Mediastinal Tumors A Diagnostic Approach
Mediastinal Tumors A Diagnostic Approach
US Respiratory Care 2006
Published: October 2008
Published: October 2008
Reference Section a report by Ken Y Yoneda, MD, Brian M Morrissey, MD, and David K Shelton, MD University of California, Davis School of Medicine, and Veterans Affairs Northern California Health Care System Mediastinal tumors comprise a diverse group of benign and malignant processes, all sharing an anatomic region the mediastinum, which occupies the medial thorax, excluding the lungs, hila, and pleura.
Traditionally, the mediastinum is divided into three compartments: anterior, middle, and posterior.
This scheme, based on divisions viewed on the lateral chest radiograph (CXR), does not correlate with any true anatomic compartments. Rather, it is based on the tendency for a given group of tumors to be located in these radiographic locations (see Table 1).
Several other schemes exist, but the authors prefer the following: " anterior mediastinum immediately posterior to the sternum and extending to the anterior cardiac and tracheal borders; " posterior mediastinum posterior to a line 1cm dorsal to the anterior edge of the vertebral bodies;and " middle mediastinum the remaining area between the two (see Figure 1).
With the diverse nature of these tumors and the often complex diagnostic and treatment strategies employed, the authors recommend a multi-disciplinary approach, enlisting the expertise of a pulmonologist, qualified radiologist, thoracic surgeon, medical oncologist, and radiation oncologist.
Imaging A CXR often initiates the evaluation of mediastinal disorders but is rarely diagnostic. Notable exceptions are, in the first instance, eggshell calcifications strongly suggesting silicosis, treated lymphoma, or sarcoidosis and, in the second instance, teeth or bones within a mass, which are diagnostic of a teratoma.Air fluid levels suggest an esophageal origin, hernia, cyst, or abscess. Except for a mass of suspected thyroid origin, evaluation should proceed to computed tomography (CT) of the chest.
CT helps delineate anatomic location, extent of disease, tissue invasion, and tissue density. Iodinated contrast should be administered unless contraindicated or thyroid origin is suspected. CT is occasionally diagnostic and is usually sufficient for pre-operative evaluation.It is useful in imaging associated mediastinal or hilar lymph nodes, distinguishing mediastinal tumors from vascular abnormalities, identifying concomitant parenchymal lung disease, and demonstrating complex or variant anatomy.2 4 Magnetic resonance imaging (MRI) is superior to CT for imaging nerve plexus and blood vessels, distinguishing tissue planes and invasion, and imaging in non-transaxial planes. MRI is particularly useful when iodinated contrast is contraindicated, for imaging posterior mediastinal masses and for assessing tissue, vascular, or cardiac invasion.5 Thyroid scanning with radioactive iodine can identify and evaluate masses of suspected thyroid origin.
Alternative thyroid imaging modalities are thalium-201 imaging, technetium-99m-sestamibi imaging,6 positron emission tomography with 18 fluorodeoxyglucose (FDG-PET),7 or scintigraphy with radiolabeled octreotide, a synthetic analog of somatostatin.8 Technetium-99m-sestamibi imaging is 90 100% sensitive for identifying parathyroid adenomas in the neck and mediastinum and may identify parathyroid carcinomas.9 10 11C-methionine PET may more accurately localize parathyroid adenomas.11 Radiolabeled octreotide is used for imaging thymic carcinoids, demonstrating both primary lesions and distant metastases.12 PET and the newer combined PET/CT fusion imaging demonstrate the metabolic activity of a tumor utilizing the glucose analog FDG or other tracers.The malignant nature of a tumor, whole body staging or re-staging, and response to therapy may be better assessed. For the mediastinum, it is most useful in thymomas, thymic carcinomas, germ cell neoplasms, lymphomas, and lung and esophageal carcinomas (see Figure 2).
Anterior Mediastinum Most anterior mediastinal masses and cysts, even when benign, require surgical resection. For many of these Mediastinal Tumors A Diagnostic Approach Ken Y Yoneda, MD, is an Associate Professor of Clinical Internal Medicine in the Division of Pulmonary and Critical Care at the University of California, Davis School of Medicine. He is also the Assistant Chief of Pulmonary and Critical Care of the Veterans Affairs, Northern California Health Care System. He is the pulmonary representative for thoracic oncology at both of these institutions and has a sub-specialty interest in invasive pulmonary. Dr Yoneda s major research interests are in lung cancer and tobacco-related disease and he is a scientific advisor to the California Lung Association and the California Tobacco Related Research Program.
