Bronchopulmonary Aspergillosis
Semi-invasive (Chronic Necrotizing)
Aspergillosis
*Factors associated with the development of this form of
aspergillosis i...
Semi-invasive (Chronic Necrotizing)
Aspergillosis
Airway-invasive Aspergillosis
*It occurs most commonly in immunocompromised
neutropenic patients and in patients with AIDS...
Airway-invasive Aspergillosis
Airway-invasive Aspergillosis
Obstructing bronchopulmonary aspergillosis is a noninvasive
form of aspergillosis characteri...
Angio-invasive Aspergillosis
*Angioinvasive aspergillosis occurs almost exclusively in
immunocompromised patients with sev...
Angio-invasive Aspergillosis
Case No. 3
• A 38-year-old man has new-onset
pressure in the right side of his
neck with accompanying dyspnea
on exertion.
Chest radiographs
CT scan
• The most likely etiology of the lesion is:
A. Thymoma.
B. Bronchogenic cyst.
C. Schwannoma.
D. Lymphoma.
• The very large mass is identified to be in the
posterior mediastinum.
• The posterior mediastinum is bounded
anteriorly ...
• Schwannomas, neurofibromas,
and
malignant tumors of the nerve sheath
originate from the peripheral nerves
while ganglion...
• Schwannomas and neurofibromas
affect men and women equally,
appearing in the third to fourth
decades of life. These tumo...
• Neurogenic tumors are the most common
cause of posterior mediastinal masses. They
account for 20% of all adult mediastin...
• Nearly one-half of all tumors are
asymptomatic and found incidentally.
• In those that are symptomatic, regional
compres...
• Thymomas are the most common tumors of
the anterior mediastinum, comprising 20% of
anterior mediastinal neoplasms in adu...
• Mediastinal lymphoma is typically an
extension of widespread regional or systemic
disease.
• Primary mediastinal lymphom...
Mediastinal Mass

Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
Symptoms associated with mediastinal masses

No symptoms (discovery by chance)

Paraneoplastic
Local
retrosternal pain
cou...
Mediastinal masses

Local symptoms

SVC- Syndrome

Claude Bernard Horner
Pericardial / pleural effusion
Phrenic / recurren...
Mediastinal tumors

Localisation within mediastinal compartments

anterior
middle
posterior
Mediastinal masses within mediastinal compartments

Lymphoma
Thymoma
Teratoma
Goiter
Cysts
Lymph nodes

Neurogenic
tumors
Lateral chest RX

Lung nodule

Mediastinal lesion

Distinction between parenchymal and mediastinal lesion
Anterior mediastinal compartment

Lymphoma
60% of mediastinal masses Thymoma
Teratoma
60% malign
Goiter
Lymphoma

23% of tumors in anterior mediastinum in adults
Young adults

Policyclic nodular aspect
Non-surgical treatment (...
Lymphoma

CT-guided biopsy (true-cut) usually sufficient
Lymphoma

Biopsy by anterior parasternal mediastinotomy (Chamberlain)
Lymphoma

Residual mediastinal Hodkin’s disease after radiochemotherapy:
Establishing proof of recurrence may require exci...
Isolated mediastinal lymphoma

Surgical resection after
chemotherapy
30d-mortality

Survival

Ricci (n= 14)

0

Free of di...
Thymic tumors

47 % of tumors in anterior mediastinum in adults
Age 50-70 years

Slowly growing tumors
Thymic tumors

CT: unique mass in the anterior
mediastinum
Thymic hyperplasia

Children and young adults
after infections, antibiotherapy, chemotherapy, irradiation
Thymic tumors

Paraneoplastic syndroms
Neuromuscular (myasthenia gravis, Eaton-Lambert)
Hematological (red cell hyperplasi...
Myasthenia gravis

Weakness of striated muscles
Predominance

ocular (ptosis, diplopia)
bulbar (dysarthria, broncho-aspira...
Nerve

ACH

Striated muscle

Acetylcholin-Receptor
Acetylcholinesterase
ACH

Degradation

ACH Receptor
Myasthenia gravis

Acetylcholinesterase
Antibody

ACH

Degradation

ACH Receptor
Diagnosis / treatment myasthenia gravis

ACHE inhibitor

Acetylcholinesterase
Antibody

ACH

Degradation

ACH Receptor
Thymic tumors and myasthenia gravis

40% of patients with thymoma have myasthenia gravis
20% of patients with myasthenia g...
Thymic tumors

Classification according Masaoka

Stage I /II

I

Encapsulated without infiltration (macroscopic /

microsc...
Thymic tumors

Classification according Masaoka

Infiltration of SVC

III

Infiltration of neighbouring structures

(Peric...
Thymic tumors

Classification according Masaoka

Pleural deposits

IVA

Pleural /pericardial dissemination

IVB

Lymph nod...
Thymic tumors

Histological WHO (Müller-Hermelink)
classification

A (medullary)

AB (mixed)

A: « atrophic », the thymic ...
Thymic tumors

Histological WHO (Müller-Hermelink)
classification

B1 (organoid)

B2 (cortical)

A: « atrophic », the thym...
Thymic tumors

Histological WHO (Müller-Hermelink)
classification

C (thymic carcinoma)
A: « atrophic », the thymic cells ...
Thymic tumors

Thymic carcinoma associated with
MEN I (multiple endocrine neoplasia)
Men <40 years
Thymic tumors

Correlation histology and Masaoka classification (n=71)
I

II

III

IV

5

0

2

0

13

4

1

0

B1 (organo...
Thymic tumors

Management

Small (< 5 cm) encapsulated
lesion

Thymectomy

Port J, Chest Surg Clin N Am 2001
Thymic tumors

Management

Complete en bloc resection

1. Thymic gland (mediastinal pleura and fatty tissue)
2. Infiltrate...
Thymic tumors

Management

Complete en bloc resection

Resection of pericardium

1. Thymic gland (mediastinal pleura and f...
Thymic tumors

Management

Complete en bloc resection

Resection of VCS

1. Thymic gland (mediastinal pleura and fatty tis...
Thymic tumors

Management

Resection by minimally invasive approach (VATS)
Risk of incomplete resection / pleural dissemin...
Thymic tumors

Management

40y old female: VATS resection of thymoma

Resection by minimally invasive approach (VATS)
Risk...
Thymic tumors

Management

7 years later recurrence (thymic carcinoma)

Resection by minimally invasive approach (VATS)
Ri...
Thymic tumors

Management

Minimally invasive resection B2 thymoma
Pleural dissemination 2 years later

Resection by minim...
Thymic tumors

Management

Small (< 5 cm) encapsulated
lesion

Thymectomy

Stage p I

no RT

Stage p II, III

RT

Port J, ...
Resection of thymic tumors

Results (n=71)1

Mortality during follow up

27%

Tumor-related mortality

14%

Recurrence loc...
Results after resection of thymic tumors

Predictors for survival

Age
Gender

ns
ns

Myasthenia gravis

ns

Masaoka class...
Results after resection of thymic tumors

Predictors for disease-free survival
Age
Gender

ns
ns

Myasthenia gravis

ns

M...
Thymic tumors

Management

Tumors > 5 cm
Tumors with invasive pattern

1. Biopsy (true-cut)
2. Induction chemotherapy
3. R...
Stage III thymic tumors

Before CHT

Partial response after chemotherapy

After CHT
Stage III thymic tumors

Clamshell incision

Resection after induction chemotherapy

Replacement of
VCS
4y follow up
Stage III thymic tumors

Induction therapy

Cisplatin-based combination CHT
Response rates
Resectability rates

79 - 100%
...
Stage III thymic tumors

Induction therapy1

Mortality

resection

10y-survival R0 resection Recurrence

Venuta (n=15) 0
1...
Stage IVA B3 thymic tumors (WDTC)

