week 4 meadiastinumtumor- 20 november 2012
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8/17/2019 Week 4 MeadiastinumTumor- 20 November 2012
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M ediastinal tum ors
Yani PurnamasariSp.P
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Mediastinal tumors are benign or cancerousgrowths that form in the area of the chest thatseparates the lungs.
the mediastinum, is surrounded by thebreastbone in front, the spine in back, and thelungs on each side (lower: diafragma, lateral:
pleura mediastinal)
he mediastinum contains the heart, aorta,esophagus, thymus and trachea.
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The m ediastinum is divided into 3 sections:
he anterior (front)
he middle he posterior (back)
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Mediastinum tumors are mostly madeof :
reproducti!e (germ) cells or de!elopin thymic,
neurogenic (ner!e),
lymphatic or mesenchymal (soft)tissue.
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W ho is affected by m ediastinal tum ors?
"n general, mediastinal tumors are rare. Mediastinaltumors are usually diagnosed in patients aged #$ to %$years, but they can de!elop at any age and form from anytissue that e&ists in or passes through the chest ca!ity.
he location of tumors within the mediastinum !ariesaccording to the age of the patient.
"n children, tumors are commonly found in the posterior(back) mediastinum. hese mediastinal tumors often begin
in the ner!es and are typically benign (noncancerous).
"n adults, most mediastinal tumors occur in the anterior(front) mediastinum and are generally malignant(cancerous) lymphomas or thymomas.
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Is a m ediastinal tum or
serious? 'ue to their location in the mediastinum mediastinal tumors (both benign andmalignant) serious complicationsincluding in!ading the heart, pericardium
(the lining around the heart), and great!essels (the aorta and !ena ca!a).
umors located in the posterior (back)mediastinum can cause compression ofthe spinal cord.
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There are several types of m ediastinal tum ors
Anterior (front) mediastinum
Germ cell * he ma+ority of germ cell neoplasms ($ * -$)are benign and are found in both males and females.
Lymphoma / Malignant tumors ( 0odgkin1s disease andnon 0odgkin1s lymphoma).
Thymoma and thymic cyst * a thymic mass, the ma+orityof thymomas are benign lesions ( contained within a 2brouscapsule). 3bout #$ of these more aggressi!e and
become in!asi!e through the 2brous capsule.
Thyroid mass mediastinal / 4sually a benign growth,such as a goiter, these can occasionally be cancerous.
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M iddle m ediastinum
Bronchogenic cyst / 3 benign growth with respiratory origins.
Lymphadenopathy mediastinal / 3n enlargement of the lymphnodes.
Pericardial cyst / 3 benign growth that results from an 5out*pouching5of the pericardium (the heart1s lining).
Thyroid mass mediastinal / 4sually a benign growth, such as agoiter. hese types of tumors can occasionally be cancerous.
Tracheal tumors / hese include tracheal neoplasms and non*euplastic masses, such as tracheobronchopathia osteochondroplastica(benign tumors).
6ascular abnormalities including aortic aneurysm and aortic dissection.
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Posterior (back) m ediastinum
Extramedullary haematopoiesis / 3 rare cause ofmasses that form from bone marrow e&pansion and areassociated with se!ere anemia.
Lymphadenopathy mediastinal / 3n enlargement of thelymph nodes.
Neuroenteric cyst mediastinal / 3 rare growth, whichin!ol!es both neural and gastrointestinal elements.
Neurogenic neoplasm mediastinal / he most commoncause of posterior mediastinal tumors, these are classi2edas ner!e sheath neoplasms, ganglion cell neoplasms, andparaganglionic cell neoplasms. ( -$ of neurogenicneoplasms are benign )
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W hat are the sym ptom s of am ediastinal tum or?
