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General Thoracic Surgery Notecards > Mediastinal Masses > Flashcards

Mediastinal Masses Flashcards

1
Q

Masses of Anterior/Superior Mediastinal Compartment

A
  • Thymic neoplasm (thymoma, thymic carcinoma, carinoid)
  • Lymphoma
  • Germ cell tumors (teratoma, seminoma, non-seminoma tumor)
  • Thyroid adenoma
  • Parathyroid adenoma
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2
Q

Masses of Middle Mediastinal Compartment

A
  • Bronchogenic cyst
  • Pericardial cyst
  • Enteric cyst
  • Lymphoma
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3
Q

Masses of Posterior Mediastinal Compartment

A
  • Neurogenic tumors
  • Esophageal/Enteric cyst
  • Lymphoma
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4
Q

Clinical presentation of mediastinal masses

A
  • Asymptomatic and incidental (MC)
  • Chest pain
  • Cough
  • Dyspnea
  • Pain and Neurologic deficit (neurogenic tumor)
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5
Q

Diagnostic study of choice for mediastinal tumors

A

CT scan

(location, morphology, relationship to other structures)

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6
Q

Diagnostic approach to small (<5cm) tumors with characteristic features (i.e. thymoma, teratoma, benign cyst)

A

Surgical resection

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7
Q

Diagnostic approach to large mediastinal tumors

A
  • CT-guided percutaneous biopsy
  • Open biopsy
    • Cervical mediastinoscopy
    • VATS
    • Chamberlain mediastinoscopy
    • Thoracotomy
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8
Q

Serum tumor markers that much be checked for mediastinal masses (anterior)

A
  • Beta-HCG
  • AFP
  • LDH
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9
Q

Diagnostic algorithm for anterior mediastinal masses

A
  • CXR
  • Chest CT
  • Tissue biopsy (percutaneous vs. open)
  • Serum tumor markers (Beta-HCG, AFP, LDH)
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10
Q

Tumors are most common in what mediastinal compartment

A

Anterior compartment

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11
Q

95% of all anterior mediastinal compartment tumors include:

A
  • Four “Ts”
    • Thymoma (MC)
    • Teratoma (germ cell tumor)
    • “Terrible” lymphoma
    • Thyroid goiter
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12
Q

MC anterior mediastinal tumor

A

Thymoma

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13
Q

Clinical presentation of thymoma

A
  • M:F (1:1)
  • 30-50 years old
  • 50% = asymptomatic/incidental
  • 50% = symptomatic (pain, dyspnea, cough, horseness)
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14
Q

Thymoma associated syndromes

A
  • Myasthenia gravis
  • Red cell hypoplasia
  • Hypogammaglobulinemia
  • SLE
  • Rheumatoid arthritis
  • UC
  • Thyroiditis
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15
Q

CT characteristics of benign thymoma

A
  • < 5 cm
  • round
  • well-circumscribed
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16
Q

CT characteristics of malignant thymoma

A
  • > 5 cm
  • Irregular shape
  • Invade neighboring structures
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17
Q

Treatment of choice for all thymoma

A
  • Complete excision
    • En bloc resection
      • Pleura
      • Pericardium
      • Innominate vein
      • SVC
      • Lung
    • Can excise one phrenic nerve and dissect tumor off other
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18
Q

MC surgical exposure/approachs for thymectomy

A

Median sternotomy

Cervical

VATS

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19
Q

Thymoma Staging (5-Yr Survival)

A

Survival based on Stage

  • Stage I (95%)
    • completely encapsulated
  • Stage II (85%)
    • IIa: mediastinal fat/pleura
    • IIb: through capsule
  • Stage III (70%)
    • direct invasion of adjacent organ
  • Stage IV (50%)
    • IVa: pleura/pericardium mets
    • IVb: distant mets
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20
Q

Indications for neoadjuvant/adjuvant therapy

A

Stage III-IV disease

(Cisplatin-based chemotherapy + XRT)

