This document discusses mediastinal tumors, including their anatomy, types, clinical presentation, diagnosis, and treatment. The mediastinum contains vital structures like the heart, lungs and blood vessels. Tumors can arise primarily in the mediastinum or spread there from other areas. Common primary tumors include thymomas, lymphomas, and neurogenic tumors. Thymomas are often associated with myasthenia gravis and can be staged using the Masaoka system. Diagnosis involves imaging tests and biopsy. Treatment depends on the tumor type but may include surgery, radiation, chemotherapy or targeted therapy. Care before and after surgery aims to optimize the patient's condition and recovery.
Testicular tumors are rare.
1 – 2 % of all malignant tumors.
Most common malignancy in men in the 15 to 35 year age group.
Benign lesions represent a greater percentage of cases in children than in adults.
Most curable solid neoplasm
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
In this presentation our agenda is
Brief introduction
Radiological Modalities
Radiological Features
Radiological Imaging Of Complications of lung cancer.
I followed Dahnert and try to describe all findings in lung cancer.
Hope it will prove an atlas in Lung cancer imaging.
Testicular tumors are rare.
1 – 2 % of all malignant tumors.
Most common malignancy in men in the 15 to 35 year age group.
Benign lesions represent a greater percentage of cases in children than in adults.
Most curable solid neoplasm
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
In this presentation our agenda is
Brief introduction
Radiological Modalities
Radiological Features
Radiological Imaging Of Complications of lung cancer.
I followed Dahnert and try to describe all findings in lung cancer.
Hope it will prove an atlas in Lung cancer imaging.
Thymectomy & Thymic Disorders - Clinical Implications, Multimodal and Surgica...RohanReddy66
A description of role of surgery for thymic diseases and myasthenia gravis within the frame of multimodality therapy. Categorical description of evolution of different techniques and classification of various types of thymic surgeries with an emphasis on thymoma.
Unlock the complexities of mediastinum tumors with our informative and comprehensive PowerPoint presentation (PPT) titled 'Mediastinum Tumors.' Designed for medical professionals, students, and anyone seeking to understand these rare but critical conditions, this presentation offers a thorough exploration of mediastinal tumors, their classification, diagnosis, and treatment options.
Our PPT delves into the anatomy of the mediastinum, providing a solid foundation for understanding the diverse range of tumors that can develop in this vital thoracic region. Learn about the clinical significance of mediastinum tumors, their prevalence, and the potential impact on surrounding structures.
We categorize mediastinal tumors, addressing their origins, including thymic tumors, neurogenic tumors, lymphomas, and more. Detailed insights into the histological characteristics of these tumors and their clinical implications are provided.
The diagnostic section of our presentation guides you through the evaluation of mediastinum tumors, covering imaging techniques, biopsy procedures, and the importance of accurate staging. Keeping pace with the latest advancements in diagnostic tools, our PPT ensures you are well-informed about the most modern practices.
Treatment options are discussed comprehensively, including surgery, radiation therapy, chemotherapy, and emerging targeted therapies. Explore the importance of a multidisciplinary approach in managing these tumors, and gain valuable knowledge for optimizing patient care.
Our 'Mediastinum Tumors' PPT is enriched with high-quality visuals, radiological images, and case studies, providing a dynamic and engaging learning experience. Medical professionals can benefit from the wealth of information for clinical practice and patient education, while students will find it an invaluable resource for exam preparation.
Families and patients facing mediastinum tumors can gain insights into their condition, treatment options, and the importance of an informed and empowered approach to healthcare decisions.
Stay up to date with the rapidly evolving field of mediastinum tumor management. Our presentation is your trusted resource for deepening your understanding and facilitating informed decision-making. Start your journey towards comprehensive knowledge about mediastinum tumors with our 'Mediastinum Tumors PPT.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
2. Anatomy
▪ The region of the body located between the two pleural spaces
▪ It is derived from the Latin words medius (middle) and stare (to stand)
and means literally "standing in the middle.“
▪ The mediastinum is a complex and tightly knit package of structures
immediately vital to the life of the individua-the central airways, the
heart, and the great vessels.
