mediastinummediastinum
Made by: Dr. Isha JaiswalMade by: Dr. Isha Jaiswal
Under guidance of: Prof M.L.B BhattUnder guidance of: Prof M.L.B Bhatt
Date:19Date:19thth
march 2014march 2014

IntroductionIntroduction
TheThe mediastinummediastinum isis the region in the chestthe region in the chest
between the pleural cavities that contain thebetween the pleural cavities that contain the
heart and other thoracic viscera except the lungsheart and other thoracic viscera except the lungs
BoundariesBoundaries
 AnteriorAnterior - sternum- sternum
 PosteriorPosterior - vertebral column and paravertebral- vertebral column and paravertebral
fasciafascia
 SuperiorSuperior -thoracic inlet-thoracic inlet
 InferiorInferior - diaphragm- diaphragm
 LateralLateral - parietal pleura- parietal pleura

Sternal Angle
Thoracic inlet
Thoracic oulet
Boundaries of mediastinumBoundaries of mediastinum
sternum
Thoracic vertebra

TS: MediastinumTS: Mediastinum
5
CS: MediastinumCS: Mediastinum

Divisions of mediastinumDivisions of mediastinum

Superior
Mediastinum
Posterior
Mediastinum
Anterior
Mediastinum
Middle
Mediastinum
Sternal
Angle
T4
T5
divided into superior mediastinum and inferior mediastinum by an imaginary line passing
through sternal angle anteriorly lower border of 4th
thoracic vertebra posteriorly
Mediastinum divisionsMediastinum divisions

Inferior mediastinumInferior mediastinum::
is subdividedis subdivided intointo
 AnteriorAnterior
mediastinummediastinum
 MiddleMiddle
mediastinummediastinum
 PosteriorPosterior
mediastinummediastinum

Superior MediastinumSuperior Mediastinum
BoundariesBoundaries
 Ant: Manubrium sterniAnt: Manubrium sterni
 Post: T-1 to T-4Post: T-1 to T-4
 Sides: Mediastinal pleuraSides: Mediastinal pleura
 Sup: Plane of thoracicSup: Plane of thoracic
inlet at T1inlet at T1
 Inf: Imaginary line joiningInf: Imaginary line joining
sternal angle and lowersternal angle and lower
border T-4border T-4
9

Superior MediastinumSuperior Mediastinum
 It contains:It contains:
 TracheaTrachea
 EsophagusEsophagus
 Blood vessels (large veinsBlood vessels (large veins
& arteries) (listed later)& arteries) (listed later)
 Nerves (listed later)Nerves (listed later)
 Thoracic ductThoracic duct
 ThymusThymus
 Lymph nodes: (listed later)Lymph nodes: (listed later)

Superior mediastinum contentsSuperior mediastinum contents
Blood VesselsBlood Vessels
Veins:
SVC
Lt & Rt brachiocephalic
veins,
Arteries:
Arch of Aorta
Brachiocepalic artery
Lt Common carotid
Lt subclavian artery

Superior MediastinumSuperior Mediastinum
NervesNerves
1.1. Vagus nerveVagus nerve
2.2. Left RecurrentLeft Recurrent
Laryngeal nerve.Laryngeal nerve.
3.3. Phrenic nerve.Phrenic nerve.

Superior MediastinumSuperior Mediastinum
Lymph nodes:
 Highest mediastinal
 Paratracheal
 Prevascular
 retrotracheal

Anterior MediastinumAnterior Mediastinum
Lies ant. to pericardiumLies ant. to pericardium
Boundaries:Boundaries:
Anterior: body of sternum
Posterior: pericardium
superior: imaginary line
separating sup. &
inf.mediastinum
Infreior: diaphragm
Lateral: mediastinal pleura

Anterior mediastinum:Anterior mediastinum:
contains:contains:
a.a. ThymusThymus
glandgland
b.b. LymphLymph
NodesNodes
c.c. Fat.Fat.

