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mediastinummediastinum
Made by: Dr. Isha JaiswalMade by: Dr. Isha Jaiswal
Under guidance of: Prof M.L.B BhattUnder guidanc...
IntroductionIntroduction
TheThe mediastinummediastinum isis the region in the chestthe region in the chest
between the pl...
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 superi...
Inferior mediastinumInferior mediastinum::
is subdividedis subdivided intointo
 AnteriorAnterior
mediastinummediastinum
...
Superior MediastinumSuperior Mediastinum
BoundariesBoundaries
 Ant: Manubrium sterniAnt: Manubrium sterni
 Post: T-1 to ...
Superior MediastinumSuperior Mediastinum
 It contains:It contains:
 TracheaTrachea
 EsophagusEsophagus
 Blood vessels ...
Superior mediastinum contentsSuperior mediastinum contents
Blood VesselsBlood Vessels
Veins:
SVC
Lt & Rt brachiocephalic...
Superior MediastinumSuperior Mediastinum
NervesNerves
1.1. Vagus nerveVagus nerve
2.2. Left RecurrentLeft Recurrent
Laryng...
Superior MediastinumSuperior Mediastinum
Lymph nodes:
 Highest mediastinal
 Paratracheal
 Prevascular
 retrotracheal
Anterior MediastinumAnterior Mediastinum
Lies ant. to pericardiumLies ant. to pericardium
Boundaries:Boundaries:
Anteri...
Anterior mediastinum:Anterior mediastinum:
contains:contains:
a.a. ThymusThymus
glandgland
b.b. LymphLymph
NodesNodes
c.c....
ThymusThymus
 Located in anteriorLocated in anterior
mediastinum.mediastinum.
 Develops from endoderm ofDevelops from en...
Middle MediastinumMiddle Mediastinum
Boundaries:Boundaries:
Anterior: posterior surface of
sternum
Posterior: oesophagu...
Middle MediastinumMiddle Mediastinum
Contents:Contents:
HeartHeart enclosed in pericardiumenclosed in pericardium
Arteries...
Posterior MediastinumPosterior Mediastinum
Boundaries:Boundaries:
Ant.Ant. Pericardium, Bifurcation of tracheaPericardium,...
20
Posterior MediastinumPosterior Mediastinum
Contents:Contents:
OesophagusOesophagus
ArteriesArteries
 Descending Aorta ...
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
...
NERVE SUPPLY:NERVE SUPPLY:
LYMPHATIC DRAINAGELYMPHATIC DRAINAGE
 PretrachealPretracheal
 paratracheal lymph nodeparatra...
Blood supplyBlood supply
ARTERIAL SUPPLYARTERIAL SUPPLY
Upper tracheaUpper trachea
 Inferior thyroid arteryInferior thy...
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 contai...
LEFT: A lung mass abutts the mediastinal surface and creates acute angles
with the lung.
RIGHT: A mediastinal mass will si...
Cervicothoracic signCervicothoracic sign
The anterior mediastinum ends at the level of theThe anterior mediastinum ends a...
See sharp
margin
above clavicle
Mass is in posterior mediastinum. because it remains sharply outlined in apex
of thorax, i...
Thoracoabdominal signThoracoabdominal sign
 A sharply marginated mediastinal mass seen throughA sharply marginated medias...
Can you
see the
outline of the
mass below
the diaphragm?
Margin of mass is apparent and below diaphragm, therefore this mu...
Hilum overlay signHilum overlay sign
 Principle of hilum overlayPrinciple of hilum overlay
 An anterior mediastinal mass...
Hilum can
be seen
through
mass
this must be an anterior
mediastinal mass
because it overlaps rather
than “pushes out” the
...
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...
Mediastinal MassesMediastinal Masses
Compartment %
Malignant
Anterosuperior 59
Middle 29
Posterior 16
Mediastinal
division...
Anterosuperior Masses
Thymus
• Thymoma
• Thymic carcinoma
• Thymic cyst
• Thymic carcinoid
• Thymolipoma
mediasTinal lymph...
Middle mediastinal masses
mediasTinal lymphoma
• Hodgkin’s Lymphoma
• Non-Hodgkin’s Lymphoma
mesenchymal Tumors
cysT:
• Br...
Posterior mediastinal masses
Mediastinal lyMphoMa
• Hodgkin’s Lymphoma
• Non-Hodgkin’s Lymphoma
MesenchyMal tuMors
neuroge...
