C 3 Mediastinum

SURGI CAL DI SEASES
OF MEDI ASTI NUM

2 hours
SURGICAL DISEASES OF MEDIASTINUM 2 hours
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C 3
- Surgical Diseases Of Mediastinum
The mediastinum is the central portion of the chest and extends from:
the thoracic inlet above
the diaphragm below.
It is bounded
anteriorly by the sternum,
laterally by the mediastinal pleura,
posteriorly by the vertebral bodies.
To assist in the localization of mediastinal abnormalities, the
mediastinum is traditionally divided into :
superior,
anterior,
middle, and
posterior compartments.
SURGICAL DISEASES OF MEDIASTINUM
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If on a lateral chest radiograph, a line is drawn from the lower end of the manubrium
to the lower edge of the body of the fourth thoracic vertebral body, the superior
mediastinum is the area above that line.
The pericardial sac and its contents divide the inferior mediastinum into its anterior,
middle, and posterior compartments.

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T4
The contents of the mediastinum and its compartments are :

Superior Mediastinum

Thymus gland
Aortic arch and great vessels
Upper trachea
Upper esophagus

Anterior Mediastinum

Thymus gland
Lymph nodes

Middle Mediastinum

Pericardium
Heart
Tracheal bifurcation
Main-stem bronchi
Subcarinal and peribronchial lymph nodes
Ascending aorta

Posterior Mediastinum

Esophagus
Descending aorta
Nerves (sympathetic, parasympathetic, and intercostal)
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CT has permitted visualization of mediastinal structures that in the past were
obscured on the standard posteroanterior chest radiograph by the sternum, spine,
and cardiac silhouette

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(A) Scan at level of the aortic arch and mid trachea.
(B) Scan at level of carina.
(C) Scan at the level of the left atrium.
ACUTE MEDIASTINITIS
Acute infection of the mediastinum,
regardless of the cause, is associated with
great morbidity and mortality.
Although acute mediastinitis can follow:
penetrating wounds of the chest
complicated with
esophageal perforation - the most
common cause of acute suppurative
mediastinitis.
tracheobronchial tree,wounds
cardiac operations in which the
mediastinum has been opened


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INFECTIONS
CAUSES OF ESOPHAGEAL PERFORATION

INSTRUMENTAL
Endoscopy
Dilation
Intubation
Sclerotherapy
Laser therapy

NONINSTRUMENTAL
Barogenic trauma
Postemetic (Boerhaave syndrome)
Blunt chest or abdominal trauma
Other (eg, labor, convulsions, defecation)
Penetrating neck, chest, or abdominal trauma
Operative trauma
Esophageal reconstruction (anastomotic disruption)
Vagotomy, pulmonary resection, hiatal hernia repair,
esophagomyotomy
Corrosive injuries (acid or alkali ingestion)
Erosion by adjacent infection
Swallowed foreign body
ESOPHAGEAL PERFORATION
Pathophysiology
Regardless of the specific cause, the resulting mediastinitis and his severe consequences
demand prompt recognition and treatment of the esophageal disruption.
Esophageal and gastric contents are sucked into the mediastinum by respiratory movements
and negative intrathoracic pressure.
Salivary enzymes, gastric acid, bile, and food enter the mediastinum, the presence of oral
bacteria in these fluids initiates a fulminant infection and an inflammatory response
progresses.
This mediastinal burn produces massive fluid accumulation, which can displace the trachea,
heart, or lungs
The entire process is aggravated if there is preexisting esophageal disease
Clinical Features
Patients with esophageal perforation characteristically present with:
cervical or thoracic pain,
difficulty swallowing,
respiratory distress,
fever.
Pain features depends with esophageal perforation location
Cervical or upper thoracic esophagus generally cause cervical or high retrosternal pain
Middle or distal esophagus produce anterior thoracic, posterior thoracic, interscapular, or
epigastric pain.
Upper thoracic esophageal perforations may produce signs of right pleural effusion
Distal esophageal perforation is associated with left pleural effusion.

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ESOPHAGEAL PERFORATION ACUTE MEDIASTINITIS
Diagnosis
Pain or fever after esophageal instrumentation or operation is indicative of an esophageal
perforation and is an indication for an immediate contrast esophagogram with hidro soluble
contrast substance.

A chest roentgenogram may help to confirm the diagnosis by demonstrating air in the soft
tissues of the neck or mediastinum(pneumomediastinum) or a hydrothorax or
pneumothorax.
A contrast-enhanced CT scan may lead to the diagnosis
The morbidity and mortality rates associated with esophageal perforation are directly
related to the time interval between diagnosis of the injury and its repair or drainage

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Barium esophagogram demonstrates a perforation (arrow) in the
middle third of the thoracic esophagus.
Management(Principles of Surgical Treatment)
The initial treatment of an acute esophageal perforation focuses on:
decreasing bacterial and chemical contamination of the mediastinum
restoring intravascular volume losses.

