به نام خدا

1. به نام خدا

2. Mediastinal Tumors and Cysts دکتر یونس شفیق متخصص جراحی عمومی استادیار دانشگاه علوم پزشکی قزوین

3. 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

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

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

8. Common Diseases of the Mediastinum

10. 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

11. 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

12. 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

13. Thymoma

14. Thymoma mass Ca++

17. Thymus

18. 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

19. Hodgkin’s Lymphoma “mediastinal widening”

21. 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)

22. Teratoma

23. Teratoma

24. Teratoma

25. Teratoma

26. 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

27. Rtrosternal Goiter

28. 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

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

30. Neurilemmoma(Schwannoma)

31. Para-ganglioma

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

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

34. 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

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

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

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

38. Pneumomediastinum

40. 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

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

42. Pericardial Cyst (1)

43. Pericardial Cyst (2)

44. 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

45. Bronchogenic Cyst

46. Bronchogenic Cyst

47. Aortic Aneurysm

49. Thymolipoma

50. Paratracheal Lymphadenopathy