Induction therapy

pleuropneumonectomy

Mortality

Wright (n=5) 0

CHT/RT

Survival
5y
...
Masaoka

Histology
A

I
II
III
IV

AB

B1/2

B3 / C

resection
resection

CHT

RT

resection + CHT/RT
Mediastinal germ cell tumors (MGCT)

15% of tumors in anterior mediasinum in adults

Average age 30 years (1-73)

Teratoma...
Mediastinal germ cell tumors (MGCT)

Teratoma (66%)

asymptomatic

Seminoma

local symptoms (cough, dyspnea, pain)

Non-se...
Mediastinal germ cell tumors (MGCT)

Teratoma

CT: fat / cartilage, delimitated

2 germinal layers

 HCG / a FP negative
...
Mediastinal germ cell tumors (MGCT)

Seminoma

Large, infiltrating tumors

High or low levels of HCG /FP
Radiosensitive /c...
Mediastinal germ cell tumors (MGCT)

Non-seminoma tumors

Large, infiltrating tumors
Mediastinal shift, pleural effusion

...
Mediastinal germ cell tumors (MGCT)

Normal markers

Elevated markers

Biopsy: Seminoma

FNA: Non-seminoma tumor

Chemothe...
Symptoms?
Diagnosis?
Goiter

Compression of airways (intra / extrathoracic)

Resection through cervicotomy
Residual tracheal deformation: video...
Diagnosis?
Subclavian artery aneurysm
Middle mediastinal compartment

Cysts
20% of mediastinal masses
benign
Posterior mediastinal compartment

Neurogenic tumors
Neurogenic tumors

20% of mediastinal tumors in adults
> 90% benign (adults)
Intraspinal extension in 10% (MRI!)
Neurogenic tumors
Benign
Nerve sheath

Malignant

Schwannoma

Neurofibrosarcoma

Neurofibroma
Granular cell tumor
Ganglion...
Neurogenic tumors

Nerve sheath tumors

Most common neurogenic mediastinal tumors
Asymptomatic, slow growing

Complete res...
Neurogenic tumors

Nerve sheath tumors

Cave localisation thoracic inlet
supraclavicular plexus dissection by experienced ...
Neurogenic tumors

Nerve sheath tumors

Von Recklinghausen‘s neurofibromatosis

Multiple neuorfibromas
Risk of malingant d...
Neurogenic tumors

Ganglioneuroma

Young adults
Sympathetic chain
Asymptomatic
Intraspinal extension (MRI): simultaneous c...
Mediastinal Lymphadenopathy

Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
Lymph

nodes

3

3

Retrosternal
Prevascular
Retrocaval
Aortic window
Carinal
Subcarinal
Hilar
Z-esophageal
Circm-cardiac
...
Lymph

Anatomic Considerations
nodes
5

Retrosternal
Prevascular
Retrocaval
Aortic window
Carinal
Subcarinal
Hilar
Z-esoph...
Lymph

Anatomic Considerations
nodes
7

7
8

9

Retrosternal
Prevascular
Retrocaval
Aortic window
Carinal
Subcarinal
Hilar...
Lymph
nodes

Enlarged hilar shadow with lobulated outlines
Normal

X-Rays
Lymph
nodes

Multiple masses at the anatomic locations of lymph nodes

CT
MRI
Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme
Supra...
Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme
3A. P...
Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme
Aorti...
Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme

Hila...
1. Supraclavicular zone nodes
1. Supraclavicular zone nodes
These include low cervical,
supraclavicular and sternal
notch ...
2R. Right Upper Paratracheal
2R nodes extend to the left lateral
border
of
the
trachea.
Upper border: upper border of
manu...
3. Prevascular and Prevertabral nodes
Station 3 nodes are not adjacent to
the trachea like station 2 nodes.
They are eithe...
On the left a 3A node in the
prevascular space.
Notice also lower paratracheal nodes
on the right, i.e. 4R nodes.
4R.

Right

Lower

Paratracheal

Upper border: intersection of caudal
margin
of
innominate
(left
brachiocephalic) vein wit...
On the left we
paratracheal nodes.

see

4R

In addition there is an aortic
node lateral to the aortic arch,
i.e. station ...
4L. Left Lower Paratracheal
4L nodes are lower paratracheal nodes that
are located to the left of the left tracheal
border...
On the left an image just above the level of the
pulmonary trunk demonstrating lower paratracheal
nodes on the left and on...
On the left an image at the level of the lower trachea just above the
carina.
To
the
left
of
the
trachea
4L
nodes.
Notice ...
5. Subaortic nodes
Subaortic or aorto-pulmonary window nodes are lateral to the ligamentum
arteriosum or the aorta or left...
7. Subcarinal nodes
These nodes are located caudally to the carina of the trachea, but are not
associated with the lower l...
8 Paraesophageal nodes

These nodes are below the carinal nodes and extend caudally to
the diaphragm.
On
the
left
an
image...
On the left a PET image demonstrating FDG uptake in a station 8
node.

On the corresponding CT image the node is not enlar...
9. Pulmonary ligament nodes

Pulmonary ligament nodes are lying within the pulmonary
ligament, including those in the post...
10 Hilar nodes

Hilar nodes are proximal lobar nodes, distal to the mediastinal
pleural reflection and nodes adjacent to t...
10 Hilar nodes

Hilar nodes are proximal lobar nodes, distal to the mediastinal
pleural reflection and nodes adjacent to t...
Axial CT of Lymph Nodes
•

Scroll through the images on the left.
1-Sternal notch nodes are just seen at this level and
ab...
•
•

Conventional mediastinoscopy
The following nodal stations can be biopsied by cervical
mediastinoscopy: the left and r...
Extended mediastinoscopy
Left upper lobe tumors may metastasize to the subaortic lymph nodes (station 5) and
paraaortic no...
EUS-FNA
Endoscopic Ultrasound with Fine Needle Aspiration can be performed
of all the mediastinal nodes that that can be a...
Thank You
Case Presentations 1
Case Presentations 1
Case Presentations 1
Case Presentations 1
Case Presentations 1
Case Presentations 1
Case Presentations 1
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Case Presentations 1

