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胸壁和胸膜疾病

Disorders of the chest wall and pleura

天津医科大学总医院 心胸外科 刘毅梅 Yimei Liu

Department of Cardiothoracic Surgery General Hospital, Tianjin Medical University

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Quick Review: Anatomy

Chest wall

soft tissue & bony thorax cage

Pleura

visceral and parietal pleura

Pleural space

a potential space between the visceral and parietal pleura

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bony thorax: ribs, costal cartilages,

sternum, clavicles, and scapulae

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Chest wall deformities

Pectus excavatum

(funnel chest) Most common in chest wall deformities

An exceedingly depressed sternum

Asymptomatic or some functional impairment

Surgery for moderate to severe deformities

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Pectus carinatum (pigeon breast)

•An overly prominent sternum

•Less likely to cause functional

impairment

•Surgery

Chest wall tumors

Tumors of the chest wall encompass a variety

of bone and soft tissue disorders.

Chest wall tumors generally present as slowly

enlarging, asymptomatic masses. With

continued growth, pain invariably occurs.

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Chest wall tumors Benign tumors

Fibrous dysplasia of the rib

Chondroma—most common

Osteochondroma

Malignant tumors

Fibrosarcoma, chondrosarcoma, osteogenic

sarcoma, myeloma, and Ewing's sarcoma

Treatment—wide excision and reconstruction

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Postoperative chest computed tomography on a patient who has had a

2-mm Gore-Tex patch placed in the right lower anterior chest wall.

Primary Chest Wall Neoplasm Malignant

Malignant fibrous histiocytoma

Chondrosarcoma

Rhabdomyosarcoma

Myeloma

Ewing’s sarcoma

Liposarcoma

Neurofibrosarcoma

Osteogenic sarcoma

Hemangiosarcoma

Leiomyosarcoma

Lymphoma 9

Benign

Osteochondroma

Chondroma

Desmoid

Lipoma

Fibroma

Neurilemoma

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Pathological diagnosis :Neurilemoma

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Pleural effusions Most common causes

Congestive heart failure

Infection

Neoplasm

Management Treatment of the underlying disease

Thoracentesis

Pleural drainage (tube thoracostomy)

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Pleural neoplasm benign or malignant

Focal pleural masses Localized fibrous neoplasm pleura Thoracic lipoma Local invasion from a bronchogenic carcinoma and metastatic spread from thymoma Very rarely melanoma and certain sarcomas (leiomyosarcoma, liposarcoma, rhabdosarcoma and fibrous histiocytoma)

extensive pleural involvement Mesothelioma Pulmonary adenocarcinoma Lymphoma

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Mesothelioma Related to asbestos exposure

Localized mesothelioma Usually arise from the visceral pleura

Treated by local incision

Malignant mesothelioma Fatal

Presents with a pleural effusion

May require palliative decortication

Chemotherapy ：Pemetrexed

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a patient with mesothelioma displaying

circumferential pleural thickening

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MRI of mesothelioma (A) and photo of gross specimen (B). A, Sagittal MRI of a

patient with mesothelioma showing pleural tumor with extension into the major fissure.

B, Photo of the gross specimen shows growth of disease into the major fissure.

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脓胸 Empyema Definition: is inflammatory fluid and

debris collected in the pleural space

Associated infections

Tuberculosis

Anerobe lung infection

Staphylococcus pneumonia

Streptococcus pneumonia

Gram-negative bacteria lung infection

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Causes Bacterial pneumonia, septic pulmonary

embolism, lung abscess or bronchopleural

fistula

Spread of infection from adjacent structures

such as chest wall, ribs, liver or subphrenic

area

Thoracic trauma or Esophageal tear

Iatrogenic introduction or indwelling catheter

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Natural history

The formation of an empyema has 3

stages:

1.Exudative stage

2.Fibrinopurulent stage

3.Organizing stage

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Natural history (1)

The formation of an empyema has 3 stages:

1.Exudative stage: Protein-rich pleural fluid

remains free-flowing. The number of

neutrophils is rapidly increasing. Glucose and

pH levels are normal. Drainage of the

effusion and appropriate antimicrobial

therapy are normally sufficient for treatment.

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Natural history (2)

2. Fibrinopurulent stage: Viscosity of the

pleural fluid is increasing. Coagulation

factors are activated, and fibroblast activity

begins coating the pleural membrane with

an adhesive meshwork. Glucose and pH

levels are lower than normal.