▪ Also contained within the mediastinum are glands, and organs,
including the esophagus, thymus, thoracic duct, vagus and phrenic
nerves, and lymphatics.
3. Cont’d
▪ The mediastinum extends from the diaphragm to the thoracic inlet
and is divided by anatomists into four regions that are defined by
their relationship to the pericardium:
– superior,
– anterior,
– middle,
– posterior.
▪ Thoracic surgeons generally divide the mediastinum into just three
compartments:
– anterior,
– middle,
– posterior
4. Cont’d
▪ The mediastinum contains a compact arrangement of vital
structures and other tissues abnormalities such as
infection, trauma, and neoplasm can have a profound
impact and can present with dramatic symptoms
▪ Because the mediastinum is relatively inaccessible to
physical examination, imaging studies such as computed
tomography (CT) play a particularly important role in the
evaluation of suspected pathology.
5.
6. Mediastinal Lesion
▪ The wide variety and diverse origins of tissues normally found within
the mediastinum account for the extraordinary assortment of tumors
and cysts that arise from them primary mediastinal lesions
▪ Secondary lesions of the mediastinum are derived from
extramediastinal tissues, such as thyroid, bone, or lung, and either
migrate into or metastasize to the mediastinum.
▪ Many benign lesions are asymptomatic and are discovered
incidentally, whereas malignant lesions are more likely to produce
symptoms from compression and invasion of adjacent structures.
12. Clinical Presentation
▪ Mediastinal lesions are symptomatic in 50%-75% of patients
▪ Symptoms can be caused by local mass effects, systemic effects of
tumorderived hormones and peptides, or infection.
▪ Local effects are dependent on the size and location of the lesion and
result from compression of adjacent structures
– Examples: cough, stridor, dyspnea, chest pain, and dysphagia
▪ Symptoms are also more common with malignant tumors are more
likely to fix, encase, and invade adjacent structures.
– Examples: Superior vena cava syndrome, back pain, and neurological deficits
such as Homer's syndrome or phrenic nerve palsy
13.
14. Diagnostic Evaluation
▪ RADIOLOGY
– Plain chest x-ray taken in two planes, posteroanterior and left lateral basic
information about the location of the mass within the mediastinum
– Diaphragm fluoroscopy, or sniff test to evaluate paradoxical motion of the
diaphragm on rapid inspiration indicative of phrenic nerve paralysis
– CT of the chest has replaced plain chest radiography as the diagnostic procedure
of choice for mediastinal masses
– MRI may enhance the diagnostic abilities of chest CT
– Echocardiography and FDG-PET have been commonly used High FDG
invasion in thymic carcinomas and invasive thymomas
15. Cont’d
▪ Histologic
– FNA or needle biopsy with CT guidance of a mediastinal mass may
provide sufficient tissue for diagnosis of thymic carcinoma or other
defined neoplasms
– Core needle biopsy, mediastinoscopy, or intrathoracic biopsy may
be considered for lymphomas in particular, and thymomas and
neural tumors
– Electron microscopy may be required for confirmation of specific
histologies
16. Thymoma
▪ The most common neoplasm of the anterosuperior compartment
▪ Peak incidence is in the third through fifth decades
▪ Radiograph: small, well-circumscribed mass or as a bulky lobulated
mass confluent with adjacent mediastinal structures
▪ Symptoms:
– chest pain,
– dyspnea,
– hemoptysis,
– cough,
– superior vena cava syndrome
– systemic syndromes caused by immunologic mechanisms
17.
18. A, CT Chest in a patient with myasthenia gravis and thymoma.The thymoma is small with a
plane of separation between the tumor and the pericardium.
