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Ph RadOnc Residency PBRROE2-3 Review 2021 > Mediastinum and Trachea > Flashcards

Mediastinum and Trachea Flashcards

1
Q

Mediastinum and Trachea

Boders:

anterior?
posterior?
lateral?
floor?

A

sternum
vertebral column
lungs&pleura
diaphragm

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2
Q

Mediastinum and Trachea

What structures form the roof of the mediastinum?

A

thoracic outlet at the level of first vertebra (rib and manubrium)

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3
Q

Mediastinum and Trachea

What are the anatomic structures separating the anterior, middle, and posterior mediastinum?

A

None

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4
Q

Mediastinum and Trachea

Anterior vs. middle vs. posterior

trachea

A

middle

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5
Q

Mediastinum and Trachea

Anterior vs. middle vs. posterior

proximal great vessels

A

middle

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6
Q

Mediastinum and Trachea

Anterior vs. middle vs. posterior

thymus

A

anterior

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7
Q

Mediastinum and Trachea

Anterior vs. middle vs. posterior

lymph nodes

A

anterior and middle

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8
Q

Mediastinum and Trachea

Anterior vs. middle vs. posterior

esophagus

A

posterior

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9
Q

Mediastinum and Trachea

Anterior vs. middle vs. posterior

sympathetic chain ganglia, vagus nerve

A

posterior

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10
Q

Mediastinum and Trachea

Anterior vs. middle vs. posterior

thoracic duct

A

posterior

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11
Q

Mediastinum and Trachea

What is the most common type of mediastinal tumor that can arise in the anterior, middle, and posterior compartments?

What is the most common tumor of the anterior mediastinum?

A

Lymphoma

Thymoma

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12
Q

Mediastinum and Trachea

Embryologically, the thymus is derived from the endoderm of the lower portion of the ____ pharyngeal pouch and involutes during adulthood, gradually being replaced by adipose tissue.

A

third

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13
Q

Mediastinum and Trachea

What is the arterial blood supplier of the thymus?

What is/are the vein/s carrying venous drainage?

A

internal mammary arteries

innominate and internal thoracic veins

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14
Q

Mediastinum and Trachea

Where does the lymph from the thymus drain?

A

lower cervical
hilar
internal mammary

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15
Q

Thymoma

What is the peak decade of onset for patients with intercurrent myasthenia gravis?

Those without?

A

4th decade

7th decade

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16
Q

Thymoma

What are the parathymic syndromes associated with thymoma?

Which is the most common?

A

MG
benign cytopenias
hypogammaglobulinemia
polymyositis

MG

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17
Q

Thymoma

Most common pattern of spread?

A

drop metastases

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18
Q

Thymoma

Magnetic resonance imaging (MRI) can provide more detail when needed, delineating the musculoskeletal anatomy and neurovascular structures of the mediastinum.

MRI may also improve sensitivity for defining the soft tissue extent of the mass in addition to providing information regarding tumor grade and invasiveness beyond that which can be gleaned from CT.

What are the common features indicative of a high-grade tumor?

A

low T2-signal foci within the mass

the presence of mediastinal lymphadenopathy

an incomplete capsule

and inhomogeneous enhancement.

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19
Q

Thymoma

FDG-PET can differentiate thymoma from thymic carcinoma based on uptake.

TRUE or FALSE?

A

True.

thymic carcinoma tends to have significantly higher metabolic
activity.

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20
Q

Thymoma

Bernatz categorization based on cell types.
What are the 4 cell types?

(theoretical purposes since this is poorly correlated clinically with prognosis)

A

lymphocytic
epithelial
mixed
spindle cell

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21
Q

Thymoma

Verley and Hollman categorization based on predominant cell types.
What are the 4 cell types?

(theoretical purposes since this is poorly correlated clinically with prognosis)

A

spindle or oval

lymphocyte-rich

differentiated epithelial cell-rich

undifferentiated epithelial (thymic carcinoma)

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22
Q

Thymoma

Müller-Hermelink categorization based on subsets of epithelial cell of the thymus.
What are the 4 cell subsets?

(theoretical purposes since this is poorly correlated clinically with prognosis)

A

cortical
medullary
mixed
well-differentiated

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23
Q

Thymoma

Identify the WHO (1999) type of thymoma.