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Natural history (3)

3. Organizing stage: Loculations are forming. Fibroblast activity causes adherence to the visceral and parietal pleura. This activity may progress with the formation of pleural peels in which the pleural layers are indistinguishable. Pus, which is a protein-rich fluid with inflammatory cells and debris, is present in the pleural space. Surgical intervention is often required at this stage.

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Symptoms Pulmonary symptoms (e.g. cough, tachypnea,

sputum production, desaturations)

Systemic symptoms

a fever and chills

excessive sweating, especially night sweats

general discomfort, uneasiness, or ill feeling (malaise)

weight loss

leukocytosis

chest pain, worse on deep inspiration (inhalation)

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Signs and tests Abnormal findings

friction rub when auscultation

same as hydrothorax

Tests include:

thoracentesis, pleural fluid gram stain and culture

chest X-ray

computed tomography

ultrasonography

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Pleural space fluid

Early/acute stage, one or more of:

pH < 7.2, glucose < 40 mg/dL, LDH >1000IU/dL, protein > 2.5 g/dL, WBC > 500/µL, specific gravity greater than 1.018

Thin serous or cloudy fluid, generally sterile

Fibrinopurulent/intermediate stage

Thicker, opaque fluid or fluid with positive cultures

Organizing/late stage

An organizing peel with entrapment of the lung

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Differential diagnosis

Between an empyema and a lung abscess

The presence of air in an empyema may be due to

the development of a bronchopleural fistula

CT scanning is useful under this circumstance

An empyema tends to have a thinner, smoother

wall than a lung abscess, is lentiform in shape and

forms an obtuse angle with the chest wall.

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Transaxial contrast-enhanced CT of a loculated left

empyema surrounded by thickened, enhancing pleura.

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Posteroanterior (PA) chest radiograph in a 52-year-old man with a history of severe pneumonia in his early 20s. This was treated with antibiotics for 3 days, followed by several weeks of high temperature and chest pain. When this image was obtained, the patient was asymptomatic. Chest radiograph shows a large right pleural-based mass.

CT scan with a mediastinal window setting in the same patient as in Image 6 shows a mass with a thick, calcified wall arising from the pleura with an air-fluid level. This finding represents an organized walled-off old empyema.

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11-year-old girl who had a one week history of chest infection. 1. Chest radiograph reveals a large pleural effusion. There is a scoliosis concave to the side of the effusion. 2. Ultrasound shows the effusion to be echogenic and full of fibrinous strands, indicating an empyema. Note the echogenic consolidated lung by underlying the effusion. 3. The CT scan shows the effusion with underlying pulmonary consolidation, but the nature of the effusion is better appreciated by ultrasound.

24-year-old boy, lung abscess

Acute angel, air sign inside

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Management (1)

The goal of treatment is to cure the infection

and remove the collection of pus from the

lung.

Three core principles

prompt initiation of appropriate antibiotics

the complete evacuation of suppurative pleural

fluid

the preservation or restoration of lung expansion

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Management (2)

Thoracentesis (maybe under ultrasonography or CT

guidance) and antibiotics alone have been

successful in treatment of empyema in 6 to 20% of

patients, particularly with early stage disease

If the effusion recurs, placement of a chest tube or

small-bore catheter for continuous drainage is the

next step

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Management (3)

Large closed-tube thoracostomy with or without

the adjunctive use of fibrinolytics has been the

traditional management with the fibrinopurulent

stage of the empyema process

Appropriate time to drain the empyema: a large free-

flowing effusion (at least half of a hemithorax), a

loculated effusion or effusion with thickened parietal

pleura, positive culture or Gram stain results, parietal

pus, and pH less than 7.20

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Management (4)

Surgical intervention is required in

effusions with multiple loculations that are

difficult to drain and effusions that have not

responded to catheter drainage

The organizing phase of empyema requires

direct removal of the restrictive coagulum

(decortication) with open or thoracoscopic

technique

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Management (5)

Surgical interventions may include the

following:

Thoracoscopic debridement

Video-assisted thoracoscopic surgery (VATS)

Open thoracotomy for debridement

Open surgical decortication

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Management (6)

Indications for Surgery

fail to respond to intravenous antibiotics with defervescence

and improving pulmonary symptoms

pleural fluid does not aspirate with needle or tube

thoracostomy

responded more quickly with earlier decortication

Caution in associated necrotizing pneumonias and

lung abscesses for fear of the development of

prolonged air leaks and bronchopleural fistulae

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Expectations(prognosis)

Usually empyema does not result in

permanent pulmonary damage

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纵隔疾病

Disorders of the Mediastinum

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Anatomy (1)

