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General Thoracic Surgery > 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 syndroms

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

TOC 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

MOA 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
Q

Confirmatory tests for MG

A

Endrophonium (short acting anticholinesterase ) test

ACh Receptor assay

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26
Q

Medical treatment for MG

A

Pryidostigmine (long-acting anticholinesterase)

Plasmapheresis and IVIg

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27
Q

Indications for thymectomy for MG

A
  • 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
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28
Q

When should thymemctomy NOT be performed for MG

A

Myasthenic crisis

Grade IV disease

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29
Q

Prevelence of primary mediastinal lymphoma

A

Rare (5-10% of anterior mediastinal masses)

30
Q

MC lymphoma subtype presenting as mediastinal mass

A

T-cell Non-Hodgkin’s lymphoma

(Hodgkins and lymphoblastic lymphoma also present in mediastinum)

31
Q

Diagnostic w/u for suspected mediastinal lymphoma

A
  • H&P
  • CXR
  • Chest CT
  • Tissue biopsy (percutaneous vs. open)
32
Q

Survival for lymphoma based on __

A

Tumor grade

33
Q

Treatmetn of lymphoma presenting in mediastinum

A

Chemotherapy and XRT

(Role of surgery: histologic diagnosis)

34
Q

Role of surgery for lymphoma presenting in mediastinum

A

Histologic diagnosis

35
Q

Prevelence of germ cell tumors among mediastinal masses

A

10-15% of mediastinal masses

36
Q

MC germ cell tumor in mediastinum

A

Teratoma

  • Assymptomatic (MC)
  • M:F (1:1)
37
Q

Characteristics of tertaoma

A
  • 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
Q

TOC for teratoma

A

Surgical excision

39
Q

MC malignant germ cell tumor of mediastinum

A

Seminoma

(males in 3rd decade)

40
Q

MC patient population with mediastinal Seminoma

A

Males in 3rd decade of life

41
Q

Diagnostic features of Seminoam

A
  • Slightly elevated Beta-HCG
  • CT: characteristic large, homogenous mass with smooth boarders
  • Slow growth
42
Q

TOC of Seminoma

A

XRT sensitive (primary treatment)

Cisplatin-based chemotherapy (metastatic disease)

(Surgical resecton reserved ro residual disease, manifested as local growth of residual mass)

43
Q

Role of surgery for Seminoma

A

Residual disease manifested as local growth of a residual mass

(after XRT/chemotherapy)

44
Q

Characteristics of Non-seminomatous germ cell tumors of mediastinum

A
  • 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
Q

Three main subtypes of non-seminomatous GC tumors

A

(In order of frequency)

  • Yolk sac carcinoma
  • Embryonal carcinoma
  • Choriocarcinoma
46
Q

1st line treatment of non-seminomatous GC tumors

A

Cisplatin-based chemotherapy

(Surgical resection of residual tumor, regardless of response in tumor markers)

47
Q

Surgical approach for removal of most intrathoracic goiters

A

Cervical incision (upper sternal split may be required)

48
Q

MC middle mediastinal mass

A

Cysts

(bronchogenic, pericardial, enteric)

49
Q

MC cyst in middle mediastinum

A

Bronchogenic cysts (60%)

50
Q

Characteristics of bronchogenic cysts

A
  • Associated with airway
  • MC location = posterior to carina
  • Symptoms of airway/esophageal compression
51
Q

TOC for bronchogenic cysts

A

Complete transthoracic surgical resection

52
Q

Definition of pericardial cysts

A

Rare, benign cysts occuring at cardiophrenic angle (most often on right)

53
Q

MC location for pericardial cysts

A

Right cardiophrenic angle

54
Q

Characteristics of pericardial cysts

A
  • CT imaging of thin, non-enhancing wall
    • Content has density similar to water
55
Q

TOC: pericardial cysts

A

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
Q

Prevelence of neurogenic mediastinal tumors

A

15-20% of all mediastinal tumors

57
Q

Classic presentaiton and Cell of Origin of neurogenic mediastinal tumors

A

Presentation: Pain or neurologic dysfunction

Cell of origin: Neural Crest Cell

58
Q

3 major subtypes of Neurogenic tumors

A
  • Nerve sheath tumors
  • Ganglion cell tumors
  • Paraganglionic tumors
59
Q

MC neurogenic tumors

A

Nerve sheath tumors (40-70%)

60
Q

MC location of nerve sheath tumors

A

Costovertebral sulcus

61
Q

Characteristics of nerve sheath tumors

A
  • Usually benign
    • neurofibrosarcoma (malignant variant)
      • increased mitotic activity
      • lack of encapsulation
  • 2 MC histologic types (schwannoma and neurofibroma)
62
Q

Neurogenic tumor that arises from sympathetic chain and adrenal medulla

A

Ganglion cell tumor

63
Q

Benign and Malignant subtypes of Ganglion cell tumor

A

Benign: ganglioneuroma (secrete VIP)

Malignant: Ganglioneuroblastoma

64
Q

Neurogenic tumors that secretes VIP

A

Ganglioneuroma (benign ganglion cell tumor)

Ganglioneuroblastoma (malignant ganglion cell tumor)

65
Q

MC extracranial malignancy in children and most aggressive ganglion cell tumor

A

Neuroblastoma

(secrete VIP and catacholamines)

66
Q

TOC for neuroblastoma

A

Surgical resection (localized disease) + adjuvant chemoradiation for residual diseaes

67
Q

Factors associated with poor prognosis for neuroblastoma

A
  • 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
Q

Tumors that arise from paraganglionic tissues in costovertebral area

A

Paraganglionic tumors

69
Q

Subtypes of paraganglionic tumors

A

Pheochromocytomas (catacholamine secretion_

Chemodectomas (hormonally inactive)

70
Q

TOC for paraganglionic tumor

A

Surgical resection (tumor capsule should be left intact)

(Chemodectomas respond to XRT)

General Thoracic Surgery (36 decks)

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