ThymusThymus
 Located in anteriorLocated in anterior
mediastinum.mediastinum.
 Develops from endoderm ofDevelops from endoderm of
33rdrd
pharyngeal pouchpharyngeal pouch
 Present in childhood,Present in childhood,
involutes in adultsinvolutes in adults
 Blood supplyBlood supply
Arterial :i nt. Mammary arteries
Venous: internal thoracic veins
Lymphatic drainage: lower cervical, int. Mammary and hilar nodes

Middle MediastinumMiddle Mediastinum
Boundaries:Boundaries:
Anterior: posterior surface of
sternum
Posterior: oesophagus, desc.
thoracic aorta, azygous vein
Superior: plane seperating sup.&
inf mediastinum
Inferior: diaphragm
Lateral: mediastinal pleura

Middle MediastinumMiddle Mediastinum
Contents:Contents:
HeartHeart enclosed in pericardiumenclosed in pericardium
Arteries:Arteries: Ascending Aorta,Ascending Aorta,
Pulmonary trunk with its Lt &Pulmonary trunk with its Lt &
Rt branchesRt branches
VeinsVeins: SVC,Pulmonary veins: SVC,Pulmonary veins
Nerves:Nerves: Phrenic, vagus nervePhrenic, vagus nerve
Bifurcation of Trachea withBifurcation of Trachea with
two principal bronchitwo principal bronchi
Tracheobronchial lymph nodesTracheobronchial lymph nodes
18

Posterior MediastinumPosterior Mediastinum
Boundaries:Boundaries:
Ant.Ant. Pericardium, Bifurcation of tracheaPericardium, Bifurcation of trachea
Post.Post. T5 to T12T5 to T12
sup.sup. Transverse thoracic planeTransverse thoracic plane
Inf.Inf. diaphragmdiaphragm
Sides:Sides: Mediastinal pleuraMediastinal pleura
19

20
Posterior MediastinumPosterior Mediastinum
Contents:Contents:
OesophagusOesophagus
ArteriesArteries
 Descending Aorta with itsDescending Aorta with its
brsbrs
VeinsVeins
 AzygosAzygos
 HemizygosHemizygos
 Accessory hemizygosAccessory hemizygos
Nerves:Nerves:
 VagusVagus
 Splanchnic nervesSplanchnic nerves
Thoracic ductThoracic duct
lymph nodeslymph nodes
 Posterior mediastinalPosterior mediastinal

Trachea: anatomyTrachea: anatomy

LENGTH:10-15 cm
 DIAMETER: 2cm in males &1.5
cm in females
 Lined by ciliated columnar
epithelium
Lower level at T6 on
inspiration & T4 on expiration
 Made of c shape rings
 2 rings per cm
 The rings make tube convex
anterolateraly
 Posteriorly the gap is filled by
trachealis muscle.

NERVE SUPPLY:NERVE SUPPLY:
LYMPHATIC DRAINAGELYMPHATIC DRAINAGE
 PretrachealPretracheal
 paratracheal lymph nodeparatracheal lymph node
 PARA SYMPHATHETIC:PARA SYMPHATHETIC:
vagus & recurrentvagus & recurrent
laryngeal nerves (laryngeal nerves (sensory &sensory &
secreto-motor to mucoussecreto-motor to mucous
membrane motor to trachealismembrane motor to trachealis
muscle)muscle)
 SYMPHATHETIC: -middleSYMPHATHETIC: -middle
cervical ganglioncervical ganglion
(vasomotor)(vasomotor)

Blood supplyBlood supply
ARTERIAL SUPPLYARTERIAL SUPPLY
Upper tracheaUpper trachea
 Inferior thyroid arteryInferior thyroid artery
Lower partLower part
 Branches of the bronchialBranches of the bronchial
arteryartery
VENOUS DRAINAGEVENOUS DRAINAGE
Upper part :Upper part :
left brachiocephalic veinleft brachiocephalic vein
Lower part:Lower part:
 Inferior thyroid veinInferior thyroid vein

Radiological antomyRadiological antomy

CHEST X-RAYCHEST X-RAY

27
Tracheobronchial anatomyTracheobronchial anatomy
Tracheal Displacement Due to Goiter

Clues to locate mass toClues to locate mass to
mediastinummediastinum
Mediastinal masses : Masses in the 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

LEFT: A lung mass abutts the mediastinal surface and creates acute angles
with the lung.
RIGHT: A mediastinal mass will sit under the surface of the mediastinum,
creating obtuse angles with the lung

