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MEDIASTINAL TUMORS

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Known to have the LUL mass for the past 40 years without change in size ... Left paravertebral mass abutting posterolateral descending aorta & extrinsic ... – PowerPoint PPT presentation

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Title: MEDIASTINAL TUMORS


1
MEDIASTINAL TUMORS
  • THE BROOKDALE UNIVERSITY HOSPITAL MEDICAL
    CENTER
  • BROOKLYN, NEW YORK, NY, 11212
  • SIVAKUMAR PADMANABHAN, MD
  • FELLOW, PULMONARY MEDICINE

2
CASE PRESENTATION
  • M.T. - 67 Y/O Caucasian female
  • Born USA
  • Asymptomatic
  • ROS - Unremarkable
  • Physical Exam - Unremarkable

3
CASE PRESENTATION
  • Had a routine CXR for evaluation of a thyroid
    nodule
  • Found to have a Left Upper Lobe Mass

4
CASE PRESENTATION
  • Known to have the LUL mass for the past 40 years
    without change in size
  • On comparison, it was found to have grown in size
    during the present evaluation
  • Patient had excision and biopsy of the mass- in
    August 1997

5
IMAGING
  • CXR-- 8/97-gt MASS LEFT UPPER LOBE chronic
    inflammatory process in right upper lobe with
    volume loss

6
IMAGING
  • CT SCAN chest- 8/97-gt Left paravertebral mass
    abutting posterolateral descending aorta
    extrinsic compression on left 6th rib
  • well demarcated, low attenuation 5x4 cm
  • No bony destruction
  • RUL - chronic inflammatory infiltrate
  • calcified lymph node _at_ R hilum c/w old
    granulomatous process

7
IMAGING
  • MRI- 8/97- 5x4 cm dumbbell shaped posterior
    mediastinal mass
  • compression of T4 body
  • No cord compression
  • Neurogenic tumor T4-T5

8
IMAGING
  • 1997 S/P RESECTION
  • MRI - Sep 1998 , NO recurrence of tumor

9
PATHOLOGY
  • 8/97 POSTERIOR mediastinal mass
  • NEURILEMMOMA
  • lung margin - free of tumor

10
MEDIASTINAL TUMORS
  • Mediastinum- Region between the pleural sacs
  • Tumors arise from anterior, middle posterior
    compartments

11
Extent
  • Anterior - sternum anteriorly to pericardium
    brachiocephalic vessels posteriorly
  • Middle - between the anterior posterior
    compartments
  • Posterior - pericardium trachea anteriorly to
    vertebral column posteriorly

12
BOUNDARIES OF MEDIASTINUM
  • Anterior - sternum
  • Posterior - Vertebral Column
  • Superior - Thoracic inlet
  • Inferior - Diaphragm
  • Mediastinum is connected to neck
    retroperitoneum allowing spread of air infection

13
ANTERIOR MEDIASTINUM-CONTENTS
  • Thymus
  • Anterior mediastinal lymph nodes
  • Internal mammary A V
  • Pericardial fat

14
MIDDLE MEDIASTINUM- CONTENTS
  • Heart Pericardium, ascending aorta arch of
    aorta, vena cavae, brachiocephalic A V ,
  • phrenic nerve
  • trachea, main stem bronchi contiguous
    lymph nodes
  • Pulmonary A V

15
POSTEIOR MEDIASTINUM-CONTENTS
  • Descending thoracic aorta
  • Esophagus
  • Thoracic duct
  • Azygos hemiazygos vein
  • Posterior group of mediastinal nodes
  • Sympathetic trunk intercostal nerves

16
CLASSIFICATION
  • Developmental
  • Neoplastic
  • Infectious
  • Traumatic
  • Cardiovascular disorders

17
ANTERIOR MEDIASTINAL MASSES
  • Thymoma
  • Teratoma
  • Thyromegaly
  • Lymphoma
  • Lipoma, Fibroma - rare

18
MIDDLE MEDIASTINAL MASSES
  • Aneurysms - aorta, innominate artery, enlarged
    pulmonary artery
  • Lymphadenopathy secondary to carcinoma /
    metastasis / granulomatosis
  • Cysts - enteric, bronchogenic, pleuropericardial
  • Dilated azygos, hemiazygos veins
  • Hernia of Foramen of Morgagni

