SCOPE OF LECTURE o Central necrosis is frequent and may lead to the

radiographic findings of a cavity (possibly with an

• Lung Cancer air-fluid level). Such cavities may become
• Central airway obstruction infected, with resultant abscess formation
• Lung abscess/Infections
• Bronchiectasis Adenocarcinoma
• Massive Hemoptysis  Peripherally-based tumor~ incidentally
• Tracheal diseases discovered
• Chest Wall neoplasms  Chest wall invasion, pleural effusion
• Mediastinal masses/Mediastinitis
 Often peripherally located and frequently discovered
• Pleural diseases~effusion/empyema incidentally on routine chest radiographs
• Key points pp606  Symptoms are due to:
LUNG CANCER o Pleural or chest wall invasion (pleuritic or chest wall
pain)
 Leading CA killer o Pleural seeding with malignant pleural effusion
 Diagnosed at advanced stage of disease  25-40% of lung cancers
 Most common lung cancer
 10 smoking ~ Squamous Cell, Small Cell  For smokers:
 2nd hand/passive smoking o 30% of lung cancers in males
o 40% of lung cancers in females
 Pre-existing lung disease  For non smokers:
 Field cancerization of o 60% of lung cancers in males
o 80% of lung cancers in females
aerodigestive tract  Occurs more frequently in females under 45 years of age,
 Non-smokers ~ 15% AdenoCA and Asian populations
Four Principal Histologic Types
Based on Microscopic Appearance Large-Cell CA
 Adenocarcinoma = 25-40%  10-20%Centrally or peripherally
 Squamous Cell Carcinoma = 30-40%  Often admixed with other cell types
 Large Cell Carcinoma = 10-20%
 Accounts for 10% to 20% of lung cancers
 Small Cell Carcinoma = 25%  Located centrally or peripherally
Non-Small Cell Lung CA  Have cell diameters of 30 to 50 μm, which are often
admixed with various other malignant cell types.
Squamous Cell Carcinoma (SCCA)  Can be confused with a large cell variant of
 Often located centrally, major bronchi neuroendocrine carcinoma, but can be
 Peripheral – TB scar, bronchiectatic differentiated by special immunohistochemical
stains.
cavity
 Central necrosis – radiographic cavity NEUROENDOCRINE CARCINOMA
Small Cell Lung CA (SCLC) 25%
 Represent 30% to 40% of lung cancers
 Most frequent cancer in men and highly correlated with
 Most malignant NEC (Gr IV)
cigarette smoking  Centrally located
 They arise primarily on the central airways: main, lobar,
or first segmental bronchi
 High mitotic rate, extensive necrosis
 Symptoms of airway irritation or obstruction:  Paraneoplastic syndromes
o Cough  Most malignant NEC and accounts for 25% of all lung
o Hemoptysis cancers
o Wheezing (due to high-grade airway obstruction)  Early, widespread metastases
o Dyspnea (due to bronchial obstruction with or without  These cancers also arise primarily in the central airways
postobstructive atelectasis)  Symptoms: cough, hemoptysis, wheezing, dyspnea,
o Pneumonia (caused by airway obstruction with pneumonia
secretion retention and atelectasis)  Three groups of grade IV NEC are recognized:
o Pure small cell carcinoma (aka oat cell carcinoma)
o Occasionally a more peripherally based o Small cell carcinoma with a large cell component
squamous cell carcinoma will develop in a o Combined (mixed) tumors
tuberculosis scar or in the wall of a
 Grade IV NECs consist of smaller cells (diameter 10 to 20
bronchiectatic cavity
μm) with little cytoplasm and very dark nuclei
o Histologically, cells develop a pattern of clusters
with intracellular bridges and keratin pearls.  Can be difficult to distinguish from lymphoproliferative
lesions and atypical carcinoid tumors.
 Histologically, a high mitotic rate with easily visualized ➢ IC nerve involvement
multiple mitoses and areas of extensive necrosis are
characteristic. ➢ Stellate ganglion, chest wall, brachial
 These tumors are the leading producer of paraneoplastic
syndromes
plexus involvement
 ➢ RLN involvement
➢ Bulky mediastinal nodes
SALIVARY GLAND-TYPE CA Medial-based RUL tumor
Adenoid cystic carcinoma
 Result from invasion of the primary tumor directly into a
 Centrally located contiguous structure or from mechanical compression of
 Slow-growing, invasive a structure by enlarged tumor-bearing lymph nodes.