Tumors are composed of neoplastic oval or spindle-shaped epithelial cells without atypia or lymphocytes.

A

type A

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24
Q

Thymoma

Identify the WHO (1999) type of thymoma.

Tumors have cytologic atypia and is distinctively unlike normal thymus
tissue.

A

type C

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25
Q

Thymoma

Identify the WHO (1999) type of thymoma.

Tumors are composed of neoplastic oval or spindle-shaped epithelial cells with foci of lymphocytes.

A

Type AB

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26
Q

Thymoma

Identify the WHO (1999) type of thymoma.

Tumors resemble normal thymic cortex with areas
similar to thymic medulla.

A

Type B1

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27
Q

Thymoma

Identify the WHO (1999) type of thymoma.

Which is B2 and which is B3?

Tumors have scattered neoplastic epithelial cells
with vesicular nuclei and distinct nucleoli among a heavy population of
lymphocytes

Cells are predominantly round or polygonal epithelial cells exhibiting mild atypia
admixed with a minor component of lymphocytes

A

first is B2

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28
Q

Thymoma

Identify the WHO (1999) type of thymoma.

Well-differentiated thymic carcinoma

A

Type B3

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29
Q

Thymoma

Identify: Masaoka Stage

Macroscopic invasion into surrounding organs

A

III

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30
Q

Thymoma

Identify: Masaoka Stage

Pleural or pericardial implants/dissemination

A

IVa

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31
Q

Thymoma

Identify: Masaoka Stage

Lymphogenous or hematogenous metastases

A

IVb

32
Q

Thymoma

Identify: Masaoka Stage

Macroscopically completely encapsulated, with no microscopic capsular invasion

A

I

33
Q

Thymoma

Identify: Masaoka Stage

Microscopic invasion into the capsule

A

IIb

34
Q

Thymoma

Identify: Masaoka Stage

Macroscopic invasion into surrounding mediastinal fatty tissue or mediastinal
pleura

A

IIa

35
Q

Thymoma

Identify: GETT staging

Encapsulated tumor, completely resected

A

Ia

36
Q

Thymoma

Identify: GETT staging

Macroscopically encapsulated tumor, completely resected
Surgeon suspects mediastinal adhesions and potential capsular invasion

A

Ib

37
Q

Thymoma

Identify: GETT staging

Invasive tumor, completely resected

A

II

IIIa is STR
(IIIb is biopsy only)

38
Q

Thymoma

Identify: GETT staging

Distant metastasis

A

IVb

IVa is distant pleural implants or supraclavicular implants

39
Q

Thymoma

Identify: ITMIG TNM

pathologically observed microscopic invasion into mediastinal fat.

Can you name the others?

A

T1a

T1b - mediastinal pleura
t2 - pericardium
t3 - more resectable organs
t4 - less or unresectable organs

40
Q

Thymoma

What are the two factors that have consistently demonstrated prognostic value in multivariate analyses in large studies?

A

tumor invasiveness (stage)
and
completenes/extent of resection

41
Q

Thymoma

Patients older than 30 to 40
years may have a better prognosis than younger patients.

TRUE or FALSE?

A

True

42
Q

Thymoma

What is the traditional definition of a bulky disease?

A

> 10 cm

Interestingly, although
bulky tumor size was classically defined in terms of a 10-cm threshold, a more
recent publication of 154 consecutive patients with thymic epithelial tumors
treated in the modern era (2000–2014) demonstrated that a size >4 cm was
associated with worse relapse-free survival, even among patients with stage I
disease

43
Q

Thymoma

What is the most common pattern of failure?

A

locoregional

44
Q

Thymoma

If technically feasible, what is the the traditional recommendation for recurrence?

A

surgery and adjuvant radiation

45
Q

Thymoma

Recurrences arise within 3 to 7 years but may occur as late as 32 years after initial resection.

TRUE or FALSE?

A

True

46
Q

Thymoma

For completely resected stage II thymoma, studies have been mixed with regard to local control benefit of adjuvant radiotherapy, with some studies showing trends toward better local control after adjuvant radiation, others finding no difference in recurrence rates, and one series reporting worse results with adjuvant radiation.

What additional risk factors are considered (by Haniuda et al) to benefit the most from PORT?