Brian M Morrissey, MD, is an Assistant Professor in the Division of Pulmonary/Critical Care Medicine at the University of California, Davis School of Medicine. He directs the Adult Cystic Fibrosis Center and acts as Associate Director of the Pulmonary Fellowship Program.
David K Shelton, MD, is a Professor of Radiology and Nuclear Medicine at the University of California Davis Medical Center. His primary areas of interest are cardiothoracic imaging and functional imaging.
Oncological imaging for tumor identification, staging, and tumor response to therapy are specific research interests.
References:
1. Vail C and Ravin C,- Mediastinal masses; , in: Freundlich I M, Braggs D C (eds), A Radiologic Approach to Diseases of the Chest, 2nd Edition,William and Wilkins, Baltimore (1997): pp. 609 624.
2. Ferretti G R, D J Vining, J Knoplioch et al.,- Tracheobronchial tree: three-dimensional spiral CT with bronchoscopic perspective; , J. Comput.Assist.Tomogr. (1996);20: pp. 777 781.
3. LoCicero J, 3rd, Costello P, Campos C T et al.,- Spiral CT with multiplanar and three-dimensional reconstructions accurately predicts tracheobronchial pathology; , Ann.Thorac. Surg. (1996);62: pp. 811 817.
4. Yoneda K Y,Tharratt R S,- Intrathoracic neoplasms other than bronchogenic carcinoma; , Curr. Opin. Pulm. Med. (1997);3: pp. 257 264.
5. Webb W,- Magnetic resonance imaging of the thorax: clinical utility in comparison with CT; , in: Freundlich I M, Braggs D C (eds), A Radiologic Approach to Diseases of the Chest, 2nd Edition,William and Wilkins, Baltimore (1997).
6. James C, Starks M, MacGillivray D C et al.,- The use of imaging studies in the diagnosis and management of thyroid cancer and hyperparathyroidism; , Surg. Oncol. Clin. N Am. (1999);8: pp. 145 169.
7. Muros M A, Llamas-Elvira J M, Ramirez-Navarro A et al., - Utility of fluorine-18-fluorodeoxyglucose positron emission tomography in differentiated thyroid carcinoma with negative radioiodine scans and elevated serum thyroglobulin levels; , Am. J.Surg. (2000);179: pp. 457 461.
8. Baudin E, Schlumberger M, Lumbroso J et al., - Octreotide scintigraphy in patients with differentiated thyroid carcinoma: Here, the right paratracheal mass with a lobulated, but well-delineated margin (arrows) should be noted.The loss of the right paratracheal stripe reveals a middle mediastinal location that was confirmed on the lateral view as well as by CT.Transbronchial needle biopsy yielded clear fluid, establishing a diagnosis of a bronchogenic cyst.Mediastinal Tumors A Diagnostic Approach contribution for patients with negative radioiodine scan; , J. Clin. Endocrinol. Metab. (1996);81: pp. 2,541 2,544.
9. Sofferman R A, Nathan M H, Fairbank J T et al., - Preoperative technetium Tc 99m sestamibi imaging. Paving the way to minimal-access parathyroid surgery; , Arch. Otolaryngol. Head. Neck. Surg. (1996);122: pp. 369 374.
10. Al-Sobhi S,Ashari L H, Ingemansson S,- Detection of metastatic parathyroid carcinoma with Tc-99m sestamibi imaging; , Clin.Nucl. Med. (1999);24: pp. 21 23.
11. Beggs A D, Hain S F,- Localization of parathyroid adenomas using 11C-methionine positron emission tomography; , Nucl.Med.Commun. (2005);26: pp. 133 136.
12. Borrero C G, McCook B, Mountz J M,- Indium-111 pentetreotide imaging of carcinoid tumor of the thymus; , Clin. Nucl.Med. (2005);30: pp. 218 221.
13. Liu R S,Yeh S H, Huang M H et al.,- Use of fluorine-18 fluorodeoxyglucose positron emission tomography in the detection of thymoma: a preliminary report; , Eur. J. Nucl. Med. (1995);22: pp. 1,402 1,407.
