Mediastinal Syndromes

1. 7 Mediastinal Syndromes

2. Mediastinum • Division - Superior, - Inferior - Anterior, - Middle, - Posterior compartments. • The mediastinum contains all of the vital structures of the chest except the pulmonary parenchyma.

3. Mediastinal Regions

4. Mediastinum • The superior mediastinumlies between the manubrium and thoracic vertebrae one to four. • The anterior mediastinumis bounded by the sternum anteriorly and pericardium posteriorly. • The middle mediastinumconsists of the heart and vascular structures; anything in the middle of the chest that is radio dense on lateral radiograph is within the middle mediastinum. • The posterior mediastinumlies between the heart and the vertebral bodies.

5. Subdivision of mediastinum • anterior mediastinum • middle mediastinum • posterior mediastinum

6. Mediastinal Lesions • Any lesion that occurs in the mediastinum – can be focal or diffuse. • CT scan or MRI with contrast is usually indicated for further evaluation.

7. Mediastinal LesionsFocal vs Diffuse Anthrax Thymoma

8. 1. Superior Mediastinum • Aortic Arch & its branches • Brachiocephalic and subclavian vessels • Superior vena cava upper half & tributaries • Trachea • Thyroid • Oesophagus • Thoracic duct • Phrenic ,Vagus ,Cardiac, Lt.Recurrent L nerves

10. 2. Anterior Mediastinum

11. Anterior mediastinal mass

12. T-cell Lymphoma Anterior Mediastinal Mass

13. Mediastinal Lesions • Anterior lesions – thymoma, thyroid lesions, teratoma, t-cell lymphomas, and lymphadenopathy. • Usually seen in retrosternal space. anterior lesion. Lymphoma

14. Mediastinal Lesions • Lateral view shows a solid tissue density in the region anterior and superior to the heart. • Lymphoma is the most common anterior mediastinal mass. Lymphoma

15. 3. Middle Mediastinum

17. Mediastinal Lesions • Middle lesions – thoracic aortic aneurysms, hematomas, neoplasms, lymphadenopathy, esophageal lesions, and diaphragmatic hernias. • Enlarged lymph nodes are the most frequent cause of a middle mediastinal mass. lymphadenopathy

18. Mediastinal Lymphadenopathy • Infection- Pneumonia, TB, Anthrax • Inflammation -Sarcoidosis • Malignancy- Lymphoma, Metastatic

19. 4. Posterior Mediastinum

20. Mediastinal Lesions • Posterior lesions – Neurogenic lesions, hiatal hernias, descending aortic aneurysm, neoplasms, and hematomas. • 90% of posterior lesions are neurogenic lesions. Aneurysm of Descending Aorta

21. Posterior mediastinal masses will give double density over left side of heart.

22. Origins of Mediastinal Mass • Developmental • Neoplastic • Infectious • Traumatic • Cardiovascular disorders

23. Mediastinologists • Thoracic Surgeon • Pulmonologist • ENT • Cardiologist • Endoscopist • Radiologist

24. Differentials • Diaphragmatic lesions; eventration ,hernia • Esophageal tumours ,achalasia • Mediastinal metastasis • Mediastinal lymph nodes: lymphomas, granulomas • Thyroid retrosternal extension • Aneurysm of aorta • Ventricular aneurysm • Tracheal , heart tumours

25. Incidence • 1 in 100000 • Thrice more common than bronchial adenoma • 1/3000 admission at large medical centre • Neural commonest 20-27% • Thymic second 19-26% • Cyst third 18-21% • Teratomas \ lymphoma fourth 12% • Neural , Thymic, developmental ,Lymphoma :88% of all mediastinal tumours

27. Malignant Tumors Invasion Structure • Tracheobronchial tree and lungs • Esophagus • Superior Vena Cava • Pleura and Chest Wall • Intrathoracic nerves

28. Neural Nerve sheath Autonomic nervous system Malignant peripheral nerve sheath Granular cell tumour Thymic Thyroid Germ cell tumours Benign Malignant Seminomatous Non seminomatous Lymphomas Developmental cysts Pleuropericardial cysts Primary Mediastinal Tumors