The mediastinum is the region of the thoracic cavity bounded by:

posteriorly: thoracic spine

anteriorly: sternum and costal cartilages

laterally: mediastinal pleura bounding the pleural cavities

superiorly: thoracic inlet

inferiorly: diaphragm

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Anatomy (2)

The mediastinum is subdivided into

various regions :

Anterior mediastinum

Middle mediastinum

Posterior mediastinum

Anatomy (3)

four compartments (classic)---Gray’s Anatomy

superior, anterior, middle, and posterior

The superior mediastinum includes all structures from the thoracic inlet superiorly to a line drawn from the lower edge of the manubrium to the lower edge of the fourth thoracic vertebrae, inferiorly.

Inferior to this line is the inferior mediastinum, which is subsequently divided into the anterior, middle, and posterior compartments that are bounded inferiorly by the diaphragm.

The boundary between the anterior and middle compartments is the anterior pericardium; between the middle and posterior compartments is the posterior aspect of the tracheal bifurcation, pulmonary vessels, and pericardium.

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Four-compartment

model of the

mediastinum.

Anatomy (4)

A revision of the four-

compartment system

combines the anterior and

superior compartments into

an anterosuperior

compartment, thus creating

three compartments.

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Anatomy (5)

An alternative model proposed by Shields in 1972.

a three-compartment model

an anterior compartment, middle (or visceral) compartment, and a posterior compartment (paraventral sulcus).

All three compartments are bounded inferiorly by the diaphragm, laterally by the pleural space, and superiorly by the thoracic inlet.

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Anatomy (6)

The anterior compartment is bounded

anteriorly by the sternum and posteriorly by

the great vessels and pericardium.

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LSCA, left subclavian artery; LMB, left main bronchus; LA, left atrium; LV, left ventricle; IMV, internal

mammary vessels; LBCV, left brachiocephalic vein. RBCV, right brachiocephalic vein; LBCV, left

brachiocephalic vein; SVC, superior vena cava; RPA, right pulmonary artery; RMB, right main bronchus.

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Anatomy (7)

Dorsal to the anterior compartment is the visceral

compartment or middle mediastinum, which is

bounded posteriorly by the ventral surface of the

thoracic spine.

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LSCA, left subclavian artery; LMB, left main bronchus; LA, left atrium; LV, left ventricle; IMV, internal

mammary vessels; LBCV, left brachiocephalic vein. RBCV, right brachiocephalic vein; LBCV, left

brachiocephalic vein; SVC, superior vena cava; RPA, right pulmonary artery; RMB, right main bronchus.

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Anatomy (8)

The posterior compartment of the mediastinum or paraventral sulcus consists of potential spaces along the thoracic vertebrae that contain the sympathetic chain, proximal portions of the intercostal neurovascular bundles, thoracic spinal ganglia, and the distal azygous vein.

The paraventral sulci are not technically in the mediastinum but contain structures that give rise to pathology that is classically considered in the posterior mediastinum (neurogenic tumors).

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Contents of the Mediastinum by Compartment Anterior

Thymus

Internal thoracic

arteries

Lymph nodes

Connective tissue

Adipose

Ectopic parathyroid

tissue

Ectopic thyroid

Germ cell rests

Paravertebral Sulci

Proximal intercostal

vessels

Proximal anterior rami

Rami communicans

Thoracic spinal ganglion

Sympathetic trunk

Connective tissue

Lymphatic tissue

Distal azygous venous

Visceral

PericardiumHeart

Great vessels

Trachea

Proximal mainstem bronchi

Esophagus

Lymphatic tissue

Vagus nerves

Phrenic nerves

Supra- and para-aortic bodies

Multiple nerve plexuses

Thoracic duct

Proximal azygous venous

system

Connective tissue

Adipose

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Anatomy (9)

Different division

Four parts

Superior

Inferior: Anterior, Middle, Posterior

Six parts

Superior: Anterior, Middle, Posterior

Inferior: Anterior, Middle, Posterior

Nine parts

Superior: Anterior, Middle, Posterior

Middle : Anterior, Middle, Posterior

Inferior: Anterior, Middle, Posterior

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trachea

esophagus

Juncture of mesosternumand

manubrium

Lower edge of hilus pulmonis

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Mediastinal mass (1)

Anterior mediastinum

Thymoma

Lymphoma

Teratoma

Thyroid mass

Germ cell neoplasm

Thymic cyst

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Mediastinal mass (2)

Middle mediastinum

Bronchogenic cyst

Lymphadenopathy

Pericardial cyst

Tracheal tumours

Vascular abnormalities including aortic aneurysm,

aortic dissection, vascular variants

Esophageal abnormalities (achalasia, neoplasm,

hiatal hernia), esophageal varices

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Mediastinal mass (3)

Posterior mediastinum

Extramedullary hematopoiesis

Lymphadenopathy

Neuroenteric cyst

Neurogenic neoplasm

Paravertebral abnormalies (infectious, malignant

and traumatic abnormalities of the thoracic spine)

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Lateral chest film divided into three anatomical subdivisions with

the most common location of the tumors and cysts.

