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Mediastinal Tumors and Cysts
Sung Chul Hwang, M.D.Dept. of Pulmonary and Critical Care Medicine
Ajou University School of Medicine
Introduction
• Silent in early phase• Mainly cause pressure symptoms• Incidentally discovered by routine x-rays• Specific disease entities according to anatomica
l, and embryologic origin• 50% malignant in children where as 25% in adult
s• Metastatic tumor is the most common tumor
• Pain• Cough• Hemoptysis• SVC syndrome• Hoarseness• Dyspnea• Horner’s syndrome
• Dysphagia• Pleural effusion• Stridor• Myathenia Gravis• Phrenic nerve palsy• Chylothorax
Symptoms and Signs
Diagnosis
• Chest PA & Lateral• Bucky film• Chest CT• Fluoroscopy• Bronchoscopy• Esophagogram
• NAB• Isotope Scanning• Angiography• Thoracotomy• VATS• Medistinoscopy
Common Diseases of the Mediastinum
Thymoma• Anterior and Superior mediastinum• Most common (20%)of mediastinal tumor in adults but rare
ly seen in children• 2/3 is malignant• Equal frequency in males and females • 30 – 50 yrs• Various Classification : Lymphocytic, Epithelial, Spindle Cel
l• 50% are asymptomatic• Associated diseases : MG (35%), PRCA, DiGeroge SD, Car
cinoid, Eaton-Lambert, agammaglobulinemia, myocarditis, thyrotoxicosis, etc
Thymoma (Staging)
• Stage I : contained within an intact capsule
• Stage II: extension through the capsule to surrounding fat, pleura, pericardium
• Stage III : Intrathoracic metastasis• Stage IV: Extrathoracic Metastasis
Thymoma(Treatment)
• Stage I : Surgical resection Recurrence 2-12%
• Stage II & III : Surgery + Radiotherapy• Stage IV : Multimodality Induction ch
emotherapy, surgery + post op Radiotherapy
• 5-year Survival 12 – 54 %, not affected by the presence of Myasthenia Gravis
Thymoma
Thymoma
massCa++
Thymus
Lymphoma
• Metastatic is most common• 5-10% is mediastinal primary• Second moost common Anterior Me
diastinal Mass in Adults• Malignant > Hodgkin’s • Dx: Mediastinoscopy, thoracotomy• NAB : Usually not confirmatory
Hodgkin’s Lymphoma
“mediastinal widening”
Germ Cell Tumors
• Anterior Mediastinal location• Mainly in late teens 15 %of Ant. Med. Tumors in
Adults, 24 % in children• 1/5 is Malignant• Cystic Teratoma(Dermoid Cyst) vs. Solid tumor (T
eratoma)• Solid tumor : 1/3 malignant• Radiosensitive• Teratoma, Malignant teratoma, Seminoma(dysger
minomas)
Teratoma
Teratoma
Teratoma
Teratoma
Substernal Thyroid Tissues
• Develops from cervical goiter or intrathoracic remnants
• Can be diagnosed without biopsy by Radioactive iodine scan
• No treatment unless symptomatic, usually pressure symptoms
Rtrosternal Goiter
Neurogenic Tumors
• Posterior mediastinal location• 1/5 of mediastinal tumor• Originate in neural crest• Ganglioheuroma : most common in the t
extbook• Neurilemmoma – most common in Kore
a : “Dumb bell Tumor”, neural sheath origin
Poosterior Mediastinal Tumor ( Neurillemmoma) )
“Dumb-bell”Tumor
Neurilemmoma(Schwannoma)
Para-ganglioma
Mesenchymal Tumors
• Lipoma, Fibroma, Mesothelioma• Superior or Anterior mediastinal location• Diagnosis with CT scan• May cause Hypoglycemia
Mediastinitis
• Acute : endoscopy complication, Boerhaave’s SD, operation, esophageal rupture, median sternotomy
• Chronic : Tbc, histoplasmosis, silicosis, fibrosing mediastinitis
Fibrosing Mediastinitis
• 20- 40 years• Cough, Dyspnea, or Hemoptysis• Most common cause of Benign SVC syndrome• Almost always remote Histoplasmosis• Plain X-rays may be normal or only minimal ch
anges• Partially calcified Mass on CT is diagnostic
Fibrosing Mediastinitis
F/29 with SVC Syndrome by Histoplasmosis
Fibrosing Mediastinitis
F/29 with SVC Syndrome by Histoplasmosis
Pneumomediastinum
• Spontaneous : mainly in young male adults
• Hamman sign• Present along the Left sternal border• Substernal pain, cough, Dyspnea, Dysph
agia
Pneumomediastinum
Benign Cysts
• Most Common in Middle mediastinum• 20% of mediastinal masses• Less common in Korea• Usually asymptomatic• Bronchogenic cyst(32%), pericardial cyst
(35%), enteric cyst(12%), thymic cyst, and thoracic duct cyst
Pericardial Cyst
• Thin-walled, mesothelial cell lining
• most common in Right C-P angle
• Simple cysts are almost always asymptomatic
• Rare cardiac impingement
Pericardial Cyst (1)
Pericardial Cyst (2)
Bronchogenic Cysts
• 30 - 60% of all mediastinal cysts• Lined by ciliated respiratory epithelium• May contain cartilages or mucous• Communicate with tracheobronchial tree
s• May become infected• Wheezing, dyspnea, recurrent pulmonar
y infections
Bronchogenic Cyst
Bronchogenic Cyst
Aortic Aneurysm
Thymolipoma
Paratracheal Lymphadenopathy
Paratracheal Lymphadenopathy with Tracheal Compression
Paratracheal Lymphadenopathy
Paratracheal Malignant Lymphadenopathy