Med|asnna| and

Cther Neop|asms


!ay P. 8yu
Iacu|ty D|sc|osures
no relauonshlps exlsL wlLh lndusLry.
Learn|ng Cb[ecnves
Aer Lhls sesslon, you wlll be able Lo:
uescrlbe Lhe dlagnosuc approach Lo medlasunal
leslons.
LlsL and descrlbe characLerlsucs of common
medlasunal Lumors.
LlsL and descrlbe characLerlsucs of some uncommon
lnLraLhoraclc neoplasms.
Med|asnna| and Cther Neop|asms
Medlasunal neoplasms
Approach Lo medlasunal masses
AnLerlor medlasunum (4 1's")
Mlddle medlasunum (wlde specLrum)
osLerlor medlasunum (mosL neurogenlc)
CLher neoplasms
Carclnold
Sallvary gland Lype carclnomas (mucoepldermold, adenold
cysuc)
PamarLoma
Med|asnna| Mass - ulagnosuc
Approach
Analyze key parameters:
1. 8adlologlc characLerlsucs - esp. locauon
2. Cllnlcal conLexL - esp. age, sympLoms, preexlsung
dlseases
3. 1empo of Lhe dlsease process
Aud|ence kesponse uesnon #1
Whlch of Lhe followlng sLaLemenLs regardlng
medlasunal masses ls correcL?
A. M8l should be obLalned ln mosL pauenLs wlLh an
undlagnosed medlasunal Lumor.
8. Less Lhan half of medlasunal masses occurrlng ln
adulLs are mallgnanL.
C. SympLomauc pauenLs are no more llkely Lo have a
mallgnanL leslon compared Lo asympLomauc ones.
u. Calclcauon seen on C1 assures benlgnlLy.
Med|asnna| Mass: lmaglng
C1 can dene Lhe locauon (anLerlor, mlddle or
posLerlor comparLmenL), slze/shape, denslLy, eecL
on ad[acenL sLrucLures.
Calclcauon does noL guaranLee benlgnlLy.
M8 Lyplcally adds llule addluonal lnformauon.
Med|asnna| Compartments
Anter|or: reLrosLernal space anLerlor Lo Lhe hearL
and greaL vessels
oster|or: from Lhe posLerlor hearL border and
Lrachea Lo Lhe posLerlor aspecL of Lhe verLebral
bodles
M|dd|e: beLween anLerlor and posLerlor
comparLmenLs
Mediastinal Compartments
Med|asnna| Mass
ln adulLs, 23-30 are mallgnanL, hlgher poruon (30) ln
chlldren.
SympLomauc pauenLs more llkely Lo have a mallgnancy
(30) compared Lo asympLomauc ones (10-20).
SympLoms may occur relaLed Lo:
Compresslon/lnvaslon of ad[acenL sLrucLures
MeLasLauc slLes
ConsuLuuonal
araneoplasuc
Med|asnna| Mass
Most common medlasunal leslons overall are:
1hymoma (anLerlor)
neurogenlc neoplasms (posLerlor)
Lymphomas (anLerlor/mlddle)
MeLasLases (anLerlor/mlddle)
Med|asnna| Mass: Causes
Anter|or M|dd|e oster|or
1hymoma Lymphomas neurogenlc Lumors
Lymphomas MeLasLases Lsophageal leslons
Cerm cell Lumors nonmallgnanL
adenopaLhy
Mlsc.
1hyrold CysLs
MeLasLases vascular leslons
Mlsc. Mlsc.
Anter|or Med|asnnum (41's")
1hymoma
Lymphomas
Cerm cell Lumors (2/3 1eraLoma)
lnLraLhoraclc 1hyrold
MeLasLauc 1umors
Mlscellaneous: paraLhyrold Lumors, mesenchymal
neoplasms, Morgagnl hernla
Aud|ence kesponse uesnon #2
Whlch of Lhe followlng ls Lhe mosL common
paraneoplasuc syndrome assoclaLed wlLh
Lhymoma?
A. Cood syndrome (hypogammaglobullnemla)
8. ure red cell aplasla
C. MyasLhenla gravls
u. 1hymoma-assoclaLed muluorgan auLolmmunlLy
1hymoma
MosL common medlasunal neoplasm ln adulLs.