 Peripherally located tumors (often adenocarcinomas)
Mucoepidermoid carcinoma extending through the visceral pleura lead to irritation or
 Centrally located growth into the parietal pleura and potentially to continued
 low or high grade: depends on growth into the chest wall structures.
 Three types of symptoms, depending on the extent of
mitotic rate & degree of chest wall involvement, are possible:
necrosis o Pleuritic pain, from noninvasive contact of the
parietal pleura with inflammatory irritation or direct
 Salivary-type submucosal bronchial glands throughout
parietal pleural invasion;
the tracheobronchial tree can give rise to tumors that are o Localized chest wall pain, from deeper invasion and
histologically identical to those seen in the salivary glands.
involvement of the rib and/or intercostal muscles; and
 The two most common: adenoid cystic carcinoma and o Radicular pain, from involvement of the intercostal
mucoepidermoid carcinoma. nerve(s); may be mistaken for renal colic in the case
 Both tumors occur centrally of tumors invading the inferoposterior chest wall.
 Adenoid cystic carcinoma
o Slow-growing tumor that is locally and systemically PANCOAST’s SYNDROM
invasive, growing submucosally and infiltrating along  Tumors originating in the superior sulcus (posterior apex)
perineural sheaths elicit:
 Mucoepidermoid carcinoma o Apical chest wall and/or shoulder pain (from
o consists of squamous and mucous cells and is graded involvement of the first rib and chest wall);
as low or high grade, depending on the mitotic rate o Horner’s syndrome (unilateral enophthalmos, ptosis,
and degree of necrosis miosis, and facial anhidrosis from invasion of the
stellate sympathetic ganglion); and
o Radicular arm pain (from invasion of t1, and
PULMONARY SYMPTOMS occasionally c8, brachial plexus nerve roots).
 Due to direct effect of the tumor on the bronchus or lung
tissue. HOARSENESS- RLN PALSY
 Symptoms (in order of frequency) include:  Most commonly occurs on the left side, given the hilar
o Cough (secondary to irritation or compression of a location of the left RLN as it passes under the aortic arch.
bronchus)  Paralysis results from:
o Dyspnea (usually due to central airway obstruction or o Invasion of the vagus nerve above the aortic arch by
compression, with or without atelectasis), a medially based left upper lobe tumor; or
o Wheezing (with narrowing of a central airway of o Direct invasion of the RLN by hilar tumor and/or hilar
>50%), or aortopulmonary lymph node metastases.
o Hemoptysis (typically, blood streaking of mucus that  Symptoms include voice change, often referred to as
is rarely massive; indicates a central airway location), hoarseness, but more typically a loss of tone associated
o Pneumonia (usually due to airway obstruction by the with a breathy quality, and coughing, particularly when
tumor), and drinking liquids.
o Lung abscess (due to necrosis and cavitation, with
subsequent infection). SVC SYNDROME
 Result of bulky enlargement of involved mediastinal lymph
NON-PULMONARY THORACIC SYMPTOMS nodes compressing or a medially based right upper lobe
tumor invading the SVC,
● Pleuritic pain  Symptoms include variable degrees of swelling of the
● Local chest wall pain head, neck, and arms; headache; and conjunctival
edema.
● Radicular chest pain  It is seen most commonly with NEC grade IV (small cell)
● Pancoast syndrome lung cancer.
● Hoarseness
● Swelling of head & arms
TUMOR BIOLOGY
CAUSE
➢ Parietal pleura irritation/invasion
➢ Rib &/or muscle involvement
  Paraneoplastic syndromes ~ tumor CLINICAL FINDINGS SUGGESTIVE OF
production/release of biologically active METASTATIC DISEASE
materials ~ 10% Symptoms on Hx
 Hypertrophic Pulmonary ● Constitutional~wt loss >10 lbs
Osteoarthropathy (HPO) – periostitis ~ ● Musculoskeletal- focal skeletal pain
SCLC ● Neurologic-HA,Szs, syncope, extremity
 Hypercalcemia ~ SCCA, r/o bone mets weakness, mental status change
 Endocrinopathies - SIADH, Cushing’s Signs on PE
 Neuropathies (peripheral,central)  Lymphadenopathy (>1cm)
Immune-mediated  Hoarseness,SVC syndrome
r/o metastatic disease  Bone tenderness
Lambert-Eaton  Hepatomegaly(>13cm)
PARANEOPLASTIC SYNDROME  Focal neurologic signs,papilledema
 Most often from systemic release of tumor-derived  Soft tissue mass
biologically active materials.