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21
Q

Neoadjuvant/Adjuvant therapy regimen

A

Cisplatin-based chemotherapy + XRT

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22
Q

Mechanism of action of Myasthenia Gravis

A

Autoantibodies to ACh receptor

(decreased transmission of AP at the NM junction)

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23
Q

Demographics of Myasthenia Gravis

A
  • 2x MC in women
  • 2-3rd decade of life
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24
Q

Myasthenia Gravis Symptoms Grades

A
  • Grade I: focal disease-ocular muscle weakness
  • Grade II: Mild-moderate generalized disease
  • Grade III: Severe generalized disease
  • Grade IV: life-threatening weakness - respiratory failure
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25
Confirmatory tests for MG
Endrophonium (short acting anticholinesterase ) test ACh Receptor assay
26
Medical treatment for MG
Pryidostigmine (long-acting anticholinesterase) Plasmapheresis and IVIg
27
Indications for thymectomy for MG
* Presence of thymic hyperplasia or thymoma * 30-50% of patients with thymoma have MG * 10-15% of patients with MG have a thymoma * Grade II-III MG
28
When should thymemctomy **_NOT_** be performed for MG
Myasthenic crisis Grade IV disease
29
Prevelence of primary mediastinal lymphoma
Rare (5-10% of anterior mediastinal masses)
30
MC lymphoma subtype presenting as mediastinal mass
T-cell Non-Hodgkin's lymphoma (Hodgkins and lymphoblastic lymphoma also present in mediastinum)
31
Diagnostic w/u for suspected mediastinal lymphoma
* H&P * CXR * Chest CT * Tissue biopsy (percutaneous vs. open)
32
Survival for lymphoma based on \_\_
Tumor grade
33
Treatmetn of lymphoma presenting in mediastinum
Chemotherapy and XRT (Role of surgery: histologic diagnosis)
34
Role of surgery for lymphoma presenting in mediastinum
Histologic diagnosis
35
Prevelence of germ cell tumors among mediastinal masses
10-15% of mediastinal masses
36
MC germ cell tumor in mediastinum
Teratoma * Assymptomatic (MC) * M:F (1:1)
37
Characteristics of tertaoma
* Assymptomatic (MC) * May present with infection or rupture into pleura or airway (coughing of hair or sebum) * M:F (1:1) * Serum tumor markers negative * Bx: _well differentiated_ tissue from _more than one cell line_
38
TOC for teratoma
Surgical excision
39
MC **_malignant_** germ cell tumor of mediastinum
Seminoma | (males in 3rd decade)
40
MC patient population with mediastinal Seminoma
Males in 3rd decade of life
41
Diagnostic features of Seminoma
* Slightly elevated Beta-HCG * CT: characteristic large, homogenous mass with smooth boarders * Slow growth
42
TOC of Seminoma
Chemo/XRT XRT sensitive (primary treatment) Cisplatin-based chemotherapy (metastatic disease) (Surgical resection reserved to residual disease, manifested as local growth of residual mass)
43
Role of surgery for Seminoma
Residual disease manifested as local growth of a residual mass (after XRT/chemotherapy)
44
Characteristics of Non-seminomatous germ cell tumors of mediastinum
* Young men (20-30 years old) * Elevated B-HCG, AFP, LDH * Rapid growth * Compress neighboring structures (symptomatic) * Metastatic disease common at presentation * Overall prognosis poor
45
Three main subtypes of non-seminomatous GC tumors
(In order of frequency) * Yolk sac carcinoma * Embryonal carcinoma * Choriocarcinoma
46
1st line treatment of non-seminomatous GC tumors
Cisplatin-based chemotherapy (Surgical resection of residual tumor, regardless of response in tumor markers)
47
Surgical approach for removal of most intrathoracic goiters
Cervical incision (upper sternal split may be required)