14. Lara P N, Jr.,- Malignant thymoma: current status and future directions; , Cancer Treat. Rev. (2000);26: pp. 127 131.
15. Becherer A, Szabo M, Karanikas G et al.,- Imaging of advanced neuroendocrine tumors with (18)F-FDOPA PET; , J. Nucl.Med. (2004);45: pp. 1,161 1,167.
16. Cirino L M, Milanez de Campos J R, Fernandez A et al.,- Diagnosis and treatment of mediastinal tumors by thoracoscopy; , Chest (2000);117: pp. 1,787 1,792.
17. Roviaro G,Varoli F, Nucca O et al., - Videothoracoscopic approach to primary mediastinal pathology; , Chest, (2000);117: pp. 1,179 1,183.
18. Demmy T L, Krasna M J, Detterbeck F C et al.,- Multicenter VATS experience with mediastinal tumors; , Ann.Thorac. Surg.(1998);66: pp. 187 192.
19. Yasufuku K, Chiyo M, Sekine Y et al.,- Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes; , Chest (2004);126: pp. 122 128.
20. Hunerbein M, Ghadimi B M, Haensch W et al.,- Transesophageal biopsy of mediastinal and pulmonary tumors by means of endoscopic ultrasound guidance; , J.Thorac. Cardiovasc. Surg. (1998);116: pp. 554 559.
21. Serna D L,Aryan H E, Chang K J et al.,- An early comparison between endoscopic ultrasound-guided fine-needle aspiration and mediastinoscopy for diagnosis of mediastinal malignancy; , Am. Surg. (1998);64: pp. 1,014 1,018.
22. Powers C N, Silverman J F, Geisinger K R et al., - Fine-needle aspiration biopsy of the mediastinum. A multi-institutional analysis; , Am. J. Clin. Pathol., (1996);105: pp. 168 173.
23. Sklair-Levy M, Polliack A, Shaham D et al.,- CT-guided core-needle biopsy in the diagnosis of mediastinal lymphoma; , Eur.Radiol. (2000);10: pp. 714 718.
24. Strollo D C, Rosado de Christenson M L, Jett J R,- Primary mediastinal tumors. Part 1: tumors of the anterior mediastinum; , Chest (1997);112: pp. 511 522.
25. Bacha E A, Chapelier A R, Macchiarini P et al., - Surgery for invasive primary mediastinal tumors; , Ann. Thorac. Surg.(1998);66: pp. 234 239.
26. Langenfeld J, Graeber G M,- Current management of thymoma; , Surg. Oncol. Clin. N.Am. (1999);8: pp. 327 339.
27. Wilkins K B, Sheikh E, Green R et al.,- Clinical and pathologic predictors of survival in patients with thymoma; , Ann. Surg.(1999);230: pp. 562 574.
28. Takeda S, Miyoshi S, Ohta M et al.,- Primary germ cell tumors in the mediastinum: a 50-year experience at a single Japanese institution; , Cancer (2003);97: pp. 367 376.
29. Moran C A, Suster S, - Primary germ cell tumors of the mediastinum: I. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging; , Cancer (1997);80: pp. 681 690.
30. Bokemeyer C, Droz J P, Horwich A et al.,- Extragonadal seminoma: an international multicenter analysis of prognostic factors and long term treatment outcome; , Cancer (2001);91: pp. 1,394 1,401.
31. Javadpour N,- Significance of elevated serum alphafetoprotein (AFP) in seminoma; , Cancer (1980);45: pp. 2,166 2,168.
32. Dusmet M E, McKneally M F,- Pulmonary and thymic carcinoid tumors; , World J. Surg. (1996);20: pp. 189 195.
33. de Montpreville V T, Macchiarini P, Dulmet E,- Thymic neuroendocrine carcinoma (carcinoid): a clinicopathologic study of fourteen cases; , J.Thorac. Cardiovasc. Surg. (1996);111: pp. 134 141.
34. Fukai I, Masaoka A, Fujii Y et al.,- Thymic neuroendocrine tumor (thymic carcinoid): a clinicopathologic study in 15 patients; , Ann.Thorac. Surg. (1999);67: pp. 208 211.
35. Strollo D C, Rosado-de-Christenson M L, Jett J R,- Primary mediastinal tumors: part II.Tumors of the middle and posterior mediastinum; , Chest (1997);112: pp. 1,344 1,357.
