CWMP - MDSTNM Flashcards
What are the contents of the anterior compartment of the mediastinum (5)
Thymus
Internal mammary artery, vein, lymphnodes
Fat
What are the contents of the posterior mediastinum? (5)
DEATH D escending aorta E sophagus A zygos T horacic duct H emiazygos
Most common mediastinal tumor in childhood
Neurogenic tumors (posterior)
Second most common mediastinal tumor in childhood
Lymphoma (anterior, middle)
Most common anterior mediastinal tumors in adults
Thymoma
Most common posterior mediastinal tumors in adults
Neurogenic tumor
True about mediastinal tumors in adults
a. 1/3 of mediastinal tumors in adults are discovered as asymptomatic abnormalities on radiologic studies
b. Even when symptomatic, the likelihood of malignancy is low
c. Mediastinal mass near the aortopulmonary window can present as hoarseness
d. AOTA
e. NOTA
C. because of compression of L laryngeal nerve
A. 2/3 of mediastinal tumors in adults are discovered as asymptomatic abnormalities
B. Symptomatic - malignant
Germ cells tumors are found in
a. Anterior compartment
b. Visceral compartment
c. Paravertebral Sulci
d. More than one answer
A
Lymphomas can be found
a. Anterior compartment
b. Visceral compartment
c. Paravertebral Sulci
d. More than one answer
D; all
Phaeochromocytoma can be found
a. Anterior compartment
b. Visceral compartment
c. Paravertebral Sulci
d. More than one answer
D; B and C
Hemangioma can be found
a. Anterior compartment
b. Visceral compartment
c. Paravertebral Sulci
d. More than one answer
A
Most common mediastinal tumors in adults
Neurogenic tumors
2nd most common: cysts
3rd most common: thymomas
Accuracy of FNA and core needle biopsy combined in detecting mediastinal tumors
98%
Between FNA and Core needle biopsy, which is better at diagnosis of benign diseases?
Core needle biopsy
Patient with dyspnea, wheezing, hemoptysis a. Lymphoma b. Thymoma C. Mediastinal Granuloma D. Gem cell tumor
C
Night Sweats, weight loss, fatigue, extrathoracic adenopathy, leukocytosis a. Lymphoma b. Thymoma C. Mediastinal Granuloma D. Gem cell tumor
A
Fluctuating weakness, early fatigue, ptosis, diplopia a. Lymphoma b. Thymoma C. Mediastinal Granuloma D. Gem cell tumor
C
Male gender, young age, elevated hCG, AFP a. Lymphoma b. Thymoma C. Mediastinal Granuloma D. Gem cell tumor
D
Patient with mediastinal tumor not amenable to endoscopic or CT-guided needle biopsy underwent surgical biopsy through sternotomy. At the time of sternotomy, the lesion was found to be easily resectable. What should be the next step?
Lesion should be completely removed.
For anterior mediastinostomy, what procedure is ideal for an anterior tumor or a tumor with significant parasternal extension?
Chamberlain procedure
The usual time course fo thymic hyperplasia is about
a. 8 months
b. 9 months
c. 10 months
d. 12 months
B
30 y.o. male with history of chemotherapy for lymphoma with mediastinal mass on CT: triangular soft tissue density in retrosternal space with characteristic bilobed anatomic appearance with low standardized uptake. What could be the diagnosis?
Benign thymic hyperplasia
What percentage of patients with thymoma have symptoms suggestive of myasthenia gravis?
10-50%
What percentage of patients with myasthenia gravis have thymoma?
10%
Thymectomy leads to resolution of symptoms of myasthenia gravis in what percentage of patients with thymomas?
25%
What percentage of patients with myasthenia gravis and no thymoma will have complete remission after thymectomy?
50%
What percentage of patients with myasthenia gravis and no thymoma will have improvement after thymectomy?
90%
True about the diagnosis of thymoma
a. Imaging alone is diagnostic
b. Biopsy should be avoided in cases where imaging is highly suggestive of thymoma
c. Thymomas usually appear with lymphadenopathy
d. AOTA
e. NOTA
B
a. Imaging alone is not diagnostic
c. thymomas usually appear as solitary encapsulated mass while lymphadenopathy occur in lymphoma
True about thymoma EXCEPT
a. it is cytologically benign and identical to early stage tumors
b. also known as malignant thymoma
c. there is lack of classical cellular features of malignancy
d. different from thymic carcinoma
B
Thymomas appear cytologically benign and identical to early stage tumors. This lack of classic cellular features of malignancy is why most pathologists use the temr thymoma or invasive thymoma rather than malignant thymoma.
Tumors with malignant cytologica features are classified separately and referred to as thymic carcinoma
What is the definitive treatment for thymoma?
Complete surgical removal
What stage of thymoma is rendered non resectable?
Stage>=II
Masoaka staging system for thymoma:
Gross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular invasion
Stage II
I - Encapsulated tumor with no gross or microscopic evidence of capsular invasion
II - Gross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular invasion
III - Gross invasion into the pericardium, great vessels, or lung
Stage IVA - Pleural or pericardial dissemination
Stage IVB - Lymphogenous or hematogenous metastasis
Masoaka staging system for thymoma:
Encapsulated tumor with no gross or microscopic evidence of capsular invasion
Stage I
I - Encapsulated tumor with no gross or microscopic evidence of capsular invasion
II - Gross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular invasion
III - Gross invasion into the pericardium, great vessels, or lung
Stage IVA - Pleural or pericardial dissemination
Stage IVB - Lymphogenous or hematogenous metastasis
Masaoka staging
Pleural or pericardial dissemination
Stage IVA
I - Encapsulated tumor with no gross or microscopic evidence of capsular invasion
II - Gross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular invasion
III - Gross invasion into the pericardium, great vessels, or lung
Stage IVA - Pleural or pericardial dissemination
Stage IVB - Lymphogenous or hematogenous metastasis
Lymphoepithelial, small cell neuroendocrine, sarcomatoid, clear cell, and undifferentiated or anaplastic features
a. Low grade thymic carcinoma
b. HIgh grade thymic carcinoma
B
Low grade - squamous cell, mucoepidermoid, basaloid
Benign tumors that grow to a very large size prior to diagnosis. Characteristic fat density dotted by islands of soft tissue density.
