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MEDIASTINUM TUMOUR.pptx
- 2. Introduction • The mediastinum is the region in the chest between the pleural cavities that contain the heart and other thoracic viscera except the lungs Boundaries Anterior Posterior -sternum -vertebral column and paravertebral fascia -thoracic inlet - diaphragm - parietal pleura Superior Inferior Lateral
- 5. Superior Mediastinum T5 Anterior Mediastinum Posterior Mediastinum Middle Mediastinum Sternal Angle T4 divided into superior mediastinum and inferior mediastinum by an imaginary line passing through sternal angle anteriorly lower border of 4th thoracic vertebra posteriorly Mediastinum divisions
- 6. Inferior mediastinum: is subdividedinto Anterior mediastinum Middle mediastinum Posterior mediastinum
- 7. Superior Mediastinum Boundaries Ant: Manubrium sterni Post: T-1 to T-4 Sides: Mediastinal pleura Sup: Plane of thoracic inlet at T1 Inf: Imaginary line joining sternal angle and lower border T-4 9
- 8. Superior Mediastinum It contains: Trachea Esophagus Blood vessels (large veins & arteries) (listed later) Nerves (listed later) Thoracic duct Thymus Lymph nodes: (listed later)
- 9. Superior mediastinum contents Blood Vessels Veins: SVC Lt & Rt brachiocephalic veins, Arteries: Arch of Aorta Brachiocepalic artery Lt Common carotid Lt subclavian artery
- 10. Superior Mediastinum Nerves 1. Vagus nerve 2. Left Recurrent Laryngeal nerve. 3. Phrenic nerve.
- 11. Superior Mediastinum Lymph nodes: Highest mediastinal Paratracheal Prevascular retrotracheal
- 12. Anterior Mediastinum Lies ant. to pericardium Boundaries: Anterior: body of sternum Posterior: pericardium Superior: imaginary line separating sup. & inf.mediastinum Infreior: diaphragm Lateral: mediastinal pleura
- 13. Anterior mediastinum: contains: a. Thymus gland b. Lymph Nodes c. Fat.
- 14. Thymus Located in anterior mediastinum. Develops from endoderm of 3rdpharyngeal pouch Present in childhood, involutes in adults Blood supply Arterial :i nt. Mammary arteries Venous: internal thoracic veins Lymphatic drainage: lower cervical, int. Mammary and hilar nodes
- 15. Middle Mediastinum Boundaries: Anterior: posterior surface of sternum Posterior: oesophagus, desc. thoracic aorta, azygous vein Superior: plane seperating sup.& inf mediastinum Inferior: diaphragm Lateral: mediastinal pleura
- 16. Middle Mediastinum Contents: Heart enclosed in pericardium Arteries: Ascending Aorta, Pulmonary trunk with its Lt & Rt branches Veins: SVC,Pulmonary veins Nerves: Phrenic, vagus nerve Bifurcation of Trachea with two principal bronchi Tracheobronchial lymph nodes 18
- 17. Posterior Mediastinum Boundaries: Ant. Pericardium, Post. T5 to T12 19 Bifurcation of trachea sup. Transverse thoracic plane Inf. diaphragm Sides: Mediastinal pleura
- 18. Posterior Mediastinum Contents: Oesophagus Arteries Descending Aorta with its brs Veins Azygos Hemizygos Nerves: Vagus Splanchnic nerves Thoracic duct lymph nodes Posterior mediastinal 20
- 20. CHEST X-RAY
- 21. 27 Tracheobronchial anatomy Tracheal Displacement Due to Goiter
- 22. Clues to locate mass to mediastinum Mediastinal masses : Mass in lung Not contain air bronchograms Mediastinal mass will create obtuse angles with the lung . Mediastinal lines will be disrupted May contain air bronchograms A lung mass abutts the mediastinal surface and creates acute angles with the lung
- 23. RIGHT: A mediastinal mass will sit under the surface of the mediastinum, creating obtuse angles with the lung LEFT: A lung mass abutts the mediastinal surface and creates acute angles with the lung.
