Overlook of mediastinal tumors

2. INTRODUCTION
 MEDIASTINUM is the central compartment in the
thoracic cavity between the two lungs
 Any age group-both sexes
 (often on routine x ray)
 (50% are asymptomatic)

3. ANATOMY
• Anteriorly : Sternum
• Posteriorly : Thoracic vertebrae
• Superiorly : Plane of thoracic inlet
• Inferiorly : Diaphragm
• Laterally : Mediastinal pleura

5. CROSS SECTION
 Anterior - 1
 Middle - 2
 Posterior - 3
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axlesson3.htm

6. SUPERIOR MEDIASTINUM
 MUSCLES : Origins of sternohyoid ,sternothyroid,lower ends of
longus colli
 ARTERIES : aortic arch,brachiocephalic artery,thoracic portions
of left common carotid, and left subclavian artery
 VEINS : brachiocephalic vein,upper part of SVC,left highest
intercostal vein
 NERVES : vagus,superficial and deep cardiac plexus,phrenic
nerve,left recurrent larnygeal nerve
 Trachea
 Oesophagus
 Thoracic duct
 Remains of thymus lymph glands

7. ANTERIOR MEDIASTINUM
 Loose areolar tissue
 Some lymphatic vessels which arise from the
convex surface of the liver
 2 or 3 mediastinal lymph nodes
 small mediastinal branches of internal mammary
artery
 Thymus

8. MIDDLE MEDIASTINUM
Pericardium
Heart
Descending aorta
Lower half of SVC and azygous veins
Right and left pulmonary veins
Trachea
Trachea Bifurcation
Main Bronchi
Phrenic Nerve
Hilar Lymph Node
Pericardiophrenic vessels

9. POSTERIOR
 Esophagus
 Vagus
 Splanchnic nerves
 Thoracic duct
 Thoracic descending Aorta
 Azygos Vein and accessory hemiazygous vein
 Hemi-azygos vein
 Paravertebral Lymph node

12. CLASSIFICATION - ANATOMICAL
ANTEROSUPERIOR:
- Thymic neoplasms - Cysts
- Mesenchymal - Lymphomas
- Germ cell tumours - Carcinoma
- Endocrine
 MIDDLE:
- Cysts - Mesenchymal
- Lymphomas - Carcinoma
 POSTERIOR MEDIASTINAL:
- Neurogenic - Mesenchymal
- Cysts - Endocrine

13. CLASSIFICATION- PATHOLOGICAL
• NEUROGENIC TUMOURS -
MOST COMMON : NEUROFIBROMA, NEURILEMOMA,
GANGLIONEUROMA, NEUROBLASTOMA,
NEUROSARCOMA
OTHERS : CHEMODECTOMA, PARAGANGLIOMA
• THYMOMA - BENIGN, MALIGNANT
• LYMPHOMA – HODGKINSDISEASE ,
• T AND B IMMUNOBLASTIC SARCOMA,
SCLEROSING FOLLICULAR CELL
• GERM CELL TUMOURS- ,
TERATODERMOID(BENIGN AND MALIGNANT)
SEMINOMA,
NONSEMINOMA
(EMBRYONAL,CHORIOCARCINOMA,ENDODERMAL )

14. • MESENCHYMAL TUMOURS –
• FIBROMA,/FIBROSARCOMA,LIPOMA/ LIPOSARCOMA,
LEIOMYOMA/LEIOMYOSARCOMA, RHABDOMYOSARCOMA,MYXOMA,
MESOTHELIOMA,XANTHOGRANULOMA,
HEMANGIOMA,HEMANGIOENDOTHELIOMA,HEMANGIOPERICYTOMA
LYMHANGIOMA,LYMPHANGIOMYOMA,,LYMPHANGIOPERICYTOMA
• ENDOCRINE –
INTRATHORACIC THYROID,PARATHYROID ADENOMA/CARCINOMA
CARCINOID
• CYSTS – BRONCHOGENIC, PERICARDIAL, ENTERIC, THYMIC,
THORACIC DUCT NONSPECIFIC
• GIANT LYMPH NODE HYPERPLASIA – CASTLEMAN'S DISEASE
• CHONDROMA
• EXTRAMEDULLARY HEMATOPOIESIS