A

+ fibrous adhesion to the mediastinal pleura without microscopic invasion

47
Q

Thymoma

Reviews of outcomes, retrospective studies, and single-institution studies are conflicting regarding the benefit of PORT to completely resected stage II or III thymomas, with majority reporting better local control but no survival benefit.

In an analysis of the NCDB by Jackson et al, PORT was associated with improved OS in what subset of patient?

A

IIB to III with positive margins

48
Q

Thymoma

What is the mechanism of action of glucocorticoids that can explain response rates in resectable thymomas (47%)?

A

induce apoptosis in CD4+CD8+ immature thymocytes.

49
Q

Thymoma

A prospective trial have shown that chemotherapy given in the neoadjuvant setting was associated with improved survival for stage IVb thymomas.

TRUE or FALSE?

A

False.

It’s III to IVa only
***

The most promising use of chemotherapy is in the neoadjuvant setting. Like
preoperative radiation, chemotherapy seems to render tumors more suitable for
complete resection. An early investigation suggested that neoadjuvant
chemotherapy was associated with improved survival for patients with stage III
or IVa thymomas. This hypothesis was more rigorously tested in a phase II
prospective trial by Park et al.: 27 patients with radiographic evidence of stage
III or IV thymic malignancies were enrolled (9 had thymoma and 18 had thymic
carcinoma)

50
Q

Thymoma

RT dose, definitive RT

A

60 to 70 Gy/1.8 to 2

51
Q

Thymoma

RT dose, + margins

A

54 Gy/1.8 to 2

52
Q

Thymoma

RT dose, postoperative dose

A

45 to 50/1.8 to 2

53
Q

Thymoma

Draining nodal distributions do not need to be included in the radiation fields.

TRUE or FALSE?

A

True.

Because thymomas do not routinely spread via the lymphatic system.

54
Q

Thymoma

Definitive RT CTV

A

gross disease + 1-2 cm margin

55
Q

Thymic Carcinoma

Thymic carcinoma is more common, more aggressive, and is more lethal than thymoma.

TRUE or FALSE?

A

False.

They are more aggressive but less common.

56
Q

Thymic Carcinoma

Although incomplete resection does not necessarily preclude long-term survival if multimodality platinum-based therapy is used, complete resection is nevertheless the cornerstone of treatment.

TRUE or FALSE?

A

True

57
Q

Thymic Carcinoma

Thymic carcinoma generally is less responsive to chemotherapy than thymoma.

TRUE or FALSE?

A

True.

58
Q

Thymic Carcinoid

Thymic carcinoid (neuroendocrine) tumors of the thymus are very rare,
accounting for <5% of all neoplasms of the anterior mediastinum. They originate
from normal thymic ________ cells, which belong to the amine-precursoruptake-
and-decarboxylation group

A

Kulchitsky

59
Q

Thymic Carcinoid

What syndromes are associated with roughly half of thymic carcinoids?

A

MEN-1
or
secondary Cushing syndrome

60
Q

Mediastinal Germ Cell Tumors

Primary mediastinal germ cell tumors have the same morphologic and histologic appearance as those of the testes. These tumors of the mediastinum are less aggressive and have a better prognosis than their gonadal counterparts.

TRUE or FALSE?

A

False.

They are more aggressive and have poorer prognosis

61
Q

Mediastinal Germ Cell Tumors

Which is less sensitive to chemotherapy and radiation, and overall has a poorer prognosis?

pure seminoma vs. nonseminomatous?

A

nonseminomatous

62
Q

Thymic Tumors

Which one is associated more with MG?

Thymolipoma
Thymoliposarcoma

A

Thymolipoma

63
Q

Mediastinal Mesenchymal Tumors

I. Mesenchymal lesions can arise in any of the three mediastinal compartments.

II. Mesenchymal tumors that present in adults seem to be more malignant than those presenting in children.

III. Mediastinal mesenchymal lesions can reach impressively large sizes before detection, typically presenting with symptoms such as chest pain and dyspnea.

Which is/are TRUE?

A

I and III.

II is other way around.

64
Q

Mediastinal Mesenchymal Tumors

What is the most common mediastinal mesenchymal lesion?

A

lipoma

65
Q

Mediastinal Mesenchymal Tumors

What is the most common curative treatment for lipomase?