B, CT Chest in a patient with a larger mediastinal mass.The location, character, and size are
noted.Transthoracic core needle biopsy was performed. Germ cell tumor markers were
normal. Pathology demonstrated thymoma. Subsequently, a 6.5 cm thymoma was
resected.There was no invasion of the pericardium. A complete resection (R0) was
accomplished.
19. Cont’d
▪ Systemic syndromes accompanies thymoma:
– Myasthenia Gravis most common
– pure red blood cell aplasia,
– pure white blood cell aplasia,
– aplastic anemia,
– Cushing’s syndrome,
– hypogammaglobulinemia,
– hypergammaglobulinemia,
– dermatomyositis,
– systemic lupus erythematosus,
– progressive systemic sclerosis,
– hypercoagulopathy with thrombosis,
– rheumatoid arthritis,
– megaesophagus,
– granulomatous myocarditis
22. Treatmentof Thymoma
▪ Surgery
– Complete surgical resection
– Median sternotomy with a vertical or submammary incision is most commonly
used
– bilateral anterolateral thoracotomies with transverse sternotomy, or “clam-shell
procedure”, preferred with advanced or laterally displaced large tumors
– Patients with MG and thymoma have a 56% to 78% 10-year survival rate and a
3% recurrence rate with 4.8% (1.7% since 1980) operative mortality after
extended thymectomy
▪ Radiation
– In stage II and III invasive disease, adjuvant radiation can decrease recurrence
rates after complete surgical resection from 28% to 5%
– Radiation therapy has proven beneficial in the treatment of extensive disease
23. Cont’d
▪ SystemicTherapy
– Steroids have been shown to be active in the management of thymomas
– Both single-agent and combination therapy have demonstrated activity in the
adjuvant and neoadjuvant settings
– Doxorubicin, cisplatin, ifosfamide, corticosteroids, and cyclophosphamide all
have been used as single-agent therapy
▪ MolecularlyTargetedTherapy
– Overexpression of c-kit is common in thymic carcinoma
– Coamplification of the HER-2/neu topoisomerase 2-alpha gene may correlate
with response to the CAP chemotherapy regimen
– antitumor activity has been reported with dasatinib, a small molecule oral,
multitargeted kinase inhibitor of Bcr-Abl and src kinases, ephrin receptor
kinases, platelet-derived growth factor receptor, and c-kit, in thymoma
24.
25.
26. Branches of the internal thoracic arteries are divided to permit the en bloc specimen to be
rotated upward, exposing the undersurface of the gland and the draining veins.The exposed
brachiocephalic and thymic veins are isolated and divided between ligatures or clips (inset).
27. Preoperative
▪ Initial workup:
– careful history and physical examination the neck and particularly the thyroid
gland require careful palpation
▪ Investigation:
– complete blood count,
– serum electrolytes,
– thyroid function tests,
– acetylcholine-receptor antibody assay,
– pulmonary function tests,
– electromyographic studies,
– immunoglobulin assay,
– bone marrow biopsy,
– cervical lymph node biopsy
28. Cont’d
▪ Radiographic Investigation:
– PlainChest X Ray 2 plane: posteroanterior and left lateral view
– CT Scan
– MRI
▪ Patient's strength and respiratory status should be optimized with
the use of pyridostigmine and immunosuppressive agents when
indicated
▪ Preoperative plasmapharesis or IV immunoglobulin therapy may be
beneficial in patients with a vital capacity of less than 2 L
29. Postoperative
▪ Usually are extubated in the OR within 30 minutes of the conclusion
of the operation
▪ Kept in a monitored setting overnight
▪ If the patient does not have an epidural catheter in place, parenteral
analgesia can be administered in small intermittent doses of
hydromorphone or morphine