Cervicothoracic signCervicothoracic sign
The anterior mediastinum ends at the level of theThe anterior mediastinum ends at the level of the
clavicles.clavicles.
The posterior mediastinum extends much higher.The posterior mediastinum extends much higher.
ThereforeTherefore
 any mass that remains sharply outlined in the apex ofany mass that remains sharply outlined in the apex of
the thorax must be posterior and entirely within thethe thorax must be posterior and entirely within the
chest, andchest, and
 any mass that disappears at the clavicles must beany mass that disappears at the clavicles must be
anterior and extends into neckanterior and extends into neck

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

Thoracoabdominal signThoracoabdominal sign
 A sharply marginated mediastinal mass seen throughA sharply marginated mediastinal mass seen through
the diaphragm must lie entirely within the chest.the diaphragm must lie entirely within the chest.
 The posterior costophrenic sulcus extends far moreThe posterior costophrenic sulcus extends far more
caudally than the anterior aspect of the lungcaudally than the anterior aspect of the lung
 ThereforeTherefore
 Any mass that extends below the dome of the diaphragmAny mass that extends below the dome of the diaphragm
and remains sharply outlined must be in the posteriorand remains sharply outlined must be in the posterior
compartments and surrounded by lung, andcompartments and surrounded by lung, and
 Any mass that terminates at dome of diaphragm must beAny mass that terminates at dome of diaphragm must be
anterioranterior

Can you
see the
outline of the
mass below
the diaphragm?
Margin of mass is apparent and below diaphragm, therefore this must
be in the middle or posterior compartments where it is surrounded by
lung
This example is a ‘Lipoma’

Hilum overlay signHilum overlay sign
 Principle of hilum overlayPrinciple of hilum overlay
 An anterior mediastinal mass will overlap the mainAn anterior mediastinal mass will overlap the main
pulmonary arteries, therefore they will be seen withinpulmonary arteries, therefore they will be seen within
the margins of the massthe margins of the mass

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

VASCULAR ANATOMYVASCULAR ANATOMY

At T3 LevelAt T3 Level

At T4 LevelAt T4 Level

At T5 LevelAt T5 Level

At T6 LevelAt T6 Level

MEDIASTINALTUMORSMEDIASTINALTUMORS
EPIDEMOLOGYEPIDEMOLOGY
 Mediastinal malignancies are heterogenous in natureMediastinal malignancies are heterogenous in nature..
 most masses (> 60%) are:most masses (> 60%) are:
 ThymomasThymomas
 NeurogenicTumorsNeurogenicTumors
 Benign CystsBenign Cysts
 Lymphadenopathy (LAD)Lymphadenopathy (LAD)
 In children the most common (> 80%) are:In children the most common (> 80%) are:
 Neurogenic tumorsNeurogenic tumors
 Germ cell tumorsGerm cell tumors
 Foregut cystsForegut cysts
 In adults the most common are:In adults the most common are:
 LymphomasLymphomas
 LADLAD
 ThymomasThymomas
 Thyroid massesThyroid masses

Mediastinal MassesMediastinal Masses
Compartment %
Malignant
Anterosuperior 59
Middle 29
Posterior 16
Mediastinal
division
Most common
tumors
Anterior-
superior
thymoma
middle lymphoma
posterior Neurogenic
tumors

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

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

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

Tumors of thymusTumors of thymus
 ThymomasThymomas
 Thymic carcinomasThymic carcinomas
 Thymic lymphomasThymic lymphomas
 CarcinoidsCarcinoids
 ThymolipomasThymolipomas
 SecondariesSecondaries

ThymomaThymoma
PresentationPresentation
 Most common primary anterior mediastinal tumorMost common primary anterior mediastinal tumor
 M=F, most >40M=F, most >40
 Most patients are asymptomaticMost patients are asymptomatic
 Half of patients suffer have associated parathymicHalf of patients suffer have associated parathymic
syndromessyndromes
• myasthenia gravismyasthenia gravis
• hypogammaglobulinemiahypogammaglobulinemia
• pure red cell aplasiapure red cell aplasia