Oral intake is withheld, the patient is instructed not to swallow saliva. A disposable
oral dental suction is often helpful for evacuating oral secretions.
Broad-spectrum intravenous antibiotics with activity against oral flora are
administered using a combination of a cephalosporin (cefazolin or cefamandole), 1 g/4
h, and an aminoglycoside (gentamicin or tobramycin), 1 to 1.5 mg/kg/8 h.
Nasogastric tube decompression of the stomach is instituted to minimize possible
gastroesophageal reflux and further soiling of the mediastinum.
Therapy of esophageal perforation is influenced by:
The location of the tear
The size of the tear
The cause of the tear,
The length of delay in diagnosis,
The extent of mediastinal and pleural contamination
The presence of intrinsic esophageal disease.
The treatment of an acute esophageal perforation must be individualized.

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Nonoperative Therapy
Although most esophageal perforations require operative intervention, BUT
selected patients may be managed nonoperatively with:
Cessation of oral intake,
Administration of antibiotics,
Intravenous hydration until the disruption heals or the small contained cavity begins
to decrease in size.
Criteria for nonoperative therapy of an esophageal perforation include the following:
A local, contained disruption without evidence of pleural contamination
(hydrothorax or pneumothorax),
A walled-off extravasation in which contrast material drains back into the
esophagus,
Minimal or no symptoms,
Minimal or no evidence of systemic infection (fever or leukocytosis).
The usual clinical settings in which such perforations are encountered are:
cervical esophageal tears caused by esophagoscopy;
intramural dissections that have occurred during dilation of a stricture or pneumatic
dilation for achalasia;
asymptomatic esophageal anastomotic disruption discovered on a routine
postoperative contrast study.

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When treating such perforations conservatively,
oral hygiene should be optimized to minimize further contamination by oral bacteria
A nasogastric tube is seldom helpful.
Nutrition may be maintained by a nasogastric feeding tube, gastrostomy, or jejunostomy or
by intravenous hyperalimentation until oral intake can be resumed, usually 1 to 3 weeks after
the injury.
Nonoperative therapy is best suited for patients presenting more than 24 hours after the injury
with no systemic evidence of sepsis and clearly demonstrable, contained, internally drained leaks
on barium esophagogram.
Infants with iatrogenic perforation can often be successfully managed without operation.
Perforations complicating pneumatic dilation for achalasia occur in 4% to 6% of patients, and
most are small and well-managed medically with antibiotics and intravenous hyperalimentation.
For the remainder of patients with perforations, operative therapy is generally indicated.
Operative Therapy Of Esophageal Perforations
Cervical and Upper Thoracic Esophageal Perforations lead to:
Progressive contamination of the mediastinum as infection descends dependently along the
fascial planes from the neck.
Unless adequate drainage is accomplished, death from mediastinitis follows.
Most cervical and upper thoracic perforations may be adequately drained through a cervical
approach, placing drains in the retroesophageal space.
An incision is made parallel to the anterior border of the sternocleidomastoid muscle, which is retracted laterally along with the carotid sheath and its
contents. The trachea, thyroid gland, and strap muscles are retracted medially. It may be necessary to divide the omohyoid muscle, middle thyroid vein, and
occasionally the inferior thyroid artery to reach the prevertebral fascia. Once this is identified, blunt finger dissection into the prevertebral space gives access
to the abscess cavity, and appropriate drains are placed and brought out through the skin incision.
When a cervical esophageal perforation extends into either pleural cavity or the lower mediastinum, the cervical approach is inadequate, and transthoracic
drainage is required.

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Operative Therapy Of Esophageal Perforations(suite)


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Approach for drainage of a cervical
esophageal perforation.
Thoracoesophageal Perforations
Normal esophagus
The earlier an esophageal perforation is recognized and treated, the better is the chance
for successful primary repair.
Most agree that such perforations that are not associated with intrinsic esophageal
disease are best treated with primary repair of the tear combined with wide mediastinal
drainage.
A change in philosophy has occurred regarding the application of primary repair to
perforations occurring in an normal esophagus regardless of the duration of the injury.
Perforations of the lower third of the esophagus are approached through a left
thoracotomy in the sixth or seventh interspace, while more proximal thoracic esophageal
tears are approached through a right thoracotomy.
Mediastinal drainage is achieved by opening the mediastinal pleura from the level of the
tear to the thoracic inlet superiorly and the diaphragm inferiorly, irrigating the
mediastinum, and placing a large-bore chest tube that allows transpleural drainage.
Perforations of the intraabdominal esophagus unassociated with pleural contamination
are approached through the abdomen.
Esophagus With Intrinsic Disease
Perforations associated with distal obstruction from intrinsic esophageal disease
constitute a problem because breakdown of an attempted repair is common in the
presence of distal obstruction.
The associated obstruction must be relieved at the same time of repair and drainage.