Tumors of thymusTumors of thymus
 ThymomasThymomas
 Thymic carcinomasThymic carcinomas
 Thymic lymphomasThymic lymphoma...
ThymomaThymoma
PresentationPresentation
 Most common primary anterior mediastinal tumorMost common primary anterior media...
 1/3 have chest pain, cough or dyspnea on presentation1/3 have chest pain, cough or dyspnea on presentation
 Myasthenia ...
ThymomaThymoma
 lobulated mass in the anterior mediastinumlobulated mass in the anterior mediastinum
thymomathymoma
Invasive thymomaInvasive thymoma
 Encasement ofEncasement of
mediastinal structures,mediastinal structures,
infiltration ...
Thymic CarcinoidThymic Carcinoid
carcinoid tumors (neuroendocrine tumors) of the thymus are very rare,carcinoid tumors (ne...
 Thymic carcinoid tumor in a 22-year-old man with a 3-month history of a persistentThymic carcinoid tumor in a 22-year-ol...
Thymic Carcinoma
Presentation
•M>F, 40s
•Thymic carcinomas are less common than thymomas, more aggressive
with a higher pr...
Thymic CarcinomaThymic Carcinoma
 Thymic carcinomasThymic carcinomas
behave morebehave more
aggressively thanaggressively...
Thymic LymphomasThymic Lymphomas
Lymphoma is the mostLymphoma is the most
common cause of ancommon cause of an
anterior m...
cancers of the head and neck, abdomen, and pelvis can involve the thymus viacancers of the head and neck, abdomen, and pel...
Mediastinal lymphomaMediastinal lymphoma
Primary Mediastinal LymphomaPrimary Mediastinal Lymphoma
 5-10% of patients with lymphoma present with5-10% of patients w...
Primary Mediastinal LymphomaPrimary Mediastinal Lymphoma
TwoTypesTwoTypes
 Primary Mediastinal Hodgkin’s LymphomaPrimary ...
Primary Mediastinal Hodgkin’s LymphomaPrimary Mediastinal Hodgkin’s Lymphoma
PresentationPresentation
 Incidental mediast...
A chest CT exam shows the mass to extend from the neck to the
diaphragm, compressing the tracheal and left mainstem bronch...
Two contiguous slices
from an enhanced chest
CT exam show a
homogenous, solid,
anterior mediastinal mass
and a large right...
Mediastinal Germ CellTumorsMediastinal Germ CellTumors
 Primary extragonadal germ cell tumors comprisePrimary extragonada...
 they presumably arise from germ cells that migrate alongthey presumably arise from germ cells that migrate along
the uro...
Mediastinal Germ CellTumorsMediastinal Germ CellTumors
Three typesThree types
 TeratomaTeratoma
 SeminomaSeminoma
 Nons...
MediastinalTeratomasMediastinalTeratomas
 Most common mediastinal germ cell tumorMost common mediastinal germ cell tumor
...
MatureTeratomaMatureTeratoma
 Occurs in children and young adultsOccurs in children and young adults
 Usually asymptomat...
Dx Teratoma,
Anterior Mediastinal
CT exam show a low
density mass in the
anterior mediastinum
with irregular walls with
ca...
Mediastinal SeminomaMediastinal Seminoma
 Represents 40% of malignant mediastinal GCTsRepresents 40% of malignant mediast...
Mediastinal SeminomaMediastinal Seminoma
PresentationPresentation
 Slow growing tumor, usually symptomatic at diagnosisSl...
Mediastinal NonseminomatousMediastinal Nonseminomatous
Germ CellTumorsGerm CellTumors
 FiveTypesFiveTypes
• Embryonal cel...
Mediastinal NonseminomatousMediastinal Nonseminomatous
Germ CellTumorsGerm CellTumors
 NSGCTs of the mediastinum have a w...
Tracheal tumorsTracheal tumors
 Extremely rare tumors.Extremely rare tumors.
 Comprise of 0.1 to 0.4 %of all diagnosed m...
Clinical presentation ofClinical presentation of
mediastinal massmediastinal mass
Clinical PresentationClinical Presentation
 Asymptomatic massAsymptomatic mass
 Incidental discovery – most commonIncide...
Clinical PresentationClinical Presentation
11 Effects on Compression or invasion ofEffects on Compression or invasion of
a...
Clinical PresentationClinical Presentation
22 Effects on Compression of nervesEffects on Compression of nerves
Hoarseness,...
Clinical PresentationClinical Presentation
 Superior vena cavaSuperior vena cava
 Vulnerable to extrinsic compression an...