 May produce symptoms even before any local Laboratory tests
symptoms are produced by the primary tumor,  Hematocrit <40% males
thereby aiding in early diagnosis.
 Their presence does not influence resectability or  Hematocrit <35% females
treatment options.  ↑ alk phos, calcium, liver enzymes
 The majority of such syndromes are associated
with grade IV NEC (small cell carcinoma),
including many endocrinopathies. ASSESS MEDIASTINAL LYMPH NODES (N2)
N2 spread may imply
Non-invasive
GENERAL APPROACH
 Chest CT scan
 Usually suspected on abN CXR
 PET scan
 Patients w/ local or systemic S/Sx
 N2 ~ ≥1.0cm
 Diagnostics dictated by presumed stage
 Confirm histologically
 Clinical evaluation ~ PE, standard lab
inoperability
tests as a screen for metastatic disease
Invasive
 Chest CT scan (w/ contrast)
 Esophageal ultrasound (EUS)
 Include upper
 EndoBronchial Ultrasound (EBUS) w
abdomen~liver/adrenals
biopsy
 Cervical mediastinoscopy
DIAGNOSIS FOR PRIMARY TUMOR
 Anterior mediastinotomy (Chamberlain)
 Sputum cytology
 Flexible fiberoptic bronchoscopy
ASSESS FUNCTIONAL STATUS
o Transbronchial needle aspiration
 Determine operability
o Brushing/washing
 Smoking cessation ~ 8wks
 Transthoracic needle biopsy
 Performance status
 Video-Assisted Thoracoscopic Surgery
 Pulmonary Function Test (PFTs) ~ FEV1
 Thoracotomy
 Perfusion scanning
ASSESSMENT OF METASTATIC DISEASE
Lung cancer TNM staging
 Distal metastasis found in 40%
 Primary Tumor (T)
 (+)Lymph nodes (LN~N2 level) or
 TX Primary tumor cannot be assessed,
systemic metastasis may imply
or tumor proven by the presence of
inoperability
malignant cells in sputum or bronchial
 History/PE: symptom directed worky-up
washings but not visualized by imaging
 Pleural effusion
or bronchoscopy
  T0 No evidence of primary tumor Tis
Carcinoma in situ
 T1 Tumor 3 cm or less in greatest
dimension, surrounded by lung or
visceral pleura, without bronchoscopic
evidence of invasion more proximal
than the lobar bronchus
 (for example, not in the main
bronchus)1
T1a Tumor 2 cm or less in greatest dimension
T1b Tumor more than 2 cm but 3 cm or less in
greatest dimension
 T2 Tumor more than 3 cm but 7 cm or
less or tumor with any of the following
features (T2 tumors with these features
are classified T2a
if 5 cm or less): involves main bronchus,
2 cm
or more distal to the carina; invades
visceral pleura (PL1 or PL2); associated
with atelectasis or obstructive
pneumonitis that extends to the hilar
region but does not involve the entire
lung
T2a Tumor more than 3 cm but 5 cm or less in
greatest dimension
T2b Tumor more than 5 cm but 7 cm or less in
greatest dimension
Lung cancer staging
 T3 Tumor more than 7 cm or one that
directly invades any of the following:
parietal pleural (PL3), chest wall
(including superior sulcus tumors),
diaphragm, phrenic nerve, mediastinal
pleura, parietal pericardium; or tumor
in the main bronchus less than 2 cm
distal to the carina1 but without
involvement of the carina; or associated
atelectasis or obstructive pneumonitis
of the entire lung or separate tumor
nodule(s) in the same lobe
 T4 Tumor of any size that invades any
of the following: mediastinum, heart,
great vessels, trachea, recurrent
laryngeal nerve, esophagus, vertebral
body, carina, separate tumor nodule(s)
in a different ipsilateral lobe
Lung cancer TNM staging
 Distant Metastasis (M)
 M0 No distant metastasis
 M1 Distant metastasis
 M1a Separate tumor nodule(s) in a