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Patients with intrinsic esophageal disease that cannot be treated effectively by more
conservative means are best treated by esophageal resection.
Immediate esophageal substitution with colon(retrosternal) or stomach (in the posterior
mediastinum) in the native esophageal bed.
15
Final position of the mobilized stomach in the posterior mediastinum after
transhiatal esophagectomy and cervical esophagogastric anastomosis.
In situations in which immediate esophageal reconstruction is not possible, the stomach
is divided from the esophagus, the cardia is oversewn, The intrathoracic esophagus is
then mobilized through the diaphragmatic hiatus and a cervical incision, delivering the
entire thoracic esophagus through the neck wound and placing it on the anterior chest
wall.
The mediastinum can be copiously irrigated through the cervical incision and the
diaphragmatic hiatus at the time of esophagectomy
A feeding jejunostomy is used for enteral alimentation until reconstruction is performed
several weeks later.

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Irrigation of the posterior mediastinum
after transhiatal esophagectomy for
irreparable esophageal disruption.
Late Esophageal Perforation
The longer the time interval between the occurrence of the perforation and operative
treatment, the more inflamed are the tissues adjacent to the tear and, at least
theoretically, the greater is the risk of failure of primary suture repair.
Patients with late-recognized esophageal perforations have been treated in a variety of
ways, with wide drainage alone, drainage and closure, drainage over a T-tube,
esophageal resection, exclusion and diversion, and even nonoperative management.

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Infection after cardiac surgery
Infection after a median sternotomy for cardiac surgery is a serious complication,
especially if the patient has prosthetic aortic graft material at the base of the wound.
Mediastinitis in this setting is typically heralded by sternal instability, drainage from the
wound, and fever.
Various approaches have been used to treat postoperative sternal wound infections:
simple dbridement and sternal reapproximation to
staged reconstruction and the use of muscle flap rotation into the sternal wound
edges.
We favor thorough sternal and mediastinal dbridement and one-stage reconstruction
with a rotated muscle flap or omentum to fill the retrosternal space.
Regardless of the technique used, it is important to obliterate the retrosternal space to
prevent reaccumulation of infection.
Adequate dbridement of all exposed cartilage from the sternum and ribs is critical
because cartilage is avascular, does not heal, and promotes formation of a chronic
draining wound sinus.
If the sternum is clearly devascularized, it is necessary to remove completely all necrotic
bone and cartilage and to then fill the anterior mediastinal space with a muscle flap, which
also aids with chest wall stability.
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INFECTION AFTER CARDIAC SURGERY
ACUTE MEDIASTINITIS
Descending necrotizing mediastinitis(DNM) is a lethal form of AM in which infection
arising from the oropharynx spreads to the mediastinum.
DNM typically develops as a complication of oropharyngeal infection (eg, odontogenic,
peritonsillar, or retropharyngeal abscesses, Ludwig angina, or infection after a pharyngeal perforation).
Although transcervical drainage is generally adequate treatment for AM resulting
from a cervical esophageal perforation, this approach does not provide adequate drainage
in the patient with descending necrotizing mediastinitis, and the resulting mortality rate
for this condition approaches 40%.
Although the standard chest radiograph may demonstrate typical findings of
mediastinitis, the CT scan is the most valuable tool in this condition for evaluating
the presence of a gas-forming infection within the mediastinum and for following the
adequacy of surgical drainage.
These patients are ill with:
fever,
pleuritic chest pain,
dysphagia, and
varying degrees of airway obstruction resulting from dissection of large amounts
of air and acute inflammation within the mediastinal fascial planes.
They require a tracheostomy to ensure an adequate airway during treatment of the
acute mediastinitis:
If only the superior mediastinum is involved and the infection remains above the
level of the fourth thoracic vertebra, standard transcervical mediastinal drainage
may be adequate but this is rarely the case.
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Descending Necrotizing Mediastinitis
Most of these patients have extensive mediastinitis, which requires a
combination of :
Transcervical and subxiphoid or transthoracic drainage.
Broad-spectrum aerobic and anaerobic antibiotic coverage should be
instituted immediately when the diagnosis is considered, and culture-
specific antibiotics should be used as the culture reports return.