  1. 1. Case Presentations Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
  2. 2. Case No. 1
  3. 3. • A 77-year-old man comes to the ED complaining of the acute onset of dyspnea and presyncope that occurred 2 hours ago while retrieving his luggage after a 6-h plane flight. • He didn’t notice any chest pain or hemoptysis. • His medical history is remarkable for long-standing, poorly controlled hypertension; diastolic heart failure; and an ischemic stroke 6 weeks ago with a residual mild right-sided hemiparesis.
  4. 4. • His medications include:  Aspirin, 325 mg daily;  Lisinopril, 40 mg daily; and  Verapamil, 360 mg daily. • On physical examination, he appears anxious. He has a BP of 122/83 mm Hg, heart rate of 113/min, temperature of 36.6C, respiratory rate of 26/min, and oxygen saturation of 86% on room air.
  5. 5. • Laboratory studies reveal the following: D-dimer level of 9.57 g/mL (52.40 nmol/L), Brain natriuretic peptide level of 968.2 pg/mL (968.2 ng/L), and Cardiac troponin T level of 0.06 ng/mL (0.06 g/L).
  6. 6. • CT pulmonary angiogram are shown:
  7. 7. • An echocardiogram is performed, which reveals left ventricular hypertrophy with normal systolic function. The right ventricle is moderately enlarged, and there is severe basal RV systolic dysfunction. Paradoxical septal motion and a D-shaped intraventricular septum are noted in both systole and diastole. The inferior vena cava expiratory diameter is dilated. Moderate tricuspid regurgitation is noted with an estimated right ventricle systolic pressure of 65 mm Hg. There are no other valvular abnormalities. At the main pulmonary artery bifurcation, there is an area of increased echogenicity protruding into both main pulmonary arteries that could represent a clot.
  8. 8. • The patient receives supplemental oxygen and IV unfractionated heparin (UFH), and is admitted for close monitoring. • Two hours after admission, his BP drops to 86/52 mm Hg. • He is given fluid without any response and vasopressor support is initiated. In addition to continuing the fluids and vasopressors, • Your next best step is to:
  9. 9. A. Switch to a low-molecular-weight heparin (LMWH). B. Insert an inferior vena cava filter. C. Perform catheter embolectomy. D. Administer systemic thrombolytic therapy. large bilateral central clot on CT angiography
  10. 10. According to ACCP antithrombotic guidelines published (2008) • Recommend thrombolytic therapy for all patients with hemodynamic compromise unless there are major contraindications owing to bleeding risk (Grade 1B).
  11. 11. Major contraindications include • A history of intracranial hemorrhage • Known intracranial aneurysm or arteriovenous malformation • Significant head trauma • Active internal bleeding • Known bleeding diathesis • Intracranial or intraspinal surgery within 3 months • A cerebrovascular accident within 2 months.
  12. 12. Relative contraindications include: • • • • • Recent internal bleeding Recent surgery or organ biopsy Uncontrolled hypertension Pregnancy Age 75 years.
  13. 13. • This patient has a major and several relative contraindications, so systemic thrombolysis would not be the best option (choice D is incorrect). • The ACCP guidelines also recommend that, in patients with massive PE who cannot receive thrombolysis because of contraindications or time, interventional catheterization techniques are used if appropriate expertise is available (Grade 2B). Catheter-directed therapy provides a less extreme advanced treatment option than surgical embolectomy.
  14. 14. • Many experts agree that patients that meet the following criteria should be considered for catheter embolectomy: (1) acute PE with hemodynamic instability; (2) subtotal or total filling defect in the left and/or right main pulmonary artery; and (3) the presence of a major contraindication to systemic thrombolysis, including ischemic stroke. and thus is an ideal candidate (choice C is correct).
  15. 15. Summary • This patient has massive pulmonary embolism (PE) (confirmed acute PE with shock and obvious right ventricular dysfunction) in the setting of several contraindications to systemic thrombolysis
  16. 16. So the next best step is to: A. Switch to a low-molecular-weight heparin (LMWH). B. Insert an inferior vena cava filter. C. Perform catheter embolectomy. D. Administer systemic thrombolytic therapy.
  17. 17. Thrombolytics in Acute Pumonary Embolism Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
  18. 18. The ACCP’s recommendation classification system: 1 = “recommendation” 2 = “suggestion” A = based on strong evidence from randomized trials B = moderate evidence that may include randomized trials or observational studies C = weak evidence, mostly consensus opinion
  19. 19. Which patients with acute pulmonary embolism should I treat with systemic thrombolytics? The ACCP suggests using systemic thrombolytics to treat patients with acute PE who are hypotensive (they propose a cutoff of systolic blood pressure less than 90 mm Hg). (Grade 2C).
  20. 20. Which patients with acute pulmonary embolism should I treat with systemic thrombolytics? ACCP recommends against treating most patients with acute PE without hypotension with systemic thrombolytics (Grade 1C).
  21. 21. Which patients with acute pulmonary embolism should I treat with systemic thrombolytics? *However, patients deemed to be at high risk for becoming hypotensive according to clinical course are suggested to receive systemic thrombolytics, if they have a low bleeding risk (Grade 2C). *“Looking sick,” dyspneic and hypoxic, right ventricular dysfunction on echocardiogram, elevated troponins, elevated neck veins, severe tachycardia have all been proposed as risk factors.
  22. 22. How should I treat acute pulmonary embolism with systemic thrombolytics? *A short infusion time of 2 hours for systemic thrombolytics is suggested, rather than a longer infusion (Grade 2C). Tissue plasminogen activator (tPA) has a short infusion time and has been recommended as the best agent for this reason. *Infuse systemic thrombolytics through a peripheral vein, rather than a pulmonary artery catheter (Grade 2C).
  23. 23. How should I treat acute pulmonary embolism with systemic thrombolytics? Randomized trials show that thrombolytics improve pulmonary artery pressures, oxygenation, and cardiac performance on echocardiography within 24 hours in people with acute pulmomary embolism. However, this comes at a significantly higher risk of bleeding compared to other therapies.
  24. 24. How should I treat acute pulmonary embolism with systemic thrombolytics? ACCP’s recommendations to provide thrombolytics to people with massive PE (with hypotension) or who are high risk for soon becoming that way. In large part, this is based on the observed mortality seen in series of patients with acute pulmonary embolism: ~5% of people with pulmonary embolus who receive treatment die (from that or another PE) within 7 days. ~2% mortality in patients without hypotension; ~30% mortality when there is shock necessitating inotropes; ~70% mortality if cardiopulmonary arrest occurs.
  25. 25. Catheter-Based Thrombus Removal for the Initial Treatment of Patients With PE In patients with acute PE associated with hypotension and who have (i) contraindications to thrombolysis, (ii) failed thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (eg, within hours), if appropriate expertise and resources are available, we suggest catheter-assisted thrombus removal over no such intervention (Grade 2C).