- 24. Cervicothoracic sign The anterior mediastinum ends at the level of the clavicles. The posterior mediastinum extends much higher. Therefore any mass that remains sharply outlined in the apex of the thorax must be posterior and entirely within the chest, and any mass that disappears at the clavicles must be anterior and extends into neck
- 25. See sharp margin above clavicle Mass is in posterior mediastinum. because it remains sharply outlined in apex of thorax, indicating that it is surrounded by lung. This particular example is a ganglioneuroma
- 26. Hilum overlay sign Principle of hilum overlay An anterior mediastinal mass will overlap the main pulmonary arteries, therefore they will be seen within the margins of the mass
- 27. Hilum can be seen through mass this must be an anterior mediastinal mass because it overlaps rather than “pushes out” the main pulmonary arteries This particular example is a thymoma
- 28. MEDIASTINALTUMORS EPIDEMOLOGY Mediastinal malignancies are heterogenous in nature. most masses (> 60%) are: Thymomas NeurogenicTumors BenignCysts Lymphadenopathy (LAD) In children the most common (> 80%) are: Neurogenic tumors Germ cell tumors Foregut cysts In adults the most common are: Lymphomas LAD Thymomas Thyroid masses
- 29. Mediastinal Masses Compartment % Malignant Anterosuperior Middle Posterior 59 29 16 Mediastinal division Most common tumors Anterior- superior thymoma lymphoma Neurogenic tumors middle posterior
- 30. Anterosuperior Masses Thymus Thymoma • • • • • Thymic carcinoma Thymic cyst Thymic carcinoid Thymolipoma mediasTinal lymphoma • • Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma mesenchymal Tumors Germ cell Tumor Seminoma Non seminomatous Germ Cell Embryonal cell carcinoma Endodermal sinus tumor Choriocarcinoma Teratoma Mature Immature endocrine Tumors Thyroid tumors Parathyroid adenoma • • • • • • • • • •
- 31. Middle mediastinal masses mediasTinal lymphoma • • Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma mesenchymal Tumors cysT: • • • Bronchogenic cyst Thoracic duct Meningoceles • cardiac & pericardial Tumors • Tracheal Tumors vascular Tumors • lymphadenopaThy • Inflammatory Granulomatous sarcoidosis • • •
- 32. Posterior mediastinal masses Mediastinal lyMphoMa • • Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma MesenchyMal tuMors neurogenic tuMors • • • Peripheral nerves Symphathetic ganglia paraganglia endocrine tuMors esophageal tuMors & cysts
- 33. Tumors of thymus Thymomas Thymic carcinomas Thymic lymphomas
- 34. THYMOMAS • Most common tumour of the anterosuperior mediastinum in adults. • Fifth to Sixth decade • Both sexes are equally affected
- 36. Types HISTOLOGY: Eithelial cell - Poor prognosis Lymphocytic Mixed Spindle - Better prognosis 50% THYMOMASARE MALIGNANT
- 37. Clinical features: ASYMPTOMATIC 50% 30 - 40% ASSOCIATED WITH MYASTHENIA GRAVIS Chest pain Dysphagia Dyspnoea SVC obstruction
- 38. Signs and symptoms of superior vena cava obstruction • headache or feeling of fullness in the head, made worse by bending or lying down. • breathlessness. • swollen veins in the neck and chest. • swelling of the face, neck, arms and hands. • changes to vision. • dizziness
- 39. Modified Masaoka clinical staging of thymoma Stage I IIA IIB Definition Macroscopically and microscopically completely encapsulated Microscopic transcapsular invasion Macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium Macroscopic invasion into neighboring organs (ie, pericardium, great vessels, or lung) Pleural or pericardial dissemination Lymphogenous or hematogenous metastasis III IVA IVB
- 40. Investigations Chest Xray : Lateral view - Opacity in mediastinum Mediastinoscopy & biopsy. T ensilon Diagnostic test : Injecting 10mg edrophonium chloride iv. Myasthenia is relieved within 1 min temporarily CT scan
- 41. Treat myasthenia - Neostigmine Thymectomy IS BENEFICIAL in: Disease < 5yrs Treatment
- 42. Surgical removal of the tumor is the preferred treatment. Surgery is often the only treatment required for stage I tumors. Stages II, III, and IV thymomas are often treated with surgery and some form of adjuvant therapy.
- 43. RETROSTERNAL GOITRE > 50 % goitre below the suprasternal notch. PRIMARY : rare (1%) - SECONDARY : common
- 44. 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
- 45. 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
- 46. CLINICAL FEATURES SYMPTOMS : Dyspnoea Cough and stridor Dysphagia SIGNS : Engorment of neck veins and superficial veins on the chest wall Lower border is not seen on inspection and not felt on palpation
- 47. PEMBERTON'S SIGN : is positive Percussion :dull note over sternum Can be nodular,toxic or malignant Rarely – recurent larygeal nerve palsy
- 48. INVESTIGATIONS Chest X -ray CT scan and MRI is diagnostic
- 50. TREATMENT Surgical removal Commonly through incision in neck Large goitre or malignant type median sternotomy is required rarely 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
- 51. Lymphomas Commonly situated in anterior 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.