contralateral lobe, tumor with pleural
nodules or malignant pleural (or
pericardial) effusion
 M1b Distant metastasis (in
extrathoracic organs)
Lung CA - surgery
TREATMENT FOR LUNG CANCER
Stage I
 Complete surgical excision almost
always possible
 Best chance for cure
 Surgical procedures depend on location
 10 external RT if medically inoperable
 Goal: eradicate tumor, sterilize
potential sites of microscopic spread
Stage II
 Complete surgical excision almost
always possible
 Best chance for cure
 Surgical procedures depend on location
& size
 10 external RT if medically inoperable
 Goal: eradicate tumor & visibly abN LN,
sterilize potential sites of microscopic
spread
Stage IIIa
 Multimodality Tx improves resection
rates
 Standard Tx
 Induction chemo ~ shrink 10 tumor +
LN, micromets
 followed by surgery & post-op chemo
or RT
 2-drug ~ paclitaxel + carboplatin
 Aggressive, curative
 Can be treated w/ Sx alone but poor 5-
yr survival (10-30%)
Stage IIIb
 Surgery NOT a Tx option
 Complete excision not possible, no
surgical advantage
  Combination Chemo ff by RT improve Malignant
survival  Primary Lung CA ~ 30%
 Standard treatment  Metastatic CA
 Platinum-based regimen Central Airway Obstruction
Lung cancer treatment – Non small cell ca  75% present locally advanced or
 Stage I- IIb metastases
Surgery (Lobectomy) ~ not candidates for curative resection
• Stage III-a ● Need palliation of obstruction
Pre-operative chemo-radiotherapy ff by symptoms
surgery ~hypoxemia,hemoptysis, obstructive
• Stage III-b and IV pneumonia
Palliative chemo/radiotherapy
• Poor pulmonary function/high risk for Clinical Significance
surgery * Cause significant M & M
radiotherapy Post obstructive pneumonia
SMALL CELL CANCER TREATMENT Hemoptysis
 Stage I (T1 No Mo) Progressive dyspnea
Surgery  Affects cancer staging & management
Chemotherapy Negative prognostic value
Non small cell CA Prognosis Bronchogenic CA
MEDIASTINOSCOPY Management
METASTASIS (M) 1. Interventional Bronchoscopy –
 Mx -presence of metastasis cannot be Palliative
determined Mechanical debulking
 M0 -no distant metastasis Laser w mechanical /resection
 M1 –(+)distant metastasis (include Electrocautery w mechanical resection
metastatic tumor nodule(s) to Cryotherapy
ipsilateral nonprimary tumor lobe(s) of Photodynamic Therapy
the lung, cervical LN(s); with a Brachytherapy
malignant pleural effusion 2. Surgical - Curative
Central airway tumors Tracheal resection
 Obstruction ~ trachea, MSB (L or R) Sleeve resection
 pure endobronchial or +/- extraluminal EFER-DUMON Rigid Bronchoscope
growth Main Endoscopic Situations
benign  Bronchial obstructions
undertermined→slow growth & low mets Bulky tumors
tendencies Purely extrinsic tumors w/ airway compression
malignant  Non-obstructive lesions
Localized infiltrative tumors (palliative)
Undetermined Early stage lung cancers (curative)
• Carcinoid Technique of mechanical debulking
• Adenoid cystic Laser
• Mucoepidermoid LUNG ABSCESS
• Spindle cell  Localized parenchymal necrosis ~
• Mixed infectious organism
• Paraganglioma  Tissue destruction cavity ≥ 2cm
• cystoadenoma
  LRTI – access via inhalation, aspiration,  Percutaneous culture sampling
hematogenous spread, direct  Routine Sputum Culture
extension, bronchial obstruction
 Risk factors MANAGEMENT
CAUSES OF LUNG ABSCESS  Systemic antibiotics
Primary  Postural drainage
 Immuno-compromised  Surgical drainage – uncommon
 Necrotizing pneumonia o indications
