CHEST WALL, MEDIASTINUM and PLEURA

Napoleon Y. De Guzman, M.D.

LEGEND Normal text : lecture and recording th Italics : Schwartz Principles of Surgery 9 edition

November 22, 2010

Drawing a straight line from T4 to the sternum divides the mediastinum into 4 compartments: Superior: contains the great vessels Anterior Middle Posterior Anatomically, there are four compartments but clinically, there are only 3 compartments: Superior + Anterior = Anterosuperior Lies between the sternum and the anterior surface of the heart and great vessels Thymus and its remnants During childhood, the size of the thymus gland is impressive, occupying the entire anterior mediastinum. After adolescence, the thymus gland decreases in both thickness and length and it takes on a more fatty content, with only residual islands of thymic cellular components. Internal mammary artery and vein, lymph nodes, and fat. Middle (Visceral Compartment) Located between the great vessels and the trachea Pericardium and its contents The ascending and transverse aorta The superior and inferior venae cavae The brachiocephalic artery and vein The phrenic nerves The upper vagus nerve trunks The trachea The main bronchi and their associated lymph nodes The central portions of the pulmonary arteries and veins Posterior (Bilateral Paravertebral Sulci) Posterior to the two compartments The descending aorta Esophagus Thoracic duct Azygos and hemiazygos veins Lymph nodes Boundaries Thoracic inlet and the straight line Anterior border of the pericardium Posterior border of the pericardium Diaphragm Signs and symptoms (of a pathologic mediastinum) Compression pressure symptoms Chest pain, dyspnea, cough Superior vena cava syndrome Face, upper body, and arm swelling, dilated neck veins, conjunctival redness Nonspecific symptoms: weight loss, fever, fatigue, night sweats Compression symptoms are indicative of malignant histologic diagnosis. Snoring is a form of stridor.

MEDIASTINUM Portion of the chest in the midline that contains the heart, great vessels, and the tracheobronchial tree. Best seen on a lateral projection. The central part of the thoracic cavity that can be divided into compartments for classification of anatomic components and disease processes.

Figure 1: The Mediastinal Compartments

TRANSCRIBED BY: Tristan Milan Tengco, Carlo Benjamin Taada

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Table 1. Usual Location of the Common Primary Tumors and Cysts of the Mediastinum Anterior Visceral Compartment Compartment Thymoma Germ cell tumor Lymphoma Enterogenous cyst Lymphoma Pleuropericardial cyst Paravertebral Sulci Neurilemoma schwannoma Neurofibroma Malignant schwannoma Ganglioneuroma Ganglioneuroblastoma Neuroblastoma Paraganglioma Pheochromocytoma Lymphoma

Neurofibroma nerve fibers and nerve sheaths Ganglioneuroma ganglion cells Malignant Neurofibrosarcoma Ganglioneuroblastoma Neuroblastoma Neurosarcoma Complication: Horners syndrome Oculosympathetic paralysis Presents with Heterochromic irises, Anhydrosis, Miosis, Ptosis THYMOMA and TERATODERMOIDS Most common mediastinal tumor (anterior mediastinum) according to Schwartz Thymoma: most common anterior mediastinal tumor Seen most frequently in 40 and 60 years of age. Rare in children. Diagnosis of malignancy rests mostly on the gross findings of invasion and spread This is because benign and malignant varieties look the same microscopically. Associated with myasthenia gravis (MG) 10-50% with thymoma have MG 90% with MG have thymic lesions (Schwartz: 10%) Diagnosis may be suspected based on CT scan and history, but are not diagnostic. CT-guided FNA biopsy has been reported to have a diagnostic sensitivity of 87% and a specificity of 95% Radical thymectomy Removal of all tissues anterior to the pericaridum including the fat pads extending from the diaphragm to the neck Procedure of choice in generalized myasthenia Table 4. 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 the pericardium, great vessels, or lung Stage IV a: Pleural or pericardial dissemination Stage IV b: Lymphogenous or hematogenous metastasis THYMIC CARCINOMA unequivocally malignant Low-grade tumors are well differentiated with squamous cell, muco-epidermoid, or basaloid features. High-grade thymic carcinomas include those with lympho-epithelial, small-cell neuroendocrine, sarcomatoid, clear-cell, and undifferentiated or anaplastic features. Complete resection is occasionally curative, but most thymic carcinomas will recur and are refractory to chemotherapy. The prognosis of such patients remains poor. CYSTS Most common middle mediastinal tumor Primary Mediastinal Cyst Account for up to 25% of mediastinal masses.

