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SURGICAL APPROACH TO MEDIASTINAL LESIONS

SURGICAL APPROACH TO MEDIASTINAL LESIONS. DR. KAMIL KAYNAK ISTANBUL UNIVERSITY CERRAHPASA MEDICAL FACULTY THORACIC SURGERY DEPARTMENT. Lymphadenomegaly is the most frequent lesion seen in mediastinum. LAM of Mediastinum. An enlarged lymph node can not always be accepted as pathological

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SURGICAL APPROACH TO MEDIASTINAL LESIONS

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  1. SURGICAL APPROACH TO MEDIASTINAL LESIONS DR. KAMIL KAYNAK ISTANBUL UNIVERSITY CERRAHPASA MEDICAL FACULTY THORACIC SURGERY DEPARTMENT

  2. Lymphadenomegaly is the most frequent lesion seen in mediastinum

  3. LAM of Mediastinum • An enlarged lymph node can not always be accepted as pathological • If there is no diagnosis of a disease, it can be accepted as hyperplasia or post-inflammatory enlargement. • Size < 1 cm : 70% benign • Size > 1.5 cm : 70% malignant • Size = 1-1.5 cm : 50% malignant

  4. Diagnosis ? • Mediastinoscopy • Cervical Mediastinoscopy • Video-Assisted Mediastinoscopy • Extended Mediastinoscopy • Anterior Mediastinoscopy and Mediastinostomy • VATS • Scalen lymph node biopsy • Other Surgical Approaches

  5. MEDIASTINOSCOPY • Most used technique in the evaluation of paratracheal and subcarinal lymph nodes • Node sampling helps to determine histological diagnosis, for this reason it is superior to CT and PET Imaging

  6. *Ronald B Poon. İnvasive Diagnostic Procedures Shilds TW Locicero III J, Ronald B,Rusch VW eds General Thoracic Surgery 6th edition.Lippincott Williams & Wilkins 2005; pp 299-313

  7. MEDIASTINOSCOPY Mortalityand morbidity rates of the technique are very low(2% - 0.08%)

  8. Video-Assisted Mediastinoscopy • Provides both direct vision and monitor display • Surgery staff can see the structures at the same time (Educational purpose, other participants can notice an undesired situation) • Provides more space for bimanual surgery

  9. EXTENDED MEDIASTINOSCOPY • For sampling lymph node stations 5 and 6 which can not be evaluated with standard cervical mediastinoscopy • Especially for left upper lobe lung tumors

  10. VATS • Used for the diagnosis and treatment of all ipsilaterallymph node stations and mediastinal masses.

  11. ANTERIOR MEDIASTINOSTOMY(CHAMBERLAIN PROCEDURE) • Appropriate technique to approach masses settled in mediastinum especially the ones settled in aortopulmonary window. • Helps to reach through the lymph nodes and masses that cannot be reached by standard cervical mediastinoscopy

  12. Thoracotomy

  13. Ant mediastinum Mid Mediastinum Post mediastinum Thymoma Pericardial cyst Schwannoma Germ cell tumor Enterogeniccyst Neurofibroma Lymphoma Lymphoid hamartoma Gangiloneuroma Thymiccyst Mediastinal granuloma Fibrosarcoma Thyroid, paratyroid adenoma Neuroentericcyst Paraganglioma Abberrant thyroid Mesothelial cyst Ganglioneuroblastoma Lymphangioma Ductus thoracicus cysts Malignant schwannoma

  14. THYMIC TUMORS • The development of thymus surgery starts with the discovery of the relationship between Myastenia Gravis and thymic tissue and the first thymectomy was performed by Sauerbruch in 1911 • Thymic tumors accounts for 47% of anterior mediastinal masses and 20% of all thymic lesions in adults

  15. THYMOMA • Macroscopic capsulation, fixation, and invasion to adjacent tissue are determinant factors.

  16. THYMOMA • A biopsy must be performed before starting the treatment for the cases in which a differential diagnosis cannot be made between other anterior mediastinal masses (lymphoma, malignant germ cell tumor, metastaticlung cancer),and for non-resectable lesions

  17. THYMOMA • Standard treatment modality is surgery except metastatic disease. • Complete resection contributes long time survive even in invasive tumors. • 40-70% of thymomas are capsulated and complete resection is a curative treatment method.

  18. Stage Definition I Macroscopically completely encapsulated, microscopically no capsular invasion. IIa Macroscopic invasion into surrounding fat or mediastinal pleura. IIb Microscopic invasion into the capsule III Macroscopic invasion into neighboring organs, i.e. pericardium, great vessels, or lung. IVa Pleural or pericardial dissemination. IVb Lymphogenous or hematogenous metastasis. Masoaka staging system

  19. THYMOMA • Principles for a successful surgery: • Complete resection with median sternotomy • Disclosure of both pleural spaces entirely • Total thymectomywith resection of normal tissue

  20. THYMOMA • To resect invasive tumors(stage III), must perform an extended resection, including pericardium, lung, brachiocephalic vein or superior vena cava resection • All pleural implants (Stage IV) and lung metastases must be resected • For a tumor confined to the anterior mediastinum, wide excision should be performed, extending from phrenic nerve to phrenic nerve and brochiocephalic vein to diaphragm

  21. THYMOMA • Thymoma with lung and pericardial invasion, resected by surgery

  22. THYMOMA

  23. THYMOMA

  24. THYMOMA • Group I (Masoaka stage I- Medullary,mixed; Stage II-Medullary) Surgery • Group II (Stage I- Cortical type;Stage II-Mixed, cortical Surgery- ChT+RT • Group III (Stage III-Mixed, Cortical; Stage IV-Cortical) Neoadjuvant T + Surgery- ChT+RT