1yplcally, superlor aspecL of Lhe anLerlor
medlasunum.
Low-grade eplLhellal neoplasm of Lhe Lhymus
Several classlcauon schemes - WPC, Lradluonal,
eLc.
1hymoma
usually adulLs (4
Lh
and 3
Lh
decades)
SympLoms ln 1/3-1/2: local, consuLuuonal,
paraLhymlc syndromes (m. gravls, pure red cell
aplasla, connecuve ussue dlseases,
hypogammaglobullnemla, eLc.)
Cx8/C1: round, well-clrcumscrlbed, so ussue mass,
usually homogeneous, Lyplcally anLerlor Lo Lhe aoruc
rooL.
Thymoma
56F with Myasthenia gravis and Thymoma
(Lymphocyte-predominant, Masaoka stage I)
1hymoma
ulagnosls: C1-gulded needle or surglcal blopsy
SLaglng and 1reaLmenL
LncapsulaLed (2/3) - Surglcal resecuon. 3-yr
survlval ~73.
lnvaslve (1/3) - Surglcal resecuon, ad[uvanL
chemo and radlauon. 3-yr survlval ~30.
MeLasLauc dlsease (rare) - Chemo
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1hymoma and Myasthen|a Grav|s
abnormallues: more oen hyperplasla (60-70) Lhan Lhymoma
(10-13).
30-30 of pauenLs wlLh
Lhymoma have M. gravls. 1hymecLomy
(ln <60 yr old) ylelds lmprovemenL ln
M. gravls, eecL noL lmmedlaLe.
yr old) ylelds lmprovemenL ln
M. gravls, eecL noL lmmedlaLe.
Cther 1hym|c 1umors

1hymlc carclnoma
adulLs (3
Lh
and 6
Lh
decades), sympLomauc
large, aggresslve Lumors.
1hymlc carclnold
ecLoplc hormone producuon ln 1/3, , Cushlng
syndrome, MLn l, SlAuP, carclnold syndrome
1hymlc lymphoma
1hymollpoma
1hymlc cysL
Med|asnna| Lymphomas
Lymphomas lnvolve Lhe medlasunum usually as parL
of wldespread dlsease.
rlmary medlasunal ln <10, Podgkln's > non-
Podgkln's.
usually young adulLs, sympLoms.
Cx8/C1: lobulaLed mass or bulky adenopaLhy ln Lhe
anLerlor medlasunum.
ulagnosls: core needle or surglcal 8x.
Hodgkin's Lymphoma (nodular sclerosing, stage II)
33F
4 yrs
later
Hodgkin's Lymphoma (nodular sclerosing, stage II)
Med|asnna| Lymphoma
1reaLmenL
Podgkln's: radlauon chemo
non-Podgkln's: radlauon + chemo
rognosls: beuer for Podgkln's (3-yr survlval
~73) Lhan non-Podgkln's.

Aud|ence kesponse uesnon #3
Whlch of Lhe followlng sLaLemenLs regardlng
germ cell Lumors ls correcL?
A. nonsemlnomaLous germ cell Lumors are assoclaLed
wlLh a beuer prognosls compared Lo LeraLomas and
semlnomas.
8. Medlasunal LeraLomas Lend Lo be cysuc.
C. Cerm cell Lumors are noL seen ln Lhe posLerlor
medlasunum.
u. Serum levels of Al and -hCC are elevaLed ln Lhe
ma[orlLy of pauenLs wlLh medlasunal semlnomas.
Germ Ce|| 1umors
3 of germ cell Lumors arlse ln exLragonadal
locauons, eg, medlasunum.
8enlgn and mallgnanL Lumors, usually anLerlor
medlasunum.
ln adulLs, 13 of anLerlor medlasunal Lumors.
Classlcauon: LeraLomas, semlnomas,
nonsemlnomaLous (embryonal) Lumors
ulagnosls: needle or surglcal blopsy, resecuon.
Germ Ce|| 1umors: 1eraLoma
60-70 of medlasunal germ cell Lumors.
