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MEDIASTINUM MEDIASTINUM Dr. Vibhay Pareek Dr. Vibhay Pareek Radiation Oncology Radiation Oncology Jupiter Hospital Jupiter Hospital

Radiology day 3 mediastinal anatomy

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Page 1: Radiology day 3   mediastinal anatomy

MEDIASTINUMMEDIASTINUM

Dr. Vibhay PareekDr. Vibhay Pareek

Radiation OncologyRadiation Oncology

Jupiter HospitalJupiter Hospital

Page 2: Radiology day 3   mediastinal anatomy

INTRODUCTIONINTRODUCTION• The mediastinum is the region in the chest between the pleural cavities that

contain the heart and other thoracic viscera except the lungs

• Boundaries • Anterior - sternum• Posterior - vertebral column and paravertebral fascia• Superior - thoracic inlet• Inferior - diaphragm• Lateral - parietal pleura

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Sternal Angle

Thoracic inlet

Thoracic oulet

BOUNDARIES OF BOUNDARIES OF MEDIASTINUMMEDIASTINUM

sternum

Thoracic vertebra

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TS: MediastinumTS: Mediastinum

5

CS: MediastinumCS: Mediastinum

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DIVISIONS OF MEDIASTINUMDIVISIONS OF MEDIASTINUM

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Superior Mediastinum

Posterior Mediastinum

Anterior Mediastinum

Middle Mediastinum

Sternal Angle T4

T5

divided into superior mediastinum and inferior mediastinum by an imaginary line passing through sternal angle anteriorly lower border of 4th thoracic vertebra posteriorly

Mediastinum divisions Mediastinum divisions

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INFERIOR MEDIASTINUMINFERIOR MEDIASTINUM: : IS SUBDIVIDEDIS SUBDIVIDED INTOINTO

Anterior Anterior mediastinummediastinum

Middle Middle mediastinummediastinum

Posterior Posterior mediastinummediastinum

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SUPERIOR MEDIASTINUMSUPERIOR MEDIASTINUM BoundariesBoundariesAnt: Manubrium sterniAnt: Manubrium sterni

Post: T-1 to T-4 Post: T-1 to T-4

Sides: Mediastinal pleuraSides: Mediastinal pleura

Sup: Plane of thoracic inlet Sup: Plane of thoracic inlet at T1at T1

Inf: Imaginary line joining Inf: Imaginary line joining sternal angle and lower sternal angle and lower border T-4 border T-4

9

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SUPERIOR MEDIASTINUM SUPERIOR MEDIASTINUM It contains:It contains:

• TracheaTrachea

• EsophagusEsophagus

• Blood vessels (large veins & arteries) Blood vessels (large veins & arteries)

• Nerves Nerves

• Thoracic ductThoracic duct

• ThymusThymus

• Lymph nodes: (listed later)Lymph nodes: (listed later)

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SUPERIOR MEDIASTINUM CONTENTSSUPERIOR MEDIASTINUM CONTENTS

Blood VesselsBlood VesselsVeins: SVCLt & Rt brachiocephalic veins,

Arteries:Arch of Aorta Brachiocepalic arteryLt Common carotid Lt subclavian artery

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SUPERIOR MEDIASTINUM SUPERIOR MEDIASTINUM

NervesNerves1.1. Vagus nerveVagus nerve2.2. Left Recurrent Left Recurrent

Laryngeal nerve.Laryngeal nerve.3.3. Phrenic nerve.Phrenic nerve.

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SUPERIOR MEDIASTINUM SUPERIOR MEDIASTINUM

Lymph nodes: Highest mediastinal Paratracheal Prevascular retrotracheal

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ANTERIOR MEDIASTINUMANTERIOR MEDIASTINUM

Lies ant. to pericardiumLies ant. to pericardium

Boundaries:Boundaries:• Anterior: body of sternum• Posterior: pericardium• Superior: imaginary line separating sup. &

inf.mediastinum• Infreior: diaphragm• Lateral: mediastinal pleura

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ANTERIOR MEDIASTINUM: CONTAINS:ANTERIOR MEDIASTINUM: CONTAINS:

a.a. Thymus glandThymus glandb.b. Lymph NodesLymph Nodesc.c. Fat.Fat.

