1. MEDIASTINAL MASSES

2. Mediastinal Anatomy

3. Mediastinal Anatomy
Anterior
thymus, aorta, great veins, lymphatics
Middle
heart, pericardium, trachea
Posterior
Esophagus, vagus nerves, thoracic duct,
sympathetic chain, azygous venous system

4. Anterior Mediastinum

5. Thymoma

6. Thymoma

7. Hodgkin’s

8. Intrathoracic goiter

9. Anterior Mediastinum
Other thymic tumors - carcinomas, carcinoid
tumors, lipomas, cysts
Germ cell tumors
Thyroid tumors
Parathyroid adenoma
Connective tissue tumors - lipomas,
liposarcomas, lymphangiomas, hemangiomas

10. Middle Mediastinum

11. Pericardial cyst

12. Bronchogenic cyst

13. Middle Mediastinum
Thyroid tumor or goiter
Tracheal tumors
Lymphadenopathy 2/2
infection
malignancy
idiopathic

14. Posterior Mediastinum

15. Posterior Mediastinum
Most neurogenic tumors
Esophageal tumors
Hiatus hernia
Neurenteric cysts
Unusual: pancreatic pseudocyst, achalasia,
extramedullary hematopoiesis

16. Paraspinal ganglioneuroma

17. Paraspinal neurilemmoma

18. Notes
Aortic aneurysms can be located in any compartment
Anterior masses more likely to be malignant
59% vs. 29% vs. 16%, converse is true in children
increased likelihood in 20-40 yo
Most common lesions:
Children - neurogenic tumors, enterogenous cysts
Adults - neurogenic tumors, thymomas, thymic
cysts

19. Signs & Symptoms
Hemoptysis, recurrent pulmonary infection (airway
compression)
Dysphagia (esophageal compression)
Paralysis (spinal column involvement)
Elevated hemidiaphragm (phrenic nerve damage)
Hoarseness (recurrent laryngeal involvement)
Horner’s & SVC syndrome (sympathetic ganglion, SVC)

20. Signs & Symptoms
Associated systemic diseases
Thymoma = myasthenia gravis, immune deficiency,
red cell aplastic anemia
Thymic carcinoid tumor = Cushing syndrome
Goiter = thyrotoxicosis
Parathyroid adenoma = hyperparathyroidism

21. Imaging
CXR -> CT with IV contrast
MRI only recommended if pt has contrast allergy or
renal failure
useful for neurogenic tumors
Transesophageal US - posterior lymph nodes
Radionuclide scanning
123-I for thyroid, sestamibi for parathyroid,
gallium for lymphomas (replaced by FDG-PET)

22. Labs
Goiter -> TFTs
Parathyroid adenoma -> Ca, P, PTH
Paragangliomas -> urine metanephrines,
catecholamines
Neurogenic tumors -> homovanillic acid,
vanillylmandelic acid
Germ cell tumor -> AFP, B-HCG
all male pts with anterior mass

23. Management
Excision
if likely benign - teratoma, thymoma
needle aspiration, VATS, sternotomy/thoracotomy
Biopsy
lymphoma, germ cell, unresectable malignancy
surgical biopsy preferred over needle aspiration
Chest wall tumor implantation is a rare complication

24. Complications
Surgical treatment has increased risk of morbidity
2/2 central airway obstruction, greatest in those with:
Cardiorespiratory symptoms
Evidence of tracheal obstruction
Mixed obstructive & restrictive PFTs

25. The End