MEDIASTINAL TUMORS

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MEDIASTINAL TUMORS

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

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CASE PRESENTATION

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

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CASE PRESENTATION

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

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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

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IMAGING

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

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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

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IMAGING

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

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IMAGING

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

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PATHOLOGY

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

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MEDIASTINAL TUMORS

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

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Extent

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

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BOUNDARIES OF MEDIASTINUM

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

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ANTERIOR MEDIASTINUM-CONTENTS

• Thymus
• Anterior mediastinal lymph nodes
• Internal mammary A V
• Pericardial fat

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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

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POSTEIOR MEDIASTINUM-CONTENTS

• Descending thoracic aorta
• Esophagus
• Thoracic duct
• Azygos hemiazygos vein
• Posterior group of mediastinal nodes
• Sympathetic trunk intercostal nerves

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CLASSIFICATION

• Developmental
• Neoplastic
• Infectious
• Traumatic
• Cardiovascular disorders

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ANTERIOR MEDIASTINAL MASSES

• Thymoma
• Teratoma
• Thyromegaly
• Lymphoma
• Lipoma, Fibroma - rare

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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

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POSTERIOR MEDIASTINAL MASSES

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

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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

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DIAGNOSTIC APPROACH

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

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TREATMENT PROGNOSIS

• Dictated by the etio-pathology of the mass

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POSTERIOR MEDIASTINAL NEUROGENIC TUMORS

• Neurilemmoma
• Neurofibroma
• Neurosarcoma
• Ganglioneuroma
• Phaeochromocytoma

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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

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CT

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

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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

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OTHER DIAGNOSTIC STUDIES

• Doppler Ultrasonography or Venography of
  brachiocephalic veins
• Arteriography

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EPIDEMIOLOGY

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

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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

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NEUROGENIC TUMORS

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

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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

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TREATMENT

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

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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

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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