  26. 26. What shall I do with the heparin infusion during administration of thrombolytic therapy for acute PE? *There is no ACCP recommendation for this question, stating it is “acceptable … to continue or suspend the unfractionated heparin infusion during administration of thrombolytics.” *In the U.S., regulatory bodies advise stopping unfractionated heparin during t-PA infusion and restarting it when aPTT is <= 80 sec after t-PA is complete. *In many other countries, heparin infusion is continued during t-PA.
  27. 27. Recommendations
  28. 28. Contraindications
  29. 29. Saddle PE :that lodges at the bifurcation of the main pulmonary artery
  30. 30. Multidetector-CT Findings • Partial or complete filling defects in lumen of pulmonary arteries – Most reliable sign is filling defect forming acute angle with vessel wall with defect outlined by contrast material – “Tram-track sign” • Parallel lines of contrast surrounding thrombus in vessel that travels in transverse plane – “Rim sign” • Contrast surrounding thrombus in vessel that travels orthogonal to transverse plane • RV strain indicated by straightening or leftward bowing of interventricular septum Macdonald S; Mayo J. Semin. Ultrasound CT. 2003;24(4):271-231.
  31. 31. Large saddle thrombus with extensive clot burden. Arrows demonstrating tram-track sign (A), rim sign (B), complete filling defect (C), and a fully non-contrasted vessel (D)
  32. 32. Embolic burden scoring system. Schematic of the pulmonary arterial tree with scores for nonocclusive emboli according to vessel. Emboli in a segmental pulmonary artery are given a score of 1. Emboli in more proximal pulmonary arteries are given a score based on the total number of segmental pulmonary arteries supplied.
  33. 33. Thrombotic and Nonthrombotic Pulmonary Arterial Embolism By Gamal Rabie Agmy , MD , FCCP Professor of Chest Diseases ,Assiut University
  34. 34. Acute Pulmonary Embolism Saddle PE :that lodges at the bifurcation of the main pulmonary artery
  35. 35. Multidetector-CT Findings • Partial or complete filling defects in lumen of pulmonary arteries – Most reliable sign is filling defect forming acute angle with vessel wall with defect outlined by contrast material – “Tram-track sign” • Parallel lines of contrast surrounding thrombus in vessel that travels in transverse plane – “Rim sign” • Contrast surrounding thrombus in vessel that travels orthogonal to transverse plane • RV strain indicated by straightening or leftward bowing of interventricular septum Macdonald S; Mayo J. Semin. Ultrasound CT. 2003;24(4):271-231.
  36. 36. Large saddle thrombus with extensive clot burden. Arrows demonstrating tram-track sign (A), rim sign (B), complete filling defect (C), and a fully non-contrasted vessel (D)
  37. 37. Acute pulmonary embolism and deep venous thrombosis (DVT) in a 48-year-old woman. (a) Contrast material–enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the basal subsegmental pulmonary artery shows multifocal low-attenuation emboli (arrows) in segmental and subsegmental arteries in the right lower lobe. (b) Contrast-enhanced indirect CT venogram (5-mm collimation) obtained at the level of the pelvic inlet 3 minutes after injection shows large low-attenuation thrombi filling the left common iliac vein (arrow).
  38. 38. Acute pulmonary embolism in a 41-yearoldwoman. Coronal gadolinium-enhanced threedimensional pulmonary MR angiogram shows a large embolus (arrows) in the proximal right interlobar artery.
  39. 39. Embolic burden scoring system. Schematic of the pulmonary arterial tree with scores for nonocclusive emboli according to vessel. Emboli in a segmental pulmonary artery are given a score of 1. Emboli in more proximal pulmonary arteries are given a score based on the total number of segmental pulmonary arteries supplied.
  40. 40. Helical CT Findings in Chronic PTE Cardiac abnormalities Right ventricular enlargement Right atrial enlargement Thrombi in the right atrium or ventricle* Vascular abnormalities Eccentric, flattened defect at an obtuse angle with the vessel wall* Irregular or nodular arterial wall Abrupt narrowing of the vessel diameter Abrupt cutoff of distal lobar or segmental artery Recanalization of thrombosed vessel Webs or bands (less frequent) Parenchymal abnormalities Bronchial artery dilatation Bronchiectasis Areas of decreased attenuation in the lung (mosaic perfusion pattern)
  41. 41. Septic Pulmonary Embolism Septic pulmonary embolism in a 28-year-old intravenous drug abuser with human immunodeficiency viral infection. Repeated blood cultures disclosed a positive culture for Nocardia. (a) Radiograph shows multiple cavitary nodules throughout both lungs. (b) CT scan (10-mm collimation) obtained at the level of the azygos arch demonstrates the feeding vessel sign (vessel leading directly to the nodule) in several nodules
  42. 42. Hydatid Embolism
  43. 43. Fat Embolism
  44. 44. Amniotic Fluid Embolism
  45. 45. Tumor Embolism
  46. 46. Air Embolism
  47. 47. Talc Embolism
  48. 48. Cement (Polymethylmethacrylate) Embolism
  49. 49. Iodinated oil embolism
  50. 50. Miscellaneous Foreign Body Embolism
  51. 51. Case No. 2
  52. 52. • History of exposure to asbestos more than 45 years ago. • He had long-standing bilateral pleural plaques, upper lobe nodules, and interstitial disease in a UIP pattern, the latter two of which are attributable to the RA • The patient began to notice streaky hemoptysis mixed with yellowish sputum about 5 months ago, but it cleared spontaneously after a few weeks, only to recur 3 weeks ago.
  53. 53. • A 72-year-old man is seen for evaluation of hemoptysis. • He had a 14-year history of rheumatoid arthritis (RA) previously treated with hydroxychloroquine, methotrexate, gold, penicillamine, and etanercept. • Currently, he is taking adalimumab and an NSAID. • He had a 40 pack-year smoking history but quit 10 years ago and
  54. 54. • He denied any fever, sweats, chills, or weight loss and stated that his chronic respiratory symptoms were stable. • His only complaint was severe neck pain attributable to severe, unstable cervical spine disease with planned fusion surgery. • Physical examination revealed bibasilar late inspiratory crackles halfway up both lung fields. • There was nothing to suggest pulmonary hypertension.
  55. 55. • His spirometry revealed an FEV1 of 2.49 L (78% of predicted) and an FVC of 2.98 L (71% predicted), with an FEV1/FVC of 0.84. • A representative image from his CT scan is shown in Figure
  56. 56. • Bronchoscopy revealed some old blood in the left upper lobe but no active bleeding or endobronchial lesions were seen. • Results of cytologic studies and initial smears for infectious organisms were negative.
  57. 57. Which is the best-recommended therapy at the present time? A. Bronchial artery embolization. B. Itraconazole. C. Surgical resection. D. Oral corticosteroids
  58. 58. • The CT scan reveals a left upper lobe cavity with a mass inside, highly suggestive of a fungus ball. • Preferred therapy in a patient with reasonably preserved lung function, as in this patient, is surgical resection (choice C is correct).
  59. 59. • For patients who are considered poor operative candidates, a number of alternative, to surgery exist. • These include bronchial artery embolization if an area of active bleeding can be found in a patient with massive hemoptysis. This is really a temporizing measure because bleeding tends to recur due to the development of massive collaterals (choice A is incorrect).
  60. 60. • Inhaled, intracavitary, and endobronchial instillations of antifungal agents have been tried in small numbers of patients without consistent success. • The most promising results have been with the use of oral itraconazole, perhaps related to its high tissue penetration. • However, it works slowly and would not be recommended in patients with significant hemoptysis who were otherwise good surgical candidates (choice C is incorrect).