36. Bousamra M 2nd, Haasler G B, Patterson G A et al.,- A comparative study of thoracoscopic vs open removal of benign neurogenic mediastinal tumors; , Chest, (1996);109: pp. 1,461 1,465.
37. Riquet M, Mouroux J, Pons F et al., - Videothoracoscopic excision of thoracic neurogenic tumors; , Ann. Thorac. Surg.(1995);60: pp. 943 946.
2. Ferretti G R, D J Vining, J Knoplioch et al.,- Tracheobronchial tree: three-dimensional spiral CT with bronchoscopic perspective; , J. Comput.Assist.Tomogr. (1996);20: pp. 777 781.
3. LoCicero J, 3rd, Costello P, Campos C T et al.,- Spiral CT with multiplanar and three-dimensional reconstructions accurately predicts tracheobronchial pathology; , Ann.Thorac. Surg. (1996);62: pp. 811 817.
4. Yoneda K Y,Tharratt R S,- Intrathoracic neoplasms other than bronchogenic carcinoma; , Curr. Opin. Pulm. Med. (1997);3: pp. 257 264.
5. Webb W,- Magnetic resonance imaging of the thorax: clinical utility in comparison with CT; , in: Freundlich I M, Braggs D C (eds), A Radiologic Approach to Diseases of the Chest, 2nd Edition,William and Wilkins, Baltimore (1997).
6. James C, Starks M, MacGillivray D C et al.,- The use of imaging studies in the diagnosis and management of thyroid cancer and hyperparathyroidism; , Surg. Oncol. Clin. N Am. (1999);8: pp. 145 169.
7. Muros M A, Llamas-Elvira J M, Ramirez-Navarro A et al., - Utility of fluorine-18-fluorodeoxyglucose positron emission tomography in differentiated thyroid carcinoma with negative radioiodine scans and elevated serum thyroglobulin levels; , Am. J.Surg. (2000);179: pp. 457 461.
8. Baudin E, Schlumberger M, Lumbroso J et al., - Octreotide scintigraphy in patients with differentiated thyroid carcinoma: Here, the right paratracheal mass with a lobulated, but well-delineated margin (arrows) should be noted.The loss of the right paratracheal stripe reveals a middle mediastinal location that was confirmed on the lateral view as well as by CT.Transbronchial needle biopsy yielded clear fluid, establishing a diagnosis of a bronchogenic cyst.Mediastinal Tumors A Diagnostic Approach contribution for patients with negative radioiodine scan; , J. Clin. Endocrinol. Metab. (1996);81: pp. 2,541 2,544.
9. Sofferman R A, Nathan M H, Fairbank J T et al., - Preoperative technetium Tc 99m sestamibi imaging. Paving the way to minimal-access parathyroid surgery; , Arch. Otolaryngol. Head. Neck. Surg. (1996);122: pp. 369 374.
10. Al-Sobhi S,Ashari L H, Ingemansson S,- Detection of metastatic parathyroid carcinoma with Tc-99m sestamibi imaging; , Clin.Nucl. Med. (1999);24: pp. 21 23.
11. Beggs A D, Hain S F,- Localization of parathyroid adenomas using 11C-methionine positron emission tomography; , Nucl.Med.Commun. (2005);26: pp. 133 136.
12. Borrero C G, McCook B, Mountz J M,- Indium-111 pentetreotide imaging of carcinoid tumor of the thymus; , Clin. Nucl.Med. (2005);30: pp. 218 221.
13. Liu R S,Yeh S H, Huang M H et al.,- Use of fluorine-18 fluorodeoxyglucose positron emission tomography in the detection of thymoma: a preliminary report; , Eur. J. Nucl. Med. (1995);22: pp. 1,402 1,407.
14. Lara P N, Jr.,- Malignant thymoma: current status and future directions; , Cancer Treat. Rev. (2000);26: pp. 127 131.
15. Becherer A, Szabo M, Karanikas G et al.,- Imaging of advanced neuroendocrine tumors with (18)F-FDOPA PET; , J. Nucl.Med. (2004);45: pp. 1,161 1,167.
16. Cirino L M, Milanez de Campos J R, Fernandez A et al.,- Diagnosis and treatment of mediastinal tumors by thoracoscopy; , Chest (2000);117: pp. 1,787 1,792.