 Aspiration pneumonia o External drainage – tube
 Esophageal disease thoracostomy, percutaneous,
Secondary cavernostomy
 Bronchial obstruction  Surgical resection <10%
 Systemic sepsis o Lobectomy ~ bleeding,
 Complications of pulmonary trauma pyopneumothorax
 Direct extension from o Protect contralateral lung
extraparenchymal infection
INDICATIONS FOR SURGICAL INTERVENTION
MICROBIOLOGY  Failure of medical Tx
 CAP → G(+)  Abscess under tension
 HAP→ 60-70% G(-)  ↑ abscess size during medical Tx
Klebsiella, Haemophilus, Proteus, Pseudomonas,  Abscess rupture
Escherichia  contralateral lung contamination
 Immunosupressed – Salmonella,  > 4-6 cm diameter
Legionella, Pneumocystis, atypical  necrotizing infection w/ mult abscess
mycobacteria, fungi  Hemoptysis
 Aspiration ~ polymicrobial  Pyopneumothorax
 exclude cavitating CA
CLINICAL PRESENTATION
 Productive cough, fever, chills, PULMONARY MYCOSES
leukocytosis Primary fungal pathogens
 Wt loss, fatigue, malaise, pleuritic chest  Histoplasma capsulatum
pain, dyspnea  Coccidiodes immitis
 indolent presentation ~ wks→months  Blastomyces dermatidis
 Aspiration ~1-2 wks before cavitation Secondary~opportunistic
 Production of putrid foul-smelling  Aspergillosis
sputum  Cryptococcosis
 Candidiasis
DIAGNOSTICS  Mucormycosis
 CXR ~ ASPERGILLOSIS
 density/mass w/ thin-walled cavity BRONCHIECTASIS
 Air-fluid level → tracheo-bronchial tree ● pathologic & permanent dilation of
communication bronchi
 Chest CT ● Localized or diffuse – medium-sized
 Equivocal CXR airways
 r/o endobronchial obstruction ● Congenital or acquired
 Associated pathologic anomalies PATHOPHYSIOLOGY
 Bronchoscopy
  Impaired airway defense & ↓
Immunologic mechanisms ~permit
colonization & infection
 Bacteria & inflammatory cells elaborate
proteolytic & oxidative molecules
 Progressively destroy muscular & elastic
components ~ fibrous tissue
Chronic airway inflammation
Airway w/ thick purulent secretions
 ↑ vascularity, hypertrophied vessels
CLINICAL PRESENTATION
 Daily persistent cough + purulent
sputum production ~correlate w/
extent
 ↑ symptoms & respiratory impairment
~ ↑ airway obstruction
 Hemoptysis – chronically inflamed
friable airway mucosa
Massive ~ erosion of hypertrophied bronchial
arteries
DIAGNOSTICS
 Chest CT– x-section bronchial
architecture
 CXR – lung hyperinflation,
bronchiectatic cysts,dilated thich-walled
bronchi from hila
 Sputum culture
 Spirometry – severity of airway
obstruction
MANAGEMENT
 Optimize secretion clearance
 Use of bronchodilators
 Correct reversible underlying causes
 Chest physiotherapy
 Acute exacerbations ~ broad-spectrum
antiBx
 Surgical resection – refractory to Med
tx
 Conserve as much N parenchyma
HEMOPTYSIS
● ‘haima’~blood, ‘ptysis’~to spit
● Expectoration of blood fr respiratory
tract
● Blood streaking of sputum to coughing
up massive amounts of blood
HEMOPTYSIS
● Bleeding w/ respiratory distress &
altered gas exchange
● Amount of blood expectorated not
necessarily represents total amount lost
into airspaces
MASSIVE HEMOPTYSIS
● Expectoration of blood >600ml/24hrs
● Pulmonary a.- high-compliance, low-
pressure, thin & delicate walls
● Bronchial a. – systemic pressure, thick
walls
Bronchiectasis ~ hyperplastic & tortuous
Systemic P combined w/ airway disease &
erosion lead to bleeding
MASSIVE HEMOPTYSIS
● Hemoptysis - important sign of an
underlying disease
● Massive ~ life threatening due to
Asphyxia
● Mortality rate ~ as high as 80%
CAUSES OF HEMOPTYSIS