  61. 61. • There are some older reports on the use of radiation therapy or corticosteroids to control hemoptysis, but neither affects long-term outcomes, and steroids carry the risk of dissemination or fungus ball enlargement (choice D incorrect)
  62. 62. • A fungus ball, or mycetoma, is the saprophytic colonization of a preexisting parenchymal cavity. This cavity may be due to previous infection (eg, TB), bronchiectasis, bullous emphysema, sarcoidosis, and rheumatoid arthritis, among others. • The fungus ball is made up of fungal hyphae matted together with mucus, fibrin, and tissue debris that together cause local inflammation. The fungus ball may move around within the cavity, making diagnosis easier, but rarely invades the surrounding parenchyma of the lung.
  63. 63. • The most common fungus causing a mycetoma is Aspergillus, hence, the use of the term aspergilloma, but other fungal species, including Zygomycetes and Fusarium, have also been reported as a cause. • The majority of patients with a mycetoma are asymptomatic, but somewhere between 50% and 74% of affected individuals will develop hemoptysis that can be life threatening. • Cough, fever, weight loss, and dyspnea have all been reported, but many of these may be related to the underlying pulmonary condition. • The majority of patients will have sputum or bronchoalveolar lavage fluid cultures that are positive for Aspergillus species, most commonly A niger.
  64. 64. • CT scanning usually shows an intracavitary mass, as in this patient, often with an air crescent sign. • Treatment of choice, as discussed previously, is surgical resection once hemoptysis starts but before it becomes too severe. • Surgical mortality ranges from 7% to 23% and is usually attributable to the underlying condition and poor pulmonary function.
  65. 65. • Poor prognostic factors includes: 1. The severity of the underlying lung disease. 2. Increasing size or number of lesions seen on chest radiographs. 3. Immunosuppression(including corticosteroids) 4. Recurrent large volume hemoptysis 5. Underlying HIV infection.
  66. 66. Surgical resection revealed classic fungus ball (fig-1) containing numerous fungal organisms on staining (Fig 2), some of which were invading the surrounding lung tissue, somewhat suggestive of necrotizing aspergillosis
  67. 67. • An aortic erosion from the Aspergillus cavity was also found and repaired.
  68. 68. So........ The best-recommended therapy at the present time? A. Bronchial artery embolization. B. Itraconazole. C. Surgical resection. D. Oral corticosteroids
  69. 69. Spectrum of Pulmonary Aspergillosis Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
  70. 70. Pulmonary Aspergillosis Pulmonary aspergillosis can be subdivided into five categories: (a) saprophytic aspergillosis (aspergilloma), (b) hypersensitivity reaction (allergic bronchopulmonary aspergillosis), (c) semi-invasive (chronic necrotizing) aspergillosis, (d) airway-invasive aspergillosis (acute tracheobronchitis, bronchiolitis, bronchopneumonia, obstructing bronchopulmonary aspergillosis), and (e) Angioinvasive aspergillosis.
  71. 71. Saprophytic Aspergillosis (Aspergilloma) *Saprophytic aspergillosis (aspergilloma) is characterized by Aspergillus infection without tissue invasion.It typically leads to conglomeration of intertwined fungal hyphae admixed with mucus and cellular debris within a preexistent pulmonary cavity or ectatic bronchus. * The most common underlying causes are tuberculosis and sarcoidosis. Other conditions that occasionally may be associated with aspergilloma include bronchogenic cyst, pulmonary sequestration,and pneumatoceles secondary to Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome (AIDS) (3–5). Although aspergillomas are usually single, they may also be present bilaterally.
  72. 72. Saprophytic Aspergillosis (Aspergilloma) *Although patients may remain asymptomatic, the most common clinical manifestation of saprophytic aspergillosis is hemoptysis. Surgical resection is indicated for patients with severe lifethreatening hemoptysis, and selective bronchial artery embolization can be performed in those with poor lung function.
  73. 73. Saprophytic Aspergillosis (Aspergilloma)
  74. 74. Saprophytic Aspergillosis (Aspergilloma)
  75. 75. Hypersensitivity Reaction (Allergic Bronchopulmonary Aspergillosis) *Allergic bronchopulmonary aspergillosis is seen most commonly in patients with long-standing bronchial asthma. *Acute clinical symptoms include recurrent wheezing, malaise ith low-grade fever, cough, sputum production, and chest pain. Patients with chronic allergic bronchopulmonary aspergillosis may also have a history of recurrent pneumonia.
  76. 76. Allergic Bronchopulmonary Aspergillosis
  77. 77. Semi-invasive (Chronic Necrotizing) Aspergillosis *Factors associated with the development of this form of aspergillosis include chronic debilitating illness, diabetes mellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid therapy, and chronic obstructive pulmonary disease. * Clinical symptoms are often insidious and include chronic cough, sputum production, fever, and constitutional symptoms. In patients with chronic obstructive pulmonary disease, semiinvasive aspergillosis may manifest with a variety of nonspecific clinical symptoms such as cough, sputum production, and fever lasting more than 6 months. Hemoptysis has been reported in 15% of affected patients
  78. 78. Semi-invasive (Chronic Necrotizing) Aspergillosis
  79. 79. Airway-invasive Aspergillosis *It occurs most commonly in immunocompromised neutropenic patients and in patients with AIDS * Clinical manifestations include acute tracheobronchitis, bronchiolitis, and bronchopneumonia.
  80. 80. Airway-invasive Aspergillosis
  81. 81. Airway-invasive Aspergillosis Obstructing bronchopulmonary aspergillosis is a noninvasive form of aspergillosis characterized by the massive intraluminal overgrowth of Aspergillus species, usually A fumigatus, in patients with AIDS .Affected patients exhibit cough,fever, and new onset of asthma. Patients may cough up fungal casts of the bronchi and present with severe hypoxemia.
  82. 82. Angio-invasive Aspergillosis *Angioinvasive aspergillosis occurs almost exclusively in immunocompromised patients with severe neutropenia. *Increase risk of invasive asprigellosis is due to the development of new intensive chemotherapy regimens for solid tumors, difficult-to-treat lymphoma, myeloma,and resistant leukemia as well as an increase in the number of solid organ transplantations and increased use of immunosuppressive regimens for other autoimmune diseases. Despite having a normal neutrophil count, affected patients have functional neutropenia because the function of the neutrophils is inhibited by the use of highdose steroids.
  83. 83. Angio-invasive Aspergillosis
  84. 84. Case No. 3
  85. 85. • A 38-year-old man has new-onset pressure in the right side of his neck with accompanying dyspnea on exertion.
  86. 86. Chest radiographs
  87. 87. CT scan
  88. 88. • The most likely etiology of the lesion is: A. Thymoma. B. Bronchogenic cyst. C. Schwannoma. D. Lymphoma.
  89. 89. • The very large mass is identified to be in the posterior mediastinum. • The posterior mediastinum is bounded anteriorly by the pericardium, posteriorly by the vertebral bodies, and laterally by the mediastinal pleura. • Contained with this compartment is the thoracic descending aorta, the greater and lesser azygos veins, splanchnic nerves, the esophagus, thoracic duct, and lymphatic tissue.
