Approach to the diagnosis and staging of mediastinal masses

Good's syndrome remains a mystery after 55 years: A systematic review of the scientific evidence

Good syndrome (GS) is a rare association of thymoma and immunodeficiency first described more than 50 years ago. However, this syndrome still remains a mystery to clinicians. We systematically reviewed all the clinical, laboratory and immunologic findings from 152 patients with Good syndrome. The syndrome has a worldwide distribution and approximately half of the cases (47%) have been described in Europe. The diagnosis of thymoma preceded the diagnosis of hypogammaglobulinemia, infection, or diarrhea in 42% of patients whereas in 38% of patients the diagnoses were made almost simultaneously within 2 months of each other. We found significant mortality in patients with this syndrome (44.5%). Astute clinical acumen and increased awareness about the clinical and immunological profile of this syndrome may increase early recognition of this syndrome and prevent mortality. Further studies are needed to elucidate this clinical entity.

[Primary cysts and tumors of the mediastinum]

OBJECTIVE

To assess results in patients with primary cysts and tumours of the mediastinum who under- went surgery.

METHODS

A retrospective single-centre study was undertaken into patients with primary cysts and tumours of the mediastinum who underwent surgery between January 1992 and December 2004. We analysed demographic data, clinical presentation, type of surgery carried out and procedure, lesion location and histological diagnosis. Predictive malignancy factors were also evaluated. Postoperative morbidity and mortality were noted, as was medium-term results.

RESULTS

171 patients underwent surgery over a 13-year period; 73 female (43%) and 98 male (57%). Mean age was 40.3+/-19.7 years (20 days-78 years). A primary cystic lesion was present in 15 patients (9%). The pri- mary tumours included thymic neoplasms (31%), lymphoma (22%), neurogenic tumours (16%), germ cell tumours (9%) and a miscellaneous group (13%). Malignant neoplasms were present in 78 patients (46%). The antero-superior mediastinum was the most commonly involved site to have a primary cyst or tumour (58%), followed by the posterior mediastinum (24%) and the middle mediastinum (18%). Symptoms were present in 68% of the patients and included chest pain (20%), fever and chills (13%), myasthenia gravis (11%), cough (10%), dyspnoea (10%), and superior vena caval syndrome (7%). Univariate analysis identified symptoms as a predictive factors of malignancy (p<0.001). Types of surgery carried out included postero-lateral thoracotomy (64 patients), median sternotomy (51 patients), anterior mediastinostomy (27 patients), antero-lateral thoracotomy (18 patients), video-assisted thoracic surgery (9 patients) and mediastinoscopy (2 patients). Total excision was performed in 116 patients, enlarged resection in 8 patients, subtotal re- section in 7 patients and biopsy in 40 patients. There was one postoperative death (0.6%). Follow-up was available in 165 patients (96.5%) and ranged from 34 days to 13.4 years (mean 5.7+/-4.0 years). Complementary treatment with chemo and/or radiotherapy was provided in 75 patients. Six patients had to be reoperated on for local recurrence (3) or metastasis (3) of the primary lesion. Fifteen patients died of their disease during the follow-up period. Actuarial survival at five years was 97.6% for benign lesions and 76.4% for malignant tumours.

CONCLUSION

Results support surgical resection for benign lesions and an aggressive multimodal approach for malignant tumours.

Imaging of the mediastinum: applications for thoracic surgery

The diagnostic approach to patients who have mediastinal masses should include thorough preoperative imaging. Once limited to plain radiographic techniques, the radiologist now has a wide variety of imaging modalities to aid in the evaluation of the mediastinum. CT is the imaging modality of choice for evaluating a suspected mediastinal mass or a widened mediastinum, and it provides the most useful information for the diagnosis, treatment, and evaluation of postoperative complications.