7ough
Shortness of breath
7hest pain
8e!er
7hills
9ight sweats
7oughing up blood
0oarseness
4ne&plained weight loss
ymphadenopathy (swollen or tender lymph nodes)
;hee
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he symptoms mediastinal tumor caused of
tumor in!asion , such as : / 9. Phrenicus diafragma paralysis
/ 9. reccurent 6ocalis 7ord paralysis
/ 99. Simpaticus 0orner syndroma( 3P=M )
/ =sophageus disphagia
/ 6. 7a!a Sup !enous congestion ( 67SS )
/ rachea > ?ronchus atelectasis / 7or pericard efusion
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H ow is a m ediastinal tum or diagnosed?
7hest &*ray
7omputed tomography (7) scan of the chest or 7*guidedneedle biopsy
Magnetic resonance imaging (M@") of the chest
Mediastinoscopy with biopsy (Performed under generalanesthesia) this e&amination of the chest ca!ity uses alighted tube inserted through a small incision under thechest boneA a sample of tissue is taken to determine ifcancer is present. Mediastinoscopy ( accurately diagnoseB$ * C$ of mediastinal tumors, and C% * D$$ of anteriormediastinal tumors.)
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H ow are m ediastinal tum orstreated?'epends on the type of tumor and its location:
hymic cancers reEuire surgery, followed by radiation or chemotherapy. ypes of surgery includethoracoscopy , mediastinoscopy and thoracotomy (a
procedure performed through an incision in the chest).
ymphomas are recommended to be treated withchemotherapy followed by radiation.
9eurogenic tumors found in the posterior (back)mediastinum are treated surgically.
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M ediastinal tum ors
umors of the mediastinum represent a wide di!ersityof disease states
he most common causes of an anterior mediastinalmass include: thymoma, germ cell tumor, thyroiddisease and lymphoma
Masses of the middle mediastinum are typically
congenital cysts and lymphoma
"n the posterior mediastinum are often neurogenictumors ,esophageal tumors and tumors of spinalcolumn
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Thym om as
he most important determinants oflong term sur!i!al in thymoma are :
complete resection Masaoka stage
;0F histologic classi2cation
Strobel et al. umor recurrence and sur!i!al inpatients treated for thymomas and thymic SE cellcarcinomasA 3 retrospecti!e analysis. G 7lin FncolH$$I AHHAD%$D*D%$C
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Thym om as
;0F classi2cation of thymomas
;0F type 7ytological 8eatures
ype 3 Medullary, spindle cell
ype 3? Mi&ed hymomas
ype ?D Frganoid, predominantly cortical , lymphocytepredominant
ype ?H 7ortical
ype ?# ;ell diJ 7a , epithelial predominant , sEuamoid ype 7 hymic carcinoma
8rom ;ilkins et al. 7ases of hymoma of the Massachusetts Keneral 0ospital . G horacic 7ardio!ascular Surg DC, %HA #HH*##$
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M asaoka Staging System for Thym om a
Stage 'escription
" Macroscopically completely encapsulated with no microscopicdetectable capsular in!asion
"" Macroscopic in!asion into surrounding mediastinal fatty tissue or
mediastinal pleura or microscopic in!asion in the capsule
""" Macroscopic in!asion into surrounding organs or intrathoracicmetastases or both (pericardium, great !essels, heart)
"6 3 Pleural or pericardial implants>dissemination
"6? ymphagenous or hematogenous metastases
3dapted from Masaoka et al. 8ollow up study of thymomas with specialreference to their clinical stages .7ancer DCBD AIBA HIB%,with permission
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Thym om as Se!eral studies ha!e attempted to correlate morphologic
staging with tumor in!asion and prognosis
"t appears that medullary ( ;0F 3) and mi&ed (;0F 3?) arenot in!asi!e and typically correspond to Masaoka stg " and ""
7ortical thymomas (;0F ?D,H and #)are more in!asi!e andoccur more commonly as stg """ and "6 lesions
he Masaoka stg system remains the most widely accepted
stg upon which current management recommendations arebased
Shneidar PM. et al. Prognostic importance of histomorpohologic sub classi2cation for epithelialthymic tumors . 3nn Surg Fncol DCCAIAI*%