  90. 90. • Schwannomas, neurofibromas, and malignant tumors of the nerve sheath originate from the peripheral nerves while ganglioneuromas, ganglioneuroblastomas, and neuroblastomas develop in the sympathetic ganglia. Together, they account for 30% to 50% of posterior mediastinal masses (choice C is correct).
  91. 91. • Schwannomas and neurofibromas affect men and women equally, appearing in the third to fourth decades of life. These tumors are spherical and sharply demarcated. • Surgical resection is the treatment of choice in patients who are symptomatic.
  92. 92. • Neurogenic tumors are the most common cause of posterior mediastinal masses. They account for 20% of all adult mediastinal masses and 35% of pediatric mediastinal masses. • 90% of all neurogenic tumors occur in the posterior mediastinum. The vast majority of neurogenic tumors, 70% to 80%, are benign and slow growing.
  93. 93. • Nearly one-half of all tumors are asymptomatic and found incidentally. • In those that are symptomatic, regional compressive symptoms or neurologic impairment occurs. • The tumors arise from the peripheral nerves, sympathetic ganglia, and on rare occasions, the parasympathetic ganglia
  94. 94. • Thymomas are the most common tumors of the anterior mediastinum, comprising 20% of anterior mediastinal neoplasms in adults (choice A is incorrect). • Bronchogenic cysts are congenital abnormalities that develop as the result of anomalous budding of the laryngotracheal groove. Bronchogenic cysts are well defi ned, round masses often arising adjacent to the carina within the middle mediastinum (choice B is incorrect).
  95. 95. • Mediastinal lymphoma is typically an extension of widespread regional or systemic disease. • Primary mediastinal lymphoma, accounting for 10% mediastinal lymphomas, may occur in any of the three compartments but typically arises in the anterior mediastinum (choice D is incorrect)
  96. 96. Mediastinal Mass Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
  97. 97. Symptoms associated with mediastinal masses No symptoms (discovery by chance) Paraneoplastic Local retrosternal pain cough signs of malignancy dyspnea (compression, phrenic palsy)
  98. 98. Mediastinal masses Local symptoms SVC- Syndrome Claude Bernard Horner Pericardial / pleural effusion Phrenic / recurrent palsy SVC- syndrome
  99. 99. Mediastinal tumors Localisation within mediastinal compartments anterior middle posterior
  100. 100. Mediastinal masses within mediastinal compartments Lymphoma Thymoma Teratoma Goiter Cysts Lymph nodes Neurogenic tumors
  101. 101. Lateral chest RX Lung nodule Mediastinal lesion Distinction between parenchymal and mediastinal lesion
  102. 102. Anterior mediastinal compartment Lymphoma 60% of mediastinal masses Thymoma Teratoma 60% malign Goiter
  103. 103. Lymphoma 23% of tumors in anterior mediastinum in adults Young adults Policyclic nodular aspect Non-surgical treatment (chemotherapy /chemo-radiation)
  104. 104. Lymphoma CT-guided biopsy (true-cut) usually sufficient
  105. 105. Lymphoma Biopsy by anterior parasternal mediastinotomy (Chamberlain)
  106. 106. Lymphoma Residual mediastinal Hodkin’s disease after radiochemotherapy: Establishing proof of recurrence may require excisional biopsy
  107. 107. Isolated mediastinal lymphoma Surgical resection after chemotherapy 30d-mortality Survival Ricci (n= 14) 0 Free of disease (1-14 y) Bacha (n=16) 6% 5y- survival 85%
  108. 108. Thymic tumors 47 % of tumors in anterior mediastinum in adults Age 50-70 years Slowly growing tumors
  109. 109. Thymic tumors CT: unique mass in the anterior mediastinum
  110. 110. Thymic hyperplasia Children and young adults after infections, antibiotherapy, chemotherapy, irradiation
  111. 111. Thymic tumors Paraneoplastic syndroms Neuromuscular (myasthenia gravis, Eaton-Lambert) Hematological (red cell hyperplasia, pancytopenia) Dermatological (pemphigus, candidosis) Endocrine (hyperparathyroidism, Addison, Hashimoto) Renal (nephrotic syndrome) Skeletal (hypertrophic osteo-arthropathy) Immunodeficiency Collagenosis (lupus, polyarthritis, Sjögren)
  112. 112. Myasthenia gravis Weakness of striated muscles Predominance ocular (ptosis, diplopia) bulbar (dysarthria, broncho-aspiration) Auto-immune disease (antibodies against acetylcholine receptors) Diagnosis / treatment acetylcholinesterase-inhibitor (prostigmine)
  113. 113. Nerve ACH Striated muscle Acetylcholin-Receptor
  114. 114. Acetylcholinesterase ACH Degradation ACH Receptor
  115. 115. Myasthenia gravis Acetylcholinesterase Antibody ACH Degradation ACH Receptor
  116. 116. Diagnosis / treatment myasthenia gravis ACHE inhibitor Acetylcholinesterase Antibody ACH Degradation ACH Receptor
  117. 117. Thymic tumors and myasthenia gravis 40% of patients with thymoma have myasthenia gravis 20% of patients with myasthenia gravis have thymoma No difference in MG remission after thymectomy (+ thymoma) No influence on survival after thymectomy for thymoma (+ MG) Wright CD, Thorac Cardiovasc Surg 2005
  118. 118. Thymic tumors Classification according Masaoka Stage I /II I Encapsulated without infiltration (macroscopic / microscopic) II Microscopic invasion Capsule (A) Mediastinal fat (B)
  119. 119. Thymic tumors Classification according Masaoka Infiltration of SVC III Infiltration of neighbouring structures (Pericardium, lung, phrenic nerve, SVC)
  120. 120. Thymic tumors Classification according Masaoka Pleural deposits IVA Pleural /pericardial dissemination IVB Lymph node metastases / distant metastases
  121. 121. Thymic tumors Histological WHO (Müller-Hermelink) classification A (medullary) AB (mixed) A: « atrophic », the thymic cells of adult life B: « bioactive » biologically active organ of the fetus / infant C: « carcinoma »
  122. 122. Thymic tumors Histological WHO (Müller-Hermelink) classification B1 (organoid) B2 (cortical) A: « atrophic », the thymic cells of adult life B: « bioactive » biologically active organ of the fetus / infant C: « carcinoma » B3 (WDTC)
  123. 123. Thymic tumors Histological WHO (Müller-Hermelink) classification C (thymic carcinoma) A: « atrophic », the thymic cells of adult life B: « bioactive » biologically active organ of the fetus / infant C: « carcinoma »
  124. 124. Thymic tumors Thymic carcinoma associated with MEN I (multiple endocrine neoplasia) Men <40 years
  125. 125. Thymic tumors Correlation histology and Masaoka classification (n=71) I II III IV 5 0 2 0 13 4 1 0 B1 (organoid) 9 4 1 0 B2 (cortical) 4 4 3 0 B3 (WDTC) 1 3 7 3 C (carcinoma) 0 0 4 1 A (medullary) AB (mixed) (p < 0.001) Lardinois D, Ann Thorac Surg 2000
  126. 126. Thymic tumors Management Small (< 5 cm) encapsulated lesion Thymectomy Port J, Chest Surg Clin N Am 2001
  127. 127. Thymic tumors Management Complete en bloc resection 1. Thymic gland (mediastinal pleura and fatty tissue) 2. Infiltrated neighbouring structures (lung, phrenic nerve, pericardium, innominate vein) Port J, Chest Surg Clin N Am 2001
  128. 128. Thymic tumors Management Complete en bloc resection Resection of pericardium 1. Thymic gland (mediastinal pleura and fatty tissue) 2. Infiltrated neighbouring structures (lung, phrenic nerve, pericardium, innominate vein) Port J, Chest Surg Clin N Am 2001
  129. 129. Thymic tumors Management Complete en bloc resection Resection of VCS 1. Thymic gland (mediastinal pleura and fatty tissue) 2. Infiltrated neighbouring structures (lung, phrenic nerve, pericardium, innominate vein) Port J, Chest Surg Clin N Am 2001
  130. 130. Thymic tumors Management Resection by minimally invasive approach (VATS) Risk of incomplete resection / pleural dissemination
  131. 131. Thymic tumors Management 40y old female: VATS resection of thymoma Resection by minimally invasive approach (VATS) Risk of incomplete resection / pleural dissemination
