THE

MEDIASTINU
M

The Mediastinum

Subdivisions of the Mediastinum

as seen in cross section

anterior
mediastinum (1)
middle
mediastinum (2)
posterior
mediastinum (3)

Anterior Superior
Mediastinum

Thymus Gland
Aortic Arch
SVC ( Superior Vena Cava )
Lymph Nodes
Parathyroid Gland
Ectopic Thyroid Tissue

Middle Mediastinum
Pericardium
Heart
Great Vessels
Trachea and tracheal bifurcation
Main Bronchi
Phrenic Nerves
Hilar Lymph Nodes

Posterior Mediastinum
Esophagus
Vagus nerves
Sympathetic Chain
Thoracic duct
Descending thoracic aorta
Azygos vein
Hemiazygos vein
Paravertebral lymph nodes

Diagnostics

Chest X-Rays
CT ( Computed Tomography)
MRI
CT guided needle biopsy
FNAB vs Core
Mediastinoscopy with biopsy
VATS
Radionuclide Scanning
Angiography

MEDIASTINAL TUMORS
AND CYSTS
Adults - 25-35% malignant
neurogenic tumors most
common
( 20% )
thymomas, congenital cysts,
lymphomas
Children - 25-45% malignant
lymphomas, neurogenic
tumors

SYMPTOMATOLOGY
1/3 - asymptomatic; in adults
correlates
with malignancy
Nonspecific chest pain, cough, dyspnea
( COMPRESSION symptoms )
Endocrine symptoms
Hypertension pheochromocytoma
Hypercalcemia parathyroid tumor
Thyrotoxicosis intrathoracic goiter
Gynecomastia - choriocarcinoma

THYMOMA
MOST COMMON anterior mediastinal
mass in adults; rare in children
1/3 asymptomatic at diagnosis
Symptoms:
Mass effects
Systemic effects due to
paraneoplastic
syndromes ( Myasthenia gravis )

THYMOMA
Myasthenia gravis seen in 10-50% of
patients with thymomas; conversely,
thymomas seen in only 8-15% of patients
with Myasthenia gravis
Histopathology based on proportion of
lymphocytes to epithelial elements
Malignancy is based on invasive character
presence of capsular or vascular invasion
Treatment: surgery
radiation / chemotherapy

GERM CELL TUMORS

Primary EXTRA-gonadal germ cell
tumors are RARE
1% of all mediastinal tumors
Most common in the anterior
mediastinum
Usually in young adults; male to
female ration is 4:1

GERM CELL TUMORS

Seminoma
Embryonal cell carcinoma
Choriocarcinoma
Malignant teratoma
Endodermal yolk sac tumor

GERM CELL TUMORS

Role of tumor markers
B-HCG
A-fetoprotein
Carcinoembryonic antigen ( CEA )
Diagnosis: CT scan
Treatment: attempt complete resection
adjuvant therapy
Seminomas radiosensitive;
better
prognosis
Other tumors - ?chemotherapy

LYMPHOMAS
Mediastinal involvement seen in 50% of
both Hodgkins and non-Hodgkins
lymphoma
MOST COMMON mediastinal malignancy
Most commonly seen in the anterior
mediastinum
Symptoms cough
fever
chest pain
weight
loss

LYMPHOMAS
Diagnosis - Chest x-ray and CT Scan
Mediastinotomy /
mediastinoscopy
with biopsy
Treatment radiotherapy
chemotherapy
surgery mainly for
diagnosis

TERATOMAS
Mostly in adolescents; 80-85% are benign
Originate from branchial cleft pouch
Contain all 3 germ layers: endoderm,
mesoderm and ectoderm
Many are asymptomatic; others have
symptoms related to compression
Smooth-walled cystic or solid lesions on xray pr CT Scan
Treatment: total surgical excision

MIDDLE MEDIASTINAL
LESIONS
Usually cystic
2 most common lesions pericardial cyst
bronchogenic cyst
Pericardial cyst usually asymptomatic;
found on chest x-ray, at cardiophrenic angle;
surgery is both diagnostic and therapeutic
Bronchogenic cyst usually arise posterior to
the carina; may be asymptomatic or may
cause compression symptoms; treated by
excision

POSTERIOR MEDIASTINAL
LESIONS
Mostly neurogenic lesions, along the
paravertebral gutter
Up to 25% are malignant
75% occur in children less than age 4; higher
probability of malignancy
Common histologic types
Neurilemomas from Schwann cells
Neurofibromas can become malignant
Neurosarcomas
Ganglioneuromas from sympathetic ganglia
Neuroblastomas also from sympathetic chain

POSTERIOR MEDIASTINAL
LESIONS
Pheochromocytomas may occur rarely;
behave similarly to adrenal lesions
Symptoms chest pain
spinal cord compression
endocrine symptoms
neuroblastoma fever, vomiting,
diarrhea, cough
Treatment: surgical
radiotherapy for malignant
lesions

SUPERIOR VENA CAVA

SYNDROME
85% of cases are due to Bronchogenic CA
( most commonly small cell type 40% )
Other causes mediastinal tumors
fibrosing mediastinitis
thoracic aortic aneurysm
SVC thrombosis due to
catheterization / instrumentation

SUPERIOR VENA CAVE

SYNDROME
Presents as venous distension, facial edema,
plethora, headache, respiratory symptoms
Diagnosis confirmed by CT Scan
Treatment usually palliative radiation or
chemotherapy
?steroids ?diuretics
role of surgery for benign lesions
( bypass or vein reconstruction )
endovascular procedures - stenting

MEDIASTINITIS
Acute vs Chronic infection
Acute infection
Fulminant infection with high morbidity and
mortality
RAPID spread through areolar planes, within
24 hours, to involve neck and lungs
Both Gram (+) and (-) bacteria
Esophageal or tracheal perforation; open
heart
surgery more indolent course; usually
due to
Staphylococcus ( MRSA )

ACUTE MEDIASTINITIS
Symptoms chest pain, dysphagia,
respiratory distress, subcutaneous
crepitation
Diagnosis chest x-ray
water soluble contrast study
Treatment must be early and aggressive
hydration, drainage, control of
primary problem

CHRONIC
MEDIASTINITIS
Chronic fibrosing mediastinitis
Chronic fibrosis and
inflammation
Usually due to granulomatous
infection
( TB, Histoplasmosis )