ConLalns varylng amounLs of ussues derlved from 2
of 3 prlmluve germ layers: ecLoderm, mesoderm,
endoderm.
1yplcally chlldren, young adulLs.
Commonly asympLomauc, expecLorauon of halr,
sebaceous debrls uncommon.
Cx8/C1: well-clrcumscrlbed round or lobular mass,
may conLaln faL (73), calclcauon (20-40), or
cysuc (80-90) changes.
16l medlasunal mass
Germ Ce|| 1umors: 1eraLoma
MosL benlgn: occaslonal mallgnanL
degenerauon
1reaLmenL
surglcal exclslon Lhrough a medlan sLernoLomy or
posLerolaLeral LhoracoLomy
Lhoracoscoplc resecuon
Germ Ce|| 1umors: Semlnoma
1yplcally young men (3rd and 4Lh decades), usually
sympLomauc (chesL paln, dyspnea, fever, eLc.)
^ serum beLa-hCC level ln a mlnorlLy (10-33),
serum Al level usually normal.
Cx8/C1: large, lobular, homogeneous, well-
clrcumscrlbed mass.
1reaLmenL: radlauon and/or chemo (ma[orlLy have
meLasLauc dlsease), 3-yr survlval 80-90.
Germ Ce|| 1umors: nonsemlnomaLous
Chorlocarclnoma, embryonal carclnoma, endodermal
slnus Lumor, LeraLocarclnoma, mlxed germ-cell Lumors.
?oung men, sympLoms common (chesL paln, cough,
fever, welghL loss, SvC syndrome).
^ serum beLa-hCC 30, ^ Al 80.
Cx8/C1: large, lrregular, heLerogeneous mass (necrosls,
hemorrhage, or cysuc), lnvaslve, meLs.
1reaLmenL: clsplaun-based comblnauon chemo,
resecuon of resldual Lumor, 3-yr survlval 40-30.
31M with Pneumonia
High AFP, CT-guided core needle biopsy embryonal cell ca
ln remlsslon 12 yrs laLer
AL dlagnosls
31M Embryonal Cell Carcinoma
Intrathorac|c 1hyro|d
1hyrold golLer exLendlng lnLo medlasunum.
Commonly asympLomauc, sympLoms by compresslng Lhe
Lrachea or esophagus.
MosL benlgn, 10-13 conLaln cancer or lymphoma.
C1: superlor medlasunal lobular, dlscreLe mass wlLh
heLerogeneous auenuauon, Lracheal narrowlng or devlauon.
Cauuon ln admlnlsLerlng lodlnaLed radloconLrasL dye - may
lnduce hyperLhyroldlsm.
1reaLmenL: surglcal exclslon, usually Lhrough cervlcal lnclslon.
73M exertional dyspnea x several yrs, recent dysphagia
Cther Anter|or Med|asnna| Masses
araLhyrold: cysLs, carclnomas, adenomas
Mesenchymal Lumors: lymphangloma, llpoma,
lelomyoma, eLc.
MeLasLauc dlsease
Morgagnl hernla
CharacLerlsuc radlologlc feaLures
Ioramen of Morgagn| nern|a
M|dd|e Med|asnnum
ConLalns hearL, large blood vessels (ascendlng
aorLa / arch, brachlocephallc vessels, maln
pulmonary arLerles / velns, vena cavae), lymph
nodes, Lrachea, and maln bronchl
Many neoplasuc and nonneoplasuc dlseases
can cause medlasunal and/or hllar
lymphadenopaLhy - meLasLases (esp. lung
cancer), lymphomas, sarcoldosls, drugs, slllcosls,
amyloldosls, CasLleman's dlsease, eLc.
M|dd|e Med|asnnum
Lymphomas
MeLasLases
nonmallgnanL lymphadenopaLhy - ,
sarcoldosls, drugs
Medlasunal cysLs
vascular leslons
Mlscellaneous - , lymphanglomas, hernlas
62F Mediastinal & R hilar adenopathy
Lx-smoker
8ecenL selzure
lnA cervlcal node -
meLasLauc breasL Ca
Med|asnna| Cysts
8ronchogen|c cyst (mosL common)
Subcarlnal, paraLracheal, occaslonally lung
usually, homogeneous waLer-auenuauon
C1-gulded or bronchoscoplc asplrauon of uld, or surglcal
exclslon
Lnter|c cyst
Ma[orlLy are dlagnosed ln chlldhood.
er|card|a| cyst
AsympLomauc, waLer-auenuauon mass aL 8 CA
usually, no lnLervenuon needed.