  132. 132. Thymic tumors Management 7 years later recurrence (thymic carcinoma) Resection by minimally invasive approach (VATS) Risk of incomplete resection / pleural dissemination
  133. 133. Thymic tumors Management Minimally invasive resection B2 thymoma Pleural dissemination 2 years later Resection by minimally invasive approach (VATS) Risk of incomplete resection / pleural dissemination
  134. 134. Thymic tumors Management Small (< 5 cm) encapsulated lesion Thymectomy Stage p I no RT Stage p II, III RT Port J, Chest Surg Clin N Am 2001
  135. 135. Resection of thymic tumors Results (n=71)1 Mortality during follow up 27% Tumor-related mortality 14% Recurrence local 14% local and distant 1Mean 4% follow up 8.3 years; complete follow up 97% Lardinois D, Ann Thorac Surg 2000
  136. 136. Results after resection of thymic tumors Predictors for survival Age Gender ns ns Myasthenia gravis ns Masaoka classification p < 0.05 Histology p < 0.05
  137. 137. Results after resection of thymic tumors Predictors for disease-free survival Age Gender ns ns Myasthenia gravis ns Masaoka classification p < 0.0001 Histology p < 0.004
  138. 138. Thymic tumors Management Tumors > 5 cm Tumors with invasive pattern 1. Biopsy (true-cut) 2. Induction chemotherapy 3. Resection Port J, Chest Surg Clin N Am 2001
  139. 139. Stage III thymic tumors Before CHT Partial response after chemotherapy After CHT
  140. 140. Stage III thymic tumors Clamshell incision Resection after induction chemotherapy Replacement of VCS 4y follow up
  141. 141. Stage III thymic tumors Induction therapy Cisplatin-based combination CHT Response rates Resectability rates 79 - 100% 36 - 69% Machiarini P, Cancer 1991 Rea F, J Thorac Cardiovasc Surg 1993 Loehrer PJ, J Clin Oncol 1997 Shin DM, Ann Intern 1998 Berutti A, Br J Cancer 1999 Kim ES, Proc Am Soc Clinic Oncol 2001
  142. 142. Stage III thymic tumors Induction therapy1 Mortality resection 10y-survival R0 resection Recurrence Venuta (n=15) 0 1response rate CHT/RT 90% 87% 27% 13% complete 53% partial Venuta F, Ann Thorac Surg 2003
  143. 143. Stage IVA B3 thymic tumors (WDTC) Induction therapy pleuropneumonectomy Mortality Wright (n=5) 0 CHT/RT Survival 5y 10y Recurrence 75% peritoneal (3) 50% Wright CD, Ann Thorac Surg 2006
  144. 144. Masaoka Histology A I II III IV AB B1/2 B3 / C resection resection CHT RT resection + CHT/RT
  145. 145. Mediastinal germ cell tumors (MGCT) 15% of tumors in anterior mediasinum in adults Average age 30 years (1-73) Teratoma men = women Malignant MGCT men 95%
  146. 146. Mediastinal germ cell tumors (MGCT) Teratoma (66%) asymptomatic Seminoma local symptoms (cough, dyspnea, pain) Non-seminoma tumors local symptoms (VCS syndrome) sick patients (fever, pleural effusion)
  147. 147. Mediastinal germ cell tumors (MGCT) Teratoma CT: fat / cartilage, delimitated 2 germinal layers  HCG / a FP negative Complete resection without adjuvant therapy
  148. 148. Mediastinal germ cell tumors (MGCT) Seminoma Large, infiltrating tumors High or low levels of HCG /FP Radiosensitive /chemosensitive tumors
  149. 149. Mediastinal germ cell tumors (MGCT) Non-seminoma tumors Large, infiltrating tumors Mediastinal shift, pleural effusion Chemotherapy Commonly associated with metastases high level HCG / FP Resection of residual masses (growing teratoma syndrome) Cave Bleomycin!
  150. 150. Mediastinal germ cell tumors (MGCT) Normal markers Elevated markers Biopsy: Seminoma FNA: Non-seminoma tumor Chemotherapy Small Large / mets RT CT: residual resectable lesions CHT Resection
  151. 151. Symptoms? Diagnosis?
  152. 152. Goiter Compression of airways (intra / extrathoracic) Resection through cervicotomy Residual tracheal deformation: video-assisted tracheopexy
  153. 153. Diagnosis?
  154. 154. Subclavian artery aneurysm
  155. 155. Middle mediastinal compartment Cysts 20% of mediastinal masses benign
  156. 156. Posterior mediastinal compartment Neurogenic tumors
  157. 157. Neurogenic tumors 20% of mediastinal tumors in adults > 90% benign (adults) Intraspinal extension in 10% (MRI!)
  158. 158. Neurogenic tumors Benign Nerve sheath Malignant Schwannoma Neurofibrosarcoma Neurofibroma Granular cell tumor Ganglion cell Ganglioneuroma Paraganglionic Chemodectoma Pheochromocytoma Ganglioneuroblastoma
  159. 159. Neurogenic tumors Nerve sheath tumors Most common neurogenic mediastinal tumors Asymptomatic, slow growing Complete resection recommended (VATS)
  160. 160. Neurogenic tumors Nerve sheath tumors Cave localisation thoracic inlet supraclavicular plexus dissection by experienced plexux surgeon!
  161. 161. Neurogenic tumors Nerve sheath tumors Von Recklinghausen‘s neurofibromatosis Multiple neuorfibromas Risk of malingant degenereration (neurofibrosarcoma)
  162. 162. Neurogenic tumors Ganglioneuroma Young adults Sympathetic chain Asymptomatic Intraspinal extension (MRI): simultaneous combined resection Complete resection (thoracotomy): local resurrence uncommon
  163. 163. Mediastinal Lymphadenopathy Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
  164. 164. Lymph nodes 3 3 Retrosternal Prevascular Retrocaval Aortic window Carinal Subcarinal Hilar Z-esophageal Circm-cardiac Anatomic Considerations
  165. 165. Lymph Anatomic Considerations nodes 5 Retrosternal Prevascular Retrocaval Aortic window Carinal Subcarinal Hilar Z-esophageal Circm-cardiac 6
  166. 166. Lymph Anatomic Considerations nodes 7 7 8 9 Retrosternal Prevascular Retrocaval Aortic window Carinal Subcarinal Hilar Z-esophageal Circm-cardiac
  167. 167. Lymph nodes Enlarged hilar shadow with lobulated outlines Normal X-Rays
  168. 168. Lymph nodes Multiple masses at the anatomic locations of lymph nodes CT MRI
  169. 169. Regional lymph node classification for lung cancer staging adapted from the American Thoracic Society mapping scheme Supraclavicular nodes 1. Low cervical, supraclavicular and sternal notch nodes From the lower margin of the cricoid to the clavicles and the upper border of the manubrium. The midline of the trachea serves as border between 1R and 1L. Superior Mediastinal Nodes 2-4 2R.Upper Paratracheal • 2R nodes extend to the left lateral border of the trachea. From upper border of manubrium to the intersection of caudal margin of innominate (left brachiocephalic) vein with the trachea. 2L.Upper Paratracheal From the upper border of manubrium to the superior border of aortic arch. 2L nodes are located to the left of the left lateral border of the trachea.
  170. 170. Regional lymph node classification for lung cancer staging adapted from the American Thoracic Society mapping scheme 3A. Pre-vascular These nodes are not adjacent to the trachea like the nodes in station 2, but they are anterior to the vessels. 3P.Pre-vertebral Nodes not adjacent to the trachea like the nodes in station 2, but behind the esophagus, which is prevertebral. • 4R. Lower Paratracheal From the intersection of the caudal margin of innominate (left brachiocephalic) vein with the trachea to the lower border of the azygos vein. 4R nodes extend from the right to the left lateral border of the trachea. 4L. Lower Paratracheal From the upper margin of the aortic arch to the upper rim of the left main pulmonary artery.
  171. 171. Regional lymph node classification for lung cancer staging adapted from the American Thoracic Society mapping scheme Aortic Nodes 5-6 5. Subaortic These nodes are located in the AP window lateral to the ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk but lateral to these vessels. • 6. Para-aortic These are ascending aorta or phrenic nodes lying anterior and lateral to the ascending aorta and the aortic arch. Inferior Mediastinal Nodes 7-9 7.Subcarinal Nodes below carina. 8. Paraesophageal 9. Pulmonary Ligament Nodes lying within the pulmonary ligaments.