Lymphangioma Mediastinal granuloma Hemangioma Lipoma Fibroma Fibrosarcoma Thymic cyst Parathyroid adenoma Lymphoid hamartoma Mesothelial cyst Neurenteric cyst Paraganglioma Thoracic duct cyst

Pheochromocytoma Fibrosarcoma

Table 2. Mediastinal Tumors in Adults Tumor Type Neurogenic tumors Cysts Thymomas Lymphoma Germ cell tumors Endocrine tumors Incidence (%) Location 21 20 19 13 11 6 Posterior All Anterior Anterior/middle Anterior All Anterior/middle

Mesenchymal tumors 7

Table 3. Mediastinal Tumors in Children Tumor Type Neurogenic tumors Lymphoma Cysts Germ cell tumors Thymomas Incidence (%) Location 40 18 18 11 Rare Posterior Anterior/middle All Anterior All Anterior

Mesenchymal tumors 9

NEUROGENIC TUMORS (DUMBBELL TUMORS) Most common mediastinal tumor (usually posterior) according to Sabiston The incidence, cell types, and risk of malignancy strongly correlate with patient age. Tumors of nerve sheath origin predominate in adults. Most present as asymptomatic incidental findings and most are benign. In children and young adults, tumors of the autonomic ganglia predominate, with up to two-thirds being malignant. Neurilemmoma encapsulated tumors of the nerve sheath.

TRANSCRIBED BY: Tristan Milan Tengco, Carlo Benjamin Taada

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A CT scan showing characteristic features of near water density in a typical location is virtually 100% diagnostic. Pericardial Cyst Usually asymptomatic and detected incidentally. Contain a clear fluid and appear in the right costophrenic angle. For most simple, asymptomatic pericardial cysts, observation alone is recommended. Surgical resection or aspiration may be indicated for complex cysts or large symptomatic cysts. Bronchogenic Cyst An abnormal budding of the foregut or tracheobronchial tree. The most frequent mediastinal location is just posterior to the carina or main stem bronchus. In children, most such cysts are symptomatic. Resection is generally recommended since serious complications may occur if the cyst becomes larger or infected. Symptomatic bronchogenic cysts should be removed. Traditionally, removal has been via posterolateral thoracotomy. Enteric Cyst Esophageal cysts should be removed, regardless of the presence or absence of symptoms. Esophageal cysts have a propensity for serious complications secondary to enlargement, leading to hemorrhage, infection, or perforation. Thus surgical resection is the treatment of choice in both adults and children. Thymic Cyst Generally asymptomatic and are incidental findings during radiographic work-up Cystic components occasionally are seen in patients with thymoma and Hodgkin's disease LYMPHOMA Overall, lymphomas are the most common malignancy of the mediastinum. Frequent lesions Should be medically or non-surgically treated In about 50% of patients who have both Hodgkin's and non-Hodgkin's lymphoma, the mediastinum may be the primary site. The anterior compartment is most commonly involved, with occasional involvement of the middle compartment and hilar nodes. The posterior compartment is rarely involved. In UERM, anterior mediastinal tumor is more common than neurogenic tumors.

How will you know if the tumor is found in the mediastinum and not in/from the lungs? If the angle formed by the mediastinal pleura is obtuse mediastinal

Figure 3 Mediastinal Tumor vs Parenchymal Tumor LEFT: A lung mass abuts the mediastinal surface and creates acute angles with the lung. RIGHT: A mediastinal mass will sit under the surface of the mediastinum creating an obtuse angle with the lung. MEDIASTINAL GERM CELL TUMOR The most common malignancy in young men between age 15 and 35 years Most are gonadal in origin Primary mediastinal germ cell tumors Teratoma Most common type of mediastinal germ cell tumors, accounting for 60 to 70% of mediastinal germ cell tumors. Contain two or three embryonic layers that may include teeth, skin, hair (ectodermal), cartilage and bone (mesodermal), or bronchial, intestinal, or pancreatic tissue (endodermal). Therapy for mature, benign teratomas is surgical resection, which confers an excellent prognosis. Seminoma Patients usually present with symptoms of local compression, including superior vena caval syndrome, dyspnea, or chest discomfort. With advanced disease, the preferred treatment is combination cisplatin-based chemotherapy regimens with bleomycin and either etoposide or vinblastine. Non-Seminomatous Germ Cell Tumors

Figure 4 Germ Cell Tumor LEIOMYOMA of the ESOPHAGUS Presents as posterior mediastinal mass Esophagogram shows smooth, esophageal mucosa with external compression If suspected, esophageal punch biopsy is contraindicated.