9akagawa et al. hymoma A 7linicopathological study based on the new ;0F classi2cation A G
hora
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Thym om as
"nLuence of Masaoka stg on complete resection,recurrence and sur!i!al (nD#H$)
Masaoa stage ! !! !!! !"A
7ompleteresection()
D$$ D$$ B% IH
@ecurrence () D I HB #I
%*Year sur!i!al() D$$ CB BC -D
'ata from Nondo et al.3nn horac.Surg.H$$#A-:B-B
B%(#%)
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Treatm ent of Tym om a
Stage ": =&tended thymo thymecthomy(=)
Stage "" :=, radiation Stage """ : = O e&tended resection,
radiotherapy O chemotherapy
Stage "63: 'ebulking,chemotherapy Oradiotherapy
Stage "6?: chemotherapy Oradiotherapy , debulking
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Treatm ent Thym ic carcinom a
he same multy*modality on lungcarcinoma
reament hymic carcinoid Ooatcell carcinoma
• Surgery, radiotherapy O chemotherapypost surgery (because in!asi!e tumor)
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he myasthenia gra!is >myasthenicreaction Plasmapharesis beforesurgery (fastest one week beforesurgery)
he symptom myasthenic reactionbefore surgery myasthenia
gra!is treatment
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M ultim odality treatm ent of locallyadvanced thym om as
Potentially operable stage """ disease are best treated withinduction therapy follow by surgery
he combination of P37( cisplatin, do&orubicin,
cyclophosphomide) or 3'F7 (cisplatin, do&orubicine, !incristine,cyclophosphomide) ha!e reported ob+ecti!e response rates from--*D$$ with resectability rates ranging between I$* -$
he administration of neoad+u!ant chemotherapy impro!ed D$yr sur!i!al from -D (no induction therapy) to C$.
ucchi M ,et al. 3d!anced stage thymomas and thymic carcinomas : results ofmultimodality treatments. 3nn horac Surg H$$% A-C ADBI$*I
6enuta f, et al. ong term outcome after multimodality treatment for stage """ thymictumors. 3nn horac Surg H$$#A-:DB*-H
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Germ cell tum or of the
m ediastinum0istologic classi2cation : Seminoma
9on seminoma =mbryonal carcinoma
7horiocarcinoma
Yolksac carcinoma
eratoma ?enigna
Malignant ( germinal cell, nongerminal,
immature)
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Sem inom a Treatm ent
7hemoradio therapy sensitif 9o surgery indication
9onseminoma treatment :@adioresisten O chemotherapy cycle=!aluation on #*I cycle with *07K
O Q*fetoprotein, thoracs photo P3 Olateral
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Benigna Teratom a treatm ent surgery
Malignan eratoma :Multimodality
(surgery,chemotherapy,radiotherapy he important thinks aboutmalignaneratoma :
• .Mature on adult not alwaysbenigna• .immature on child not alwaysmalignan• .mature on child alwa s beni na
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Neurogenic Tum or
0istologic classi2cation : Peripheral ner!es 9euro2broma
9eurilemoma (schwannoma)
9eurosarcoma
Symphathetic ganglia Kanglioneroma
Kanglioneuroblastoma
9euroblastoma
Paraganglionic Pheochromacythoma
Paraganglioma
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Treatm ent of neurogenic tum or
Surgery,
=&cept neuroblastoma (radiosensitif)
radiochemotherapy 9eurilemoma (Schwanoma)
chemotherapy ad+u!ant (pre!entreccurency)
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M esenchim al tum or & Endocrine tum or
@are found
Speci2c treatment
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Evaluation of treatm ent m ediastinaltum ors
Side efec chemotherapy
@espons of therapy after H cycle or
radiation H$$$ cKy O photo thoracs Partial respons > stable disease
chemotherapy Oradiation
Stop treatment if progresi!e diseases
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Thank ou
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Prosedur D iagnostik tum or m ediastinum tanpakegaw atan
umor mediastinum tanpa kegawatan (telahteratasi)
3namnesis,P&. 8isik, lab.rutin
@adiologik =ndoskopi
0istopatologi
aboratorium
orakotomieksplorasi8oto
toraksP3>lateral omogra27 Scantoraks dgkontras
P&. lain8luoroskopi,=sofagogra2,3ngiogra2, 4SK,Nedoktera
n 9uklir,M@"
?ronkosko
pi,Mediastinoskopi,=sofagoskopi,
orakoskop
i
Sitologi,?