The value of a noninvasive diagnostic approach to mediastinal masses

BACKGROUND

Mediastinal tumors show a wide variability, and therefore, a standardized diagnostic and therapeutic workup is instrumental. We subdivided mediastinal tumors into nonlymphatic mediastinal tumors (NLMTs), most of which require surgical resection without need of preoperative histology, and mediastinal lymphadenopathy (MLA), requiring surgical biopsy for exact histologic classification. We investigated the accuracy of noninvasive diagnostic studies distinguishing between the two groups of MLA and NLMT.

METHODS

A retrospective analysis was performed on patients who had previously undergone surgery on mediastinal tumors. Their data were statistically analyzed (chi2 test, logistic regression analysis), and the values of medical history, physical examination, laboratory tests, and computerized tomography scan discriminating between MLA and NLMT were assessed.

RESULTS

Out of 299 patients included in the study, 242 (80.9%) had MLA and 57 (19.1%) had NLMT. Sensitivity and specificity of noninvasive investigations for differentiation of MLA and NLMT were 98.2% and 86.0%, respectively. Whereas the prevalence of thoracic symptoms such as shortness of breath, cough, or chest pain was similar in both groups (MLA, 165 [69.3%]; NLMT, 41 [69.5%]; p = 0.98), systemic symptoms, including fever, night sweats, or weight loss (MLA, 110 [49.8%]; NLMT, 17 [29.3%]; p < 0.01), and signs of inflammation, such as c-reactive protein, erythrocyte sedimentation rate, and leukocytosis (MLA, 202 [85.6%]; NLMT, 34 [57.6%]; p < 0.001), were significantly more common in MLA.

CONCLUSIONS

Noninvasive diagnostic procedures, including medical history, physical examination, laboratory tests, and computerized tomographic scan, are highly sensitive in detecting MLAs that should undergo surgical biopsy. Our data suggest confirming all suspected NLMTs by fine needle aspiration (FNA) biopsy before surgery.

Diagnosis and treatment of mediastinal tumors by thoracoscopy

OBJECTIVES

Thoracoscopic management of mediastinal tumors is still subject to analysis. Seventy-three patients underwent thoracoscopy for treatment of mediastinal masses and were analyzed retrospectively in order to evaluate the effectiveness and complications of the procedure.

METHODS

Between 1983 and 1999, 21 conventional thoracoscopies and 52 video-assisted thoracic surgeries were performed (33 for diagnostic purposes and 40 for therapy). Patient ages ranged from 2 to 81 years (mean, 43.8 years) with a slight predominance of girls and women over men and boys (41 vs 32, respectively). All patients underwent general anesthesia using simple intubation (22 patients) or double-lumen intubation (51 patients).

RESULTS

The histologic type of tumors was obtained in all patients. For therapeutic purposes, a change of procedure to thoracotomy was necessary in nine patients. The reasons for this change were tumor size, tumor invasion of nearby structures, difficulties in continuing the dissection, the performance of an upper lobectomy, and suturing the iatrogenic lesion of the diaphragm. Four patients died during the first 30 postoperative days as a consequence of their primary pathology.

CONCLUSION

Thoracoscopy was confirmed as an effective diagnostic and therapeutic alternative for the treatment of mediastinal disorders.

Videothoracoscopic approach to primary mediastinal pathology

STUDY OBJECTIVES

Personal results and validity of videothoracoscopic (VTS) approach to primary mediastinal diseases are analyzed.

DESIGN

Retrospective review of personal experience.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milano, Italy.

PATIENTS

From September 1991 to January 1999, of a personal series of 1,653 VTS procedures, 118 regarded primary mediastinal diseases. In 47 cases, diagnostic videothoracoscopy was performed to obtain large biopsy specimens or to carry out accurate staging; in 71 cases, full resection was anticipated.

INTERVENTIONS

The patient, intubated with a double-lumen Carlen's tube and in the lateral decubitus position, underwent videothoracoscopy. Two ports and a small anterior utility thoracotomy were completed. Thorough exploration of the mediastinum and, if possible, complete resection of the lesion were accomplished.