15. Common Pathologies
• ANTEROSUPERIOR MEDIASTINUM -
THYMIC NEOPLASM-33%
LYMPHOMA-19%
GERM CELL TUMOUR-17%
• MIDDLE MEDIASTINUM -
CYSTS-61%,LYMPHOMA-21%
• POSTERIOR MEDIASTINUM -
NEUROGENIC-53%,CYST-32%

16. CHILDREN
 Posterior Mediastinum
 Most often benign
 2/3 of tumors symptomatic
Neurogenic tumors(40%)
Lymphoma(18%)
Cysts(18%)
Germ cell tumors(11%)
Mesenchymal
tumors(9%)
Thymomas -Rare

17. ADULTS
 Anterior Mediastinum
 Often Malignant
 Ages 30 – 50
 1/3 of tumors are symptomatic
Neurogenic tumours(21%)
Cysts(20%)
Thymomas(19%)
Lymphoma(13%)
Germ cell tumours(11%)
Mesenchymal tumours(7%)
Endocrine tumours(6%)

18. MALIGNANCY
 All tumors 25%
− Per Section

Anterior Superior 59%

Posterior 16%

Middle 16%

19. Symptoms
 Chest pain
 Dyspnea
 Cough
 Fever
 Weight loss
 Fatigue
 Dysphagia
 Night sweats

20. Clinical Features
 SVC syndrome
Myasthenia gravis, Immune deficiency,
Aplastic anemia - Thymoma
Sympathetic ganglion - Horner’s
Syndrome
In late stages : Diaphragmatic palsy
Pleural Effusion
Haemorrage (Erosion of major vessels)

21. Malignant Tumors Invasion
Structure
 Tracheobronchial tree and lungs
 Esophagus
 Superior Vena Cava
 Pleura and Chest Wall
 Intrathoracic nerves

22. CLINICAL MANIFESTATIONS OF ANATOMIC
COMPRESSION OR INVASION BY NEOPLASMS
OF THE MEDIASTINUM
Vena caval obstruction
 Pericardial tamponade
Congestive heart failure
Dysrhythmias
Pulmonary stenosis
Tracheal compression
Esophageal
compression
Vocal cord paralysis
Postobstructive
pneumonitis
 Horner's syndrome
 Phrenic nerve paralysis
 Chylothorax
 Chylopericardium
 Spinalcord compressive
syndrome
 Pancoast's syndrome

23. DIAGNOSTIC EVALUATION
 History and Physical examination
 Radiology - Standard chest films ,Barium swallow,
Fluroscopy ,Arteriography,Venography,
CT,MRI,USG,Myelography
Radioisotope scanning
 Serology
Endoscopy
 Bronchoscopy
 Needle aspiration and biopsy
 Operative procedures – Mediastinoscopy,
Mediastinotomy Thoracotomy

24. ULTRASTUCTURAL CHARACTERISTICS OF
MEDIASTINAL TUMOURS
 Carcinoid : Dense core granules,fewer
tonofilaments and desmosomes
 Lymphomas : Absence of junctional attatchments
and epithelial features
 Thymoma : Well formed desmosomes ,bundles of
tonofilaments
 Germ cell : Prominent nucleoli ,even chromatin,
scant desmosomes, rare tonofilaments
 Neuroblastoma :Neurosecretory granules
,synaptic endings

25. Treatment
 Thoracotomy and removal
 If malignant - Adjuvant therapy like
radiotherapy & chemotherapy
 Sternotomy - Sup. and ant.tumours

26. • Thymic cancers require surgery, followed by
radiation or chemotherapy. Types of surgery
include thoracoscopy (a minimally invasive
approach), mediastinoscopy (minimally
invasive) and thoracotomy (a procedure
performed through an incision in the chest).
• Lymphomas are recommended to be treated
with chemotherapy followed by radiation.
• Neurogenic tumors found in the posterior
(back) mediastinum are treated surgically.