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MIDDLE MEDIASTINUMMIDDLE MEDIASTINUM

Boundaries:Boundaries:• Anterior: posterior surface of sternum

• Posterior: oesophagus, desc. thoracic aorta, azygous vein

• Superior: plane seperating sup.& inf mediastinum

• Inferior: diaphragm• Lateral: mediastinal pleura

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MIDDLE MEDIASTINUMMIDDLE MEDIASTINUMContents:Contents:

HeartHeart enclosed in pericardium enclosed in pericardium

Arteries:Arteries: Ascending Aorta, Ascending Aorta, Pulmonary trunk with its Lt &Pulmonary trunk with its Lt & Rt branchesRt branches

VeinsVeins: SVC,Pulmonary veins: SVC,Pulmonary veins

Nerves:Nerves: Phrenic, vagus nerve Phrenic, vagus nerve

Bifurcation of Trachea with Bifurcation of Trachea with two principal bronchitwo principal bronchi

Tracheobronchial lymph nodesTracheobronchial lymph nodes 17

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POSTERIOR MEDIASTINUMPOSTERIOR MEDIASTINUM Boundaries:Boundaries:

Ant.Ant. Pericardium, Bifurcation of trachea Pericardium, Bifurcation of tracheaPost.Post. T5 to T12 T5 to T12

sup. sup. Transverse thoracic planeTransverse thoracic plane

Inf. Inf. diaphragmdiaphragm

Sides: Sides: Mediastinal pleuraMediastinal pleura 18

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19

POSTERIOR MEDIASTINUMPOSTERIOR MEDIASTINUMContents:Contents: OesophagusOesophagus Arteries Arteries • Descending Aorta with its brsDescending Aorta with its brs VeinsVeins • AzygosAzygos• Hemizygos Hemizygos • Accessory hemizygosAccessory hemizygos Nerves:Nerves: • VagusVagus• Splanchnic nervesSplanchnic nervesThoracic ductThoracic ductlymph nodeslymph nodes• Posterior mediastinal Posterior mediastinal

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RADIOLOGICAL ANTOMYRADIOLOGICAL ANTOMY

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CHEST X-RAYCHEST X-RAY

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TRACHEOBRONCHIAL TRACHEOBRONCHIAL ANATOMYANATOMY

23Tracheal Displacement Due to Goiter

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CLUES TO LOCATE MASS TO MEDIASTINUMCLUES TO LOCATE MASS TO MEDIASTINUM Mediastinal Masses Masses In The Lung

Not Contain Air

Bronchograms Mediastinal Mass Will

Create Obtuse Angles With The Lung .

Mediastinal Lines Will Be Disrupted

– May Contain Air Bronchograms

– A Lung Mass Abutts The Mediastinal Surface And

Creates Acute Angles With The Lung

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LEFT: A lung mass abutts the mediastinal surface and creates acute angles with the lung.

RIGHT: A mediastinal mass will sit under the surface of the mediastinum, creating obtuse angles with the lung

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CERVICOTHORACIC SIGNCERVICOTHORACIC SIGN

• The anterior mediastinum ends at the level of the clavicles.The anterior mediastinum ends at the level of the clavicles.• The posterior mediastinum extends much higher.The posterior mediastinum extends much higher.

• ThereforeTherefore• any mass that remains sharply outlined in the apex of the thorax any mass that remains sharply outlined in the apex of the thorax

must be posterior and entirely within the chest, and  must be posterior and entirely within the chest, and  • any mass that disappears at the clavicles must be anterior and any mass that disappears at the clavicles must be anterior and

extends into neckextends into neck

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See sharp margin

above clavicle

Mass is in posterior mediastinum. because it remains sharply outlined in apex of thorax, indicating that it is surrounded by lung.This particular example is a ganglioneuroma

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THORACOABDOMINAL SIGNTHORACOABDOMINAL SIGN

• A sharply marginated mediastinal mass seen through the diaphragm A sharply marginated mediastinal mass seen through the diaphragm must lie entirely within the chest.must lie entirely within the chest.