▪ On the morning after the operation, oral medication and a clear
liquid diet are begun and advanced as tolerated
▪ The chest tubes are removed when no air leak or significant output is
present and the lungs are fully expanded on chest x-ray 2nd
postoperative day
30. Cont’d
▪ Antibiotics and the continuous epidural infusion are discontinued,
and oral narcotic analgesics are started once the chest tubes are
removed
▪ Patients with MG are discharged when their symptoms are
adequately controlled with oral medication and they are well able to
tolerate a regular diet
▪ Most patients are able to return to normal activity and work within 2–
3 weeks after transsternal thymectomy
▪ Tapering of medications in patients with MG begins at various times
after operation depending on the judgment of the neurologist
31. Substernal Goiter
▪ Goiters usually are considered substernal (also referred to as
mediastinal, intrathoracic, or retrosternal) when more than 50% of the
thyroid parenchyma is located below the sternal notch
▪ Mediastinal goiters are classified as primary or secondary
▪ Primary mediastinal goiters, also referred to as ectopic or aberrant
goiters, uncommon, 1% of all surgically excised goiters
▪ Secondary mediastinal goiters are a much more common, 5–15% of
all goiters demonstrate some extension into the mediastinum
34. Consideration for Thoracotomy
▪ Atypical anatomy
▪ Extramediastinal extension with known malignancy
▪ Posterior location or extension of tumor
▪ Goiters that extend to the tracheal carina
▪ Adherence to visceral or intrathoracic parietal pleura
35. Consideration for Median Sternotomy
▪ Primary retrosternal/ectopic
goiter
▪ Atypical anatomy
▪ Dense adhesions from prior
surgery
▪ Inability to deliver the gland
into the neck
▪ Extracapsular extension or
known mediastinal malignancy
▪ Recurrent intrathoracic goiter
▪ Prior thyroid surgery, especially
for cancer
▪ Goiters that extend to the
tracheal carina
▪ Goiters that cause life-
threatening compression of
mediastinal structures
▪ Significant intraoperative
mediastinal bleeding
▪ Adherence to mediastinal
pleura
36.
37. Goiters usually can be removed via cervical incision with the use of careful blunt
finger dissection to mobilize the gland from its attachment to mediastinal
structures. Most large goiters can be removed through a 2-cm collar incision.
38.
39.
40. Preoperative
▪ Radiographic:
– Chest x-ray mediastinal mass, superior mediastinal widening, tracheal
deviation or compression
– Chest CT scans define the full extent and anatomic relationships of the
substernal thyroid to surrounding structures and to facilitate preoperative
planning
▪ serum thyroid-stimulating hormone measurement If
hyperthyroidism is present antithyroid medications and beta
blockade should be undertaken before elective resection
▪ Pulmonary functiong testing is useful
▪ discuss these patients with the anesthesiologist in advance of
surgery
41. Postoperative
▪ Length of stay for an uncomplicated procedure is overnight
▪ patients can be discharged uneventfully with calcium or calcitriol
supplementation
▪ If a thoracotomy or sternotomy is required, length of stay is
increased
▪ major complications injury to the trachea, parathyroid glands, or
recurrent laryngeal nerves
▪ The need for tracheostomy is rare
42. Germ Cell Tumors
▪ Arise from primordial germ cells that fail to complete the migration
from the urogenital ridge and rest in the mediastinum
▪ Anterosuperior mediastinum is the most common extragonadal
primary site
▪ The current recommendations for evaluating the testes of a patient
with mediastinal germ cell tumor are:
– careful physical examination
– ultrasonography of the testes.