Figure 2: Anterior Mediastinal Tumor

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Punch biopsy will open the mucosa. You need an intact mucosa in doing resection of this tumor. Treatment: Excision biopsy, thoracotomy Treatment of Mediastinal Tumor Surgery is the best option except for lymphomas High incidence of invasion of adjacent structures if left for some time PLEURA Parietal Pleura Mesothelial lining of each hemithorax that invaginates at the hilum of each lung Visceral Pleura Covers the lungs Pathologies of the thorax: Pneumothorax air Hemothorax blood Hydrothorax fluid Pyothorax or empyema pus Pleural effusion transudate as in CHF, uermia, or SLE, or exudate as in pneumonia Chylothorax chyle Empyema necessitates Abscess in the chest wall that recurs even if drained because it is connected to empyema Associated with pulmonary tuberculosis PNEUMOTHORAX Tension pneumothorax is life-threatening CVS collapse mediastinal shift and kinking of vena cava Blood pressure decreases. Kink low pressure vena cava, decreasing venous return, decreasing SV, decreasing CO and BP Pulmonary shunting of blood through collapsed lung With collapsed lung, no gas exchange so blood goes back to the heart with no oxygen. Normal shunt: 3-5% With collapse: as high as 40-45% Most common cause: ruptured bleb Most common symptom: sudden dyspnea and chest pain Treatment: Bed rest and 100% O2 Everyday: 1.4%/day resolution of pneumothorax Tube thoracostomy anterior chest When 20% or greater is ruptured Chronic lung disease Elderly Symptomatic Be careful when putting a tube and reexpanding the lungs: May lead to rapid re-expansion pulmonary edema If lung is collapsed after 48 hours, do not reexpand abruptly. Just connect the chest tube to a water seal bottle, no suction. The following day you can suction. Suction 10-25% cm H20 applied after 24 hrs Recurrent affair (continuous air leak): tube thoracostomy plus: Thoracotomy and closure VATS (video assisted thoracic surgery) and closure Limitation: may not see all the blebs Pleurodesis through tetracycline

Salient points in putting the chest tube Finger in the pleural cavity To avoid inserting the tube in the abdomen Hit the rib first during the creation of the tract Other treatment options: Observation Needle aspiration Percutaneous catheter to drain Water seal of pleura-evacuation type Heimlich valve Tube thoracostomy Water seal of pleura-evacuation type Heimlich valve Tube thoracostomy with instillation of pleural irritant VATS (Video-Assisted Thoracoscopic Surgery) Thoracotomy Superior to everything Indications for operative intervention for pneumothorax Persistent air leak Recurrent pneumothorax First episode in a patient with prior pneumonectomy First episode with occupational hazard Airplane pilot Diver Surgical procedures for pneumothorax Pleural abrasion Parietal pleurectomy Apical Complete Talcage: creates fibrosis By slurry - mixture of bulk sterile talc with sterile normal saline; most common administration volume is 50 mL to 100 mL By insufflations - involves blowing the powder or aerosol with a powder blower through a thoracoscope inserted into the pleural space Talcage, after extensive googling, is the intrapleural administration of talc, either by slurry or by insufflations (poudrage). *All include excision or obliteration of the offending bleb or bulla. HEMOTHORAX Treatment: tube thoracostomy, monitor output Clotted hemothorax: VATS within 1 month and suction After a month when the fibrosis sets in: thoracotomy then decortication (peel the pleura and release the lungs) Drainage for Filipinos Initial drainage of 1,000 ml (for caucasians: 2,000 ml) Hourly output of 100 ml for 4 hrs 24-hr output of 2,000 ml PLEURAL EFFUSION Any significant collection of fluid within the pleural space Normally, between 5-10 L of fluid enters the pleural space daily. Normal volume of fluid in the pleural space is 15-20 ml of pleural fluid. Any disturbance in these forces can lead to imbalance and accumulation of pleural fluid. Differentials: Parapneumonic (pneumonia)