• The posterior costophrenic sulcus extends far more caudally than the The posterior costophrenic sulcus extends far more caudally than the anterior aspect of the lunganterior aspect of the lung

• ThereforeTherefore• Any mass that extends below the dome of the diaphragm and Any mass that extends below the dome of the diaphragm and

remains sharply outlined must be in the posterior compartments remains sharply outlined must be in the posterior compartments and surrounded by lung, andand surrounded by lung, and

• Any mass that terminates at dome of diaphragm must be Any mass that terminates at dome of diaphragm must be anterioranterior

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Can you see the

outline of themass below

the diaphragm?

Margin of mass is apparent and below diaphragm, therefore this must be in the middle or posterior compartments where it is surrounded by lungThis example is a ‘Lipoma’

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HILUM OVERLAY SIGNHILUM OVERLAY SIGN• Principle of hilum overlayPrinciple of hilum overlay• An anterior mediastinal mass will overlap the main An anterior mediastinal mass will overlap the main

pulmonary arteries, therefore they will be seen within the pulmonary arteries, therefore they will be seen within the margins of the massmargins of the mass

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Hilum can be seen through mass

this must be an anterior mediastinal mass because it overlaps rather than “pushes out” the main pulmonary arteries

This particular example is a thymoma

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VASCULAR ANATOMYVASCULAR ANATOMY

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At T3 LevelAt T3 Level

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At T4 LevelAt T4 Level

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At T5 LevelAt T5 Level

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At T6 LevelAt T6 Level

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MEDIASTINAL TUMORS EPIDEMOLOGYMEDIASTINAL TUMORS EPIDEMOLOGY

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MEDIASTINAL MASSESMEDIASTINAL MASSES

Compartment % Malignant

Anterosuperior 59

Middle 29

Posterior 16

Mediastinal division

Most common tumors

Anterior-superior

thymoma

middle lymphoma

posterior Neurogenic tumors

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Anterosuperior Masses

Thymus• Thymoma• Thymic carcinoma• Thymic cyst• Thymic carcinoid• Thymolipoma

Mediastinal Lymphoma• Hodgkin’s Lymphoma• Non-Hodgkin’s Lymphoma

Mesenchymal tumors

Germ Cell Tumor• Seminoma• Non seminomatous Germ Cell

• Embryonal cell carcinoma• Endodermal sinus tumor• Choriocarcinoma

• Teratoma• Mature• Immature

Endocrine tumors• Thyroid tumors• Parathyroid adenoma

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Middle mediastinal masses

Mediastinal Lymphoma• Hodgkin’s Lymphoma• Non-Hodgkin’s Lymphoma

Mesenchymal tumors

CYST:• Bronchogenic cyst• Thoracic duct• Meningoceles

Cardiac & pericardial tumors

Tracheal tumors

vascular tumors

Lymphadenopathy• Inflammatory• Granulomatous• sarcoidosis

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Posterior mediastinal masses

Mediastinal Lymphoma• Hodgkin’s Lymphoma• Non-Hodgkin’s Lymphoma

Mesenchymal tumors

Neurogenic tumors• Peripheral nerves• Symphathetic ganglia• paraganglia

ENDOCRINE TUMORS

ESOPHAGEAL TUMORS & CYSTS

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TUMORS OF THYMUSTUMORS OF THYMUS

• ThymomasThymomas• Thymic carcinomasThymic carcinomas• Thymic lymphomasThymic lymphomas• CarcinoidsCarcinoids• ThymolipomasThymolipomas• SecondariesSecondaries

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THYMOMATHYMOMA

PresentationPresentation• Most common primary anterior mediastinal tumorMost common primary anterior mediastinal tumor• M=F, most >40M=F, most >40• Most patients are asymptomaticMost patients are asymptomatic• Half of patients suffer have associated parathymic syndromesHalf of patients suffer have associated parathymic syndromes

• myasthenia gravismyasthenia gravis• hypogammaglobulinemiahypogammaglobulinemia• pure red cell aplasiapure red cell aplasia

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• 1/3 have chest pain, cough or dyspnea on presentation1/3 have chest pain, cough or dyspnea on presentation• Myasthenia gravis occurs in 30-50% of pts with thymoma. Myasthenia gravis occurs in 30-50% of pts with thymoma.

