Recommended
More Related Content
Similar to mediastinal tumors.pptx
Similar to mediastinal tumors.pptx (20)
More from TemesgenAgegnehu1
Recently uploaded
Recently uploaded (20)
mediastinal tumors.pptx
- 1. Mediastinal Tumors Mgt By: Dr.Mebrate-GSR-IV Moder:Dr.Gutu(Ass.Prof.of Surgery)
- 2. Outline • Anatomy • Introduction • Clinical presentation • Diagnostic work-ups • Rx approaches • References
- 3. Anatomy • Mediastinum-thoracic space located b/n two pleural cavities
- 4. Introduction Mediastinal masses span a wide histopathological and radiological spectrum benign or malignant primary or secondary Affect people of all age groups, more common in young and middle-aged adults Most are benign & usually asymptomatic Precise dx is difficult to w/o histopathologic examination
- 5. Clin.presentation • Majority- asymptomatic • detected incidentally • Sign and sxs vary depending on: o The age of the patient o Nature and location of the mass o Presence or absence of infection o Biochemical products o Associated disease states
- 6. Cont… • Local c/f – Chest pain – Dyspnea – Cough – Hemoptysis – SVC syndrome – Hoarseness – Dysphagia – Pleural /pericardial effusion – Phrenic nerve palsy – Spinal cord compression • Constitutional sxs – Fever – Night sweats – Anorexia – Weight loss
- 7. Cont… autoimmune Myasthenia gravis Red blood cell aplasia Osteoarthropathy • Hormone production – Cushing's syndrome – Thyrotoxicosis – Hypertension – Hypercalcemia – Hypoglycemia – Diarrhea
- 8. Diagnostic work-ups I-Non-invasive RADIOGRAPHY Most masses detected incidentally on CXR Limited delineation and r/ship of structures Felson method
- 9. Cont… CT(Contrast) • most useful in localizing the origin • to evaluate the extent • to guide biopsy and follow Rx response MRI • better soft tissue cxn than CT • delineating the composition of the mass • Very useful in imaging neurogenic tumors
- 10. Cont… NUCLEAR MEDICINE • PET & PET-CT- evaluation of mediastinal LN involvement in lung Ca and lymphoma • PET-CT…commonly used to evaluate Rx response • 123I or 131I-presence of thyroid tissue within the mediastinum • Examination of neuroendocrine tumors and pheochromocytomas
- 11. Cont… ULTRASOUND • Echo-differentiates cardiac from paracardiac masses. • EUS…guides LN biopsy • U/S… differentiates cystic from solid masses
- 12. IMAGING FEATURES THYROID MASSES • 3%-17% of goiters extend into the thorax • Rounded or irregular, well-defined areas of calcification - benign areas • Amorphous cloud-like calcification-seen within carcinomas • tracheal narrowing or deviation of the trachea depending on the location of the mass
- 13. Cont… • CT features of mediastinal goiters High attenuation on a non- contrast exam (high I2 ) Intense and prolonged enhancement ff contrast enhancement Continuity of the mass with the cervical thyroid gland Calcifications and cystic regions resulting in foci of heterogeneous attenuation
- 14. … THYMIC MASSES 1. Thymomas • benign or low-grade malignant tumors of thymic epithelium. • demonstrates an abnormal contour or widening of the mediastinum on PA radiographs • opacity in the anterior clear space on the lateral radiograph • homogeneous density and uniform enhancement on contrast CT
- 15. Cont…
- 16. Cont… • On MRI-low T1 signal intensity,relatively high T2 signal intensity • MRI is superior to CT for defining the invasion of contiguous structures such as the pleura and pericardium
- 17. Thymic Carcinomas • poor prognosis despite treatment with surgery and radiotherapy • typically large, heterogeneous masses, with areas of necrosis and calcification and evidence of invasion of adjacent structures • On MRI-intermediate signal intensity on T1 and high signal intensity on T2
- 18. … . Thymic Hyperplasia- increase in size with normal gross and histologic appearance • commonly occurs ff atrophy due to o stress o steroid therapy or o chemotherapy Axial CT image demonstrating a well-defined, homogeneous appearing mass within the anterior mediastinum suggestive of thymic hyperplasia (arrow).
