Mediastinal Tumors and Cysts Sung Chul Hwang, M.D. Dept. of Pulmonary and Critical Care Medicine Ajou University School of Medicine

Introduction Silent in early phase Mainly cause pressure symptoms Incidentally discovered by routine x- rays Specific disease entities according to anatomical, and embryologic origin 50% malignant in children where as 25% in adults Metastatic tumor is the most common tumor

Pain Cough Hemoptysis SVC syndrome Hoarseness Dyspnea Horner ’ s syndrome Dysphagia Pleural effusion Stridor Myathenia Gravis Phrenic nerve palsy Chylothorax Symptoms and Signs

Diagnosis Chest PA & Lateral Bucky film Chest CT Fluoroscopy Bronchoscopy Esophagogram NAB Isotope Scanning Angiography Thoracotomy VATS Medistinoscopy

Common Diseases of the Mediastinum

Thymoma Anterior and Superior mediastinum Most common (20%)of mediastinal tumor in adults but rarely seen in children 2/3 is malignant Equal frequency in males and females 30 – 50 yrs Various Classification : Lymphocytic, Epithelial, Spindle Cell 50% are asymptomatic Associated diseases : MG (35%), PRCA, DiGeroge SD, Carcinoid, Eaton-Lambert, agammaglobulinemia, myocarditis, thyrotoxicosis, etc

Thymoma (Staging) Stage I : contained within an intact capsule Stage II: extension through the capsule to surrounding fat, pleura, pericardium Stage III : Intrathoracic metastasis Stage IV: Extrathoracic Metastasis

Thymoma(Treatment) Stage I : Surgical resection  Recurrence 2-12% Stage II & III : Surgery + Radiotherapy Stage IV : Multimodality  Induction chemotherapy, surgery + post op Radiotherapy 5-year Survival 12 – 54 %, not affected by the presence of Myasthenia Gravis

Thymoma

mass Ca++

Thymus

Lymphoma Metastatic is most common 5-10% is mediastinal primary Second moost common Anterior Mediastinal Mass in Adults Malignant > Hodgkin’s Dx: Mediastinoscopy, thoracotomy NAB : Usually not confirmatory

Hodgkin’s Lymphoma “mediastinal widening”

Germ Cell Tumors Anterior Mediastinal location Mainly in late teens 15 %of Ant. Med. Tumors in Adults, 24 % in children 1/5 is Malignant Cystic Teratoma(Dermoid Cyst) vs. Solid tumor (Teratoma) Solid tumor : 1/3 malignant Radiosensitive Teratoma, Malignant teratoma, Seminoma(dysgerminomas)

Teratoma

Substernal Thyroid Tissues Develops from cervical goiter or intrathoracic remnants Can be diagnosed without biopsy by Radioactive iodine scan No treatment unless symptomatic, usually pressure symptoms

Rtrosternal Goiter

Neurogenic Tumors Posterior mediastinal location 1/5 of mediastinal tumor Originate in neural crest Ganglioheuroma : most common in the textbook Neurilemmoma – most common in Korea : “ Dumb bell Tumor ”, neural sheath origin

Poosterior Mediastinal Tumor ( Neurillemmoma) ) “Dumb-bell” Tumor

Neurilemmoma(Schwannoma)

Para-ganglioma

Mesenchymal Tumors Lipoma, Fibroma, Mesothelioma Superior or Anterior mediastinal location Diagnosis with CT scan May cause Hypoglycemia

Mediastinitis Acute : endoscopy complication, Boerhaave ’ s SD, operation, esophageal rupture, median sternotomy Chronic : Tbc, histoplasmosis, silicosis, fibrosing mediastinitis

Fibrosing Mediastinitis years Cough, Dyspnea, or Hemoptysis Most common cause of Benign SVC syndrome Almost always remote Histoplasmosis Plain X-rays may be normal or only minimal changes Partially calcified Mass on CT is diagnostic

Fibrosing Mediastinitis F/29 with SVC Syndrome by Histoplasmosis

Fibrosing Mediastinitis F/29 with SVC Syndrome by Histoplasmosis

Pneumomediastinum Spontaneous : mainly in young male adults Hamman sign Present along the Left sternal border Substernal pain, cough, Dyspnea, Dysphagia

Pneumomediastinum

Benign Cysts Most Common in Middle mediastinum 20% of mediastinal masses Less common in Korea Usually asymptomatic Bronchogenic cyst(32%), pericardial cyst(35%), enteric cyst(12%), thymic cyst, and thoracic duct cyst

Pericardial Cyst Thin-walled, mesothelial cell lining most common in Right C-P angle Simple cysts are almost always asymptomatic Rare cardiac impingement

Pericardial Cyst (1)

Pericardial Cyst (2)

Bronchogenic Cysts % of all mediastinal cysts Lined by ciliated respiratory epithelium May contain cartilages or mucous Communicate with tracheobronchial trees May become infected Wheezing, dyspnea, recurrent pulmonary infections

Bronchogenic Cyst

Aortic Aneurysm

Thymolipoma

Paratracheal Lymphadenopathy

Paratracheal Lymphadenopathy with Tracheal Compression

Paratracheal Lymphadenopathy

Paratracheal Malignant Lymphadenopathy