Hypogammaglobulinemia occurs in 10% of pts with Hypogammaglobulinemia occurs in 10% of pts with thymomathymoma

• Pure red cell aplasia occurs in 5%, but thymoma occurs in Pure red cell aplasia occurs in 5%, but thymoma occurs in 50% of pts with red cell aplasia50% of pts with red cell aplasia

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THYMOMATHYMOMA

• lobulated mass in the anterior mediastinum

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THYMOMATHYMOMA

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INVASIVE THYMOMAINVASIVE THYMOMA

• Encasement of mediastinal structures, infiltration of fat planes, and an irregular interface between the mass and lung parenchyma, are highly suggestive of invasion.

• Pleural thickening, nodularity, or effusion generally indicates pleural invasion by the thymoma

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THYMIC CARCINOIDTHYMIC CARCINOID

carcinoid tumors (neuroendocrine tumors) of the thymus are very rare, carcinoid tumors (neuroendocrine tumors) of the thymus are very rare,

accounting for <5% of all neoplasms of the anterior mediastinum.accounting for <5% of all neoplasms of the anterior mediastinum.

They originate from the normal thymic Kulchitsky cells, which belong to the amine precursor uptake They originate from the normal thymic Kulchitsky cells, which belong to the amine precursor uptake and decarboxylation (APUD) group and decarboxylation (APUD) group

PresentationPresentation• men aged 30 to 50 years men aged 30 to 50 years • (male/female ratio: 3:1)(male/female ratio: 3:1)• Rarely associated with carcinoid syndromeRarely associated with carcinoid syndrome• Associated endocrine abnormalities: Cushing’s syndrome due to ectopic ACTH or MENAssociated endocrine abnormalities: Cushing’s syndrome due to ectopic ACTH or MEN• 73% have regional lymph node and/or distant osteoblastic bone mets73% have regional lymph node and/or distant osteoblastic bone mets

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• Thymic carcinoid tumor in a 22-year-old man with a 3-month history of a persistent dry Thymic carcinoid tumor in a 22-year-old man with a 3-month history of a persistent dry cough. cough.

• Contrast-enhanced CT scan shows a heterogeneously enhancing thymic mass . Contrast-enhanced CT scan shows a heterogeneously enhancing thymic mass . • PET image shows intense FDG uptake by the massPET image shows intense FDG uptake by the mass

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THYMIC CARCINOMATHYMIC CARCINOMA

• Thymic carcinomas behave more Thymic carcinomas behave more aggressively than invasive thymomas aggressively than invasive thymomas and are more likely to metastasize to and are more likely to metastasize to distant sites distant sites

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THYMIC LYMPHOMASTHYMIC LYMPHOMAS

• Lymphoma is the most Lymphoma is the most common cause of an anterior common cause of an anterior mediastinal mass in children mediastinal mass in children and the second most common and the second most common cause of an anterior cause of an anterior mediastinal mass in adults. mediastinal mass in adults.

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CANCERS OF THE HEAD AND NECK, ABDOMEN, AND PELVIS CAN INVOLVE CANCERS OF THE HEAD AND NECK, ABDOMEN, AND PELVIS CAN INVOLVE THE THYMUS VIA LYMPHATIC PATHWAYS THE THYMUS VIA LYMPHATIC PATHWAYS

• Metastatic disease to the Metastatic disease to the thymus in a 10-year-old boy 2 thymus in a 10-year-old boy 2 years after diagnosis of years after diagnosis of alveolar rhabdomyosarcoma alveolar rhabdomyosarcoma of the thigh. of the thigh.

