DISORDERS of The MEDIASTINUM
DISORDERS of The MEDIASTINUM
DISORDERS of The MEDIASTINUM
B.Adhiwidjaja.
Disorders of the Mediastinum
B.Adhiwidjaja.
MEDIASTINUM
ANTERIOR
INTRATHORACIC
THYROID
POSTERIOR
MIDDLE
THYMOMAS.
Benign
Malignant.
PARATHYROID
LYMPHOMAS.
ADENOMA
Hodgkin’s disease
Lymphocytic lymphoma.
Lymphocytic/histiocytic NEUROGENIC TUMORS.
lymphoma. Neurofibroma
Histiocytic lymphoma. Neurilemoma.
TERATODERMOIDS. CYST
Neurosarcoma.
Benign. Pericardial.
Ganglioneuroma.
Malignant. Bronchogenic.
Ganglioneuroblastoma
GERM CELL TUMORS Enteric.
Neuroblastoma.
Seminoma. Chemodectoma.
Embryonal carcinoma Phaeochromocytoma.
Choriocarcinoma
Structure are in the anterior
mediastinum
Thymus gland
Anterior mediastinal lymph nodes
Aortic arch
B.Adhiwidjaja.
Structure are in the middle
mediastinum
Heart
Pericardium
Trachea and main bronchi
Paratracheal and tracheobronchial lymph
nodes.
Phrenic and recurrent laryngeal nerves.
B.Adhiwidjaja.
Structures are in the posterior
Mediastinum
Sympathetic chain
Vagus nerve
Esophagus
Thoracic duct
Posterior mediastinal lymph nodes
Descending aorta.
B.Adhiwidjaja.
Anterior mediastinal mass
Thymoma
Thyroid
Teratoma
Terrible ”lymphoma (‘T- cell” tumor)
Germ cell tumor
Hemangioma
Fibrosarcoma
Parathyroid adenoma
Lymphoma
Thymic cyst.
B.Adhiwidjaja.
VISCERAL COMPARTMENT
Tumors.
Enterogenous cyst
Lymphoma
Pleuropericardial cyst
Mediastinal granuloma
Mesothelial cyst
Lymphoid hamartoma
Thoracic duct cyst
B.Adhiwidjaja.
PARAVERTEBRAL SULCI
Tumors.
Neurilemoma- schwannoma
Neurofibroma
Malignant schwannoma
Ganglioneuroma
Ganglioneuroblastoma
Neuroblastoma
Paraganglioma
Pheochromocytoma
Fibrosarcoma
Lymphoma
B.Adhiwidjaja.
Investigation of the
Mediastinum.
Chest Radiographic: PA and Lateral.
Computed Tomography.
Magnetic Resonance Imaging.
Radionuclide Studies.
Mediastinal Tumor Markers.
Mediastinoscopy.
Video- Assisted Thoracic Surgery.
B.Adhiwidjaja.
Etiologic Factors in Acute
Mediastinitis
Esophageal Perforation.
Iatrogenic : Baloon dilatation
Bougienage.
Esophagoscopy.
Sclerotherapy.
Spontaneous : Postemetic
Straining .
Ingestion of Foreign Bodies.
Trauma
Postsurgical
Deep sternotomy wound infection
Oropharynx and Neck infections.
Retropharyngeal abscess. B.Adhiwidjaja.
Clinical Signs and Symptoms
Fever
Chest pain
Dysphagia
Respiratory distress.
Cervical and upper thoracic subcutaneous
crepitus.
Sepsis
Hemodynamic instability and death.
B.Adhiwidjaja.
Treatment
B.Adhiwidjaja.
Mayor causes of
pneumomediastinum
Spontaneous rupture of alveoli
Trauma
Rupture of the esophagus or trachea.
B.Adhiwidjaja.
Mediastinal Tumors in Adults
B.Adhiwidjaja.
Thymic Tumors
Thymomas
Thymic carcinoma.
Tumors of neuroendocrine origin.
B.Adhiwidjaja.
Modern classification of Thymic
Tumors
Thymomas:
Noninvasive
Epithelial predominant.
Spindle cell variant.
Lymphocytic predominant.
Mixed lymphoepithelial.
Invasive
Epithelial predominant.
Lymphocytic predominant.
Mixed lymphoepithelial. B.Adhiwidjaja.
Modern classification cont.
Thymic carcinoma:
Low grade malignancy.
Well differentiated squamous cell carcinoma
Mucoepidermoid carcinoma.
Basaloid carcinoma.
High grade malignancy.
Lymphoepithelial like carcinoma.
Clear cell carcinoma
Sarcomatoid carcinoma
Anaplastic/Undifferentiated carcinoma.B.Adhiwidjaja.
Modern classification cont.
B.Adhiwidjaja.
MASAOKA Classification of
Thymoma Staging
Stage I: Encapsulated tumor with no gross or microscopic
evidence of capsular invasion.