▪ Biopsy is reserved for positive findings
43. Teratomas
▪ The most common mediastinal germ cell neoplasms
▪ Usually located in the anterosuperior mediastinum
▪ Composed of multiple tissue elements derived from the three primitive
embryonic layers
▪ The peak incidence is in the second and third decades of life
▪ Radiographic evidence of normal tissue (e.g., well-formed teeth or globular
calcifications, a fatty mass) in an abnormal location can be considered
specific
▪ The teratodermoid (dermoid) cyst is the simplest form of a teratoma and
composed of derivatives of the epidermal layer, including dermal and
epidermal glands, hair, and sebaceous material
44. Cont’d
▪ Diagnosis and therapy rely on surgical excision
▪ For benign tumors that are so large or with involvement of adjacent
mediastinal structures so that complete resection is impossible
partial resection (debulking) can lead to the resolution of symptoms,
frequently without relapse
▪ Malignant teratomas chemotherapy and radiation therapy,
combined with surgical excision
▪ Overall prognosis is poor for malignant teratomas
45. Malignant Nonteratomatous Germ Cell
Tumors
▪ Occur predominantly in the anterosuperior mediastinum with a
marked male predominance
▪ Usually in the third and fourth decades of life
▪ Symptoms: chest pain, cough, dyspnea, and hemoptysis
▪ The superior vena cava syndrome occurs commonly
▪ Diagnostic imaging: A large anterior mediastinal mass
▪ CT and MRI are helpful to define the extent of disease and
involvement of mediastinal structures
46. Cont’d
▪ Serologic measurements (α-fetoprotein and β-hCG) useful for:
– differentiating seminomas from nonseminomas tumors,
– assessing response to therapy,
– diagnosing relapse or failure of therapy
▪ Seminomas rarely produce β-hCG and never produce α-fetoprotein
▪ More than 90% of nonseminomas secrete one or both of these
hormones
▪ seminomas are radiosensitive and nonseminomas are relatively
radiosensitive
47. Seminomas
▪ Constitute 50% of malignant germ cell tumors
▪ Usually remain intrathoracic
▪ Symptoms are related to the mechanical effects of the tumor on
adjacent mediastinal and pulmonary structures
▪ SuperiorVena Cava syndrome occurs in 10% to 20% of patients.
▪ Sensitive to irradiation and chemotherapy
▪ Treatment consists of systemic and local therapy:
– chemotherapy with salvage surgery
– combined chemoradiotherapy
48. Cont’d
▪ Radiation therapy may be considered for early-stage disease, but is
not recommended for regional disease
▪ Platinum-based chemotherapy is common
▪ Occasionally, excision is possible without injury to vital structures and
can be recommended
▪ When complete resection is possible, the use of adjuvant therapy is
unnecessary
49. Nonseminomatous Tumors
▪ Malignant nonseminomatous germ cell tumors include:
– choriocarcinomas,
– embryonal cell carcinomas,
– immature teratomas,
– teratomas with malignant components,
– endodermal cell (yolk sac) tumors
▪ Occur mostly in men in their third or fourth decade
▪ Diagnostic imaging: large anterior mediastinal mass with frequent
extension to the lung, chest wall, and mediastinal structures
50. Cont’d
▪ Mediastinal nonseminomas, but not testicular germ cell tumors, are
associated with the development of hematologic malignancies:
– acute megakaryocytic leukemia,
– systemic mast cell disease,
– malignant histiocytosis
– Myelodysplastic syndrome
– idiopathic thrombocytopenia refractory to treatment.
▪ Current treatment: cisplatin and etoposide-based regimens
▪ When tumor necrosis or a benign teratoma is found during surgical
exploration after chemotherapy excellent or intermediate
prognosis
51. Lymphomas
▪ Hodgkin’s and non-Hodgkin’s lymphoma are distinct clinical entities
with overlapping features
▪ Symptoms: chest pain, cough, dyspnea, hoarseness, and superior
vena caval syndrome
▪ Nonspecific systemic symptoms: fever and chills, weight loss, and
anorexia
▪ Symptoms characteristic of Hodgkin’s lymphoma chest pain after
consumption of alcohol and the cyclic fevers
52. Cont’d
▪ Surgeon’s primary role is to provide sufficient tissue for diagnosis
and to assist in pathologic staging.
▪ Thoracoscopy, mediastinoscopy, or mediastinotomy and, rarely,
thoracotomy or median sternotomy may be necessary to obtain
sufficient tissue
▪ Lymphoblastic lymphoma occurs predominantly in children,
adolescents, and young adults and represents 60% of cases of
mediastinal non-Hodgkin’s lymphoma.