G0>893?,punksiPleura,?ilasan>sikatan>?3
bronkus
?, ?7*Kuide
0istologi:
?iopsiNK?>'aniel, ?iopsiMediastinal, ?iopsi=ksisiona
l
orakoskopi,63S,?iopsi lain
α-Fetoprotein,
β-HCG
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Prosedur diagnostik tum or m ediastinum dg kegaw atan
umor Mediastinum dgkegawatan
Negawatan nonnapas
Negawatannapas
N.kardio!asculer
N.sal.cerna
Steroid R @adiasi #$$*D$$$ cKy R stand bybedahS6NS Peneka
nanaorta
?eda
h
Prosedurdptdilakukan
Prosedurdiagn
ostik
Prosedurtdk dptdilakukan
@adiasi#$$*D$$$cKyProsedurdiagnost
iklan+utka
?edah
@espons(R)(klinismembaik)
@espons(*) (mshadagangguan)
Prosedur
diagnostikdilan+utkan
?edah
=77(=&tra7orpored
7irculation
anpa=77
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!enatalaksanaan Tum or m ediastinum
umormediastinum
Ginak
Kanas
?edah
imfoma
9onlimfoma
0odgkin1s
9on0odgkin1s
Penatalaksanaan sesuai
dg imfoma0odgkin1s
Penatalaksanaan sesuai
dg imfoma9on
0odgkin1s
imoma O
umor imus
Kermcell
umorneurogenik
umormesengial O
umorendokrin
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Penatalaksanaan um or !el "erm inal # onsem inom am ediastinum
Nemoterapi #*Isiklus
Nadar 07KO38Pnormal,fototoraks
normal
Nadar 07K O 38Pnormal, fototoraksstabil>abnormal
Nadar 07Katau 38Pmeningkat
idak perlu terapi@eseksibedah
an+utankemoterapi
eratoma +inak O
+ar.nekrotik
umor dptdiangkat >
ada sisatumor
Nadar 07K O38Pnormal, foto
toraksstabil>abnormal
Nadar07K O
38P tetaptinggi
idak perluterapilan+utan
an+utkankemoterapi
Suporti!ecare
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$lasifikasium orm ediastinum m enurut
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$lasifikasi um or m ediastinum m enurut%osen"erg
Neurogenic Germ cell Tumor EndocrineTumor
3rising from peripheral
ner!es
Seminoma hyroid
9euro2broma 9onseminomatoustumors
hyroid
9eurilemoma(Schwanoma)
Pure embryonal cell Parathyroid
9eurosarcoma Mi&ed embryonal cell 7ysts
3rising fromsymphatetic ganglia
;ith seminomatouselements
Pericardial
Kanglioneuroma ;ith trophoblasticelements
?ronchogenic
Kanglioneuroblastoma ;ith teratoid elements =nteric
9euroblastoma ;ith entodermal sinuselements
hymic
3rising fromparaganglionic tissue
eratoma,benign horacic duct
Pheochromocytoma Meningoceles
Th i A # i
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Thymic Aneurysms #ernias
hymoma Mesenchymal umors 0iatal
7arcinoid 8ibroma O 8ibrosarcoma Morgagni
hymolipoma ipoma O iposarcoma
My&oma
Mesothelioma
eiomyoma Oeiomyosarcoma
ymphoma @habdomyosarcoma ymphadenopathy
0odgkin1s disease antogranuloma "nLamatory
0istiocyticymphoma
Mesenchymoma Kranulomatous
4ndiJerentiated 0emangioma Sarcoid
0emangioendothelioma
0emangiopericytoma
ymphangioma
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