Stage II: Gross capsular invasion or invasion into the
mediastinal fat or pleura or microscopic capsular invasion.
Stage III: Gross invasion into pericardium, great vessels, or
lung.
Stage IVa: Pleural or pericardial dissemination.
Stage IVb: Lymphogenous or hematogenous metastasis.
B.Adhiwidjaja.
Clinical Presentation
Locally symptomatic:
Vague chest pain
Shortness of breath.
Cough.
Superior vena cava syndrome.
Hoarseness.
Pleural or pericardial effusion
.Neuromuscular syndromes
Myasthenia gravis.
Myotonic dystrophy.
Eaton- Lambert syndrome.
Myositis. B.Adhiwidjaja.
Treatment
B.Adhiwidjaja.
MYASTHENIA GRAVIS
IS A NEUROMUSCULAR DISORDER OR GROUP
OF DISORDERS CHARACTERIZED: A) ABNORMAL
FATIGABILITY OF VOLUNTARY MUSCLE ON REPETITIVE
ACTIVITY.
B)DECREMENTAL RESPONSE TO REPETITIVE
STIMULATION.
C)IMPROVEMENT IN NEUROMUSCULAR
TRANSMISSION ON ADMINISTRATION OF
ANTICHOLINESTERASE DRUGS.
D)ASSOCIATION WITH ABNORMALITIES OF THE
THYMUS SUCH AS HYPERPLASIA, NEOPLASIA.
B.Adhiwidjaja.
MYASTHENIA….
E)REDUCTION IN NUMBER AND
ALTERATION IN STRUCTURE OF THE
POSTSYNAPTIC ACETHLCHOLINE RECEPTOR.
F)IMMUNOLOGICALLY : PRESENCE OF
CIRCULATING ANTIBODIES TO AChRs
and complement-mediated damage to those
receptors and by favor response to
immunosuppressive therapy, including
corticosteroids, immunosuppressive drugs and
plasmapheresis.
B.Adhiwidjaja.
Results of Treatment
Classification
I. Complete remission
A. Without any medication
B. With medication:
1. Immunosuppresive drugs.
2. Corticosteroids.
3.Anticholinesterases.
4.Combination of 1, 2, 3.
II. Improvement
A. Marked
B. Moderate
III. Unchanged
IV. Worse
V. Dead
B.Adhiwidjaja.
Oosterhuis Classification: Global
Clinical Classification of Myasthenic
Severity.
Class 0 : No complain, no signs after excertion or at special
testing.
Class 1 : No disability. Minor complaints, minor signs.
Class 2 : Slight disability, clear sings after excertion.
Class 3 : Moderate disability, clear signs at rest
Class 4 : Severe disability. The patient needs constant
support in daily activities. Bulbar signs are pronounced.
Respiratory function is decreased
Class 5 : Respiratory support is needed. B.Adhiwidjaja.
Benign Mediastinal
Lymphadenopathies
I. Mediastinal granulomatous disease.
Tuberculosis
Fungal infection
Sarcoidosis
Silicosis
Wegener’s granulomatosis.
II . Castelman’s disease
III. Others.
Systemic lupus erythematosus.
Infectious mononucleosis
Reactive lymph node hyperplasia.
Amyloidosis.
HIV
B.Adhiwidjaja.
Signs and Symptoms Associated with
Mediastinal Tumors.
B.Adhiwidjaja.
Mediastinal Neurogenic Tumors in
Infant and Children
Tumors of autonomic ganglia.
Neuroblastoma
Ganglioneuroblastoma
Ganglioneuroma.
Tumors of nerve sheath origin.
Schwannoma.
Neurofibroma.
Neurogenic sarcoma.
Tumors of neuroectodermal origin.
Melanotic progonoma.
Askin tumor.
Tumors of paraganglia.
B.Adhiwidjaja.
Paraganglioma.
Neurogenic Benign Tumors of the
Mediastinal in Adults
Nerve sheath origin.
Neurilemoma.
Neurofibroma.
Melanotic schwanoma.
Granular cell tumor.
Autonomic ganglia.
Ganglioneuroma.
Paraganglionic system
Pheochromocytoma; biologically active.
Paraganglioma; chemodectoma; biologically active.
Peripheral neuroectodermal tumor.
B.Adhiwidjaja.
Malignant Neurogenic Tumors of
the Mediastinal in Adults
B.Adhiwidjaja.
Treatment
Seminoma is a radiosensitive tumor.
Surgical intervention at presentation should generally
be limited to a diagnostic procedure.
Unfavorable prognostic factors for cure by radiation
include: age >35 years, SVC syndrome, cervical or
supraclavicular node involvement, hilar disease.
Cisplatin- based chemotherapy is higly effective
against mediastinal seminoma
B.Adhiwidjaja.