27. THYMOMAS
 Most common tumour of the anterosuperior
mediastinum in adults
 Fifth to Sixth decade
 Both sexes are equally affected

29. Types
 HISTOLOGY:
 Epithelial cell - Poor prognosis
 Lymphocytic
 Mixed
 Spindle - Better prognosis
50% THYMOMAS ARE MALIGNANT

30. Clinical features:
 ASYMPTOMATIC 50%
 30 - 40% ASSOCIATED WITH
MYASTHENIA GRAVIS
 Chest pain
 Dysphagia
 Dyspnoea
 SVC obstruction

31. Modified Masaoka clinical staging of thymoma
Stage Definition
I Macroscopically and microscopically completely encapsulated
IIA Microscopic transcapsular invasion
IIB Macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through
mediastinal pleura or pericardium
III Macroscopic invasion into neighboring organs (ie, pericardium, great vessels, or lung)
IVA Pleural or pericardial dissemination
IVB Lymphogenous or hematogenous metastasis

32. Investigations
 Chest Xray : Lateral view - Opacity in
mediastinum
 Mediastinoscopy & biopsy.
 Tensilon Diagnostic test : Injecting 10mg
edrophonium chloride iv. Myasthenia is relieved within
1 min temporarily
 CT scan

34.  Treat myasthenia - Neostigmine
 Thymectomy IS BENEFICIAL in:
 Disease < 5yrs
 Myasthenia without thymoma
 In young females
Treatment

35.  Surgical removal of the tumor is the preferred
treatment. Surgery is often the only treatment
required for stage I tumors. Treatment of
thymoma often relieves the symptoms caused by
paraneoplastic syndromes.
 Stages II, III, and IV thymomas are often
treated with surgery and some form of adjuvant
therapy.

36. RETROSTERNAL GOITRE
 > 50 % goitre below the suprasternal notch.
 PRIMARY : rare (1%) -
SECONDARY : common

37. PRIMARY
 Arises from ectopic thyroid tissue from mediastinum.
 It gets it blood supply from mediastinum itself,not
from the neck.
Not related to existing thyroid tissue in the neck
SECONDARY
 Extension from an enlarged thyroid from the neck
 Arises from lower pole of a nodular goitre usually.
 Commonly seen in short neck or obese individuals
 Nodule gets drawn into the superior medistinum due
To negative intrathoracic pressure

38. TYPES
 Substernal type : part of the nodule is palpable in
the lower neck
 Plunging goitre : an intrathoracic goitre is
occasionally forced into the neck by increased
intrathoracic pressure
 Intrathoracic goitre: neck is normal

39. CLINICAL FEATURES
SYMPTOMS :
Dyspnoea
 Cough and stridor
Dysphagia
SIGNS :
Engorgement of neck veins and superficial veins on
the chest wall
Lower border is not seen on inspection and not felt
on palpation

40.  PEMBERTON'S SIGN : is positive
 Percussion :dull note over sternum
 Can be nodular,toxic or malignant
 Rarely – recurent larygeal nerve palsy

41. INVESTIGATIONS
 Chest X -ray
 CT scan and MRI is diagnostic

43. TREATMENT
 Surgical removal
 Commonly through incision in neck
 Large goitre or malignant type median sternotomy
is required rarely
 Radiodine therapy is not not accepted
 Stridor –due to compression of tracheobronchial
tree it is very dangerous, as often it is not possible
to clear airway either by intubation or
tracheostomy
 Surgical removal should be complete : recurrence
– very difficult to operate

