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Mediastinal Tumors and Cysts

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

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Mediastinal Tumors and Cysts

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  1. Mediastinal Tumors and Cysts Sung Chul Hwang, M.D. Dept. of Pulmonary and Critical Care Medicine Ajou University School of Medicine

  2. Introduction • Silent in early phase • Mainly cause pressure symptoms • Incidentally discovered by routine x-rays • Specific disease entities according to anatomical, and embryologic origin • 50% malignant in children where as 25% in adults • Metastatic tumor is the most common tumor

  3. Pain Cough Hemoptysis SVC syndrome Hoarseness Dyspnea Horner’s syndrome Dysphagia Pleural effusion Stridor Myathenia Gravis Phrenic nerve palsy Chylothorax Symptoms and Signs

  4. Chest PA & Lateral Bucky film Chest CT Fluoroscopy Bronchoscopy Esophagogram NAB Isotope Scanning Angiography Thoracotomy VATS Medistinoscopy Diagnosis

  5. Common Diseases of the Mediastinum

  6. Thymoma • Anterior and Superior mediastinum • Most common (20%)of mediastinal tumor in adults but rarely seen in children • 2/3 is malignant • Equal frequency in males and females • 30 – 50 yrs • Various Classification : Lymphocytic, Epithelial, Spindle Cell • 50% are asymptomatic • Associated diseases : MG (35%), PRCA, DiGeroge SD, Carcinoid, Eaton-Lambert, agammaglobulinemia, myocarditis, thyrotoxicosis, etc

  7. 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

  8. Thymoma(Treatment) • Stage I : Surgical resection Recurrence 2-12% • Stage II & III : Surgery + Radiotherapy • Stage IV : Multimodality Induction chemotherapy, surgery + post op Radiotherapy • 5-year Survival 12 – 54 %, not affected by the presence of Myasthenia Gravis

  9. Thymoma

  10. Thymoma mass Ca++

  11. Thymus

  12. Lymphoma • Metastatic is most common • 5-10% is mediastinal primary • Second moost common Anterior Mediastinal Mass in Adults • Malignant > Hodgkin’s • Dx: Mediastinoscopy, thoracotomy • NAB : Usually not confirmatory

  13. Hodgkin’s Lymphoma “mediastinal widening”

  14. 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 (Teratoma) • Solid tumor : 1/3 malignant • Radiosensitive • Teratoma, Malignant teratoma, Seminoma(dysgerminomas)

  15. Teratoma

  16. Teratoma

  17. Teratoma

  18. Teratoma

  19. 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

  20. Rtrosternal Goiter

  21. Neurogenic Tumors • Posterior mediastinal location • 1/5 of mediastinal tumor • Originate in neural crest • Ganglioheuroma : most common in the textbook • Neurilemmoma – most common in Korea : “Dumb bell Tumor”, neural sheath origin

  22. Poosterior Mediastinal Tumor ( Neurillemmoma) ) “Dumb-bell” Tumor

  23. Neurilemmoma(Schwannoma)

  24. Para-ganglioma

  25. Mesenchymal Tumors • Lipoma, Fibroma, Mesothelioma • Superior or Anterior mediastinal location • Diagnosis with CT scan • May cause Hypoglycemia

  26. Mediastinitis • Acute : endoscopy complication, Boerhaave’s SD, operation, esophageal rupture, median sternotomy • Chronic : Tbc, histoplasmosis, silicosis, fibrosing mediastinitis

  27. 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 changes • Partially calcified Mass on CT is diagnostic

  28. Fibrosing Mediastinitis F/29 with SVC Syndrome by Histoplasmosis

  29. Fibrosing Mediastinitis F/29 with SVC Syndrome by Histoplasmosis

  30. Pneumomediastinum • Spontaneous : mainly in young male adults • Hamman sign • Present along the Left sternal border • Substernal pain, cough, Dyspnea, Dysphagia

  31. Pneumomediastinum

  32. 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

  33. Pericardial Cyst • Thin-walled, mesothelial cell lining • most common in Right C-P angle • Simple cysts are almost always asymptomatic • Rare cardiac impingement

  34. Pericardial Cyst (1)

  35. Pericardial Cyst (2)

  36. Bronchogenic Cysts • 30 - 60% of all mediastinal cysts • Lined by ciliated respiratory epithelium • May contain cartilages or mucous • Communicate with tracheobronchial trees • May become infected • Wheezing, dyspnea, recurrent pulmonary infections

  37. Bronchogenic Cyst

  38. Bronchogenic Cyst

  39. Aortic Aneurysm

  40. Thymolipoma

  41. Paratracheal Lymphadenopathy

  42. Paratracheal Lymphadenopathy with Tracheal Compression

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