The highly lethal nature of this fulminant infection cannot be overemphasized,
and patients may experience exsanguination from erosion of the great vessels
of the neck and mediastinum, aspiration, cranial nerve paralysis, brain
abscesses, and necrotizing fasciitis.
Recognition of the fact that one is dealing with more than localized upper
mediastinal infection of the type commonly associated with acute esophageal
perforations is critical. Aggressive drainage of the mediastinum using the
cervical, subxiphoid, or transthoracic route is virtually the only means of
salvaging these patients.

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Descending Necrotizing Mediastinitis
Chronic Granulomatous Mediastinitis (CGM)
CGM frequently involve paratracheal (right more than left) and subcarinal
mediastinal lymph nodes.
Tuberculosis was in the past, the most common cause of mediastinal
granulomatous infection;
Histoplasmosis is now the leading etiologic agent.
The granulomatous reaction within the mediastinal lymph node may incite an
intense surrounding inflammatory response that produces mediastinal fibrosis,
which can cause compression of the superior vena cava (SVC), esophagus,
trachea, or airways.
Resection of large, acutely inflamed mediastinal lymph nodes involved with
histoplasmosis has been recommended to minimize the late sequelae of this
disease.
In cases of vena cava obstruction due to mediastinal fibrosis, vascular
reconstruction using either a spiral vein graft or a Gore-Tex graft may be required if
symptoms are severe.
The necrosis of the adjacent esophageal and tracheobronchial walls with the
development of a bronchoesophageal fistulais another potential complication of
mediastinal granulomatous disease.
This complication requires a transthoracic approach, identification and division of
the fistulous opening, closure of both the tracheal and esophageal openings, and
interposition of a flap of viable adjacent pleura or mediastinal fat to prevent
reformation of the fistula.
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Chronic Granulomatous Mediastinitis
MEDIASTINAL TUMORS AND CYSTS
Mediastinal tumors can arise:
primarily,
secondary metastases to mediastinal lymph nodes and direct invasion of the
mediastinum by tracheobronchial, esophageal, or
other malignancies.
The differential diagnosis of a mediastinal mass includes:
Neoplasms,
Congenital cysts, which are not neoplastic.
The most reported series of mediastinal tumors include both congenital and neoplastic
processes:
Neurogenic tumors are most common and account for 21% of mediastinal
masses
Thymomas (20%),
Cysts (20%), and
Lymphomas (12%).
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The locations of tumors in the mediastinal compartments are as follows:

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Superior Mediastinum
Thymoma
Lymphoma
Thyroid adenoma
Parathyroid adenoma
Anterior Mediastinum
Thymoma
Teratoma
Carcinoma
Lymphangioma
Hemangioma
Lipoma
Posterior Mediastinum
Neurogenic tumor
Enteric cyst
Middle Mediastinum
Pericardial cyst
Bronchogenic cyst
Lymphoma
MASAOKA STAGING SYSTEM FOR THYMOMA

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Stage Definition
I Macroscopically, completely encapsulated;
microscopically, no capsular invasion
IIA Macroscopic invasion in surrounding fatty tissues or
mediastinal pleura
IIB Microscopic invasion into the capsule
III Macroscopic invasion into a neighboring organ,
such as pericardium, great vessels, or lung
IVA Pleural or pericardial dissemination
IV B Hematogenous or lymphogenous metastases
GENERALITIES
In nearly two thirds of adult patients, mediastinal masses cause the following symptoms:
chest pain,
cough,
Dyspnea
Half of symptomatic mediastinal tumors are malignant,
95% of asymptomatic mediastinal masses discovered fortunately are benign.
Children have a higher incidence of malignancy of mediastinal tumors than adults.
Patients with mediastinal masses and evidence of involvement of adjacent
structures are more likely to have malignant disease. For example:
Hoarseness is indicative of recurrent laryngeal nerve invasion,
Horner syndrome signifies invasion of the stellate ganglion,
SVC syndrome or tracheal compression suggests mediastinal infiltration by tumor,
Back pain may be indicative of chest wall invasion with intercostal nerve involvement
IMAGING STUDIES
A variety of radiographic studies are used in assessing a mediastinal mass:
The standard posteroanterior and lateral chest radiograph assists in localization
of the mass.
Fluoroscopy, barium esophagogram, and laminography have also been of value.
These latter studies have all been replaced by
CT
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IMAGING STUDIES (suite)
magnetic resonance imaging, (MRI)
These modern imaging studies provide the most information about:
the exact location of the mediastinal mass,
its vascularity,
relation to adjacent mediastinal structures, and
consistency (ie, cystic, solid, or fat).
Aortography is needed to differentiate a mediastinal tumor from an aneurysm.
BIOPSIES
Fine-needle aspiration or core-needle biopsy of mediastinal masses under CT scan or fluoroscopic
guidance may provide enough tissue for cytologic or pathologic diagnosis,
A transbronchial needle aspiration of subcarinal or paratracheal lymphadenopathy using the flexible
fiberoptic bronchoscope and fluoroscopic guidance,
Mediastinoscopy, This procedure provides access to paratracheal and subcarinal lymph nodes for
the purpose of biopsy but is inappropriate for the assessment of an anterior mediastinal mass.
requires general anesthesia, involves passage of a rigid endoscope through a low cervical incision along the anterior trachea into
the mid-mediastinum. Because the mediastinoscope follows the course of the trachea into the mid-mediastinum, it cannot
be angled forward sufficiently to reach the anterior mediastinum. In patients thought to have an unresectable anterior
mediastinal or anterior hilar tumor (eg, lymphoma or metastatic carcinoma), a limited anterior second or third interspace
parasternal (Chamberlain) approach can be used. Diagnosis of the paratracheal, superior mediastinal and hilar regions can also
be obtained through a transaxillary third interspace minithoracotomy, displacing the apex of the lung downward.