● Chronic Pulmonary Inflammatory
Disease
● TB
Erosion of broncholith, Rasmussen’s aneurysm
● Bronchogenic CA - if massive, usually
terminal
● Necrotizing pneumonia, fungal, other
lung infection
● Chemotherapy & Bone Marrow
Transplantation
● Immunologic Lung Disease
● Cardiac or Vascular Disease
MANAGEMENT
● Multidisciplinary approach
1. Achieve respiratory stabilization
prevent asphyxiation
2. Localize bleeding
3. Stop hemorrhage
4. Determine cause
5. Definitively prevent recurrence
HISTORY & PE
● History, PE & CXR ~ not very reliable
but important
● Important points in the history:
Age
Hx of prior lung & cardiac disease, tx
Hx of smoking
Hx of prior hemoptysis, pulmonary symptoms
or infectious symptoms
Hx of loss of consciousness
BRONCHOSCOPY
BRONCHIAL ARTERY EMBOLIZATION
● Selective angiography of bleeding
bronchial artery → injection of
embolizing particles (Gelfoam, steel
coils, polyvinyl alcohol foam)
● Success rate~ 90% w/ in 24 hrs for
massive hemoptysis
● 20% had recurrence of hemoptysis in 1
yr
● Most serious complication - accidental
embolization of the spinal artery
BRONCHIAL ARTERY EMBOLIZATION
, degenerate→chondrosarcoma
ENDOBRONCHIAL BLOCKADE
INDICATIONS FOR SURGERY
1) Failure of Medical treatment
2) Disease is localized & site of bleeding
accurately identified
3) Patient has acceptable surgical risk w/
sufficient pulmonary reserve to tolerate
resection
SURGERY FOR MASSIVE HEMOPTYSIS
Tracheal diseases
• Tracheoinnominate Artery Fistula
• Tracheoesophageal Fistula
• Tracheal 10 neoplasms
CHEST WALL TUMORS
● Goal: not compromise the px’s survival
● Initially consider all as malignant ~ 50-
80%
● Slowly enlarging palpable mass
● Late medical evaluation/consult
● Pain localized to area of tumor
Often (+) in malignant, more intense
● Age ~ > 40yrs ~ malignant
BENIGN CHEST WALL TUMORS
Chondroma
● More in children & young adults
● Costochondral junction anteriorly
● Usually painless mass
● Xray → lobulated
● 4-cm margin
FIBROUS DYSPLASIA
● Ribs frequent origin
● Young adults
● Posterolateral aspect of rib cage
● May be associated w/ trauma
● Xray → cortical thinning, no calcification
● 2-cm margin
OSTEOCHONDROMA
● Most common benign tumor -
incidental radiographic findings
● 1st 2 decades of life
● At/near growth plate of bones, rib
cortex
● Autosomal dominant syndrome
hereditary exostoses
❖ Potential to
● Benign→local excision, malignancy
suspected→wide excision 4cm margin
DESMOID TUMORS
● Fascial or musculoaponeuroitic
structures
● Associated w/ familial
polyposis(Gardner),
↑estrogen(pregnancy), trauma
● Pain, chest wall mass or both
● Usually fixed to chest wall but not skin
● Propensity to recur locally
● Wide local excision 2-4 cm margin, rib
above/below
MALIGNANT CHEST WALL BONE TUMORS
Chondrosarcoma
● Most common 10 CW malignancy
● Anteriorly costochondral arches
● Painful masses on ACW
● Slow-growing, low grade
● 4cm margin
● Not sensitive to Chemo/RT
OSTEOSARCOMA
● Most common bone, uncommon in
chest wall
● Rapidly-enlarging, painful masses
● Young adults, age >40 yrs w/ previous
RT,Paget’s, chemo
 ● Xray → sunburst appearance
● Sensitive to chemo~neoadjuvant
● 4-cm margins
EWING’S SARCOMA
● adolescent/young adults
● Progressive pain w/o presence of mass
● Xray → onion-peel
● Multimodality treatment
● Propensity to spread to lungs
MALIGNANT CHEST WALL SOFT TISSUE
TUMORS
Malignant Fibrous Histiocytoma
● Most common soft tissue sarcoma of
late adult life 50-70 y.o.