Bronchogenic Cyst
53M
Chest
discomfort
Pericardial Cyst
80M COPD, abnormal CXR
Pericardial Cyst
80M COPD, abnormal CXR
Vascu|ar Les|ons
vascular leslons, , aneurysms and sLulas,
consuLuLe ~10 of all medlasunal masses.
May radlologlcally resemble neoplasm.
ulagnosls: by conLrasL-enhanced C1, M8l,
and/or anglography
76M Aneurysms
Cther M|dd|e Med|asnna| Masses
Lymphanglomas
congenlLal or acqulred
usually ln neck, can be medlasunal
sollLary or mululobulaLed cysuc masses
benlgn buL can slowly enlarge and lnlLraLe
1reaLmenL: compleLe resecuon, lf feaslble
Medlasunal llpomaLosls
abnormal adlpose ussue accumulauon ln Lhe medlasunum
cllnlcal conLexL - obeslLy, sLerold excess
67I Med|asnna| Lymphang|oma
67I Med|asnna| Lymphang|oma
Mediastinal Lipomatosis
oster|or Med|asnnum
neurogenlc neoplasms
Lsophageal leslons
Mlscellaneous - , laLeral menlngocele,
exLramedullary hemaLopolesls, descendlng
aoruc aneurysm, 8ochdalek hernla
Aud|ence kesponse uesnon #4
Whlch of Lhe followlng sLaLemenLs regardlng
neurogenlc Lumors ls correcL?
A. AccounL for Lhe ma[orlLy of prlmary posLerlor
medlasunal neoplasms.
8. MosL pauenLs are sympLomauc.
C. nearly one-half of neurogenlc Lumors exLend
Lhrough Lhe neural foramen lnLo Lhe splnal canal
(dumbbell Lumor").
u. MosL are mallgnanL.
Neurogen|c 1umors
AccounLs for 73 of prlmary posLerlor
medlasunal neoplasms.
Arlse from Lhe perlpheral, auLonomlc, or
paragangllonlc nervous sysLems.
90 ln Lhe paraverLebral guuers.
AsympLomauc ln 1/2 of cases.
1yplcally rsL deLecLed on Cx8.
Neurogen|c 1umors
Ma[orlLy (70-80) benlgn.
10 of medlasunal neurogenlc Lumors exLend Lhrough
neural foramen lnLo splnal canal ( shape), M8l
ls more sensluve Lhan C1 ln dellneaung lnLrasplnal
exLenslon.
Cccurrence of muluple leslons suggesLs
neurobromaLosls.
1reaLmenL: surglcal resecuon (LhoracoLomy or vA1S),
when feaslble.
Neurogen|c 1umors
erlpheral nerve sheaLh Lumors
MosL common Lype of neurogenlc Lumor (~1/2).
8en|gn - schwannoma (neurllemmoma),
neurobroma, commonly asympLomauc, round or
lobular mass bony eroslon.
Ma||gnant - mallgnanL perlpheral nerve sheaLh
neoplasm (ganglloneuroma, ganglloneuroblasLoma,
neuroblasLoma), palnful, heLerogeneous mass wlLh
local lnvaslon. neurobromaLosls ln 1/2.