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Thoracoscope-directed biopsy is appropriate in most patients who require diagnosis
before complete excisionm, when the other modalities fail, For most newly diagnosed
mediastinal masses, unless there is strong evidence to suggest unresectability, excisional
biopsy is the standard approach.


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PULMONARY ANGIOGRAM
Acute shortness of breath. The right pulmonary
artery is cut off by an extrinsic mediastinal
mass.
POSTEROANTERIOR (A) AND LATERAL (B) CHEST ROENTGENOGRAMS
a mediastinal neurofibroma that appears as a typically rounded posterior
mediastinal paravertebral mass.
NEUROGENIC TUMORS
Neurogenic tumors, are the most common mediastinal tumors, typically occur in a
paravertebral location in the posterior mediastinum, where they arise from the
intercostal nerves or sympathetic nerve trunks.
Their classic appearance on a standard posteroanterior and lateral chest radiograph is that of a
rounded paravertebral mass.
The spectrum of neurogenic tumors includes:
neurilenoma,
neurofibroma,
neurosarcoma,
ganglioneuroma,
neuroblastoma,
paraganglioma, and
pheochromocytoma.
In adults, most neurogenic tumors are benign; in children, they tend to be malignant.
Because of their neural crest origin some neurogenic tumors have hormonal activity.
Elevated vasoactive intestinal polypeptide levels have been reported with ganglioneuromas
and neurofibromas, whereas elevated urinary vanillylmandelic acid levels occur with
ganglioneuromas.
Neurogenic mediastinal tumors may produce hypertension, flushing, diaphoresis, diarrhea,
and abdominal distention, just as is the case with pheochromocytomas.
Mediastinal neurofibromas arise from the nerve sheaths and fibers and occur in patients with
von Recklinghausen disease.

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Ganglioneuromas arise from the sympathetic chain, contain ganglion cells, and are the
most common neurogenic tumor in children.
The biologic behavior of these tumors varies considerably.
The ganglioneuroblastoma, the most aggressive, is associated with an 85% 5-year
survival rate if it is completely excised.
Neuroblastomas which are highly aggressive malignant tumors that require
multimodality therapy combining resection, radiation, and chemotherapy.
Neuroblastomas in children may be associated with a neurologic syndrome that includes cerebellar ataxia, opsoclonus,
and polymyoclonia; these neurologic changes often regress when the tumor is resected.
The cellular DNA content of the tumor has been used as a predictor of response
to chemotherapy and as a prognostic indicator in children with neuroblastomas.
A major preoperative concern in the patient with a neurogenic tumor is whether there
is an intraspinous extension of the tumor through the intervertebral foramen.
A tumor with both an intraspinous and intrathoracic component is termed a dumbbell
neurogenic tumor(10%) and has the potential for intraoperative disaster if it is not
recognized and planned for preoperatively.
This should be suspected in any patient with a posterior mediastinal tumor who
presents with either radicular pain, vertebral body pedicle erosion, or enlargement of
an intervertebral foramen on spinal radiographs or CT scan.
In such situations, either a myelogram or magnetic resonance imaging scan of the
spine is indicated to determine if there is an intraspinous component of the tumor.