29. Cough often recurrent Shortness of Breath may be with wheeze Chest pain Fever Chills Weight loss Night Sweats Hemoptysis Airway compression with Stridor Hoarseness Esophageal compression dysphagia SVC compression …. Neck vein engorgement, facial swelling Rt.ventricular outflow obstn Pericarditis Cardiac temponade Heart failure Symptoms

30. Nerve sheath t0 Benign (neurolemmoma) Schwannoma Neurofibroma Malignant peripheral nerve sheath t0 Neurosarcoma Neurofibrosarcoma Neurogenic sarcoma Malignant schwannoma Malignant neurinoma Granular cell tumour Granular cell myoblastoma Autonomic nervous system (neurocyte) Ganglioneuroma Ganglioneuroblastoma Neuroblastoma Paraganglioma Aorticopulmonary Aorticosympathetic Mediastinal Neural tumours

31. Large Neuroma

33. Intrathoracic Meningocele

34. Thymus of a Neonate

35. Thymus • Thymic hyperplasia • Thymoma • Thymic cyst • Thymic carcinoma • Thymic carcinoid tumours • Thymolipoma • Germ cell tumours • Ectopic parathyroid adenomas • Lymphoma • Secondary neoplastic

36. Thymic hyperplasia • Nearly always infantile or childhood • Usually asymptomatic • Pronounced in HIV, SLE,Thyrotoxicosis • Indistinct from other thymic t0 on Radio or CT • Steroids may reduce • Subtotal surgery

37. Thymoma • Epithelial neoplasms • most common primary neoplasms of the anterior superior mediastinum • Any age , rare <20, nearly all middle-aged adults. • Male predominance • ½ of the patients are asymptomatic • 25-30% of patients have symptoms related to compression of adjacent mediastinal structures including cough, chest pain, and shortness of breath

38. Thymoma • may have myasthenia gravis (30-40%), • pure red cell aplasia, • hypogammoglobulinemia, • endocrine disorders • can be completely encapsulated (benign) or locally invasive without a fibrous capsule • classified by predominant cell types: • epithelial, • lymphoid, or • Biphasic , mixed or lymphoepithelial type • one- third of thymomas are invasive and may grow into the surrounding mediastinal structures,

39. Thymoma • This is determined at surgery and is not a histologic diagnosis, • local invasion of the pleura occurs frequently, • distant metastases are infrequent • Surgical removal enmass with capsule intact • Median sterotomy • Thoracotomy • Transcervical approach • Radiotherapy usually reserved for incomplete excission • Chemo-sensitive (May be) : cis, doxo, vin, c-phos

40. Encapsulated thymoma

41. Invasive Thymoma

42. Germ cell tumours • As a result of the proliferation of the primary extragonadal germ cell • Mostly found near the midline • Adults :anterior mediastinum • Child : sacrococcygeal area

43. Germ cell tumours • Benign • Mature cystic teratoma • Malignant • Seminomatous* : • Non Seminomatous*

44. Anterior mediastinal mass Teratoma

45. Malignant Germ cell tumours • Seminomatous* : Seminoma • Exclusively young male 20-40 yrs • 1/3 asymptomatic , • Chest pain, dysponea, SVC obstruction • Radio ; lobulated , non cacified ,anterior mediastinal • Normal serum AFP • USG testicle discrete hypoecoic masses,with microcalcifictions • Treatment ; chemotherapy* , Radio or combi • Et +cis *4 cycle or Et +cis +bleo * 3 cycles • Highly radiosensitive radio reserved for bulky

47. Mediastinal Lymphoma • Mediastinum is involved in 50% Hodgkin’s diseases • Most cases are of nodular sclerosing type • Treatable and many are curable too • Intensive chemotherapy or radiotherapy or both • Radio alone relapse 50-74% • Chemo alone relapse 33-50% • “MOPP” or “DBVD” followed by radio preferred

48. Anterior mediastinal nodes Lymphoma

49. Anterior mediastinal nodes Lymphoma

50. Mediastinal Mesenchymal tumours