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SURGICAL TREATMENT
OF
MEDIASTINAL TUMOR
BY
DR. INNOCENT KINGSLEY ASOGWA
ML - 608
USUAL LOCATION OF MEDIASTINAL LESIONS
TREATMENTOF THYMOMA
 Surgery
 Complete surgical resection
 Median sternotomy with a vertical or submammary incision is ...
CONT’D
 Systemic Therapy
 Steroids have been shown to be active in the management of thymomas
 Both single-agent and co...
Branches of the internal thoracic arteries are divided to permit the en bloc specimen to
be rotated upward, exposing the u...
PREOPERATIVE
 Initial workup:
 careful history and physical examination  the neck and particularly the
thyroid gland re...
CONT’D
 Radiographic Investigation:
 Plain Chest X Ray 2 plane: posteroanterior and left lateral view
 CT Scan
 MRI
 ...
POSTOPERATIVE
 Usually are extubated in the OR within 30 minutes of the conclusion of
the operation
 Kept in a monitored...
CONT’D
 Antibiotics and the continuous epidural infusion are discontinued, and
oral narcotic analgesics are started once ...
TREATMENT OF Substernal Goiter
CONSIDERATION FOR THORACOTOMY
 Atypical anatomy
 Extramediastinal extension with known malignancy
 Posterior location o...
CONSIDERATION FOR MEDIAN STERNOTOMY
 Primary retrosternal/ectopic
goiter
 Atypical anatomy
 Dense adhesions from prior
...
Goiters usually can be removed via cervical incision with the use of careful
blunt finger dissection to mobilize the gland...
PREOPERATIVE
 Radiographic:
 Chest x-ray  mediastinal mass, superior mediastinal widening, tracheal
deviation or compre...
POSTOPERATIVE
 Length of stay for an uncomplicated procedure is overnight
 patients can be discharged uneventfully with ...
TREATMENT OF TERATOMAS
 For benign tumors that are so large or with involvement of adjacent
mediastinal structures so tha...
SEMINOMAS
 Sensitive to irradiation and chemotherapy
 Treatment consists of systemic and local therapy:
 chemotherapy w...
MEDIASTINAL NONSEMINOMAS
 Current treatment: cisplatin and etoposide-based regimens
 When tumor necrosis or a benign ter...
LYMPHOMAS
 Surgeon’s primary role is to provide sufficient tissue for diagnosis and
to assist in pathologic staging.
 Th...
NEUROGENIC TUMORS: SCHWANNOMA / NEURILIMOMA
 During resection, the intraspinal component should be removed first
via a po...
Magnetic resonance image of a neurogenic tumor with extension into the spinal
canal via the foramen, which gives a typical...
Approach for dumbbell tumors.
A. Hemilaminectomy (black arrow).
B. Resection of intraspinal
component of tumor prior to th...
NEUROBLASTOMAS
 Therapy is determined by the stage of the disease
 stage I  surgical excision
 stage II  excision and...
INTERNATIONAL NEUROBLASTOMA STAGING SYSTEM
GANGLION TUMORS
 Ganglioneuroblastomas  composed of mature and immature ganglion cells
 Treatment  from surgical excis...
PREOPERATIVE
 Initial workup:
 physical examination and accurate history
 Imaging
 CT scan  to define the morphology ...
POSTOPERATIVE
 Patients are managed similarly to any patient who has undergone
thoracotomy or thoracoscopy
 Chest drains...
REFERENCES
1. Sugarbaker D, Bueno R, Krasna M, Mentzer S, Zellos L. Adult Chest
Surgery. McGraw Hill Professional; 2009.
2...
THANK YOU
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
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Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa

Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa

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Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa

  1. 1. SURGICAL TREATMENT OF MEDIASTINAL TUMOR BY DR. INNOCENT KINGSLEY ASOGWA ML - 608
  2. 2. USUAL LOCATION OF MEDIASTINAL LESIONS
  3. 3. TREATMENTOF THYMOMA  Surgery  Complete surgical resection  Median sternotomy with a vertical or submammary incision is most commonly used  bilateral anterolateral thoracotomies with transverse sternotomy, or “clam- shell procedure”, preferred with advanced or laterally displaced large tumors  Patients with MG and thymoma have a 56% to 78% 10-year survival rate and a 3% recurrence rate with 4.8% (1.7% since 1980) operative mortality after extended thymectomy  Radiation  In stage II and III invasive disease, adjuvant radiation can decrease recurrence rates after complete surgical resection from 28% to 5%  Radiation therapy has proven beneficial in the treatment of extensive disease
  4. 4. CONT’D  Systemic Therapy  Steroids have been shown to be active in the management of thymomas  Both single-agent and combination therapy have demonstrated activity in the adjuvant and neoadjuvant settings  Doxorubicin, cisplatin, ifosfamide, corticosteroids, and cyclophosphamide all have been used as single-agent therapy  Molecularly Targeted Therapy  Overexpression of c-kit is common in thymic carcinoma  Coamplification of the HER-2/neu topoisomerase 2-alpha gene may correlate with response to the CAP chemotherapy regimen  antitumor activity has been reported with dasatinib, a small molecule oral, multitargeted kinase inhibitor of Bcr-Abl and src kinases, ephrin receptor kinases, platelet-derived growth factor receptor, and c-kit, in thymoma
  5. 5. Branches of the internal thoracic arteries are divided to permit the en bloc specimen to be rotated upward, exposing the undersurface of the gland and the draining veins. The exposed brachiocephalic and thymic veins are isolated and divided between ligatures or clips (inset).