A

GTR
***
Mediastinal lipomas are the most common of the mediastinal mesenchymal
lesions; they represent 1% to 5% of all lipomas.

Mediastinal lesions
can occur in isolation or in multiples and may mimic cardiomegaly or pleural
effusion on a chest x-ray.

They are usually well circumscribed and encapsulated but can grow to 20 cm in diameter before detection.

Though these tumors
can be quite large and cause significant compressive symptoms, gross total resection is almost always curative.

Technically, lipomas are
considered “benign” tumors, but those that are growing or causing symptoms
should be referred for surgical resection.

66
Q

Mediastinal Mesenchymal Tumors

Where is the most common location of mediastinal liposarcomas?

A

posterior compartment.
***

In contrast to lipomas, liposarcomas consist of immature fat cells with malignant histology and behavior.
Distinguishing lipomas from liposarcomas can be difficult histologically; liposarcomas are distinguished by size heterogeneity, hyperchromatic nuclei, and eosinophilic cytoplasm.
Primary mediastinal liposarcomas often appear in the posterior portion of the mediastinum.
Anterior mediastinal liposarcomas are possible albeit rare.
Tumors often appear to be encapsulated and well circumscribed, even when invasion is present, giving rise to the term “pseudocapsule.”

In one historical review, survival times for patients with well-circumscribed lesions ranged from 3 to 17 years, whereas patients with grossly invasive tumors died within 2 years.
As is true for all sarcomas, the prognosis depends on the histologic grade. Like other sarcomas, optimal treatment consists of surgical resection and adjuvant radiation therapy.
Because well-differentiated tumors have little propensity for distant metastases, withholding adjuvant radiation for a trial of observation can be considered after an R0 resection, but the significant local recurrence rates of 20% to 30% should be acknowledged during multidisciplinary discussion and with the patient.

67
Q

Mediastinal Mesenchymal Tumors

hemangiomas, hemangioendotheliomas, and hemangiopericytomas

A. Which are notable for high rates of metastasis at presentation?

B. Hemangiomas can be capillary or cavernous; cavernous hemangiomas (i.e., angiomyomas or hamartomas) are distinguished from capillary hemangiomas by the presence of _________.

A

A. Hemangioperictyomas

B. smooth muscles

68
Q

Mediastinal Mesenchymal Tumors

What is the hallmark finding in hemangioendothelioma?

A

cytoplasmic Weibel-Palade bodies.

69
Q

MPNST

What histopathologic factor is most reliably correlated with malignancy?

A

mitotic figures of 5 or more in 50 high-power fields.

70
Q

Tracheal Cancer

What histologic subtype is usually equally distributed in both men and women, not asssociated with smoking, and present at younger ages?

A

adenoid cystic carcinomas

71
Q

Tracheal Cancer

What are the bony landmarks for the superior and inferior borders of the trachea?

A

C6-7 to T4-6.

The upper border lies around the sixth or seventh cervical vertebra and the lower border around the fourth (full expiration) or sixth (full inspiration) thoracic vertebra.

72
Q

Tracheal Cancer

What is the most common symptom?

A

cough (Yang et al.)

followed by dyspnea

73
Q

Tracheal Cancer

Management

A

Resection + PORT

74
Q

Tracheal Cancer

Most common dreaded adverse reaction to dose escalation in RT of tracheal malignancies?

A

treacheoesophageal fistula

75
Q

Tracheal Cancer

Prophylactic/elective nodal irradiation is a mainstay of treatment especially if the histology is squamous cell.

TRUE or FALSE?

A

False.
***
The role of elective nodal irradiation for tracheal carcinoma is uncertain. As
mentioned earlier, nodal status does not seem to have prognostic significance;
even cervical adenopathy was not associated with poorer outcome.

Given the
low proclivity for lymphatic spread of adenoid cystic carcinomas, the choice to
avoid elective nodal irradiation for this variant is certainly reasonable. Because
local recurrence is the major factor influencing survival, nodal and regional
failure patterns are not a main concern. Yet, if mediastinal or cervical nodes are
seen on radiographic or pathologic examination, or if worrisome pathologic risk
features are discovered at surgery, radiation to these regions should be
considered.

Ph RadOnc Residency PBRROE2-3 Review 2021 (57 decks)

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