Mediastinal Mass: 1 NonSeminomatous Germ Cell Carcinoma

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Mediastinal Mass 1 Non-Seminomatous Germ Cell
Carcinoma

• Preoperative ChT reliably shrinks tumor
• Complete resection often possible post-ChT
• Long term cure in approx 40

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Kleinfelter Syndrome Neoplasia

• KS Most common abnormality of sex chromosomes
  1/576 male births.
• KS 1 mediastinal GCT are 30-50 times more common
  than in normal males
• KS 8-18 of all 1 mediastinal GCT.
• 2-5 of GCT are extragonadal in normal males
  almost never testicular in location in KS.
• Extragonadal GCT present at an earlier age in KS
  
• .

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Mediastinal Mass Sarcoma

• Rare mediastinal neoplasms
• 2nd neoplasm following Rx
• of mediastinal HD

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Mediastinal Mass Metastatic Carcinoma

• NSCLC
• SCLC
• Breast CA
• Misc.

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Mediastinal Mass Metastatic Carcinoma

• Locally recurrent NSCLC
• following R lung resection without mediastinal
  node dissection.

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Neurogenic Tumors

• Neuroblastoma
• Ganglioneuroblastoma
• Ganglioneuroma
• Schwannoma
• Malignant Schwannoma
• Neurofibroma
• Plexiform Neurofibroma
• Paraganglioma

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Neuroblastoma

• Rare after 5 years
• Better prognosis lt 1 yr.
• Typically large post. MT with calcification
• VMA, HVA, NSE MIBG scan
• Complete resection neurosurgical assist
• Adjuvant ChT RT
• Ganglioneuroma rare lt2yrs predominate gt 5yrs.
• Lemoine

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Neurogenic Tumor

• Usually benign in adults
• Watch out for dumbbell tumor (10)
• Excellent results with local resection

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Neurogenic Tumor Neurofibromatosis

• Familial
• Café au lait and other skin findings
• Multiple neurofibromata
• Higher incidence of malignant tumors
• Plexiform Neurofibroma

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Differential diagnosis of thoracic mass in NF1

• Common
• Schwannoma
• neurofibroma
• neurofibrosarcoma
• lateral meningocoel
• plexiform neurofibroma sympathetic
  chain intercostal nerve dumbbell tumor
  Aughenbaugh GL. Thoracic manifestations of
  neurocutaneous diseases. Radiol Clin NA 1984
  Sept22741-56.eurogenic Tumor Neurofibromatosis

• Uncommon rhabdomyosarcoma
• triton tumor
• fibrosarcoma
• pheochromocytoma
• neuroblastoma vagus nerve phrenic nerve

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Neurogenic Tumor Vagus nerve

• Middle MT
• LgtR
• Voice change /-
• Very rare

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Neurogenic Tumor Paraganglioma

• Rare (149 cases)
• Middle and Post MT
• Hypertension (70)
• Prior resection of pheochromocytoma (40)
• Carney syndrome (17)
• norepinephrineMIBG octreotide scans

• Very vascular
• Typically invade aorta and PA
• CPB available
• Local recurrence 50
• Metastasis 25
• Complete resection important

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Carneys Triad

• Gastric Stromal Sarcoma
• Pulmonary Chondroma
• Extra-adrenal paraganglioma

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Mediastinal Tumor Cysts

• Bronchogenic
• Enteric
• Esophageal duplication
• Mesothelial
• Pericardial

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Bronchogenic Cysts

• Embryological error at about 4-8 weeks
• Birth to old age
• Life threatening airway obstruction in neonates.
• Symptoms 60 compression 40
• 8 communicate with airway
• Occasional infection, CA

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Enteric Esophageal Duplication Cysts

• Associated spinal abnormalities
• Mucoid cyst contents
• Posterior MT
• Compression of esophagus
• Rarely communicate

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Pericardial Cysts

• Abut pericardium
• Spring water contents
• Seldom cause complications
• Aspiration vs. TSCOP resection

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Mediastinal Mass Vascular

• Aneurysm dissection
• R aortic arch
• R subclavian artery from Desc. Aorta
• L SVC
• Azygos continuation of IVC
• Sarcoma of Aorta or Pulmonary artery very rare

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Superior Vena Caval Obstruction Syndrome

• A very dangerous complication of mediastinal
  tumors is SVCO syndrome.
• Increased CVP
• Facial swelling
• Headache
• Collateral veins in upper torso.
• Often a SCLC and lymphoma respond rapidly to ChT

This is an emergency condition
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Minimally Invasive Surgery for Pericardial
Effusion and Tamponade

• Sherfield Dawson MD and Frederic W. Grannis Jr.
  MD.
• Section of Thoracic Surgery, City of Hope
  National Medical Center

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Pericardial Tamponade
May be on the exam
Becks Triad

• Often missed high index of suspicion
• Dyspnea with hypotension
• Distended neck veins
• Muffled heart tones
• Pulsus alternans
• Paradox
• Electrical Alternans
• Definitive Dx by Echo or CT
• Very high mortality mandates urgent Rx

Drop in BP with respiration
w/ QRS
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Pre-operative Considerations

• Life expectancy?
• Quality of Life?
• General Medical Condition?
• Tamponade?
• Pulmonary function status?

• Prior cardiac or pericardial surgery?
• Malignant pleural effusion?
• Previous chest tube or pleurodesis?
• Lung neoplasm or metastasis?

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Rx of Malignant Pericardial Effusion Alternatives
1st Tx in ED

• Pericardiocentesis
• sclerosing agent
• balloon dilation
• Medical Rx
• chemotherapy
• Radiation Rx

• Sub-total pericardiectomy
• Open pericardial window
• Sub-ziphoid
• pericardial-peritoneal window
• Thoracoscopic partial pericardiectomy

Need to do with image guidance
preferred
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Minimally Invasive Surgery for Pericardial
Effusion and Tamponade

• Partial pericardiectomy via thoracoscopic
  approach attempted in 23 patients.
• Success in 22 patients
• Sex 8 males, 14 females
• Age 27-73 (Avg.53.2 years)
• 30 Day mortality 4/22 18.2 at days 4, 14, 22
  and 25. (three deaths due to progression of
  primary malignancy).
• Recurrent effusion1 4.5

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Minimally Invasive Surgery for Pericardial
Effusion and Tamponade
Steps

• Single Lung Anesthesia
• Thoracoscopic access (R or L) 3 incisions
• Exploration
• Identify phrenic nerve
• Pericardiocentesis (direct vision)

• Grasp pericardium
• Cut
• Partial pericardiectomy
• Hemostasis
• Chest tube drainage

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Minimally Invasive Surgery for Pericardial
Effusion and Tamponade

• Single Lung Anesthesia
• Thoracoscopic access and exploration (R or L)
• Pericardiocentesis (direct vision)

W/ balloon blocker
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Minimally Invasive Surgery for Pericardial
Effusion and Tamponade

• Single Lung Anesthesia
• Thoracoscopic access and exploration (R or L)
• Pericardiocentesis (direct vision)

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Minimally Invasive Surgery for Pericardial
Effusion and Tamponade

• Single Lung Anesthesia
• Thoracoscopic access and exploration (R or L)
• Pericardiocentesis (direct vision)
• Grasp pericardium