44. Neurogenic tumors
Neurofibroma,Neurilemmoas
Melanotic schwannoma
Ganglioneuromas
Chemodectoma
Pheochromocytomas
Benign Malignant
Neurofibrosarcomas
Ganglioneuroblastoma
Neuroblastomas
Malignant chemodectoma
Malignant
Pheochromocytoma

45. Neurilemmomas
Most common
Arises from the
Schwann cells of the nerve
sheath
Well encapsulated
X-ray :dense homogenous
mass in the posterior
mediastinum
Surgical excision

46. Neurofibromas
Arises from the nerve sheath and nerve fibres
Poorly encapsulated
Treatment :
Difficult to excise due to its infiltrating nature
Multiagent chemotherapy due to aggressive nature

48. Ganglioneuromas
Originates from sympathetic chain
Composed of ganglionic cells and nerve fibres
More common in children
Mostly asymptomatic
Usual location is paravetebral region
INVESTIGATION: X ray- well marginated lesion on
anterolateral aspect of spine
TREATMENT: surgical resection

49. Neuroblastomas
Usually seen among young children
Most poorly differentiated tumor
Arising from the sympathetic nerves
Highly invasive tumor 75% -children clinical feature is fever
cough diarrhea vomiting
At time of presentation – pain,neurological defects,Horners
syndrome,respiratory distress ataxia
-lymph node metastasis
Metastasis to spinal cord
Investigation : CT,MRI,radionucleide imaging
Treatment :
Radiotherapy and chemotherapy

51. Germ cell tumors
Benign Malignant
Seminomatous Non seminomatous
Choriocarcinomas
Embryonal carcinomas
Mixed tumors
Teratocarcinomas
Yolk sac carcinomas.

52. LAB STUDIES
Beta human
chorionic
gonadotropin
Alpha-fetoprotein
IMAGING
Chest
radiography
CT scan of the
chest and
mediastinum
DIAGNOSTIC
PROCEDURES
Transthoracic needle
biopsy
Cervical
mediastinoscopy and
substernal extended
mediastinoscopy
Anterior
mediastinotomy
Video-assisted
thoracoscopy
Sternotomy and
thoracotomy

53.  TERATOMA is the commonest.
 Symptoms: usually asymptomatic, cough, dyspnoea and chest pain can
occur.
 Investigations : Chest Xray, CT, MRI
 Treatment: complete surgical excision and chemotherapy.
 SEMINOMA:
 25- 50% of GCT
 Men 20- 40 yrs
 Symptoms: dysnoea, substernal pain, weakness, gynaecomastia, SVC
syndrome
 Investigations: chest Xray, CT,
 Treatment: radiotherapy

54.  Non Seminoma:
 Embryonal cell carcinoma, endodermal thymus
tumours, choriocarcinoma, yolk sac tumours with
multiple cellular components.
 Symptoms: chest pain, hemoptysis, cough, fever,
wt loss, gynaecomastia
 Investigation: AFP, beta HCG are increased.
 Treatment: chemotherapy with bleomycin,
etoposide and cisplatin
 If there is residual tumour then = surgery

55. Lymphomas
Commonly situated in anterior mediastinum
Commonest Hodgkin's lymphomas
Common in 40-60 yrs
Non Hodgkin’s affects any age.
Symptoms: fever, wt loss, night sweats, compressive
symtoms like pain, dyspnoea, wheezing, SVC syndrome
and pleural effusion.
Investigations : x-ray , CT scan, cervical lymph node
biopsy
Treatment: Combination chemotherapy
Surgery not usually done.

56. Vascular and Lymphatics
Hemangiomas
Lymphangiomas
Haemangimyomas
Lymphangimyomas
Commonest is lymphangioma(cystic hygroma)
Seen in ant mediastinum

57. Mediastinal cysts
Primary cyst
Pericardial cyst
Bronchogenic cyst
Enteric cyst
Thymic cyst

58. Thank You…