Secondary Tumors of the Thymus

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MEDIASTINAL LYMPHOMAMEDIASTINAL LYMPHOMA

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PRIMARY MEDIASTINAL LYMPHOMAPRIMARY MEDIASTINAL LYMPHOMA

• 5-10% of patients with lymphoma present with primary 5-10% of patients with lymphoma present with primary mediastinal lesionsmediastinal lesions

• Primary mediastinal lymphoma represents 10-20% of Primary mediastinal lymphoma represents 10-20% of primary mediastinal masses in adults and are usually in primary mediastinal masses in adults and are usually in the anterosuperior compartmentthe anterosuperior compartment

• Usually present with fever, weight loss and night sweatsUsually present with fever, weight loss and night sweats• Pain, dyspnea, stridor, SVC syndrome due to mass Pain, dyspnea, stridor, SVC syndrome due to mass

effects are uncommoneffects are uncommon

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PRIMARY MEDIASTINAL LYMPHOMAPRIMARY MEDIASTINAL LYMPHOMA

Two TypesTwo Types• Primary Mediastinal Hodgkin’s LymphomaPrimary Mediastinal Hodgkin’s Lymphoma• Primary Mediastinal Non-Hodgkin’s LymphomaPrimary Mediastinal Non-Hodgkin’s Lymphoma

• Poorly differentiated lymphoblasticPoorly differentiated lymphoblastic• Diffuse lymphocyticDiffuse lymphocytic• Primary Mediastinal B-cell LymphomaPrimary Mediastinal B-cell Lymphoma

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PRIMARY MEDIASTINAL HODGKIN’S PRIMARY MEDIASTINAL HODGKIN’S LYMPHOMALYMPHOMA

PresentationPresentation• Incidental mediastinal mass on chest xray is 2nd most common Incidental mediastinal mass on chest xray is 2nd most common

presentation after asymptomatic lymphadenopathypresentation after asymptomatic lymphadenopathy• Mass is usually large, rarely causes retrosternal chest pain, Mass is usually large, rarely causes retrosternal chest pain,

cough, dyspnea, effusions or SVC syndromecough, dyspnea, effusions or SVC syndrome• Bimodal age distribution Bimodal age distribution • ““B” symptoms: fever, weight loss (>10% body wt in 6 months), B” symptoms: fever, weight loss (>10% body wt in 6 months),

night sweatsnight sweats• Generalized pruritus presentGeneralized pruritus present

Page 57: Radiology day 3   mediastinal anatomy

A chest CT exam shows the mass to extend from the neck to the diaphragm, compressing the tracheal and left mainstem bronchus leading to left lower lobe atelectasis. The chest wall mass is partially eroding the sternum.

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Two contiguous slices from an enhanced chest CT exam show a homogenous, solid, anterior mediastinal mass and a large right pleural effusion.

Dx-LymphomaNon-Hodgkin, Anterior Mediastinal

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MEDIASTINAL GERM CELL TUMORSMEDIASTINAL GERM CELL TUMORS

• Primary extragonadal germ cell tumors comprise 2% to 5% Primary extragonadal germ cell tumors comprise 2% to 5% of all germ cell tumors of all germ cell tumors

• Approximately two thirds of these tumors occur in the Approximately two thirds of these tumors occur in the mediastinum mediastinum

• The mediastinum is the most common site of primary The mediastinum is the most common site of primary extragonadal germ cell tumors in young adults extragonadal germ cell tumors in young adults

• Represent 10-15% of adult anterosuperior mediastinal Represent 10-15% of adult anterosuperior mediastinal tumorstumors

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MEDIASTINAL GERM CELL TUMORSMEDIASTINAL GERM CELL TUMORS

• they presumably arise from germ cells that migrate along the they presumably arise from germ cells that migrate along the urogenital ridge during embryonic development .urogenital ridge during embryonic development .

• The embryologic urogenital ridge extends from C6 to L4 and The embryologic urogenital ridge extends from C6 to L4 and after malignant transformation of displaced germ cells, explains after malignant transformation of displaced germ cells, explains the development of primary germ cell tumors outside the the development of primary germ cell tumors outside the gonadsgonads

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MEDIASTINAL GERM CELL TUMORSMEDIASTINAL GERM CELL TUMORS

Three typesThree types• TeratomaTeratoma• SeminomaSeminoma• Nonseminomatous Germ Cell TumorNonseminomatous Germ Cell Tumor

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MEDIASTINAL TERATOMASMEDIASTINAL TERATOMAS

• Most common mediastinal germ cell tumorMost common mediastinal germ cell tumor• Three types:Three types:

• Mature:Mature: benign, well-differentiated benign, well-differentiated• Immature:Immature: contains >50% immature components, may contains >50% immature components, may

recur or metastasizerecur or metastasize• Malignant:Malignant: a mature teratoma that contains a focus of a mature teratoma that contains a focus of

carcinoma, sarcoma or malignant GCTcarcinoma, sarcoma or malignant GCT

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MATURE TERATOMAMATURE TERATOMA

• Occurs in children and young adultsOccurs in children and young adults• Usually asymptomatic, but if large enough, may cause chest Usually asymptomatic, but if large enough, may cause chest

pain, dyspnea, cough or other symptoms of mediastinal pain, dyspnea, cough or other symptoms of mediastinal compressioncompression

• Contains derivatives of all three primitive germ layers includingContains derivatives of all three primitive germ layers including• Ectoderm: teeth, skin, hairEctoderm: teeth, skin, hair• Mesoderm: cartilage and boneMesoderm: cartilage and bone• Endoderm: bronchial, intestinal and pancreatic tissueEndoderm: bronchial, intestinal and pancreatic tissue

• Expectoration of hair (trichoptysis) is rare but pathognomonicExpectoration of hair (trichoptysis) is rare but pathognomonic

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Dx Teratoma, Anterior Mediastinal

CT exam show a low density mass in the anterior mediastinum with irregular walls with calcium in it.

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MEDIASTINAL SEMINOMAMEDIASTINAL SEMINOMA

• Represents 40% of malignant mediastinal GCTsRepresents 40% of malignant mediastinal GCTs• Afflicts Caucasian men in 20s-30sAfflicts Caucasian men in 20s-30s• Only rarely represents a metastatic lesion from a testicular primary Only rarely represents a metastatic lesion from a testicular primary

tumor, but testicular USG is usually performed to rule this outtumor, but testicular USG is usually performed to rule this out• If any other germ cell tumor histology is identified in the tumor, it If any other germ cell tumor histology is identified in the tumor, it

is treated as a mixed NSGCTis treated as a mixed NSGCT• AFP normal, AFP normal, -HCG may be elevated in 10%-HCG may be elevated in 10%

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MEDIASTINAL SEMINOMAMEDIASTINAL SEMINOMA

PresentationPresentation• Slow growing tumor, usually symptomatic at diagnosisSlow growing tumor, usually symptomatic at diagnosis• Commonly presents with chest pain, dyspnea, cough, Commonly presents with chest pain, dyspnea, cough,

weight lossweight loss• Presents infrequently with SVC syndromePresents infrequently with SVC syndrome• Bulky, lobulated, homogeneous mass, no calcificationsBulky, lobulated, homogeneous mass, no calcifications• Usually not invasive, but many have metastasized to Usually not invasive, but many have metastasized to

regional lymph nodes, lung and/or bone by the time of regional lymph nodes, lung and/or bone by the time of diagnosisdiagnosis

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MEDIASTINAL NONSEMINOMATOUS GERM MEDIASTINAL NONSEMINOMATOUS GERM CELL TUMORSCELL TUMORS

• Five TypesFive Types• Embryonal cell carcinomaEmbryonal cell carcinoma• Endodermal sinus tumor: elevated AFPEndodermal sinus tumor: elevated AFP• Choriocarcinoma: elevated Choriocarcinoma: elevated -HCG -HCG • Malignant TeratomaMalignant Teratoma• MixedMixed

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MEDIASTINAL NONSEMINOMATOUS GERM MEDIASTINAL NONSEMINOMATOUS GERM CELL TUMORSCELL TUMORS

• NSGCTs of the mediastinum have a worse prognosis than NSGCTs of the mediastinum have a worse prognosis than mediastinal seminomas or teratomasmediastinal seminomas or teratomas

• Occur in men in the 20-40 age groupOccur in men in the 20-40 age group• 20% of patients also have Klinefelter’s syndrome20% of patients also have Klinefelter’s syndrome

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TRACHEAL TUMORSTRACHEAL TUMORS

• Extremely rare tumors.Extremely rare tumors.• Comprise of 0.1 to 0.4 %of all diagnosed malignanciesComprise of 0.1 to 0.4 %of all diagnosed malignancies• Two types: squamous cell carcinoma M:F=3:1 Age:6Two types: squamous cell carcinoma M:F=3:1 Age:6thth decade decade adenoid cystic carcinomas M:F=1:1 younger ageadenoid cystic carcinomas M:F=1:1 younger age• Clinical feature: cough, dysnoea, dysphagia,stridor hemoptysis, Clinical feature: cough, dysnoea, dysphagia,stridor hemoptysis,

dysphoniadysphonia

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• Middle mediastinum is the commonest site of intrathoracic Middle mediastinum is the commonest site of intrathoracic lymphadenopathy.lymphadenopathy.