19
POSTERIOR MEDIASTINAL MASSES
  • Neurogenic tumors
  • Meningo-myelocele, meningocele
  • Esophageal - tumor, cyst, diverticula
  • Hiatus hernia
  • Hernia of Foramen of Bochdalek
  • Thoracic spine disease,
  • Extramedullary hematopoiesis

20
DIAGNOSTIC APPROACH
  • Imaging - CT, MRI, Radionuclide study,
  • Tissue sampling - Mediastinoscopy, Thoracoscopy,
    Needle aspiration, Open Biopsy
  • Barium study for hernia, achalasia, diverticula
  • I-131 for intrathoracic goiter

21
DIAGNOSTIC APPROACH
  • Mediastinoscopy or anterior mediastinotomy can
    definitively diagnose anterior middle
    mediastinal masses
  • Video assisted thoracoscopy plays an important
    role in diagnosis

22
TREATMENT PROGNOSIS
  • Dictated by the etio-pathology of the mass

23
POSTERIOR MEDIASTINAL NEUROGENIC TUMORS
  • Neurilemmoma
  • Neurofibroma
  • Neurosarcoma
  • Ganglioneuroma
  • Phaeochromocytoma

24
ROLE OF MRI
  • Distinction between vessels and masses
  • no need for contrast
  • better delineation of hilar structures
  • images in multiple planes unlike CT which does
    axial imaging only

25
CT
  • 10 dumbbell tumors present with cord compression
  • CT scan is essential to rule out intraspinal
    extension along nerve roots - dumbbell tumors

26
CLINICAL FEATURES
  • Nospecific-gt mass effect on sorrounding
    structures
  • Insidious onset of retrosternal chest pain,
    dyspnea , dysphagia
  • 50 are asypmtomatic
  • mass detected on CXR
  • Physical findings depend on nature location of
    mass

27
OTHER DIAGNOSTIC STUDIES
  • Doppler Ultrasonography or Venography of
    brachiocephalic veins
  • Arteriography

28
EPIDEMIOLOGY
  • Neurogenic tumors are common in children
  • 50 mediastinal masses are malignant in children
  • 15 mediastinal masses are malignant in adults

29
NEUROGENIC TUMORS
  • Origin - Embryonic neural crest cells around
    spinal ganglia from sympathetic or
    parasympathetic components
  • In paravertebral sulci in association with
    intercostal nerves
  • Can arise from vagus phrenic nerves

30
NEUROGENIC TUMORS
  • Can be ASYPMTOMATIC
  • Cord compression,
  • Chest pain, dyspnea, hoarse voice
  • Horners syndrome - unusual

31
NERVE SHEATH TUMORS
  • Neurilemmoma( Schwannoma)
  • well encapsulated , gray- tan, firm, - common
  • Neurofbroma - 25-40 have VonRecklinghausens
    disease
  • Neurogenic Sarcoma- at extremes of age
  • Malignant Schwannoma
  • Malignancy - 10-20 associated with VR disease

32
TREATMENT
  • Resection by Thoracotomy or Video
    Assisted Thoracoscopic Surgery
  • Post-op radiation for malignant tumors

33
UNIQUE CASE
  • Our patient had the mass for 40 years and
    suddenly found to grow in size
  • So it was resected for suspicion of malignant
    transformation
  • Histopathology proved it to be benign

34
REFERENCES
  • Fishmans - Pulmonary Diseases Disorders, 3rd
    ed, Ch. 96, Acquired lesions of Mediastinum-
    benign malignant, John R Roberts, Larry
    R Kaiser, p 1509-1536
  • Manual of Clinical Problems in Pulmonary
    Medicine, 4th ed, 101, Mediastinal masses,
    Stephen P Bradley, p 482-484
  • Comprehensive Respiratory Medicine, R
    Albert, S Spiro, J Jett, Sec 18,
    ch 74. 1-10, Disorders of Mediastinum
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