ABTS - Thoracic Surgery Notecards IA > Mediastinal Masses > Flashcards

Mediastinal Masses Flashcards

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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 syndromes

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

Treatment of choice 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

Thymoma

Definition of surgically resectable

A

Surgery is indicated as the initial treatment for patients in whom a complete, R0 resection is considered feasible, ie, those with

  1. Completely encapsulated tumors or
  2. those with tumors invading readily resectable structures, such as the mediastinal pleura, pericardium, or adjacent lung.
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19
Q

Treatment of Stage I and Stage II Thymoma

A

Treatment of stage I and stage II thymoma is surgery, which may be followed by radiation therapy.

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20
Q

Treatment of stage III and stage IV thymoma that may be completely removed by surgery

A

Surgery followed by radiation therapy.
Neoadjuvant chemotherapy followed by surgery and radiation therapy.

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21
Q

Treatment of stage III and stage IV thymoma that cannot be completely removed by surgery

A

Chemotherapy.
Chemotherapy followed by radiation therapy.
Neoadjuvant chemotherapy followed by surgery (if operable) and radiation therapy.

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22
Q

Thymoma

Indications for Postoperative radiation therapy

A

*Stage I thymoma (Masaoka stage I to II)

-For patients with no capsular invasion, we offer observation given the low risk of recurrence and lack of overall survival benefit with postoperative RT (PORT). Such patients should be followed with annual imaging of the chest (computed tomography [CT]/magnetic resonance imaging [MRI]) for a minimum of ten years due to the risk of late recurrences. (See ‘Surveillance after treatment’ below.)

-For patients with invasion into the mediastinal fat or pleura and microscopic or grossly positive surgical margins, we suggest the addition of PORT, as this approach reduces the risk of recurrence to that of patients with R0 resections and lower-risk features. However, observation is an appropriate alternative given limited data. (See ‘Surveillance after treatment’ below.)

*Stage II to III thymoma (Masaoka stage III) – PORT is indicated in such patients given a higher risk of local recurrence.

*Stage IV thymoma (Masaoka stage IV) – RT should be individualized to the needs of the patient. RT can be used for palliation and possibly as curative therapy in oligometastatic disease.