 1/3 have chest pain, cough or dyspnea on presentation1/3 have chest pain, cough or dyspnea on presentation
 Myasthenia gravis occurs in 30-50% of pts with thymoma.Myasthenia gravis occurs in 30-50% of pts with thymoma.
Hypogammaglobulinemia occurs in 10% of pts withHypogammaglobulinemia occurs in 10% of pts with
thymomathymoma
 Pure red cell aplasia occurs in 5%, but thymoma occurs inPure red cell aplasia occurs in 5%, but thymoma occurs in
50% of pts with red cell aplasia50% of pts with red cell aplasia

ThymomaThymoma
 lobulated mass in the anterior mediastinumlobulated mass in the anterior mediastinum

thymomathymoma

Invasive thymomaInvasive thymoma
 Encasement ofEncasement of
mediastinal structures,mediastinal structures,
infiltration of fatinfiltration of fat
planes, and an irregularplanes, and an irregular
interface between theinterface between the
mass and lungmass and lung
parenchyma, areparenchyma, are
highly suggestive ofhighly suggestive of
invasion.invasion.
 Pleural thickening,Pleural thickening,
nodularity, or effusionnodularity, or effusion
generally indicatesgenerally indicates
pleural invasion by thepleural invasion by the
thymomathymoma

Thymic CarcinoidThymic Carcinoid
carcinoid tumors (neuroendocrine tumors) of the thymus are very rare,carcinoid tumors (neuroendocrine tumors) of the thymus are very rare,
accounting for <5% of all neoplasms of the anterior mediastinum.accounting for <5% of all neoplasms of the anterior mediastinum.
They originate from the normal thymic Kulchitsky cells, which belong to theThey originate from the normal thymic Kulchitsky cells, which belong to the
amine precursor uptake and decarboxylation (APUD) groupamine precursor uptake and decarboxylation (APUD) group
PresentationPresentation
 men aged 30 to 50 yearsmen aged 30 to 50 years
 (male/female ratio: 3:1)(male/female ratio: 3:1)
 Rarely associated with carcinoid syndromeRarely associated with carcinoid syndrome
 Associated endocrine abnormalities: Cushing’s syndrome due to ectopicAssociated endocrine abnormalities: Cushing’s syndrome due to ectopic
ACTH or MENACTH or MEN
 73% have regional lymph node and/or distant osteoblastic bone mets73% have regional lymph node and/or distant osteoblastic bone mets

 Thymic carcinoid tumor in a 22-year-old man with a 3-month history of a persistentThymic carcinoid tumor in a 22-year-old man with a 3-month history of a persistent
dry cough.dry cough.
 Contrast-enhanced CT scan shows a heterogeneously enhancing thymic mass .Contrast-enhanced CT scan shows a heterogeneously enhancing thymic mass .
 PET image shows intense FDG uptake by the massPET image shows intense FDG uptake by the mass

Thymic Carcinoma
Presentation
•M>F, 40s
•Thymic carcinomas are less common than thymomas, more aggressive
with a higher propensity for capsular invasion
•Early local invasion, widespread lymphatic and hematogenous
metastases
•Clinically, patients present initially with tussis, dyspnea, pleuritic chest
pain, phrenic nerve palsy, or superior vena cava syndrome
80% of patients with thymic carcinoma may have radiographic evidence
of invasion into adjacent structures in the mediastinum
40% may have evidence of mediastinal lymphadenopathy
•Distant metastases to regional lymphatics, bone, liver, kidney, and lung
are a common clinical feature

Thymic CarcinomaThymic Carcinoma
 Thymic carcinomasThymic carcinomas
behave morebehave more
aggressively thanaggressively than
invasive thymomasinvasive thymomas
and are more likely toand are more likely to
metastasize to distantmetastasize to distant
sitessites

Thymic LymphomasThymic Lymphomas
Lymphoma is the mostLymphoma is the most
common cause of ancommon cause of an
anterior mediastinalanterior mediastinal
mass in children andmass in children and
the second mostthe second most
common cause of ancommon cause of an
anterior mediastinalanterior mediastinal
mass in adults.mass in adults.

cancers of the head and neck, abdomen, and pelvis can involve the thymus viacancers of the head and neck, abdomen, and pelvis can involve the thymus via
lymphatic pathwayslymphatic pathways
 Metastatic disease toMetastatic disease to
the thymus in a 10-the thymus in a 10-
year-old boy 2 yearsyear-old boy 2 years
after diagnosis ofafter diagnosis of
alveolaralveolar
rhabdomyosarcomarhabdomyosarcoma
of the thigh.of the thigh.
Secondary Tumors of the Thymus