  172. 172. Regional lymph node classification for lung cancer staging adapted from the American Thoracic Society mapping scheme Hilar, Lobar and (sub)segmental Nodes 1014 These are all N1-nodes. 10. Hilar nodes These include nodes adjacent to the main stem bronchus and hilar vessels. On the right they extend from the lower rim of the azygos vein to the interlobar region. On the left from the upper rim of the pulmonary artery to the interlobar region.
  173. 173. 1. Supraclavicular zone nodes 1. Supraclavicular zone nodes These include low cervical, supraclavicular and sternal notch nodes. Upper border: lower margin of cricoid. Lower border: clavicles and upper border of manubrium. The midline of the trachea serves as border between 1R and 1L.
  174. 174. 2R. Right Upper Paratracheal 2R nodes extend to the left lateral border of the trachea. Upper border: upper border of manubrium. Lower border: intersection of caudal margin of innominate (left brachiocephalic) vein with the trachea. 2L. Left Upper Paratracheal Upper border: upper border of manubrium. Lower border: superior border of aortic arch. On the left a station 2 node in front of the trachea, i.e. a 2R-node. There is also a small prevascular node, i.e. a station 3A node
  175. 175. 3. Prevascular and Prevertabral nodes Station 3 nodes are not adjacent to the trachea like station 2 nodes. They are either: 3A anterior to the vessels or 3B behind the esophagus, which lies prevertebrally. Station 3 nodes are not accessible with mediastinoscopy. 3P nodes can be accessible with endoscopic ultrasound (EUS). 3A and 3P nodes
  176. 176. On the left a 3A node in the prevascular space. Notice also lower paratracheal nodes on the right, i.e. 4R nodes.
  177. 177. 4R. Right Lower Paratracheal Upper border: intersection of caudal margin of innominate (left brachiocephalic) vein with the trachea. Lower border:lower border of azygos vein. 4R nodes extend to the left lateral border of the trachea.
  178. 178. On the left we paratracheal nodes. see 4R In addition there is an aortic node lateral to the aortic arch, i.e. station 6 node.
  179. 179. 4L. Left Lower Paratracheal 4L nodes are lower paratracheal nodes that are located to the left of the left tracheal border, between a horizontal line drawn tangentially to the upper margin of the aortic arch and a line extending across the left main bronchus at the level of the upper margin of the left upper lobe bronchus. These include paratracheal nodes that are located medially to the ligamentum arteriosum. Station 5 (AP-window) nodes are located laterally to the ligamentum arteriosum.
  180. 180. On the left an image just above the level of the pulmonary trunk demonstrating lower paratracheal nodes on the left and on the right. In addition there are also station 3 and 5 nodes
  181. 181. On the left an image at the level of the lower trachea just above the carina. To the left of the trachea 4L nodes. Notice that these 4L nodes are between the pulmonary trunk and the aorta, but are not located in the AP-window, because they lie medially to the ligamentum arteriosum. The node lateral to the pulmonary trunk is a station 5 node.
  182. 182. 5. Subaortic nodes Subaortic or aorto-pulmonary window nodes are lateral to the ligamentum arteriosum or the aorta or left pulmonary artery and proximal to the first branch of the left pulmonary artery and lie within the mediastinal pleural envelope. 6. Para-aortic nodes Para-aortic (ascending aorta or phrenic) nodes are located anteriorly and laterally to the ascending aorta and the aortic arch from the upper margin to the lower margin of the aortic arch.
  183. 183. 7. Subcarinal nodes These nodes are located caudally to the carina of the trachea, but are not associated with the lower lobe bronchi or arteries within the lung. On the right they extend caudally to the lower border of the bronchus intermedius. On the left they extend caudally to the upper border of the lower lobe bronchus. On the left a station 7 subcarinal node to the right of the esophagus.
  184. 184. 8 Paraesophageal nodes These nodes are below the carinal nodes and extend caudally to the diaphragm. On the left an image below the carina. To the right of the esophagus a station 8 node.
  185. 185. On the left a PET image demonstrating FDG uptake in a station 8 node. On the corresponding CT image the node is not enlarged (blue arrow). The probability that this is a lymph node metastasis is extremely high since the specificity of PET in unenlarged nodes is higher than in enlarged nodes.
  186. 186. 9. Pulmonary ligament nodes Pulmonary ligament nodes are lying within the pulmonary ligament, including those in the posterior wall and lower part of the inferior pulmonary vein. The pulmonary ligament is the inferior extension of the mediastinal pleural reflections that surround the hila.
  187. 187. 10 Hilar nodes Hilar nodes are proximal lobar nodes, distal to the mediastinal pleural reflection and nodes adjacent to the intermediate bronchus on the right. Nodes in station 10 - 14 are all N1-nodes, since they are not located in the mediastinum.
  188. 188. 10 Hilar nodes Hilar nodes are proximal lobar nodes, distal to the mediastinal pleural reflection and nodes adjacent to the intermediate bronchus on the right. Nodes in station 10 - 14 are all N1-nodes, since they are not located in the mediastinum.
  189. 189. Axial CT of Lymph Nodes • Scroll through the images on the left. 1-Sternal notch nodes are just seen at this level and above this level 2-Upper Paratracheal: below clavicles and on the right above the intersection of caudal margin of innominate (left brachiocephalic) vein with the trachea and on the left above the aortic arch. 3-Pre-vascular and Retrotracheal : anterior to the vessels (3A) or prevertebral (3P) 4-Lower Paratracheal : below upper margin of aortic arch down to level of main bronchus 5-Subaortic (A-P window): nodes lateral to ligamentum arteriosum or lateral to aorta or left pulmonary artery 6-Para-aortic: nodes lying anterior and lateral to the ascending aorta and the aortic arch beneath the upper margin of the aortic arch 7-Subcarinal 8-Paraesophageal (below carina) 9-Pulmonary Ligament: nodes lying within the pulmonary ligament. 10--14: nodes are all N1 nodes
  190. 190. • • Conventional mediastinoscopy The following nodal stations can be biopsied by cervical mediastinoscopy: the left and right upper paratracheal nodes (station 2L and 2R), left and right lower paratracheal nodes (station 4L and 4R) and the subcarinal nodes (station 7). Station 1 nodes are located above the suprasternal notch and are not routinely accessed by cervical mediastinoscopy.
  191. 191. Extended mediastinoscopy Left upper lobe tumors may metastasize to the subaortic lymph nodes (station 5) and paraaortic nodes (station 6). These nodes can not be biopsied through routine cervical mediastinoscopy. Extended mediastinoscopy is an alternative for the anterior-second interspace mediastinotomy which is more commonly used for exploration of mediastinal nodal stations. This procedure is far less easy and therefore less routinely performed than conventional mediastinoscopy.
  192. 192. EUS-FNA Endoscopic Ultrasound with Fine Needle Aspiration can be performed of all the mediastinal nodes that that can be assessed from the oesophagus. In addition the left adrenal gland and the left liver lobe can be visualized.EUS particularly provides access to nodes in the lower mediastinum (station 7,8 and 9)
  193. 193. Thank You

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