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Clinical features

Asymptomatic: in more than 50% of cases,

the lesion being detected as an incidental

finding.

Symptomatic: pressure effects on the

surrounding structures. Features may include

insidious onset of restrosternal chest pain,

dysphagia or dyspnea.

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Investigations (1)

Over 50% as incidental findings on a chest X-ray

Further information from:

CT scan

barium swallow - if esophageal disease is suspected

doppler sonography or venography of brachiocephalic veins

or superior vena cava

Arteriography

MRI - when results of CT scan are equivocal

biopsy - if suspected neoplasm

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Investigations (2)

advantages of MRI over CT:

distinguishes vessels and masses

contrast media unnecessary

imaging in multiple planes

good delineation of hilar structures

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sagittal plane sagittal plane

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sagittal plane coronal plane

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Management (1)

thoracotomy may be considered for diagnosis

and removal

radiotherapy may be indicated for the

primary tumour or for any tumour residue -

this may be curative in neuroblastoma and

thymoma; it may achieve long-term control in

malignant teratoma

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Management (2)

combination chemotherapy may be required

for neuroblastoma

note that treatment with radiotherapy may

cause dysphagia and an irritant cough during

and immediately after treatment. Occasionally

there may be later symptoms of pulmonary

fibrosis and pericardial fibrosis

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CASES

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病理报告：胸腺大B细胞淋巴瘤

pathological report: The thymus B cell lymphoma

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淀粉样变amyloidosis

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精原细胞瘤 seminoma

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纵隔脂肪肉瘤 liposarcoma

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胸骨后甲状腺肿Thyroid mass

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纵隔神经纤维瘤Neurogenic neoplasm

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心包囊肿Pericardial cyst

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畸胎瘤Teratoma

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胸腺瘤 Thymoma

Thymomas are one of the most common mediastinal

neoplasms - 90% are benign.

Association with a number of systemic disorders,

notably myasthenia gravis, hematologic cytopenias,

hypogamma-globulinemia, various collagen-vascular

diseases, and nonthymic cancers

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Histological classification

Histological type via cell composition

Lymphocytic: More than two-thirds lymphocytic

Epithelial: Less than one-third lymphocytic

Lymphoepithelial (mixed): Neither more than

two-thirds nor less than one-third lymphocytic

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Histological Classification of Thymoma

Cell Composition

细胞构成

Histological Type

组织学类型

>2/3 lymphocytic Lymphocytic

<1/3 lymphocytic Epithelial

>1/3, <2/3lymphocytic Lymphoepithelial (mixed)

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lymphocyte-

predominant type

(IHC, CK)

mixed lymphocyte

and epithelial type

(IHC, CD57)

epithelium-

predominant type

(IHC, CK)

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Types Three main types are recognised

benign - the most common, accounting for 80-90% of thymomas. Characterized by a diffuse proliferation of neoplastic thymic epithelial cells and an abundance of lymphocytes. There is no capsular invasion.

malignant type I - cytologic features are identical to the benign thymoma but with additional invasion of the capsule. Occasionally, there may be metastases to the lungs and bone.

malignant type II - known as thymic carcinoma. There is capsular invasion and cytologic pleomorphism. The tumour often resembles a squamous cell carcinoma.

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Comparison of the Different Classifications of Thymic Epithelial Tumors(Muller-Hermelink, 1999)

Clinicopathologic

Classification

WHO Type

WHO分型

Terminology of the Histogenetic Classification for

the Histologic Subtypes of Thymic Epithelial Tumors

Benign thymoma A

AB

Medullary thymoma

Mixed thymoma

Malignant thymomas,

Category I

B1

B2

B3

Predominantly cortical thymoma

Cortical thymoma

Well-differentiated thymic carcinoma

Malignant thymomas,

Category II

C Epidermoid keratinizing (squamous cell) carcinoma

Epidermoid nonkeratinizing carcinoma

Lymphoepithelioma-like carcinoma

Sarcomatoid carcinoma (carcinosarcoma)