● Pain w/ or w/o presence of mass
● Xray → mass + surrounding destruction
● 4cm margin w/ reconstruction
● Distant mets & recurrence common
● Propensity to spread to lungs
LIPOSARCOMA
● Low-grade w propensity to recur locally
● Painless masses
● Wide resection w/ FS + reconstruction
FIBROSARCOMA
● Large masses w/ pain
● Xray → mass + surrounding destruction
● Wide excision w FS, reconstruction
● Local & systemic recurrence frequent
CHEST WALL RECONSTRUCTION
CHEST WALL RECONSTRUCTION
MEDIASTINAL MASSES
Mediastinum
● 3 compartment model
● Anterior – anterosuperior
● Visceral – middle
● Paravertebral sulci bilateral - posterior
COMMON TYPES
Adults
● neurogenic → posterior
● Benign cysts→ any
● thymoma → anterior
Children
● neurogenic → posterior
● lymphoma → anterior or
middle
nd
2 most common mediastinal tumor
● !!!!Table 19-26,27,28,29 pp570-71
CLINICAL PRESENTATION
● 2/3 asymptomatic – seen on xray
● Benign most likely asymptomatic
● Large bulky tumor – compression
● Chest pain, dyspnea – effusion, phrenic
● Hoarseness – involvement of RLN
CLINICAL PRESENTATION
● Mass, enlarged LN, consitutional S/Sx~
lymphoma
● Ant mass + weakness, ptosis, fatigue~
thymoma w/ MG
● Extrathoracic adenopathy ~ lymphoma
● Young adult, mass + testicular mass ~
Germ Cell Tumor (GCT)
● Systemic S/Sx+mass ~
lymphoproliferative d/o
● ESR, CRP, 10 leukocytosis
DIAGNOSTICS
● CT scan – delineation
● MRI – vascular invasion or spinal
involvement
● Serum markers – ßHCG, αFP
Seminomatous vs NSGCT
● Percutaneous~ FNA, core-needle
● Surgical biopsy
SURGICAL BIOPSY
● Not amenable to CTGAB, poor tissue
yield
● Anterior mass – median sternotomy
● If resection not best option, do less
invasive procedure
● Paratracheal – mediastinoscopy
● Parasternal – anterior mediastinotomy
THORACIC INCISIONS
❖ median sternotomy or lateral
thoracotomy
● Lateral thoracotomy w/ sternal
extension (clamshell)
● L Antero-lateral thoracotomy→extend R
(hemiclamshell)
● Video-Assisted Thoracoscopic Surgery
(VATS)
THYMOMA
● Most asymptomatic ~ 40% w/
Myaesthenia Gravis (MG)
MG ~ <10% w/ thymoma
Thymectomy – better prognosis if w/o
● Masaoka staging ~ “invasive thymoma”
 ● CT areas of low attenuation 2o necrosis,
THYMOMA hemorrhage, cyst formation
● Surgical removal of all resectable tumor ● ↑↑ LDH, ßHCG, αFP
● Ff-up/post-op RT if w/ residual ● Chemo preferred Tx: cisplatin,
● Advanced stage →chemo bleomycin, etoposide
THYMOMA NEUROFIBROMA
THYMOMA FIBROUS TUMOR
NEUROGENIC TUMOR Mediastinitis
Most tumors of mediastinum ● Acute ~ fulminant infectious process
1. Nerve sheath tumor (NST) Acute Mediastinitis
2. Ganglion cells • Fulminant Infection of mediastinal
3. Paraganglionic system space
Adults – Peripheral NST • Potentially fatal
● Asymptomatic, incidental • Perforation of mediastinal structures
finding, benign • Suppurative mediastinitis
Children/young adults – autonomic ganglia a modern phenomenon
● 2/3 malignant largely a complication of procedures involving a
● All neurogenic tumors should median sternotomy
be removed • !!!!Table 19-33 pp 577
LYMPHOMA Patient with Mediastinitis
● Most common malignancy of Before Reoperation
mediastinum
● Most common ~ anterior compartment Sternectomy in a patient
● Chemo &/or RT cure rate ~ 90% with mediastinitis
● If suspect mass to be lymphoma, Cross sectional view of the sternum
establish tissue diagnosis by with suction dressing
aspiration/open biopsy→ chemo/RT Pectoralis major muscle flap
GERM CELL TUMOR (GCT) Post operative appearance of patient after
● Most gonadal in origin pectoralis muscle flap
● Mediastinum as 10 site rare (<5% GCT) MEDIASTINAL CYSTS
● If malignant~exclude gonadal as 10 ● 10 mediastinal cyst
● 1/3 10 mediastinal GCT seminomatous ● Pericardial cyst
● 2/3 NSGCT or teratomas ● Bronchogenic cyst
TERATOMA ● Enteric cyst
● Most common benign mediastinal GCT ● Thymic cyst
● ~ 60-70% PLEURAL EFFUSION
● 3 embryonic layers ● Etiologies – single, bilateral
● Surgical resection excellent prognosis ● Transudate vs exudate
● Rarely ~ Teratocarcinoma ● Fluid analysis, VATS, biopsies
Locally aggressive ● Malignant pleural effusion
Late diagnosis, poor response to chemo/RT ● Empyema
Poor prognosis ● Chylothorax
NONSEMINOMATOUS THANK YOU
● Include embryonal cell CA, chorioCA,
EST, mixed types
● Often bulky, irregular tumors of
anterior