35M physician with asymptomatic posterior
mediastinal mass on CXR - Neurilemmoma
Dumbbell Tumor
20M Neurofibromatosis-1
27F Neurofibromatosis-1
Malignant peripheral nerve sheath tumor
Neurogen|c 1umors
neoplasms of Lhe sympaLheuc ganglla
more common ln Lhe pedlaLrlc populauon
ma[orlLy mallgnanL
ganglloneuroma, ganglloneuroblasLoma, and
neuroblasLoma
Medlasunal paragangllonlc Lumors
low-grade, lndolenL neoplasms
caLecholamlne-secreung paragangllomas are
assoclaLed wlLh neurobromaLosls-1, von Plppel-
Llndau dlsease, Carney Lrlad, and MLn2
Cther oster|or Med|asnna| Masses
PlaLal hernlas
LaLeral Lhoraclc menlngoceles
CharacLerlsuc radlologlc feaLures
LxLramedullary hemaLopolesls
Cllnlcal conLexL - hemogloblnopaLhles, chronlc anemla,
myeloprollferauve dlsorders
1horaclc ducL cysL
lncreaslng slze wlLh meals, dlagnose by needle asplrauon
of chylous uld
8ochda|ek
nern|a
28F Extramedullary Hematopoiesis - Thalassemia major
28l Lxtramedu||ary nematopo|es|s - 1halassemla ma[or
Med|asnna| Mass: Causes
Anter|or M|dd|e oster|or
1hymoma Lymphomas neurogenlc Lumors
Lymphomas MeLasLases Lsophageal leslons
Cerm cell Lumors nonmallgnanL
adenopaLhy
Mlsc.
1hyrold CysLs
MeLasLases vascular leslons
Mlsc. Mlsc.
C1nLk NLCLASMS
(unCCMMCn 1PC8AClC 1uMC8S nC1
ulSCuSSLu LLSLWPL8L ln 1PL CCu8SL)

WnC C|ass|hcanon of Lung]|eura|
1umors
1. LplLhellal - lung cancers, carc|no|d, sa||vary-g|and
type (mucoepldermold, adenold cysuc), eLc.
2. So 1lssue - brous, chondroma, eLc.
3. MesoLhellal - mesoLhelloma, eLc.
4. Mlscellaneous - hamartoma, Lhymoma, eLc.
3. Lymphoprollferauve - Ll, MAL1oma, eLc.
6. Secondary Lumors
7. unclassled Lumors
8. 1umor-llke leslons - LumorleL, pseudoLumor, eLc.
Carc|no|d
MallgnanL wlLh neuroendocrlne dlerenuauon,1-2 of
all Lhoraclc Lumors.
no clear assoclauon wlLh smoklng. Someumes assoclaLed
wlLh MLn 1 or famlllal carclnold.
PlsLologlcally subclassled: Lyplcal and aLyplcal (hlgher
mlLouc acuvlLy and necrosls).
1yplcal carclnold - lndolenL behavlor, nodal spread
uncommon. 3-year survlval 83-100.
ALyplcal carclnold - aggresslve course, meLasLasls Lo
medlasunal nodes ln 20-60. 3-year survlval 40-60.
Carc|no|d
1yplcal bronchlal carclnold usually presenL ln Lhe 3Lh
decade of llfe, older for aLyplcal.
Cen sympLoms relaLed Lo bronchlal obsLrucuon
(recurrenL pneumonlas or wheezlng) or vascularlLy
(hemopLysls), occaslonally carclnold syndrome, Cushlng's
syndrome, acromegaly.
Cenerally auached Lo Lhe bronchus by a broad base, can
be polypold, creaLe a ball-valve eecL.
Cx8, C1: obsLrucuve pneumonla, dlscreLe hllar mass, or
perlpheral nodule.
67M asymptomatic nonsmoker, hemoptysis -
Carcinoid, typical
67M asymptomatic nonsmoker, hemoptysis
- Carcinoid, typical
Carc|no|d
Locallzed bronchlal carclnold - surglcal resecuon
of Lhe Lumor wlLh medlasunal lymphadenecLomy.
MeLasLauc carclnold Lumors - ocLreoude, alpha
lnLerferon, cyLoLoxlc chemoLherapy. ConLrol of llver
meLasLases by surglcal resecuon, embollzauon
Lherapy, radlofrequency ablauon, or cryoablauon
can be consldered for hepauc-predomlnanL dlsease.
Sa||vary G|and 1ype Carc|nomas
Mucoepldermold carclnoma and adenold
cysuc carclnoma are Lhe mosL common forms
ln Lhe Lhorax.
AccounL for 0.1-0.2 of all Lhoraclc Lumors.
Low-grade mallgnancles, lymph node spread ls
rare Lo uncommon.
no clear assoclauon wlLh smoklng.
