mediastinal tumors and cysts sung chul hwang, m.d. dept. of pulmonary and critical care medicine...

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