TRANSCRIBED BY: Tristan Milan Tengco, Carlo Benjamin Taada

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TB Malignancy Diagnosis Thoracentesis and fluid analysis Differential count, CHO, CHON, LDH, Gram stain, C/S, cytology Pleural biopsy Cope/Abrams needle Thoracoscopy/VATS and pleural biopsy Treatment Parapneumonic Antibiotics Drainage Malignant effusion Pleurodesis using Tetracycline/talc/AgNO3 2 g 1.0% TB effusion 6 mo. Anti-TB Quadruple 2 months Triple: 4 months Decortication: within 4 weeks Do not do pleurodesis because this will promote fibrosis leading to restrictive lung disease. *You can do adhesiolysis within 1 month then open the patient *Prerequisite in pleurodesis The visceral and parietal pleura should be in contact with each other (i.e. lungs are expanded). EMPYEMA Defined by a purulent pleural effusion. The most common causes are parapneumonic, but postsurgical or posttraumatic empyema is also common. Grossly purulent, foul-smelling pleural fluid makes the diagnosis of empyema obvious. Small to moderate turbid pleural effusions in the setting of a pneumonic process may require further pleural fluid analysis Pathogens Pneumococci and Stapgylococci most common cause Gram negative aerobes and anaerobes E. coli Klebsiella Pseudomonas Enterobacteriaceae Treatment th Drainage thoracostomy at the 6-7 ICS post. axillary Antibiotics C/S Nutritional support For chronic affair (1 month) Pleural window for poor risks Decortication for good risks CHYLOTHORAX There is rupture or after surgical trauma of thoracic duct Generally unilateral but if the mediastinal pleura is disrupted on both sides, bilateral chylothoraces may occur Chylothorax may also follow nonsurgical trauma, including penetrating or blunt injuries to the chest or neck area, central line placements, and other surgical misadventures. Test for triglycerides if present, (+) chyle Treatment: 2-weeks initial intensive management

Figure 5 Cisterna Chyli

Figure 6: Treatment Schema When you enter the chest, go to the diaphragm and then ligate the area above the diaphragm because this is where the thoracic duct enters to join the subclavian vein. PLEURAL TUMORS Primary Mesothelioma (rare) Arises from the peritoneum Asbestos exposure is the only known risk factor Secondary (most common)

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From the lungs, breast, ovaries, etc. Treatment Primary: Poor result: pleurectomy Secondary : pleurodesis for effusion CHEST WALL Chest wall tumors are considered malignant unless proven otherwise. Malignant: 89% Chondrosarcoma: most common usually arise anteriorly from the costochondral arches slowly-enlarging, often painful masses of the anterior chest wall Osteosarcoma Most common bone malignancy but are uncommon malignancy of the chest wall It takes 21 days to decalcify the bone and analyze the bone difficult and matagal to diagnose Benign: 11% Most common: lipoma Management: Wide resection: Rib: include 1 rib above and 1 rib below Sternum: whole sternum Closure: or else end up with flail chest Bony thorax Soft tissue cover Congenital Chest Wall Pectus carinatum - deformity of the chest characterized by a protrusion of the sternum and ribs caused by an overgrowth of cartilage causing the sternum to protrude forward Vitamin D deficiency Pectus excavatum - most common congenital deformity of the anterior wall of the chest , in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest. Defect: costal cartilage

A Needle Aspiration; B Chest tube Insertion; C Tube connected to a water-seal drainage system SHOUTOUTS Maraming salamat kina Tantan at Carlo sa trans na ito! We are also sorry for the slight delay and the lack of organization sa trans committee ng surgery (my fault, haha. I believe I am less enthusiastic in making transes now, compared to last year). We missed 2 lectures and there wont be any make-up so we made do with what we have. And to lighten up the mood a bit, since there seems to be an exponential increase in the release of transes lately, Imma greet a few people and give one-word Pangasinense descriptions for them. Here goes: Daphne ba-bansot Abby mantalandeyew Goldie masa-salti Nizh mapasaset Gayle matetew Armi madeldel Trish makutikot Pepin makapa-elew Jessa masansamit Charm uga-ugaw Domar makapakelaw Kimmy makapalek Rey maayew Vida manjalteng

No labay nyon alamen iraratay salitan akatepew iras ngaran da ray kaklase tayo, mampabangat kayod mgay Pangasinense tayon kaklase. Be proud of your sexy, native tongue. Francis Xavier Beacon of religiousness

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