Clinical PresentationClinical Presentation
 Systemic symptoms and syndromesSystemic symptoms and syndromes
 Fever, anore...
Mediastinal mass: pre treatmentMediastinal mass: pre treatment
evaluationevaluation
thankyothankyo
uu
Mediastinal tumors
Mediastinal tumors
Mediastinal tumors
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Mediastinal tumors

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anatomy,radiological anatomy,epidemology and case presentation of mediastinal tumors

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Mediastinal tumors

  1. 1. 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
  2. 2. 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
  3. 3. Sternal Angle Thoracic inlet Thoracic oulet Boundaries of mediastinumBoundaries of mediastinum sternum Thoracic vertebra
  4. 4. TS: MediastinumTS: Mediastinum 5 CS: MediastinumCS: Mediastinum
  5. 5. Divisions of mediastinumDivisions of mediastinum
  6. 6. 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
  7. 7. Inferior mediastinumInferior mediastinum:: is subdividedis subdivided intointo  AnteriorAnterior mediastinummediastinum  MiddleMiddle mediastinummediastinum  PosteriorPosterior mediastinummediastinum
  8. 8. 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
  9. 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)
  10. 10. 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
  11. 11. Superior MediastinumSuperior Mediastinum NervesNerves 1.1. Vagus nerveVagus nerve 2.2. Left RecurrentLeft Recurrent Laryngeal nerve.Laryngeal nerve. 3.3. Phrenic nerve.Phrenic nerve.
  12. 12. Superior MediastinumSuperior Mediastinum Lymph nodes:  Highest mediastinal  Paratracheal  Prevascular  retrotracheal
  13. 13. 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
  14. 14. Anterior mediastinum:Anterior mediastinum: contains:contains: a.a. ThymusThymus glandgland b.b. LymphLymph NodesNodes c.c. Fat.Fat.
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 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
  19. 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
  20. 20. Trachea: anatomyTrachea: anatomy
  21. 21. 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.
  22. 22. 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)
  23. 23. 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
  24. 24. Radiological antomyRadiological antomy
  25. 25. CHEST X-RAYCHEST X-RAY
  26. 26. 27 Tracheobronchial anatomyTracheobronchial anatomy Tracheal Displacement Due to Goiter
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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’
  33. 33. 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
  34. 34. 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
  35. 35. VASCULAR ANATOMYVASCULAR ANATOMY
  36. 36. At T3 LevelAt T3 Level
  37. 37. At T4 LevelAt T4 Level
  38. 38. At T5 LevelAt T5 Level
  39. 39. At T6 LevelAt T6 Level
  40. 40. 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
  41. 41. Mediastinal MassesMediastinal Masses Compartment % Malignant Anterosuperior 59 Middle 29 Posterior 16 Mediastinal division Most common tumors Anterior- superior thymoma middle lymphoma posterior Neurogenic tumors
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. Tumors of thymusTumors of thymus  ThymomasThymomas  Thymic carcinomasThymic carcinomas  Thymic lymphomasThymic lymphomas  CarcinoidsCarcinoids  ThymolipomasThymolipomas  SecondariesSecondaries
  46. 46. 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
  47. 47.  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
  48. 48. ThymomaThymoma  lobulated mass in the anterior mediastinumlobulated mass in the anterior mediastinum
  49. 49. thymomathymoma
  50. 50. 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
  51. 51. 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
  52. 52.  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
  53. 53. 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
  54. 54. 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
  55. 55. 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.
  56. 56. 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
  57. 57. Mediastinal lymphomaMediastinal lymphoma
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64.  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
  65. 65. Mediastinal Germ CellTumorsMediastinal Germ CellTumors Three typesThree types  TeratomaTeratoma  SeminomaSeminoma  Nonseminomatous Germ CellTumorNonseminomatous Germ CellTumor
  66. 66. 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
  67. 67. 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
  68. 68. Dx Teratoma, Anterior Mediastinal CT exam show a low density mass in the anterior mediastinum with irregular walls with calcium in it.
  69. 69. 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%
  70. 70. 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
  71. 71. 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
  72. 72. 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
  73. 73. 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
  74. 74. Clinical presentation ofClinical presentation of mediastinal massmediastinal mass
  75. 75. 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
  76. 76. 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
  77. 77. 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
  78. 78. 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
  79. 79. 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 .
  80. 80. Mediastinal mass: pre treatmentMediastinal mass: pre treatment evaluationevaluation
  81. 81. thankyothankyo uu

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