Mediastinal lymphomaMediastinal lymphoma

Primary Mediastinal LymphomaPrimary Mediastinal Lymphoma
 5-10% of patients with lymphoma present with5-10% of patients with lymphoma present with
primary mediastinal lesionsprimary mediastinal lesions
 Primary mediastinal lymphoma represents 10-Primary mediastinal lymphoma represents 10-
20% of primary mediastinal masses in adults and20% of primary mediastinal masses in adults and
are usually in the anterosuperior compartmentare usually in the anterosuperior compartment
 Usually present with fever, weight loss and nightUsually present with fever, weight loss and night
sweatssweats
 Pain, dyspnea, stridor, SVC syndrome due toPain, dyspnea, stridor, SVC syndrome due to
mass effects are uncommonmass effects are uncommon

Primary Mediastinal LymphomaPrimary Mediastinal Lymphoma
TwoTypesTwoTypes
 Primary Mediastinal Hodgkin’s LymphomaPrimary Mediastinal Hodgkin’s Lymphoma
 Primary Mediastinal Non-Hodgkin’s LymphomaPrimary Mediastinal Non-Hodgkin’s Lymphoma
• Poorly differentiated lymphoblasticPoorly differentiated lymphoblastic
• Diffuse lymphocyticDiffuse lymphocytic
• Primary Mediastinal B-cell LymphomaPrimary Mediastinal B-cell Lymphoma

Primary Mediastinal Hodgkin’s LymphomaPrimary Mediastinal Hodgkin’s Lymphoma
PresentationPresentation
 Incidental mediastinal mass on chest xray is 2nd mostIncidental mediastinal mass on chest xray is 2nd most
common presentation after asymptomaticcommon presentation after asymptomatic
lymphadenopathylymphadenopathy
 Mass is usually large, rarely causes retrosternal chestMass is usually large, rarely causes retrosternal chest
pain, cough, dyspnea, effusions or SVC syndromepain, cough, dyspnea, effusions or SVC syndrome
 Bimodal age distributionBimodal age distribution
 ““B” symptoms: fever, weight loss (>10% body wt in 6B” symptoms: fever, weight loss (>10% body wt in 6
months), night sweatsmonths), night sweats
 Generalized pruritus presentGeneralized pruritus present

A chest CT exam shows the mass to extend from the neck to the
diaphragm, compressing the tracheal and left mainstem bronchus leading to
left lower lobe atelectasis. The chest wall mass is partially eroding the
sternum.
Dx:Lymphoma, Hodgkin, Anterior Mediastinal, Sternal
Involvement

Two contiguous slices
from an enhanced chest
CT exam show a
homogenous, solid,
anterior mediastinal mass
and a large right pleural
effusion.
Dx-Lymphoma
Non-Hodgkin,
Anterior Mediastinal

Mediastinal Germ CellTumorsMediastinal Germ CellTumors
 Primary extragonadal germ cell tumors comprisePrimary extragonadal germ cell tumors comprise
2% to 5% of all germ cell tumors2% to 5% of all germ cell tumors
 Approximately two thirds of these tumors occur inApproximately two thirds of these tumors occur in
the mediastinumthe mediastinum
 The mediastinum is the most common site ofThe mediastinum is the most common site of
primary extragonadal germ cell tumors in youngprimary extragonadal germ cell tumors in young
adultsadults
 Represent 10-15% of adult anterosuperiorRepresent 10-15% of adult anterosuperior
mediastinal tumorsmediastinal tumors

 they presumably arise from germ cells that migrate alongthey presumably arise from germ cells that migrate along
the urogenital ridge during embryonic development .the urogenital ridge during embryonic development .
 The embryologic urogenital ridge extends from C6 to L4The embryologic urogenital ridge extends from C6 to L4
and after malignant transformation of displaced germand after malignant transformation of displaced germ
cells, explains the development of primary germ cellcells, explains the development of primary germ cell
tumors outside the gonadstumors outside the gonads
Mediastinal Germ CellTumorsMediastinal Germ CellTumors