29

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MR image demonstrating intraspinous and intrathoracic
components of a dumbbell neurogenic tumor.
CT tomography shows the mass to be cystic
(cursor), and the right pulmonary artery draped
over it.
Patients with an asymptomatic posterior mediastinal tumor that is suspected on the
basis of chest radiograph and CT scan to be a neurogenic tumor require only a routine
preoperative assessment before thoracotomy.
Those in whom an intraspinous component of the tumor has been demonstrated require
a combined neurosurgicalthoracosurgical approach.
If such a dumbbell tumor is inadvertently amputated during resection of the
intrathoracic component of the tumor, allowing the remainder of the tumor to retract
into the spinal canal, subsequent intraspinous bleeding may result in paraplegia or
death.
Therefore, when dealing with a dumbbell neurogenic tumor, the intraspinous
component should be resected first and then the intrathoracic component. This is
achieved in one operation by extending the posterior laminectomy neurosurgical incision
into a posterior thoracotomy in the appropriate interspace.
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Pheochromocytoma
Pheochromocytomas are hormonally active tumors of the sympathetic nervous system.
They are termed chromaffin tumors because of their affinity for chromic salts on staining.
Chromaffin tissue is of neural crest origin and occurs in the adrenal medulla, in the
sympathetic ganglia, in the paraganglia along the sympathetic chain and the organ of
Zuckerkandl, in small nests scattered along the aorta, in walls of blood vessels, and in the
heart, prostate, and ovary.
Any of these aberrant collections of chromaffin tissue can give rise to pheochromocytomas.
90 % of pheochromocytomas occur in the adrenal gland, where they produce excessive
catecholamines, predominantly norepinephrine. Ten percent of pheochromocytomas occur
in an extraadrenal location, and fewer than 2% of all pheochromocytomas occur in the chest.
using the relatively newly developed radiopharmaceutical 131I-metaiodobenzylguanidine
(131-MIBG), which has permitted scintigraphic localization of pheochromocytomas.
Using the 131-MIBG scan in combination with contrast-enhanced CT, a growing number of
cardiac pheochromocytomas are reported.
Intrathoracic pheochromocytomas present both diagnostic and therapeutic challenges.
Unlike pheochromocytomas of the abdomen or posterior chest, these tumors do not shell out
from adjacent tissue. They frequently require resection of involved myocardium or coronary
vessels with pericardial patching or coronary artery bypass grafting, and therefore
cardiopulmonary bypass must be available for their removal.


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Paragangliomas
Paragangliomas (chemodectomas) of the parasympathetic nervous system do not
contain chromaffin and, unlike pheochromocytomas, usually do not produce hormones.
These tumors typically occur in carotid body, glomus jugulare, aorticopulmonary glomus,
vagal body, and ciliary glomus chemoreceptor tissues.
These relatively rare tumors most often are localized to the posterior mediastinum, as is the
case with most thoracic neurogenic tumors. In this latter location, where they arise from the
paravertebral sympathetic ganglia, they are readily resectable, as are most posterior
mediastinal neurogenic tumors.

Teratoma
Teratomas are composed of cells that arise from more than one embryonic germ cell layer.
Totipotential cells of the ovary, testis, and embryonic rests that can differentiate into any of
the three primary germ cells layers give rise to teratomas.
Mediastinal teratomas typically occur as dermoid cysts in the anterior mediastinum,
frequently growing to large size and containing hair and teeth.
Most teratomas are benign, and the 10% to 20% that are malignant are frequently
associated with elevated -fetoprotein and carcinoembryonic antigens.
When a malignant teratoma is suspected preoperatively, serum tumor marker levels should
be obtained and a needle biopsy performed to establish a tissue diagnosis.
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Multidrug chemotherapy, based primarily on cisplatin, is then instituted, and when the
tumor markers fall to a normal range, wide resection of the tumor is carried out.
Although most teratomas are benign and can be resected through a median sternotomy,
their large size and the surrounding inflammatory response that they induce may
complicate the resection.

Thymoma
Thymic tumors occur more frequently in adults than in children.
Rarely, infants with marked thymic enlargement due to hyperplasia require emergent
thymectomy to relieve their cardiorespiratory embarrassment. This approach is now
thought to be preferable to radiotherapy, which was used in the past, but which is
associated with a definite increased risk of malignancy in the field of radiation.
The relation between the thymus gland and myasthenia gravis has been appreciated for
many years. Myasthenia gravis is generally regarded as an immunologic disorder in which
serum antibodies form against acetylcholine receptors in the muscle. The thymus gland
has been postulated to be the source of the acetylcholine receptorlike antigen.
Some 10% to 20% of patients with myasthenia gravis have thymomas, and
60% have thymic hyperplasia. Nearly
75% of patients with thymomas develop myasthenia gravis within 10 years.
Thymoma has been associated with other conditions besides myasthenia gravis, specifically, red blood cell
aplasia, Cushing syndrome, hypogammaglobulinemia, and collagen vascular disease.