• Gross lymphadenopathy is a feature ofGross lymphadenopathy is a feature of 1)Tuberculosis1)Tuberculosis 2)Histoplasmosis. 2)Histoplasmosis. 3) Metastatic carcinoma3) Metastatic carcinoma 4) Lymphomas, 4) Lymphomas, 5)Sarcoidosis.5)Sarcoidosis.

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ENTERIC CYSTSENTERIC CYSTS

• Are located in the posterior mediastinum Are located in the posterior mediastinum • Lined by gastric or intestinal epithelium. Lined by gastric or intestinal epithelium. • All cysts may become1) InfectedAll cysts may become1) Infected 2) Bleed2) Bleed 3)Rupture 3)Rupture • Rupture into the Mediastinum. Rupture into the Mediastinum. Pleural cavity.Pleural cavity.

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NEUROGENIC TUMORSNEUROGENIC TUMORS

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PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM

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CLINICAL PRESENTATION OF MEDIASTINAL CLINICAL PRESENTATION OF MEDIASTINAL MASSMASS

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CLINICAL PRESENTATIONCLINICAL PRESENTATION

Asymptomatic massAsymptomatic massIncidental discovery – most commonIncidental discovery – most common50% of all mediastinal mass are asymptomatic50% of all mediastinal mass are asymptomatic80% of such mass are benign80% of such mass are benignMore than half are malignant if with symptomsMore than half are malignant if with symptoms

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CLINICAL PRESENTATIONCLINICAL PRESENTATION

Effects on Compression or invasion of adjacent tissues

• Chest pain, from traction on mediastinal mass, tissue invasion, or bone erosion is common

• Cough, because of extrinsic compression of the trachea or bronchi, or erosion into the airway itself

• Hemoptysis, hoarseness or stridor• Pleural effusion, invasion or irritation of pleural space• Dysphagia, invasion or direct invasioin of the esophagus• Pericarditis or pericardial tamponade• Right ventricular outflow obstruction and cor pulmonale

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CLINICAL PRESENTATIONCLINICAL PRESENTATION

Effects on Compression of nerves

• Hoarseness, invading or compressing the nerves recurrent laryngeal nerve • Horners syndrome, involvement of the sympathetic ganglia• Dyspnea, from phrenic nerve involvement causing diaphragmatic paralysis• Tachycardia, secondary to vagus nerve involvement

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CLINICAL PRESENTATIONCLINICAL PRESENTATION

• Superior vena cava• Vulnerable to extrinsic compression and obstruction because it is thin walled and

its intravascular pressure is low.

• Superior vena cava syndrome• Results from the increase venous pressure in the upper thorax , head and neck • characterized by dilation of the collateral veins in the upper portion of the head

and thorax and edema and phlethora of the face, neck and upper torso, suffusion and edema of the conjunctiva and cerebral symptoms such as headache, disturbance of consciousness and visual distortion

• Bronchogenic carcinoma and lymphoma are the most common etiologies

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MEDIASTINAL MASS: PRE TREATMENT MEDIASTINAL MASS: PRE TREATMENT EVALUATIONEVALUATION

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LYMPH NODESLYMPH NODES

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SUPRACLAVICULAR AND UPPER SUPRACLAVICULAR AND UPPER PARATRACHEALPARATRACHEAL

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PREVERTEBRAL AND PREVASCULARPREVERTEBRAL AND PREVASCULAR

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LOWER PARATRACHEALLOWER PARATRACHEAL

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SUBAORTIC AND PARAAORTICSUBAORTIC AND PARAAORTIC

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CARINAL, PARAESOPHAGEAL AND HILARCARINAL, PARAESOPHAGEAL AND HILAR

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THANK YOUTHANK YOU