53.
54. Neurogenic Tumors
▪ Usually located in the posterior mediastinum
▪ Originate from:
– The sympathetic ganglia (ganglioma, ganglioneuroblastoma, and
neuroblastoma)
– intercostal nerves (neurofibroma, neurilemoma, and neurosarcoma)
– paraganglia cells (paraganglioma)
▪ Peak incidence occurs in adults but it make up a proportionally
greater percentage of mediastinal masses in children
▪ Most neurogenic tumors in adults are benign but a greater
percentage of neurogenic tumors are malignant in children.
55. Schwannoma / Neurilimoma
▪ The most common neurogenic tumor
▪ Originates from perineural Schwann cells
▪ benign, slow-growing neoplasms, frequently arise from a spinal
nerve root, but can involve any thoracic nerve, well circumscribed
and have a defined capsule
▪ Peak incidence: third through fifth decades of life
▪ Many are asymptomatic
▪ Pain occur from compression or invasion of intercostal nerve, bone,
and chest wall
56. Cont’d
▪ cough and dyspnea are caused by compression of the
tracheobronchial tree
▪ Pancoast syndrome and Horner’s syndrome result from involvement
of t
▪ 10% of neurogenic tumors have extensions into the spinal columnhe
brachial and the cervical sympathetic chain dumbbell tumors
▪ MRI scan to evaluate the presence and extent of the tumor and its
relationship to the neural foramen and intraspinal space
▪ During resection, the intraspinal component should be removed first
via a posterior laminectomy minimizes the potential for spinal
column hematoma, cord ischemia, and paralysis
57. Magnetic resonance image of a neurogenic tumor with extension into the spinal canal
via the foramen, which gives a typical dumbbell appearance
58. Approach for dumbbell tumors.
A. Hemilaminectomy (black arrow).
B. Resection of intraspinal component
of tumor prior to thoracic approach
59. Neuroblastomas
▪ originate from the sympathetic nervous system
▪ most common location: retroperitoneum; however, 10% to 20%
occur primarily in the posterior mediastinum
▪ highly invasive neoplasms, frequently metastasized
▪ occur in children 4 years of age or younger.
▪ Therapy is determined by the stage of the disease
– stage I surgical excision
– stage II excision and radiation therapy
– stages III and IV multimodality therapy using surgical debulking, radiation
therapy, and multiagent chemotherapy
61. Ganglion Tumors
▪ Ganglioneuroblastomas composed of mature and immature ganglion cells
▪ Treatment from surgical excision alone to various chemotherapeutic strategies,
depending on:
– histologic characteristics,
– age at diagnosis,
– stage of disease
▪ Ganglioneuromas benign tumors originating from the sympathetic chain that are
composed of ganglion cells and nerve fibers
▪ typically present at an early age the most common neurogenic tumors occurring
during childhood
▪ usual location: paravertebral region; well encapsulated, cystic degeneration when
cross-sectioned
▪ Surgical excision is curative.
62. Preoperative
▪ Initial workup:
– physical examination and accurate history
▪ Imaging
– CT scan to define the morphology and location of the tumor, local invasion, bony or
airway involvement
– MRI to clarify the relationship of the tumor to the neural foramen and spinal canal
▪ Laboratory test:
– serum and urine free catecholamine levels
– Insulin and glucose levels
▪ Adjunctive workup:
– pulmonary function test
– cardiac risk stratification
63. Postoperative
▪ Patients are managed similarly to any patient who has undergone
thoracotomy or thoracoscopy
▪ Chest drains are removed early (i.e., on the day of surgery or
postoperative day 1) based on output and reexpansion of the lung
▪ extubated in the OR, and early mobilization is advocated
▪ Diet may be resumed in short order as tolerated
▪ patients with paragangliomas warrants special attention to heart
rate and blood pressure
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