  25. Rea et al. (2004) 132 patients with thymic epithelial tumor treated surgically: • 108 complete resection (%81.8) • 12 partial resection (%9.1) • 12 biopsy (%9.1) • 5 year s.r. %72 -10 year s.r. %61- 15 year s.r. %52 * Rea et al. / Long-term survival and prognostic factors in thymic epithelial tumours European Journal of Cardio-thoracic Surgery 26 (2004) 412–418

  26. Survival by extent of surgical resection: radical resection (n=108); debulking (n=12)and biopsy (n=12) * Rea et al. /Long-term survival and prognostic factors in thymic epithelial tumours European Journal of Cardio-thoracic Surgery 26 (2004) 412–418

  27. Masaoka staging • 44 (33.3%) stage I • 18 (13.6%) stage II • 52 (39.5%) stage III • 18 (13.6%) stage IV • Stage I, 5 and 10 year survival 93 % and 84 % • Stage II, 5 and 10 year survival 93 % and 82 % • Stage III, 5 and 10 year survival 60 % and 51 % • Stage IV, 5 and 10 year survival 36 % and 0 % * Rea et al. /Long-term survival and prognostic factors in thymic epithelial tumours European Journal of Cardio-thoracic Surgery 26 (2004) 412–418

  28. Survival according to the Masaoka staging system. * Rea et al. / Long-term survival and prognostic factors in thymic epithelial tumours European Journal of Cardio-thoracic Surgery 26 (2004) 412–418

  29. * Wentao Fang et all,Surgical Management of Thymic Epithelial Tumors:A Retrospective Review of 204 CasesAnn Thorac Surg 2005;80:2002–7 • Fang et al.(2005) 204 cases treated with surgery, • 180 (88%)Complete resection • 17 (8.3%) Partial resection • 7 (3.4%) Biopsy • 5 year s.r. 63.2 % -10 year s.r. 50.4 %

  30. Overall survival function after complete and incomplete resection (debulking or biopsy) (log-rank test; p= 0.003). * Wentao Fang et all,Surgical Management of Thymic Epithelial Tumors:A Retrospective Review of 204 CasesAnn Thorac Surg 2005;80:2002–7

  31. Masaoka staging • 87 (42.6 %) stage I • 22 (10.8 %) stage II • 76 (37.3 %) stage III • 19 (9.3 %) stage IV • Stage I and II ;5 and 10 year survival 78.2% and 64.9 % • Stage III and IV ;5 and 10 year survival % 42,5 and 30,1 % * Wentao Fang et all,Surgical Management of Thymic Epithelial Tumors:A Retrospective Review of 204 CasesAnn Thorac Surg 2005;80:2002–7

  32. Overall survival function of Masaoka stages I and II andstages III and IV thymic epithelial tumors p (0.001) * Wentao Fang et all,Surgical Management of Thymic Epithelial Tumors:A Retrospective Review of 204 CasesAnn Thorac Surg 2005;80:2002–7

  33. VATS THYMECTOMY

  34. THYMICCARCINOMA • Thymic carcinomas are invasive tumors and usually are resistant to medical and surgical therapy. • The most popular treatment modality is surgery followed by chemotherapy or radiotherapy or both. • Most of the tumors are unresectable and the effect of surgery on survival is still unclear, even with a complete resection • Prognosis is poor. Mean survival time is 20 months approximately and long term survival is shorter than 40%.

  35. *TONY Y. ENG et all, THYMIC CARCINOMA: STATE OF THE ART REVIEWInt. J. Radiation Oncology Biol. Phys., Vol. 59, No. 3, pp. 654–664, 2004 • 5 year survival rate is between 30-50 %

  36. *TONY Y. ENG et all, THYMIC CARCINOMA: STATE OF THE ART REVIEWInt. J. Radiation Oncology Biol. Phys., Vol. 59, No. 3, pp. 654–664, 2004

  37. Ectopic tumors originated from thymus • Ectopic thymomas can be seen at neck,in pericardium, lungs and pleura. • Ectopiccervical thymomasare the most common type • They arise from thymus that completed migration and from thymic remnants.

  38. Thymiccysts • A rare,benign thymic lesion that accounts for 1-3% of all mediastinal lesions • Standard treatment method is surgery.

  39. Germ cell tumors • Germ cell tumors rarely can be seen in mediastinum(1-3%) • Teratomas can occur at any age and have equal incidence in males and females • Various histological types of gonadal germ cell tumors can be seen in mediastinum

  40. Germ cell tumors • Plasma levels of HCG (human chorionic gonadotropin b) and AFP (a-fetoprotein) must be evaluated for the diagnose and treatment of germ cell tumors • Surgical resection is the satisfactory treatment method for benign germ cell tumors. • Different treatment modalities can be considered for malignant tumors due to histological structure of the tumor

  41. Teratoma

  42. Teratoma

  43. Lymphoma • Accounts for 10-14% of mediastinal masses and they are the second common tumor of anterior mediastinum. • Although they usually settle in anterior mediastinum they can be seen in other mediastinal localizations originated from lymphoid tissue located at this mediastinal sites.

  44. Lymphoma • FNAB can be performed for diagnosis but usually it is ineffective because of insufficient biopsy material. • Definite diagnose can be made by surgical methods such as mediastinostomyor mediastinoscopy • Chemotherapy is the treatment method

  45. Lymphoma

  46. Lymphoma

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