Mediastinal Germ CellTumorsMediastinal Germ CellTumors
Three typesThree types
 TeratomaTeratoma
 SeminomaSeminoma
 Nonseminomatous Germ CellTumorNonseminomatous Germ CellTumor

MediastinalTeratomasMediastinalTeratomas
 Most common mediastinal germ cell tumorMost common mediastinal germ cell tumor
 Three types:Three types:
• Mature: benign, well-differentiatedMature: benign, well-differentiated
• Immature: contains >50% immature components, may recurImmature: contains >50% immature components, may recur
or metastasizeor metastasize
• Malignant: a mature teratoma that contains a focus ofMalignant: a mature teratoma that contains a focus of
carcinoma, sarcoma or malignant GCTcarcinoma, sarcoma or malignant GCT

MatureTeratomaMatureTeratoma
 Occurs in children and young adultsOccurs in children and young adults
 Usually asymptomatic, but if large enough, may causeUsually asymptomatic, but if large enough, may cause
chest pain, dyspnea, cough or other symptoms ofchest pain, dyspnea, cough or other symptoms of
mediastinal compressionmediastinal compression
 Contains derivatives of all three primitive germ layersContains derivatives of all three primitive germ layers
includingincluding
• Ectoderm: teeth, skin, hairEctoderm: teeth, skin, hair
• Mesoderm: cartilage and boneMesoderm: cartilage and bone
• Endoderm: bronchial, intestinal and pancreatic tissueEndoderm: bronchial, intestinal and pancreatic tissue
 Expectoration of hair (trichoptysis) is rare butExpectoration of hair (trichoptysis) is rare but
pathognomonicpathognomonic

Dx Teratoma,
Anterior Mediastinal
CT exam show a low
density mass in the
anterior mediastinum
with irregular walls with
calcium in it.

Mediastinal SeminomaMediastinal Seminoma
 Represents 40% of malignant mediastinal GCTsRepresents 40% of malignant mediastinal GCTs
 Afflicts Caucasian men in 20s-30sAfflicts Caucasian men in 20s-30s
 Only rarely represents a metastatic lesion from aOnly rarely represents a metastatic lesion from a
testicular primary tumor, but testicular USG istesticular primary tumor, but testicular USG is
usually performed to rule this outusually performed to rule this out
 If any other germ cell tumor histology is identifiedIf any other germ cell tumor histology is identified
in the tumor, it is treated as a mixed NSGCTin the tumor, it is treated as a mixed NSGCT
 AFP normal,AFP normal, ββ-HCG may be elevated in 10%-HCG may be elevated in 10%

Mediastinal SeminomaMediastinal Seminoma
PresentationPresentation
 Slow growing tumor, usually symptomatic at diagnosisSlow growing tumor, usually symptomatic at diagnosis
 Commonly presents with chest pain, dyspnea, cough,Commonly presents with chest pain, dyspnea, cough,
weight lossweight loss
 Presents infrequently with SVC syndromePresents infrequently with SVC syndrome
 Bulky, lobulated, homogeneous mass, no calcificationsBulky, lobulated, homogeneous mass, no calcifications
 Usually not invasive, but many have metastasized toUsually not invasive, but many have metastasized to
regional lymph nodes, lung and/or bone by the time ofregional lymph nodes, lung and/or bone by the time of
diagnosisdiagnosis

Mediastinal NonseminomatousMediastinal Nonseminomatous
Germ CellTumorsGerm CellTumors
 FiveTypesFiveTypes
• Embryonal cell carcinomaEmbryonal cell carcinoma
• Endodermal sinus tumor: elevated AFPEndodermal sinus tumor: elevated AFP
• Choriocarcinoma: elevatedChoriocarcinoma: elevated ββ-HCG-HCG
• MalignantTeratomaMalignantTeratoma
• MixedMixed

Mediastinal NonseminomatousMediastinal Nonseminomatous
Germ CellTumorsGerm CellTumors
 NSGCTs of the mediastinum have a worse prognosis thanNSGCTs of the mediastinum have a worse prognosis than
mediastinal seminomas or teratomasmediastinal seminomas or teratomas
 Occur in men in the 20-40 age groupOccur in men in the 20-40 age group
 20% of patients also have Klinefelter’s syndrome20% of patients also have Klinefelter’s syndrome