Mucoep|dermo|d carc|noma
uerlved from mlnor sallvary gland ussue.
Lndobronchlal mass ln Lhe Lrachea or ma[or bronchl.
PlsLologlcally, 3 componenLs: mucus-secreung,
squamous, and lnLermedlaLe cells.
Wlde age range, chlldren Lo elderly.
usually cough, hemopLysls, wheezlng, or obsLrucuve
pneumonla.
Surglcal resecuon, lf successful, excellenL prognosls.
44l nonsmoker wlLh cough/wheeze x 10 mo
44l nonsmoker wlLh cough/wheeze x 10 mo
- Mucoepldermold Ca
Adeno|d Cysnc Carc|noma (Cyllndroma)
usually ln Lhe Lrachea or a ma[or bronchl.
AdulLs (mosL commonly 3Lh decade)
uyspnea, cough wheeze, hemopLysls.
Surglcal resecuon ls Lhe LreaLmenL of cholce.
Medlan survlval aer resecuon ~6 years.
ropenslLy Lo recur locally and meLasLaslze, laLe
recurrence (13-20 years).
8adlauon and palllauve laser Lherapy for
unresecLable Lumors.
31l nonsmoker wlLh asLhma" x 2 yr, obsLrucuve
pneumonla/empyema - Adenold cysuc carclnoma
namartoma
MosL common benlgn neoplasm Lo occur ln Lhe lung
(73 of benlgn lung Lumors), accounLs for 4 of
Sns.
8enlgn Lumor-llke malformauon composed of an
abnormal and dlsorganlzed mlxLure of ussue
elemenLs (carulage, connecuve ussue, smooLh
muscle, faL, and resplraLory eplLhellum).
All pauenL age groups (hlghesL lncldence ln 4
Lh
- 7Lh
decades of llfe)
AsympLomauc
namartoma
Cx8, C1: perlpheral, sollLary, round or lobulaLed
opaclLy wlLh smooLh marglns, generally 1-3 cm ln
slze. Calclcauon ln 23, appearlng as small ecks
LhroughouL Lhe leslon (popcorn" calclcauon
lnfrequenL). Areas of faL denslLy by C1 ln 30.
Crow slowly, lf aL all
ulagnosuc conrmauon, lf needed, by 11nA,
bronchoscopy or vA1S.
namartoma
(Hartman. Radiol Clin N Am 2005)
(Tang ERJ 2003)
64M ex-smoker, sLable mass
Med|asnna| and Cther Neop|asms
Medlasunal neoplasms
Approach Lo medlasunal masses
AnLerlor medlasunum (4 1's")
Mlddle medlasunum (wlde specLrum)
osLerlor medlasunum (mosL neurogenlc)
CLher neoplasms
Carclnold
Sallvary gland Lype carclnomas (mucoepldermold, adenold
cysuc)
PamarLoma
Summary of key o|nts
ulagnosuc approach Lo medlasunal mass lnvolves
analysls of radlologlc characLerlsucs (esp. locauon),
cllnlcal conLexL, and Lempo of dlsease process.
MosL common medlasunal leslons are Lhymoma,
neurogenlc neoplasms, lymphomas, and meLasLauc
dlsease.
uncommon lnLraLhoraclc Lumors such as carclnold,
sallvary gland Lype neoplasms, and hamarLoma are
assoclaLed wlLh characLerlsuc presenung feaLures.
kecommended kead|ng and Add|nona|
kesources
uuwe 8v, eL al. 1umors of Lhe medlasunum. ChesL
2003,128:2893-909.
klm !? eL al. 1umors of Lhe medlasunum and chesL wall. Surg
Clln n Am 2010,90:1019-40.
1ormoehlen LM, eL al. 1hymoma, myasLhenla gravls, and
oLher paraneoplasuc syndrome. PemaLol Cncol Clln n Am
2008,22: 309-26.
1anveLyanon 1. undersLandlng Lhe uncommon Lhoraclc
Lumors. Cancer ConLrol 2006,13:232-3.
8orczkuk AC. 8enlgn Lumors and Lumorllke condluons of Lhe
lung. Arch aLhol Lab Med 2008,132:1133-48.
1he Lnd - 1hank you