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23
Q

MC surgical exposure/approachs for thymectomy

A

Median sternotomy

Cervical

VATS

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24
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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25
# Thymoma Indications for neoadjuvant/adjuvant therapy
Stage III-IV disease Chemotherapy is offered in the neoadjuvant setting for those with potentially resectable thymoma or thymic carcinoma, or as primary therapy (with or without RT) for those with unresectable thymoma or thymic carcinoma.
26
# Thymoma Neoadjuvant/Adjuvant therapy regimen
Cisplatin-based chemotherapy + XRT
27
Mechanism of action of Myasthenia Gravis
Autoantibodies to ACh receptor (decreased transmission of AP at the NM junction)
28
Demographics of Myasthenia Gravis
* 2x MC in women * 2-3rd decade of life
29
Myasthenia Gravis Symptoms Grades
* 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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Confirmatory tests for Myasthenia Gravis
Endrophonium (short acting anticholinesterase ) test ACh Receptor assay
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Medical treatment for Myasthenia Gravis
Pryidostigmine (long-acting anticholinesterase) Plasmapheresis and IVIg
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Preop Mgmt for the patient with myasthenia gravis: Anticholinesterase agent
* We suggest continuing anticholinesterase agents (ie, pyridostigmine or neostigmine) up to and including the morning of surgery. *
33
Preop Mgmt for the patient with myasthenia gravis: Immunomodulating therapy
* In the occasional patient with persistent mild residual respiratory impairment or dysphagia despite treatment with pyridostigmine and immunotherapy (eg, glucocorticoids), we administer a course of IVIG (2 grams/kg over two to five days) or plasmapheresis (three to five exchanges over 7 to 14 days) preoperatively. * This practice is empiric, with a goal of reducing the risk of a postoperative flare evolving quickly into myasthenic crisis. *** Treatment should be timed to end the week prior to surgery so that the effects of the rapid therapy peak and persist through the perioperative period. **
34
# Myasthenia Gravis Induction and maintenance of anesthesia
* NMBAs should be avoided when possible. * If NMBAs are necessary, we suggest the use of rocuronium or vecuronium, and then reversal with sugammadex.
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# Myasthenia Gravis Response to Depolarizing neuromuscular blocking agents
Patients with MG are resistant to neuromuscular blockade with depolarizing NMBAs (eg, succinylcholine), possibly because they have a decreased number of acetylcholine receptors [27,28]. T
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# Myasthenia Gravis Response to Nondepolarizing neuromuscular blocking agents
Patients with MG are extremely sensitive to nondepolarizing NMBAs (eg, rocuronium, vecuronium, cisatracurium). Very small doses and residual drug effect may result in respiratory distress or loss of airway protection after emergence from anesthesia.
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Indications for thymectomy for Myasthenia Gravis
* 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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When should thymemctomy **_NOT_** be performed for Myasthenia Gravis
Myasthenic crisis Grade IV disease
39
Prevelence of primary mediastinal lymphoma
Rare (5-10% of anterior mediastinal masses)
40
Most common lymphoma subtype presenting as mediastinal mass
T-cell Non-Hodgkin's lymphoma (Hodgkins and lymphoblastic lymphoma also present in mediastinum)
41
Diagnostic w/u for suspected mediastinal lymphoma
* H&P * CXR * Chest CT * Tissue biopsy (percutaneous vs. open)
42
Survival for lymphoma based on \_\_
Tumor grade
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Treatment of lymphoma presenting in mediastinum
Chemotherapy and XRT (Role of surgery: histologic diagnosis)
44
Role of surgery for lymphoma presenting in mediastinum
Histologic diagnosis
45
Prevelence of germ cell tumors among mediastinal masses
10-15% of mediastinal masses
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Most common germ cell tumor in mediastinum
Teratoma * Assymptomatic (MC) * M:F (1:1)
47
Characteristics of tertaoma
* 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_
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Treatment of Choice for teratoma
Surgical excision
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Most common **_malignant_** germ cell tumor of mediastinum
Seminoma | (males in 3rd decade)
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Most common patient population with mediastinal Seminoma
Males in 3rd decade of life
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Diagnostic features of Seminoma
* Slightly elevated Beta-HCG * CT: characteristic large, homogenous mass with smooth boarders * Slow growth
52
TOC of Seminoma
Chemo/XRT XRT sensitive (primary treatment) Cisplatin-based chemotherapy (metastatic disease) (Surgical resection reserved to residual disease, manifested as local growth of residual mass)
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Role of surgery for Seminoma
Residual disease manifested as local growth of a residual mass (after XRT/chemotherapy)
54
Characteristics of Non-seminomatous germ cell tumors of mediastinum
* 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
55
Three main subtypes of non-seminomatous GC tumors
(In order of frequency) * Yolk sac carcinoma * Embryonal carcinoma * Choriocarcinoma
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1st line treatment of non-seminomatous GC tumors
Cisplatin-based chemotherapy (Surgical resection of residual tumor, regardless of response in tumor markers)
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Surgical approach for removal of most intrathoracic goiters
Cervical incision (upper sternal split may be required)
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MC middle mediastinal mass
Cysts | (bronchogenic, pericardial, enteric)
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MC cyst in middle mediastinum
Bronchogenic cysts (60%)
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Characteristics of bronchogenic cysts
* Associated with airway * MC location = posterior to carina (subcarinal) * Symptoms of airway/esophageal compression; infection of the cyst
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Treatment of choice for bronchogenic cysts
Complete transthoracic surgical resection; even if asymptomatic to avoid future complications.
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Definition of pericardial cysts
Rare, benign cysts occuring at cardiophrenic angle (most often on right)
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Most common location for pericardial cysts
Right cardiophrenic angle
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Characteristics of pericardial cysts
* CT imaging of _thin, non-enhancing wall_ * Content has density similar to water
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TOC: pericardial cysts
Aspirate: 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)
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Prevalence of neurogenic mediastinal tumors
15-20% of all mediastinal tumors
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Classic presentaiton and Cell of Origin of neurogenic mediastinal tumors
Presentation: Pain or neurologic dysfunction Cell of origin: Neural Crest Cell
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3 major subtypes of Neurogenic tumors
* Nerve sheath tumors * Ganglion cell tumors * Paraganglionic tumors
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MC neurogenic tumors
Nerve sheath tumors (40-70%)
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Most common location of nerve sheath tumors
Costovertebral/paravertebral sulcus
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Characteristics of nerve sheath tumors
* Usually benign * neurofibrosarcoma (malignant variant) * increased mitotic activity * lack of encapsulation * 2 MC histologic types (schwannoma and neurofibroma)
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Neurogenic tumor that arises from _sympathetic chain_ and _adrenal medulla_
Ganglion cell tumor
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Benign and Malignant subtypes of Ganglion cell tumor
Benign: ganglioneuroma (secrete VIP) Malignant: Ganglioneuroblastoma
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Neurogenic tumors that secretes VIP
Ganglioneuroma (benign ganglion cell tumor) Ganglioneuroblastoma (malignant ganglion cell tumor)
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MC extracranial malignancy in children and most aggressive ganglion cell tumor
Neuroblastoma (secrete VIP and catacholamines)
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TOC for neuroblastoma
Surgical resection (localized disease) + adjuvant chemoradiation for residual diseaes
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Factors associated with poor prognosis for neuroblastoma
* Metastatic disease * Age \< 18 months * Histolgic differentiation * DNA ploidy * Presence of residual disease * N-myc amplification * High levels of neuron-specific enolase and LDH
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Tumors that arise from paraganglionic tissues in costovertebral area
Paraganglionic tumors
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Subtypes of paraganglionic tumors
Pheochromocytomas (catacholamine secretion\_ Chemodectomas (hormonally inactive)
80
TOC for paraganglionic tumor
Surgical resection (tumor capsule should be left intact) (Chemodectomas respond to XRT)
81
Name the Mass
Thymoma
82
Name that mass
Well-differentiated teratoma
83
Name that mass?
mediastinal lymphoma
84
Name that Mass?
Mediastinal seminoma
85
Name that mass?
Mediastinal Non-seminoma
86
Name that Mass?
Bronchogenic cyst
87
Masaoka staging * I * IIa * IIb * III * IVa * IVb
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## Footnote Thymoma: treatment based on masaoka stage: I IIa IIb III IVa IVb
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Venous and arterial blood supply of the thymus.
Blood supply to the thymus comes from the internal thoracic artery as well as the superior and inferior thyroid arteries. Drainage is to the left innominate vein as well as the superior, middle and inferior thyroid veins.
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Thymoma: “Recommended follow-up protocols by ITMIG”
ABTS - Thoracic Surgery Notecards IA
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