Mediastinal Tumors and Cysts
Sung Chul Hwang, M.D.
Dept. of Pulmonary and Critical Care Medicine
Ajou University School of Medicine
Introduction
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Silent in early phase
Mainly cause pressure symptoms
Incidentally discovered by routine x-rays
Specific disease entities according to
anatomical, and embryologic origin
• 50% malignant in children where as 25%
in adults
• Metastatic tumor is the most common
tumor
Symptoms and Signs
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Pain
Cough
Hemoptysis
SVC syndrome
Hoarseness
Dyspnea
Horner’s syndrome
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Dysphagia
Pleural effusion
Stridor
Myathenia Gravis
Phrenic nerve palsy
Chylothorax
Diagnosis
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Chest PA & Lateral
Bucky film
Chest CT
Fluoroscopy
Bronchoscopy
Esophagogram
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NAB
Isotope Scanning
Angiography
Thoracotomy
VATS
Medistinoscopy
Common Diseases of
the Mediastinum
Thymoma
• Anterior and Superior mediastinum
• Most common (20%)of mediastinal tumor in
adults but rarely seen in children
• 2/3 is malignant
• Equal frequency in males and females
• 30 – 50 yrs
• Various Classification : Lymphocytic,
Epithelial, Spindle Cell
• 50% are asymptomatic
• Associated diseases : MG (35%), PRCA,
DiGeroge SD, Carcinoid, Eaton-Lambert,
agammaglobulinemia, myocarditis,
thyrotoxicosis, etc
Thymoma (Staging)
• Stage I : contained within an intact
capsule
• Stage II: extension through the
capsule to surrounding fat, pleura,
pericardium
• Stage III : Intrathoracic metastasis
• Stage IV: Extrathoracic Metastasis
Thymoma(Treatment)
• Stage I : Surgical resection Recurrence
2-12%
• Stage II & III : Surgery + Radiotherapy
• Stage IV : Multimodality Induction
chemotherapy, surgery + post op
Radiotherapy
• 5-year Survival 12 – 54 %, not affected
by the presence of Myasthenia Gravis
Thymoma
Thymoma
Ca++
mass
Thymus
Lymphoma
• Metastatic is most common
• 5-10% is mediastinal primary
• Second moost common Anterior
Mediastinal Mass in Adults
• Malignant > Hodgkin’s
• Dx: Mediastinoscopy, thoracotomy
• NAB : Usually not confirmatory
Hodgkin’s Lymphoma
“mediastinal widening”
Germ Cell Tumors
• Anterior Mediastinal location
• Mainly in late teens 15 %of Ant. Med. Tumors
in Adults, 24 % in children
• 1/5 is Malignant
• Cystic Teratoma(Dermoid Cyst) vs. Solid
tumor (Teratoma)
• Solid tumor : 1/3 malignant
• Radiosensitive
• Teratoma, Malignant teratoma,
Seminoma(dysgerminomas)
Teratoma
Teratoma
Teratoma
Teratoma
Substernal Thyroid Tissues
• Develops from cervical goiter or
intrathoracic remnants
• Can be diagnosed without biopsy by
Radioactive iodine scan
• No treatment unless symptomatic,
usually pressure symptoms
Rtrosternal Goiter
Neurogenic Tumors
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Posterior mediastinal location
1/5 of mediastinal tumor
Originate in neural crest
Ganglioheuroma : most common in
the textbook
• Neurilemmoma – most common in
Korea : “Dumb bell Tumor”, neural
sheath origin
Poosterior Mediastinal Tumor
( Neurillemmoma) )
“Dumb-bell”
Tumor
Neurilemmoma(Schwannoma)
Para-ganglioma
Mesenchymal Tumors
• Lipoma, Fibroma, Mesothelioma
• Superior or Anterior mediastinal
location
• Diagnosis with CT scan
• May cause Hypoglycemia
Mediastinitis
• Acute : endoscopy complication,
Boerhaave’s SD, operation,
esophageal rupture, median
sternotomy
• Chronic : Tbc, histoplasmosis,
silicosis, fibrosing mediastinitis
Fibrosing Mediastinitis
• 20- 40 years
• Cough, Dyspnea, or Hemoptysis
• Most common cause of Benign SVC
syndrome
• Almost always remote Histoplasmosis
• Plain X-rays may be normal or only minimal
changes
• Partially calcified Mass on CT is diagnostic
Fibrosing Mediastinitis
F/29 with SVC Syndrome by Histoplasmosis
Fibrosing Mediastinitis
F/29 with SVC Syndrome by Histoplasmosis
Pneumomediastinum
• Spontaneous : mainly in young male
adults
• Hamman sign
• Present along the Left sternal border
• Substernal pain, cough, Dyspnea,
Dysphagia
Pneumomediastinum
Benign Cysts
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Most Common in Middle mediastinum
20% of mediastinal masses
Less common in Korea
Usually asymptomatic
Bronchogenic cyst(32%), pericardial
cyst(35%), enteric cyst(12%), thymic
cyst, and thoracic duct cyst
Pericardial Cyst
• Thin-walled, mesothelial cell lining
• most common in Right C-P angle
• Simple cysts are almost always
asymptomatic
• Rare cardiac impingement
Pericardial Cyst (1)
Pericardial Cyst (2)
Bronchogenic Cysts
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30 - 60% of all mediastinal cysts
Lined by ciliated respiratory epithelium
May contain cartilages or mucous
Communicate with tracheobronchial
trees
• May become infected
• Wheezing, dyspnea, recurrent pulmonary
infections
Bronchogenic Cyst
Bronchogenic Cyst
Aortic Aneurysm
Thymolipoma
Paratracheal Lymphadenopathy
Paratracheal Lymphadenopathy with
Tracheal Compression
Paratracheal Lymphadenopathy
Paratracheal Malignant
Lymphadenopathy