Thymolipoma
True of Neurogenic tumors EXCEPT
a. The incidence, cell types, and risk of malignancy is not related to age.
b. Tumors of nerve sheath origin predominate in children
c. In adults, tumors of the autonomic ganglia predominate
d. 2/3 of tumors in from autonomic ganglia in children and young adults are malignant
D
A. related to age
b. nerve sheath tumor: adults
c. autonomic ganglia tumor: children and young adults
95% of nerve sheath tumors
Neurilemomas or neurofibromas
Nerve sheath tumors account for __% of mediastinal tumors
More than 95%
Arise from Schwann cells in intercostal nerves. 2 histologic types: Antoni Type A and Antoni Type B A. Neurofibroma B. Ganglioneuroma C. Neurilemoma D. Neuroblastoma
C
Both nerve sheath and nerve cells and account for up to 25% of nerve sheath tumors. 40% of these patients have von Recklinghausen's disease. 70% benign. A. Neurofibroma B. Ganglioneuroma C. Neurilemoma D. Neuroblastoma
A
Mainstay treatment of Neurofibrosarcomas
Complete surgical resection
Well-differentated benign tumors characterized histologically by well-differentiated ganglion cells with a background of Schwann cells. Diarrhea related to secretion of a VIP has been described in some patients. A. Schwannoma B. Ganglioneuroma C. Ganglioneuroblastoma D. Neuroblastoma
B
Mixture of benign ganglion cells and malignant neuroblasts. A. Schwannoma B. Ganglioneuroma C. Ganglioneuroblastoma D. Neuroblastoma
C.
Most common extracranial solid malignancy of childhood
Neuroblastoma
What percentage of neuroblastoma is intrathoracic
14%
What percentage of thoracic pheochromocytomas are malignant
10%
What percentage of pheochromocytomas are located in an extra-adrenal site?
10%
Most common thoracic location of phaeochromocytomas
costovertebral sulcus
Confirmation test for phaeochromocytomas
a. CT scan
b. MRI
c. urinary catecholamines and their metabolites
d. serum catecholamines and their metabolites
C
Rare tumors that may be located around the aortic arch, vagus nerves, or aorticosympathetics. Rarely secrete catecholamines and are malignant in up to 30% of patients.
Chemodectomas
Most common malginancy of the mediastinum
Lymphoma
Most commonly involved mediastinal compartment in lymphoma
anterior compartment
Cure rate of early stage Hodgkin’s disease with chemotherapy and/or radiation?
90%
Cure rate of advanced stage Hodgkin’s disease with chemotherapy and/or radiation?
60%
Most common malignancy in young men 15-35 y.o.
Germ cell tumors
If a malignant mediastinal germ cell tumor is found, it is important to exclude primary tumor at this site
gonads
True about teratomas EXCEPT
a. a.k.a. nonseminomatous germ cell tumor
b. 2/3 of mediastinal germ cell tumors
c. mature teratomas are benign
d. high hCG and AFP levels
e. NOTA
A
Note: 10% of seminomatous germ cell tumor could have elevated hCG
What is the most frequent diagnostic surgical approach? for mediastinal germ cell tumors
Thoracoscopy
Mediastinal Germ cell tumor wherein most patients present with advanced disease and present with symptoms of local compression including SVC syndrome, dyspnea, or chest discomfort.
Seminomatous germ cell tumor
Embryonal cell carcinomas, chorocarcinomas, endodermal sinus tumors, mixed types. Often bulky, irregular tumors of anterior mediastinum with areas of low attenuation on CT scan because of necrosis, hemorrhage or cyst formation.
Non-seminomatous germ cell tumors
Most common type of mediastinal germ cell tumors
Teratoma
Asymptomatic, detected incidentally in the R costophrenic angle. Cyst that contain clear fluid lined with single layer of mesothelial cells.
Pericardial cyst
Management of simple, asymptomatic pericardial cyst
observation
Management of complex or large symptomatic cyst
surgical resection or aspiration
Result of abnormal budding of the foregut or tracheobronchial tree. Arise most often in the mediastinum just posterior to the carina or main stem bronchus. Contain protein rich mucoid material and varying amounts of seromucous glands, smooth muscle, and cartilage.
Bronchogenic cyst
What percentage of bronchogenic cysts are found in CXRs?
78%
Symptoms of bronchogenic cysts (4)
Chest pain
Cough
Dyspnea
Fever
When is resection indicated for bronchogenic cyst?
large (>6cm) or symptomatic
This type of cyst should be removed regardless of the presence or absence of symptoms. Have propensity for serious complications secondary to enlargement leading to hemorrhage, infection, or perforation.
Enteric cyst
Fulminant infectious process of the mediastinum that spreads rapidly along the continuous fascial plains connecting the cervical and mediastinal compartments. U
Acute mediastinitis
Most common source of infection in acute mediastinitis (4)
esophageal perforation
sternal infections
oropharyngeal or neck infections
Patient with fever, chest pain, dysphagia, respiratory distress, and cervical and upper thoracic subcutaneous crepitus.
Acute mediastinitis