48
MC middle mediastinal mass
Cysts | (bronchogenic, pericardial, enteric)
49
MC cyst in middle mediastinum
Bronchogenic cysts (60%)
50
Characteristics of bronchogenic cysts
* Associated with airway * MC location = posterior to carina (subcarinal) * Symptoms of airway/esophageal compression; infection of the cyst
51
Treatment of choice for bronchogenic cysts
Complete transthoracic surgical resection; even if asymptomatic to avoid future complications.
52
Definition of pericardial cysts
Rare, benign cysts occuring at cardiophrenic angle (most often on right)
53
Most common location for pericardial cysts
Right cardiophrenic angle
54
Characteristics of pericardial cysts
* CT imaging of _thin, non-enhancing wall_ * Content has density similar to water
55
TOC: pericardial cysts
Aspirate: Surgical resection (symptomatic) (Some argue for surgical resection of all pericardial cysts to avoid potential for rupture, erosion, or compression of heart or great vessels)
56
Prevalence of neurogenic mediastinal tumors
15-20% of all mediastinal tumors
57
Classic presentaiton and Cell of Origin of neurogenic mediastinal tumors
Presentation: Pain or neurologic dysfunction Cell of origin: Neural Crest Cell
58
3 major subtypes of Neurogenic tumors
* Nerve sheath tumors * Ganglion cell tumors * Paraganglionic tumors
59
MC neurogenic tumors
Nerve sheath tumors (40-70%)
60
Most common location of nerve sheath tumors
Costovertebral/paravertebral sulcus
61
Characteristics of nerve sheath tumors
* Usually benign * neurofibrosarcoma (malignant variant) * increased mitotic activity * lack of encapsulation * 2 MC histologic types (schwannoma and neurofibroma)
62
Neurogenic tumor that arises from _sympathetic chain_ and _adrenal medulla_
Ganglion cell tumor
63
Benign and Malignant subtypes of Ganglion cell tumor
Benign: ganglioneuroma (secrete VIP) Malignant: Ganglioneuroblastoma
64
Neurogenic tumors that secretes VIP
Ganglioneuroma (benign ganglion cell tumor) Ganglioneuroblastoma (malignant ganglion cell tumor)
65
MC extracranial malignancy in children and most aggressive ganglion cell tumor
Neuroblastoma (secrete VIP and catacholamines)
66
TOC for neuroblastoma
Surgical resection (localized disease) + adjuvant chemoradiation for residual diseaes
67
Factors associated with poor prognosis for neuroblastoma
* Metastatic disease * Age \< 18 months * Histolgic differentiation * DNA ploidy * Presence of residual disease * N-myc amplification * High levels of neuron-specific enolase and LDH
68
Tumors that arise from paraganglionic tissues in costovertebral area
Paraganglionic tumors
69
Subtypes of paraganglionic tumors
Pheochromocytomas (catacholamine secretion\_ Chemodectomas (hormonally inactive)
70
TOC for paraganglionic tumor
Surgical resection (tumor capsule should be left intact) (Chemodectomas respond to XRT)
71
Name the Mass
Thymoma
72
Name that mass
Well-differentiated teratoma
73
Name that mass?
mediastinal lymphoma
74
Name that Mass?
Mediastinal seminoma
75
Name that mass?
Mediastinal Non-seminoma
76
Name that Mass?
Bronchogenic cyst
77
Masaoka staging * I * IIa * IIb * III * IVa * IVb
78
## Footnote Thymoma: treatment based on masaoka stage: I IIa IIb III IVa IVb
79
Venous and arterial blood supply of the thymus.
Blood supply to the thymus comes from the internal thoracic artery as well as the superior and inferior thyroid arteries. Drainage is to the left innominate vein as well as the superior, middle and inferior thyroid veins.
80
Thymoma: “Recommended follow-up protocols by ITMIG”

General Thoracic Surgery Notecards (38 decks)

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