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Thymectomy is generally most beneficial in young women with myasthenia gravis who
have no thymomas and a short duration of their disease. Most neurologists still use
anticholinesterase drugs (pyridostigmine and neostigmine), immunosuppressants
(azathioprine, antilymphocyte serum, antithymocyte serum), and occasionally steroids as
the primary treatment for myasthenia gravis. Any patient who has a thymoma should
undergo a thymectomy both to establish the diagnosis of the mediastinal mass and to
prevent potential spread of the tumor. One quarter of thymomas are malignant.
Traditional teaching has held that the diagnosis of malignant thymoma is extremely
difficult on the basis of histologic criteria, the most important determinant of malignancy
being the surgeons assessment of invasion by the tumor of adjacent tissues such as
pleura, blood vessels, pericardium, or lung. The Masaoka staging system for thymoma
combines both operative findings and histologic evaluation to guide therapy
A 10-year survival rate of 87% has been reported for encapsulated thymoma,
62% for locally invasive, and
40% if there is pleural seeding.
With the addition of chemotherapy and radiotherapy for patients with stage II or greater
disease, survival was markedly improved by the addition of neoadjuvant radiation and
chemotherapy.
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Miscellaneous Tumors
Mediastinal lymph node involvement by lymphoma may present as an anterior mediastinal
mass on chest radiograph. Because the accurate diagnosis of lymphoma by cytology of tissue
obtained from fine-needle aspiration is notoriously difficult unless there is associated
adenopathy at other sites that are more amenable to biopsy, biopsy of mediastinal lymph nodes
may be required to obtain adequate diagnostic specimens. Either mediastinoscopy (for
paratracheal or subcarinal adenopathy), or an anterior mediastinotomy through a parasternal
second or third interspace incision (Chamberlain) approach is used. Radical resection or
debulking of mediastinal lymphoma is inappropriate therapy because these tumors are more
responsive to combined radiation and chemotherapy.
Large goiters of the thyroid gland may grow retrosternally into the superior mediastinum.
Although these substernal goiters present as an anterior superior mediastinal mass on chest
radiograph, their resection rarely requires a sternal split, and they can virtually all be resected
through a standard transcervical approach. Because tracheomalacia may result from prolonged
pressure on the trachea by the enlarged thyroid, prolonged ventilatory assistance may be
required postoperatively. Ectopic mediastinal thyroid tissue may present as a thyroid adenoma.
These tumors characteristically present as asymptomatic mediastinal masses. Ten percent of
parathyroid adenomas are located within the anterosuperior mediastinum and may require a
variety of studies for diagnosis and localization (eg, venous angiography with sequential
parathyroid hormone assays and CT, thallium, and technetium scanning).
Less common mesenchymal tumors of the mediastinum include fibrosarcomas and
liposarcomas, fibrous histiocytomas, leiomyosarcomas, and mesotheliomas. Mediastinal
tumors of the vascular and lymphatic systems (hemangiomas, hemangiopericytomas,
and lymphangiomas) are extremely rare and usually occur in the anterior mediastinum.

36
Mediastinal Cysts
Mediastinal cysts are classified as:
bronchogenic,
enteric (duplication),
pericardial.
Bronchogenic cysts originate from the primordial respiratory tissues of the ventral foregut
and are generally found in proximity to the trachea, main-stem bronchi, or posterior carina.
They have a ciliated respiratory epithelial lining. Although usually asymptomatic in adults and
presenting as a smooth mediastinal mass near the carina, these cysts can attain large size
and cause compression of adjacent structures.
Enteric (duplication or enterogenous) cysts arise from the dorsal foregut from which the
alimentary tract evolves and are therefore located in proximity to the esophagus in the
posterior mediastinum, occasionally being found intramurally within the wall of the esophagus
Functioning gastric epithelium that lines some of these cysts may result in ulceration and
bleeding. Technetium scanning has been used to localize gastric mucosa within the
mediastinum. Enterogenous cysts are often associated with vertebral body abnormalities and
spinal cord attachments.

37
Mediastinal Cysts (suite)
Pericardial cysts Almost 75% of them occur in the right cardiophrenic angle, either in
continuity with the pericardial space or separately as a pericardial developmental abnormality.
They rarely cause symptoms and are most often detected on a chest radiograph obtained for
other reasons. In the past, resection of these masses was recommended to establish a tissue
diagnosis; the CT scan now usually can identify the cystic nature of the lesion, making the
need for resection less compelling. Percutaneous CT-guided needle aspiration of pericardial
cysts has been recommended, and the fluid obtained is evaluated cytologically.