MEASUREMENTS AND RESULTS

Videothoracoscopy yielded adequate diagnosis or staging in all patients operated on for diagnostic purposes. Of 71 patients operated on with resective intent, 66 had complete thoracoscopic resection (22 stage-I thymomas, 4 thymic cysts, 21 myasthenia gravis associated with thymic hyperplasia, 19 miscellaneous tumors). Conversion was required in five cases, mostly for invasion of mediastinal structures. Complications included the following: one patient developed intraoperative bleeding controlled endoscopically, two patients experienced postoperative bleeding requiring re-thoracoscopy, and one patient had postoperative pneumonia requiring assisted ventilation. One recurrence of malignant thymoma occurred 4 years postoperatively.

CONCLUSIONS

Videothoracoscopy can attain a leading role in obtaining large samples in lymphatic mediastinal diseases. Dysembriomas, schwannomas, simple cysts, and similar lesions can benefit from VTS removal. Total thymectomy for myasthenia gravis associated with thymic hyperplasia can be performed thoracoscopically. Further data and more extensive experience are needed.

Videothoracoscopic excision of mediastinal masses: indications and technique

Mediastinal masses are generally excised through wide thoracotomies or median sternotomies. These lesions are often benign, usually asymptomatic, discovered incidentally, and relatively easy to resect. For these reasons, a minimally invasive approach is appropriate. Videothoracoscopy allows an optimal exploration of the pleural cavity and a panoramic view of the mass. Dissection is usually easy to perform, and the mass can be extracted from the thorax through a trocar incision or through a limited "utility thoracotomy." To avoid possible tumor seeding, the mass is inserted in a plastic bag before extraction. From September 1991 to January 30, 1994, 20 mediastinal masses (6 thymomas, 2 thymic cysts, 1 hyperplastic thymus, 1 fibrous tumor of the mediastinum, 2 pleuropericardial cysts, 2 thoracic teratomas, 2 large thoracic lipomas, 3 neurogenic tumors, and 1 bronchogenic cyst) were removed through such a minimally invasive approach. Eighteen patients had an uneventful postoperative course. Two patients hemorrhaged in the immediate postoperative period, and repeat thoracoscopy was done. In 1 patient, electrocoagulation of a bleeding intercostal artery controlled the hemorrhage. In the other, the source of bleeding could not be found, and removal of the clots and irrigation of the cavity stopped the hemorrhage. Further data and long-term follow-up are necessary, but videothoracoscopy offers a new, less invasive approach for the management of noninvasive mediastinal masses.

A patient presenting for pharyngeal biopsy

A 68-yr-old man presented for pharyngeal biopsy under general anaesthesia. Coincidentally he was found to have a large mediastinal mass. The evaluation of this patient is described. The exact risk of catastrophic airway collapse on induction of anaesthesia in patients with mediastinal masses is controversial but probably small. As there is no test to prevent airway collapse, it is suggested that attempts at biopsy be performed with regional anaesthesia after radiotherapy.

Thymoma

Thymomas and thymic carcinomas are thymic epithelial tumors that constitute approximately 15% of all mediastinal masses. From 28 to 66% of thymomas cause chest symptoms as the initial manifestation; the rest are discovered on routine chest roentgenograms or during investigations prompted by the presence of a paraneoplastic syndrome. Forty percent of patients with thymoma have one or more paraneoplastic syndromes, including myasthenia gravis, pure red cell aplasia, and hypogammaglobulinemia. Extrathymic malignant lesions develop in up to 20% of patients. Traditional histologic classifications have not accurately predicted tumor behavior; a recently developed classification based on cellular differentiation toward thymic medullary or cortical epithelium may correlate better with prognosis. Nevertheless, the prognosis is best predicted by stage of the tumor determined intraoperatively and is poorer in patients with incomplete resection than in those with complete resection of the thymoma. In addition to surgical intervention, irradiation and chemotherapy have important roles in the management of thymomas, particularly in advanced stages. In this article, the clinical manifestations, diagnosis, pathologic features, staging, and treatment of thymomas are reviewed, and the prognosis of affected patients is discussed.