Clear cell carcinoma

Mucoepidermoid carcinoma

Undifferentiated carcinoma

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Clinical features (1)

Mean age of patients with thymomas is 50

years; rare in children where they are

associated with a poor prognosis

Males and females equally affected

Radiographic mass - most common in

anterosuperior mediastinum

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Clinical features (2)

Variable clinical presentation dependent upon

the aggressiveness of the lesion include:

asymptomatic

features attributable to local pressure effects e.g.

cough, dyspnoea, dysphagia and superior venal

caval obstruction

associated systemic disorders (see associated

conditions)

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Associated conditions Thymomas may occur in association with a variety of

autoimmune and hematologic phenomena including:

myasthenia gravis - the most common association but less

often associated with more aggressive thymomas

hematologic cytopenias e.g. aplastic aneamia

Hypogammaglobulinemia

collagen vascular diseases e.g. systemic lupus erythematous

non-thymic malignancies

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Aplastic aneamia blood smear

Normal blood smear

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Diagnostic procedures Imaging Studies

PA and lateral chest radiographs

CT scan

CT scan with intravenous contrast dye

Biopsy: limited anterior mediastinotomy

or thoracoscopic approach

Fine-needle aspiration

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CT scan image

clearly illustrates the

mass in the right

anterolateral

mediastinum. X-ray showing a mass in the left

anterolateral mediastinum

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CT scan showing a small thymoma seen as a round mass within the anterior mediastinum (arrows). This lesion was too small to be depictable on the chest radiograph. CT scan was performed because the patient manifested clinical myasthenia. Note calcifications of the subcarinal lymph nodes

Postcontrast CT scan in a patient with thymoma showing a large lobulated mass located in the prevascular space of the mediastinum. The mass is of soft tissue attenuation and contains irregular calcifications.

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Masaoka Staging System and Corresponding Therapy

Stage Definition Treatment

I Encapsulated tumor with no gross or

microscopic invasion Complete surgical excision

II Macroscopic invasion into the

mediastinal fat or pleura or microscopic invasion into the capsule

Complete surgical excision and postoperative radiotherapy to decrease the

incidence of local recurrence

III Invasion of the pericardium, great

vessels, or lung

Complete surgical excision and postoperative radiotherapy to decrease the

incidence of local recurrence

IVa Pleural or pericardial metastatic spread Surgical debulking, radiotherapy, and

chemotherapy

IVb Lymphatic or hematogenous Surgical debulking, radiotherapy, and

chemotherapy

Surgical approaches for thynoma depend on the mass’s size, extraesophageal extension of the primary tumor .

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Classical approach: median sternotomy

Sternotomy. A midline sternal split is tipical.

Exposure of the anterior and middle mediastinum through a sternotomy.

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半蛤壳切口（Bain's Cut）

The hemiclamshell incision incorporates the sternotomy with extension to a thoracotomy to increase the intrathoracic exposure.

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胸部正中倒“L”切口 Upside-down “L”

Combining a partial longitudinal division of the sternum with a partial transverse cut creates a partial sternal split.

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Prognosis

benign - excellent prognosis but there is a

2% recurrence rate if excision is incomplete

malignant type I - excellent prognosis if

resection is complete

malignant type II - approximate 20% 5-year

survival after treatment.

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Survival of Thymoma by Stage

Stage 5-Year Survival 10-Year Survival

I 90% 80%

II 90% 80%

III 60% 30%

IV Less than 25% N/A

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CASES

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实验室检查：血糖（Blood sugar）12.2mmol/L↑，24小时尿糖(24hUrine sugar) 67.8g↑，血钾 K+ 1.7 mmol/L↓，空腹血浆皮质醇（Cortisol ）＞50μg/ml↑，血浆促肾上腺皮质激素（ACTH）＞1250ng/ml，尿皮质醇＞1100μg/24h↑，大小剂量地塞米松抑制试验（dexamethasone suppression test）均不被抑制

Cushing's syndrome

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病理报告：类癌 Carcinoid ，IgA（+），Syn（+），

符合异位内分泌肿瘤-Ectopia Endocrine Tumors

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Female

58 yrs

No treatment with

thymoma for 8 yrs

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Abnormal immune

system

Xerosis maybe

干燥综合征

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Questions Term

Empyema

Blank

Natural history of empyema(3 stages)

3 anatomy regions of mediastinum

Simple answer

Core principles of empyema management

Types of anterior mediastinal masses(4 or more)

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