38
Barium esophagogram, posteroanterior (A) and lateral
(B) views, showing an intramural esophageal
duplication cyst.
Mediastinal emphysema (pneumomediastinum)
Entry of air into the mediastinum may occur from the tracheobronchial tree, the neck, or
the abdomen. Both penetrating wounds of the mediastinum as well as blunt chest trauma
may be responsible for mediastinal emphysema.
Compression injuries of the thorax may cause a marked rise in intrathoracic pressure,
rupture of peripheral alveoli, and the initiation of dissection of air in the interstitial planes
of the lung toward the hilum and then into the mediastinum.
A forceful sneeze or bout of asthma can produce mediastinal emphysema in the same
way (spontaneous mediastinal emphysema).
Clinical presentation mediastinal emphysema may have a dramatic clinical presentation
but is usually not life-threatening.
Patients often complain of :
retrosternal discomfort
subcutaneous crepitus at the base of the neck
air continues to dissect upward from the mediastinum into the subcutaneous tissue
planes, cervical, fascial, thoracic, truncal, scrotal, and extremity swelling and crepitus
can develop.
air within the periorbital tissues may cause sufficient swelling to prevent the patient
from opening the eyelids.
a precordial crunch is heard typically during systole (Hamman sign) on auscultation
over the anterior chest.


39
Mediastinal emphysema (pneumomediastinum) (suite)
Air is seen in the mediastinal tissue planes, along the pericardium, and in the soft
tissues of the neck, chest, and upper abdomen on chest radiographs.
Rarely in adults, tension pneumomediastinum may interfere with venous return to the
heart and result in cardiovascular collapse.
Most often, spontaneous mediastinal emphysema is self-limiting and requires little
treatment other than sedation and supplemental oxygen.
If an associated pneumothorax is identified, a tube thoracostomy should be performed. If
the patient is distressed by the inability to open the eyes, 5-mm decompressing incisions
made in the skin folds of the eyelids or neck using local anesthesia permit the
subcutaneous air to be milked out by gentle pressure, allowing the patient to open the
eyes.

40
Superior vena cava syndrome is due to obstruction of the SVC and presents clinically :
facial and upper extremity edema,
distention of the veins of the head, neck, arms, and upper thorax,
dusky rubor of these areas suggesting cyanosis.
Patients complain of :
periorbital swelling,
a full feeling in their head, and
a roaring in the ears aggravated by lying supine or bending.
Differential diagnosis
congestive heart failure,
cirrhosis,
constrictive pericarditis may be included in, these conditions are excluded by the
absence of swelling in the lower half of the body.
75% of patients with SVC syndrome have malignant disease within the mediastinum
compressing the SVC, most often bronchogenic carcinoma involving the right upper lobe.
SVC obstruction can also result from lymphoma and metastatic carcinoma within the
mediastinum.
25% of patients with SVC syndrome have a benign cause, such as mediastinal
granulomatous disease, idiopathic mediastinal fibrosis, goiter, or bronchogenic cysts.
Despite the rather characteristic clinical presentation that leaves little doubt as to the
diagnosis, many physicians still feel compelled to obtain a venogram.

41
Superior vena cava syndrome
Not only does this study add little information to that provided by the physical examination, but it may also be associated with
considerable morbidity if injected contrast material extravasates into the subcutaneous tissues of the arm when an injection is
performed in the presence of marked venous hypertension. The venogram for evaluation of SVC obstruction has been replaced
with the use of MR imaging and angiography, which delineate mediastinal structures as well as vascular impingement from
extrinsic compression. In most patients with SVC syndrome due to malignant disease, cure is not possible because of the extent of
mediastinal invasion by the tumor. Nevertheless, a tissue diagnosis is important because it may alter therapy. Therefore, sputa
should be collected for cytologic evaluation. A central lung mass identified on CT scan may be diagnosed with bronchoscopy and
biopsy or transthoracic fine-needle aspiration biopsy. Mediastinoscopy has also been used in patients with SVC syndrome,
although there are two concerns with the use of this procedure in this setting. First, mediastinal venous hypertension may be
responsible for bleeding complications. Second, SVC obstruction may produce submucosal edema of the tracheobronchial tree
that can precipitate acute airway obstruction when aggravated by endotracheal intubation that is required for general anesthesia in
these patients. Both radiotherapy and chemotherapy are often effective in providing rapid and acute relief of SVC obstruction due
to malignant disease. Because of the poor prognosis of patients with SVC obstruction due to malignant disease, surgical therapy is
seldom indicated. Most patients with SVC obstruction due to benign disease gradually develop chest wall and mediastinal venous
collaterals, so that their symptoms improve with time. In rare cases, autogenous or prosthetic vein graft replacement or bypass is
used to relieve the SVC obstruction.
42
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