Tracheal tumorsTracheal tumors
 Extremely rare tumors.Extremely rare tumors.
 Comprise of 0.1 to 0.4 %of all diagnosed malignanciesComprise of 0.1 to 0.4 %of all diagnosed malignancies
 Two types: squamous cell carcinoma M:F=3:1 Age:6Two types: squamous cell carcinoma M:F=3:1 Age:6thth
decadedecade
adenoid cystic carcinomas M:F=1:1 younger ageadenoid cystic carcinomas M:F=1:1 younger age
 Clinical feature: cough, dysnoea, dysphagia,stridorClinical feature: cough, dysnoea, dysphagia,stridor
hemoptysis, dysphoniahemoptysis, dysphonia

Clinical presentation ofClinical presentation of
mediastinal massmediastinal mass

Clinical PresentationClinical Presentation
 Asymptomatic massAsymptomatic mass
 Incidental discovery – most commonIncidental discovery – most common
 50% of all mediastinal mass are asymptomatic50% of all mediastinal mass are asymptomatic
 80% of such mass are benign80% of such mass are benign
 More than half are malignant if with symptomsMore than half are malignant if with symptoms

Clinical PresentationClinical Presentation
11 Effects on Compression or invasion ofEffects on Compression or invasion of
adjacent tissuesadjacent tissues
 Chest painChest pain, from traction on mediastinal mass, tissue invasion,, from traction on mediastinal mass, tissue invasion,
or bone erosion is commonor bone erosion is common
 CoughCough, because of extrinsic compression of the trachea or, because of extrinsic compression of the trachea or
bronchi, or erosion into the airway itselfbronchi, or erosion into the airway itself
 Hemoptysis, hoarseness or stridorHemoptysis, hoarseness or stridor
 Pleural effusion, invasion or irritation of pleural spacePleural effusion, invasion or irritation of pleural space
 Dysphagia, invasion or direct invasioin of the esophagusDysphagia, invasion or direct invasioin of the esophagus
 Pericarditis or pericardial tamponadePericarditis or pericardial tamponade
 Right ventricular outflow obstruction and cor pulmonaRight ventricular outflow obstruction and cor pulmonalele

Clinical PresentationClinical Presentation
22 Effects on Compression of nervesEffects on Compression of nerves
Hoarseness, invading or compressing the nerves recurrentHoarseness, invading or compressing the nerves recurrent
laryngeal nervelaryngeal nerve
 Horners syndrome, involvement of the sympatheticHorners syndrome, involvement of the sympathetic
gangliaganglia
 Dyspnea, from phrenic nerve involvement causingDyspnea, from phrenic nerve involvement causing
diaphragmatic paralysisdiaphragmatic paralysis
 Tachycardia, secondary to vagus nerve involvemenTTachycardia, secondary to vagus nerve involvemenT

Clinical PresentationClinical Presentation
 Superior vena cavaSuperior vena cava
 Vulnerable to extrinsic compression and obstruction because it is thinVulnerable to extrinsic compression and obstruction because it is thin
walled and its intravascular pressure is low.walled and its intravascular pressure is low.
 Superior vena cava syndromeSuperior vena cava syndrome
 Results from the increase venous pressure in the upper thorax , headResults from the increase venous pressure in the upper thorax , head
and neckand neck
 characterized by dilation of the collateral veins in the upper portion ofcharacterized by dilation of the collateral veins in the upper portion of
the head and thorax and edema oand phlethora of the face, neck andthe head and thorax and edema oand phlethora of the face, neck and
upper torso, suffusion and edema of the conjunctiva and cerebralupper torso, suffusion and edema of the conjunctiva and cerebral
symptoms such as headache, disturbance of consciousness and visualsymptoms such as headache, disturbance of consciousness and visual
distortiondistortion
 Bronchogenic carcinoma and lymphoma are the most commonBronchogenic carcinoma and lymphoma are the most common
etiologiesetiologies

Clinical PresentationClinical Presentation
 Systemic symptoms and syndromesSystemic symptoms and syndromes
 Fever, anorexia, weight loss and other non specificFever, anorexia, weight loss and other non specific
symptoms of malignancy .symptoms of malignancy .

Mediastinal mass: pre treatmentMediastinal mass: pre treatment
evaluationevaluation

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