17. Roviaro G,Varoli F, Nucca O et al., - Videothoracoscopic approach to primary mediastinal pathology; , Chest, (2000);117: pp. 1,179 1,183.
18. Demmy T L, Krasna M J, Detterbeck F C et al.,- Multicenter VATS experience with mediastinal tumors; , Ann.Thorac. Surg.(1998);66: pp. 187 192.
19. Yasufuku K, Chiyo M, Sekine Y et al.,- Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes; , Chest (2004);126: pp. 122 128.
20. Hunerbein M, Ghadimi B M, Haensch W et al.,- Transesophageal biopsy of mediastinal and pulmonary tumors by means of endoscopic ultrasound guidance; , J.Thorac. Cardiovasc. Surg. (1998);116: pp. 554 559.
21. Serna D L,Aryan H E, Chang K J et al.,- An early comparison between endoscopic ultrasound-guided fine-needle aspiration and mediastinoscopy for diagnosis of mediastinal malignancy; , Am. Surg. (1998);64: pp. 1,014 1,018.
22. Powers C N, Silverman J F, Geisinger K R et al., - Fine-needle aspiration biopsy of the mediastinum. A multi-institutional analysis; , Am. J. Clin. Pathol., (1996);105: pp. 168 173.
23. Sklair-Levy M, Polliack A, Shaham D et al.,- CT-guided core-needle biopsy in the diagnosis of mediastinal lymphoma; , Eur.Radiol. (2000);10: pp. 714 718.
24. Strollo D C, Rosado de Christenson M L, Jett J R,- Primary mediastinal tumors. Part 1: tumors of the anterior mediastinum; , Chest (1997);112: pp. 511 522.
25. Bacha E A, Chapelier A R, Macchiarini P et al., - Surgery for invasive primary mediastinal tumors; , Ann. Thorac. Surg.(1998);66: pp. 234 239.
26. Langenfeld J, Graeber G M,- Current management of thymoma; , Surg. Oncol. Clin. N.Am. (1999);8: pp. 327 339.
27. Wilkins K B, Sheikh E, Green R et al.,- Clinical and pathologic predictors of survival in patients with thymoma; , Ann. Surg.(1999);230: pp. 562 574.
28. Takeda S, Miyoshi S, Ohta M et al.,- Primary germ cell tumors in the mediastinum: a 50-year experience at a single Japanese institution; , Cancer (2003);97: pp. 367 376.
29. Moran C A, Suster S, - Primary germ cell tumors of the mediastinum: I. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging; , Cancer (1997);80: pp. 681 690.
30. Bokemeyer C, Droz J P, Horwich A et al.,- Extragonadal seminoma: an international multicenter analysis of prognostic factors and long term treatment outcome; , Cancer (2001);91: pp. 1,394 1,401.
31. Javadpour N,- Significance of elevated serum alphafetoprotein (AFP) in seminoma; , Cancer (1980);45: pp. 2,166 2,168.
32. Dusmet M E, McKneally M F,- Pulmonary and thymic carcinoid tumors; , World J. Surg. (1996);20: pp. 189 195.
33. de Montpreville V T, Macchiarini P, Dulmet E,- Thymic neuroendocrine carcinoma (carcinoid): a clinicopathologic study of fourteen cases; , J.Thorac. Cardiovasc. Surg. (1996);111: pp. 134 141.
34. Fukai I, Masaoka A, Fujii Y et al.,- Thymic neuroendocrine tumor (thymic carcinoid): a clinicopathologic study in 15 patients; , Ann.Thorac. Surg. (1999);67: pp. 208 211.
35. Strollo D C, Rosado-de-Christenson M L, Jett J R,- Primary mediastinal tumors: part II.Tumors of the middle and posterior mediastinum; , Chest (1997);112: pp. 1,344 1,357.
36. Bousamra M 2nd, Haasler G B, Patterson G A et al.,- A comparative study of thoracoscopic vs open removal of benign neurogenic mediastinal tumors; , Chest, (1996);109: pp. 1,461 1,465.
37. Riquet M, Mouroux J, Pons F et al., - Videothoracoscopic excision of thoracic neurogenic tumors; , Ann. Thorac. Surg.(1995);60: pp. 943 946.
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