Mediastinal Neoplasms pt.1 Flashcards
Where in the mediastinal cavity do we find tumors?
- Around 55% in the anterior cavity
- Around 10% in the middle cavity
- Around 35% in the posterior cavity
Types of tumors found in anterior mediastinum
- Thymoma
- Lymphoma
- Germ cell tumors
- Mesenchymal tumors
- Cysts
- Endocrine tumors
Types of tumors found in middle mediastinum
- Pericardial cysts
- Lymphoma
- Mesenchymal tumors
Types of tumors found in posterior mediastinum
- Sarcoma
- Lymphoma
- Neurogenic tumors
- Dysontogenic tumors
- Mesenchymal tumors
Types of lymphoma tumors found in mediastinum
Hodgkin’s and non Hodgkin’s lymphoma
What are specific symptoms of mediastinal neoplasm?
Symptoms, if present, may be due to the direct mass effect of the mediastinal anomaly or to systemic effects of the illness. In general, malignant lesions are more likely to be symptomatic
- Cough
- Dyspnea
- Dysphagia
- Dysphonia
- Stridor
- Tirage
- Pain
- Bradycardia
- Cardiac arrhythmia
- Cardiac tamponade
- Facial and/or upper extremity swelling due to vascular compression (eg, superior vena cava syndrome)
- Glottic spasm
- Horner’s (due to sympathetic chain involvement)
What are non specific symptoms of mediastinal neoplasm?
- Chest pain
- Anorexia
- Asthenia
- Weight loss
- Fever
What is asthenia?
Generalized weakness; lack of energy and strength
What are some systemic mediators released in neoplasms and their effect?
- Catecholamines –> Hypertension
- Parathyroid hormone –> Hypercalcemia
- Beta HCG —> Gynecomastia
- Insulin –> Hypoglycemia
- VIP –> Diarrhea
What are imaging techniques used to diagnose mediastinal neoplasms?
- Chest X-Ray
- CT (usually performed with intravenous (IV) contrast)
- MRI
- PET-CT
Which imaging technique is the first that should be done when suspecting mediastinal neoplasms?
Chest X-ray
What can a chest X-ray reveal in a patient with a mediastinal tumor and its purpose?
- Widened mediastinum or a mass in the chest
- Help localize the mass is in the anterior, posterior, or medial mediastinum to help with the differentials
What is the purpose of a CT in diagnosis of mediastinal tumors?
- Providing more accurate information about tumor (exact location, whether the mass is well-circumscribed, or if it infiltrates other organs)
- Guiding at biopsy
- Providing information about involvement of other critical structures such as the bronchi and the vocal chords
- Determining whether an obstruction is due to external compression or due to thrombosis
What are biopsy techniques for mediastinal tumors?
Percutaneous (core needle preferred over fine needle aspiration), endobronchial (EBUS-TBNA), endoscopic, and surgical techniques
Advantages of MRI for mediastinal neoplasms
- Providing images in several planes of view
- Useful in distinguishing compression versus invasion, particularly in cases of large anterior mediastinal masses where this distinction can be difficult on CT
Not required iodinated contrast
material
An acceptable alternative for patients with renal failure or contrast allergies
Disadvantages of MRI for mediastinal tumors
Potential disadvantages include increased scanning time with attendant
problems in patient compliance and
increased cost
Stridor meaning
Abnormal, high-pitched respiratory sound
Stridor cause
Narrowed or obstructed airway
Circumscribed definiton
confined to a limited area, Inclosed within certain limit
When should an endobronchial biopsy be considered?
Reasonable to consider when the mediastinal mass is located immediately adjacent to an airway
When should endoscopic biopsy be considered?
Endoscopic ultrasound via the esophagus may allow for FNA of certain peri-esophageal posterior mediastinal masses
Surgery biopsy techniques available
- Minimally invasive approaches (eg, mediastinoscopy, video-assisted thoracoscopy and video-assisted thoracoscopic surgery (VATS)) can be tried prior to resorting to open surgical approaches
- Open surgical approaches include:
●Anterior mediastinotomy (ie, Chamberlain procedure)
●Cervical mediastinoscopy
Type of PET scan for mediastinal tumors
18 FDG PET CT scanning appear to be the most accurate, non invasive and cost effective exam
Which of the biopsy techniques is usually used first?
Percutaneous biopsy when its possible
What type of guidance can be used for percutaneous mediastinal biopsies?
CT or US guided
Advantages of percutaneous mediastinal biopsies
- Safe and feasible for posterior and anterior mediastinal tumors
Diagnostic yield for percutaneous mediastinal biopsies
The diagnostic yield of percutaneous biopsy of mediastinal masses is about 75%, with a rate of up to 100 percent for thymic neoplasms, but a nondiagnostic result occurs in 75 percent of patients ultimately found to have lymphoma
Disadvantages of percutaneous mediastinal biopsies
Often not sufficient in lymphomatous disease
EBUS stands for
Endobronchial ultrasound bronchoscopy
TBNA stands for
Transbronchial needle aspiration
Use of EBUS-TBNA
For peri tracheal or peri
bronchial mass
When is mediastinoscopy and mediastinotomy considered?
- Anterior superior mediastinal exploration for biopsy of pre tracheal, left and right para tracheal, carinal and sub carinal lymphnodes or masses
- Anterior approach considered for substernal/retrosternal lesions. Performed to biopsy para-aortic and subaortic nodes, as well as to biopsy an anterior mediastinal mass
- Superior approach option for lesions in the middle mediastinum. This approach is effective at obtaining tissue from mediastinal masses that are adjacent to the airway. Lesions in the paratracheal and subcarinal spaces can be safely sampled with this approach
How are cervical/superior mediastinoscopy performed?
Under general anesthesia, a mediastinoscope is inserted through a small incision just above the sternal notch (jugular incision), dissection directed into the mediastinum is performed above the pretracheal space unto the carina
What is the carina
A cartilaginous ridge at the base of the trachea that separates the openings of the right and left main bronchi
Complications and mortality of mediastinoscopy and mediastinotomy
- Anterior mediastinotomy is a more invasive procedure than mediastinoscopy and hence carries a higher risk of morbidity and mortality compared with mediastinoscopy
- Complication 1-10% (hemorrhage, Recurrent laryngeal nerve injury, pneumothorax, tracheal or esophageal tear) (about 1% for mediastinoscopy)
- Mortality 0.1%
How is anterior mediastinotomy performed?
Under general or local anesthesia, a transverse incision is made immediately lateral and to the left of the sternum at the angle of Louie, along the second costal cartilage