  6. 6. PREOPERATIVE  Initial workup:  careful history and physical examination  the neck and particularly the thyroid gland require careful palpation  Investigation:  complete blood count,  serum electrolytes,  thyroid function tests,  acetylcholine-receptor antibody assay,  pulmonary function tests,  electromyographic studies,  immunoglobulin assay,  bone marrow biopsy,  cervical lymph node biopsy
  7. 7. CONT’D  Radiographic Investigation:  Plain Chest X Ray 2 plane: posteroanterior and left lateral view  CT Scan  MRI  Patient's strength and respiratory status should be optimized with the use of pyridostigmine and immunosuppressive agents when indicated  Preoperative plasmapharesis or IV immunoglobulin therapy may be beneficial in patients with a vital capacity of less than 2 L
  8. 8. POSTOPERATIVE  Usually are extubated in the OR within 30 minutes of the conclusion of the operation  Kept in a monitored setting overnight  If the patient does not have an epidural catheter in place, parenteral analgesia can be administered in small intermittent doses of hydromorphone or morphine  On the morning after the operation, oral medication and a clear liquid diet are begun and advanced as tolerated  The chest tubes are removed when no air leak or significant output is present and the lungs are fully expanded on chest x-ray  2nd postoperative day
  9. 9. CONT’D  Antibiotics and the continuous epidural infusion are discontinued, and oral narcotic analgesics are started once the chest tubes are removed  Patients with MG are discharged when their symptoms are adequately controlled with oral medication and they are well able to tolerate a regular diet  Most patients are able to return to normal activity and work within 2–3 weeks after transsternal thymectomy  Tapering of medications in patients with MG begins at various times after operation depending on the judgment of the neurologist
  10. 10. TREATMENT OF Substernal Goiter
  11. 11. CONSIDERATION FOR THORACOTOMY  Atypical anatomy  Extramediastinal extension with known malignancy  Posterior location or extension of tumor  Goiters that extend to the tracheal carina  Adherence to visceral or intrathoracic parietal pleura
  12. 12. CONSIDERATION FOR MEDIAN STERNOTOMY  Primary retrosternal/ectopic goiter  Atypical anatomy  Dense adhesions from prior surgery  Inability to deliver the gland into the neck  Extracapsular extension or known mediastinal malignancy  Recurrent intrathoracic goiter  Prior thyroid surgery, especially for cancer  Goiters that extend to the tracheal carina  Goiters that cause life- threatening compression of mediastinal structures  Significant intraoperative mediastinal bleeding  Adherence to mediastinal pleura
  13. 13. Goiters usually can be removed via cervical incision with the use of careful blunt finger dissection to mobilize the gland from its attachment to mediastinal structures. Most large goiters can be removed through a 2-cm collar incision.