- 19. … 4.Thymic Cyst • uncommon,1% of all mediastinal masses • On CXR can’t be differentiated from other thymic masses. • On CT…well- defined,water attenuation masses • On MR…typical cxc of fluid with low T1 and high T2 intensity
- 20. … PARATHYROID TUMORS • rare cause of an anterior mediastinal mass • most commonly located in or around the thymus • small and almost invisible on plain radiographs • 99mTc scintigraphy- most sensitive imaging • CT-small nodules,minimal or no enhancement • MRI- isointense on T1- weighted and hyperintense on T2
- 21. GCT of the MEDIASTINUM • derived from primitive germ-cell elements • most common extragonadal site is the mediastinum • 60% arises in the anterior mediastinum
- 22. Cont… 1.TERATOMAS • Mature teratomas are found at all ages • usually asymptomatic and diagnosed incidentally on CXR or CT • but may be symptomatic if they compress the bronchial tree or SVC ,or if they rupture
- 23. Teratoma cont… o well-defined, rounded or lobulated mass, localized to the anterior mediastinum o On CT-combinations of fat, fluid, soft tissue components, and calcification may be seen o presence of fat is a very helpful diagnostic feature favoring mature (benign) cystic teratoma o On MRI…Fat - fluid levels are virtually diagnostic of teratomas
- 24. … 2. SEMINOMAS • occurs almost exclusively in males(2-4 decades) • Symptoms-usually due to mass effect on adjacent structures • On CT and MR - homogenous attenuation and signal intensity
- 25. NSGCT • CT -lobular, asymmetrical mass • obliteration of mediastinal fat • multiple areas of contrast enhancement interspersed with areas of decreased attenuation due to necrosis and hemorrhage • On MRI-heterogeneous intensities
- 26. LYMPHOMA • common cause of mediastinal adenopathy • prevascular and paratracheal nodes- most frequently involved(Hodgkin’s disease, particularly)
- 27. … BRONCHOGENIC CYSTS • usually asymptomatic solitary mass • may compress surrounding structures and cause symptoms • The most common location is subcarinal • CXR- round mass in the middle mediastinum abutting the carina or main bronchi • CT… thin-walled mass, with contents measuring simple fluid attenuation
- 28. … NEUROGENIC TUMORS • most common tumors in the posterior mediastinum • Most tumors in adults are benign and are discovered as asymptomatic masses on chest radiographs • The best modality for imaging these tumors is MRI
- 29. SERUM MARKERS (in 10 mediastinal GCT) 1.AFP • major fetal serum protein • normally produced during gestation by fetal liver,GIT and the yolk sac • AFP…present in embryonal carcinoma and in yolk sac tumors • never present in pure seminomas or choriocarcinomas
- 30. 2.β-HCG • elevated in the majority of choriocarcinoma and • in10% of patients with seminomas
- 31. … 3.LDH • its specificity for GCTs is extremely poor. • But for monitoring Rx response and recurrence • (predicts relapse-free survival, and overall survival) • Therefore, in patients with GCTs,evaluation of LDH levels, together with levels of AFP and β-HCG, is strongly recommended
- 32. Dxtic Non-surgical Biopsies • 60% anterior mediastinal masses treated non-surgically • CT-guided needle biopsy, • EBUS- and EUS- guided FNA, and core-needle biopsy • FNA + core needle biopsy = 98%acc. • Vs 79% for each independently
- 33. Invasive Ix • Surgical approaches for Dx o anterior mediastinotomy- • for large masses in the anterior mediastinum o Cervical mediastinoscopy- • lesions located in the superior-middle mediastinum o VATS- • large masses protruding in the pleural cavity
- 34. Surgical Approaches • For complete tumor removal, larger incisions must be used. • The two most common incisions: median sternotomy (full or partial) and Thoracotomy • The most common thoracotomy incision for mediastinal exposure : Clamshell incision.
- 35. … • TECHNIQUE FOR FULL STERNOTOMY • Supine • standard midline incision … suprasternal notch to a point just below the xiphoid process • Subcutaneous tissue dissection… electrocautery • two chest tubes are generally used to drain the mediastinum. • If the pleura has been entered, one of the chest tubes is placed in that pleural space • sternum is reapproximated using interrupted sutures …no. 5 or 6 wire • subcutaneous tissue and fascia can be closed in layers
- 36. … • COMPLICATIONS • Rare, <3% • mediastinitis after sternotomy…1% to 2% • Delayed complications Costochondral separation, occult rib fractures chronic osteomyelitis of the sternum rib cartilage necrosis sternal nonunion sternal wire erosion • Advantages of sternotomy – speed of opening and closing – the sparing of major thoracic muscles – Relative reduced postoperative pain • Main disadvantages – limited exposure of the posterolateral compartment – sternal infection
- 37. • Thoracotomy (muscle sparing lateral or posterolateral) – the most common approach in general thoracic surgery – lung resections – esophageal lesions – posterior mediastinal and paravertebral sulcus tumors
- 38. Cont… • TECHNIQUE • lateral decubitus position • Incision just below the tip of the scapula…down with the electrocautery through the subcutaneous tissue to the fascia of the serratus anterior and beyond the border of the latissimus dorsi • mobilize the latissimus dorsi posteriorly, split the serratus anterior in the direction of its fibers and retract them away from the intercostal space to be entered • fourth intercostal space…usual entry point for exposure to the anterior mediastinum • For higher exposure… axillary thoracotomy
- 39. Cont… • COMPLICATIONS • Bleeding • Acute post- thoracotomy pain • long-term postoperative chronic pain
- 40. … • CLAMSHELL INCISION – excision of giant masses – good exposure to both the right and left hilar structures
- 41. Cont… • TECHNIQUE – A curvilinear bilateral submammary incision – extends from one midaxillary line to the contralateral
- 42. Cont… • COMPLICATIONS – increased postoperative pain – increased risk of sternal override – pseudoarthrosis
- 43. References
- 44. Thanks