  14. 14. PREOPERATIVE  Radiographic:  Chest x-ray  mediastinal mass, superior mediastinal widening, tracheal deviation or compression  Chest CT scans  define the full extent and anatomic relationships of the substernal thyroid to surrounding structures and to facilitate preoperative planning  serum thyroid-stimulating hormone measurement  If hyperthyroidism is present  antithyroid medications and beta blockade should be undertaken before elective resection  Pulmonary functiong testing is useful  discuss these patients with the anesthesiologist in advance of surgery
  15. 15. POSTOPERATIVE  Length of stay for an uncomplicated procedure is overnight  patients can be discharged uneventfully with calcium or calcitriol supplementation  If a thoracotomy or sternotomy is required, length of stay is increased  major complications  injury to the trachea, parathyroid glands, or recurrent laryngeal nerves  The need for tracheostomy is rare
  16. 16. TREATMENT OF TERATOMAS  For benign tumors that are so large or with involvement of adjacent mediastinal structures so that complete resection is impossible  partial resection (debulking) can lead to the resolution of symptoms, frequently without relapse  Malignant teratomas  chemotherapy and radiation therapy, combined with surgical excision  Overall prognosis is poor for malignant teratomas
  17. 17. SEMINOMAS  Sensitive to irradiation and chemotherapy  Treatment consists of systemic and local therapy:  chemotherapy with salvage surgery  combined chemoradiotherapy  Radiation therapy may be considered for early-stage disease, but is not recommended for regional disease  Platinum-based chemotherapy is common  Occasionally, excision is possible without injury to vital structures and can be recommended  When complete resection is possible, the use of adjuvant therapy is unnecessary
  18. 18. MEDIASTINAL NONSEMINOMAS  Current treatment: cisplatin and etoposide-based regimens  When tumor necrosis or a benign teratoma is found during surgical exploration after chemotherapy  excellent or intermediate prognosis
  19. 19. LYMPHOMAS  Surgeon’s primary role is to provide sufficient tissue for diagnosis and to assist in pathologic staging.  Thoracoscopy, mediastinoscopy, or mediastinotomy and, rarely, thoracotomy or median sternotomy may be necessary to obtain sufficient tissue  Lymphoblastic lymphoma occurs predominantly in children, adolescents, and young adults and represents 60% of cases of mediastinal non-Hodgkin’s lymphoma.
  20. 20. NEUROGENIC TUMORS: SCHWANNOMA / NEURILIMOMA  During resection, the intraspinal component should be removed first via a posterior laminectomy  minimizes the potential for spinal column hematoma, cord ischemia, and paralysis
  21. 21. Magnetic resonance image of a neurogenic tumor with extension into the spinal canal via the foramen, which gives a typical dumbbell appearance
  22. 22. Approach for dumbbell tumors. A. Hemilaminectomy (black arrow). B. Resection of intraspinal component of tumor prior to thoracic approach
  23. 23. NEUROBLASTOMAS  Therapy is determined by the stage of the disease  stage I  surgical excision  stage II  excision and radiation therapy  stages III and IV  multimodality therapy using surgical debulking, radiation therapy, and multiagent chemotherapy
  24. 24. INTERNATIONAL NEUROBLASTOMA STAGING SYSTEM
  25. 25. GANGLION TUMORS  Ganglioneuroblastomas  composed of mature and immature ganglion cells  Treatment  from surgical excision alone to various chemotherapeutic strategies, depending on:  histologic characteristics,  age at diagnosis,  stage of disease  Ganglioneuromas  benign tumors originating from the sympathetic chain that are composed of ganglion cells and nerve fibers  typically present at an early age  the most common neurogenic tumors occurring during childhood  usual location: paravertebral region; well encapsulated, cystic degeneration when cross-sectioned  Surgical excision is curative.
  26. 26. PREOPERATIVE  Initial workup:  physical examination and accurate history  Imaging  CT scan  to define the morphology and location of the tumor, local invasion, bony or airway involvement  MRI  to clarify the relationship of the tumor to the neural foramen and spinal canal  Laboratory test:  serum and urine free catecholamine levels  Insulin and glucose levels  Adjunctive workup:  pulmonary function test  cardiac risk stratification
  27. 27. POSTOPERATIVE  Patients are managed similarly to any patient who has undergone thoracotomy or thoracoscopy  Chest drains are removed early (i.e., on the day of surgery or postoperative day 1) based on output and reexpansion of the lung  extubated in the OR, and early mobilization is advocated  Diet may be resumed in short order as tolerated  patients with paragangliomas warrants special attention to heart rate and blood pressure
  28. 28. REFERENCES 1. Sugarbaker D, Bueno R, Krasna M, Mentzer S, Zellos L. Adult Chest Surgery. McGraw Hill Professional; 2009. 2. DeVita VT, Lawrence TS, Rosenberg SA. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. Lippincott Williams & Wilkins; 2008. 3. Jr CMT, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: Expert Consult Premium Edition: Enhanced Online Features. 19th ed. Elsevier Health Sciences; 2012. 4. Brunicardi F, Andersen D, Billiar T, Dunn D, Hunter J, Matthews J, et al. Schwartz’s Principles of Surgery. 9th ed. McGraw-Hill Education; 2009. 5. Norton JA, Barie PS, Bollinger RR, Chang AE, M.D SFL, M.D SJM, et al. Surgery: Basic Science and Clinical Evidence. Springer; 2009.
  29. 29. THANK YOU

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