Malignant Mediastinal Tumors Research Articles

A Study of Clinical Characteristics of Mediastinal Mass

Mediastinal tumours are uncommon lesions encountered in clinical practice. There has been a significant increase in the incidence of malignant mediastinal tumours over the past four decades. The presentation varies from asymptomatic lesions detected incidentally on imaging to severe life threatening presentations. The study was conducted to assess the clinical characteristics, types, treatment modalities and outcome of mediastinal masses. In this two year prospective study, a total of 35 cases with or without symptoms of mediastinal mass, confirmed by Computed Tomography (CT) imaging were included. The results were expressed as percentages or proportions. Maximum numbers of patients (25.71%) were seen in the 3(rd) decade and majority (94.3%) was symptomatic at presentation. Malignant lesions (68.57%) were more common than benign (31.43%) and lymphoma was the commonest malignant tumour (50%). Mediastinal widening on chest X-ray was seen in 27 cases (77.14%), pleural effusion and lung mass in 5 cases each (14.29%). On CT imaging and sub-classification, anterior mediastinum was the commonest compartment involved (42.86%). Mediastinal masses are usually symptomatic at presentation. Majority of the masses were malignant lesions and the symptoms of mediastinal obstruction was significantly higher in malignant lesions and anterior mediastinal masses. Lymphoma was the most frequent primary mediastinal mass and thymoma constituted the commonest benign anterior mediastinal tumour.

Giant thoracoabdominal ganglioneuroblastoma in a 17-year-old patient

The most common malignant neurogenic tumors in children are neuroblastic tumors, classified as ganglioneuroblastoma or neuroblastoma. Ganglioneuroblastomas usually occur at the sympathetic ganglia in the mediastinum, whereas neuroblastomas occur in the abdominal cavity. We describe a case of large posterior mediastinal ganglioneuroblastoma extending from the aortic arch to the left renal hilum in a 17-year-old boy. Despite chemotherapy, post-treatment computed tomography showed disease progression. The patient underwent a thoracolaparotomy incision and excision of the tumor. These malignant mediastinal tumors can potentially grow to a very large size. If alternative treatment has failed, resection can be accomplished with relative safety.

Additional value of dual-energy CT to differentiate between benign and malignant mediastinal tumors: An initial experience

ObjectivesTo investigate the feasibility of dual-energy computed tomography (DECT) in differentiating malignant from benign mediastinal tumors. Materials and methodsWe prospectively enrolled 25 patients (14 males; mean age: 56.7 years) who had suspected mediastinal tumors on chest radiography or non-contrast chest computed tomography (CT). All patients underwent a two-phase DECT using gemstone spectral imaging (GSI) mode (GE HD750). For the quantitative analysis, two investigators measured the following parameters of the tumors in the early and the delayed phases: CT attenuation value in Hounsfield units (HU) and iodine concentration (mg/ml). Pathological results were used for a final diagnosis. Statistical analyses were performed using the Fisher's exact test and the Mann–Whitney t-test. Results10 patients (40%) had benign pathology, while 15 (60%) had malignant pathology. The iodine concentration measurements were significantly different between benign and malignant tumors both in the early phase (1.38mg/ml vs. 2.41mg/ml, p=0.001) and in the delayed phase (1.52mg/ml vs. 2.84mg/ml, p=0.001), while mean attenuation values were not significantly different in both phases (57.8HU vs. 69.1HU, p=0.067 and 67.4HU vs. 78.4HU, p=0.086, respectively). ConclusionsDual-energy CT using a quantitative analytic methodology can be used to differentiate between benign and malignant mediastinal tumors

Immunohistochemical analysis of thymic carcinoma focusing on the possibility of molecular targeted and hormonal therapies

Thymic carcinoma is a rare mediastinal malignant tumor, and in many patients, the tumor is detected in an inoperable advanced stage. Even when chemotherapy is administered to such patients, the patients show a poor response. We investigated new biomarkers of therapeutic molecular targets. This study included 44 patients diagnosed and treated for primary thymic epithelial tumors at Showa University Northern Yokohama Hospital, Showa University Hospital, and Showa University Fujigaoka Hospital from 2003 to 2011. We investigated new biomarkers of therapeutic molecular targets, such as the peroxisome proliferator-activated receptor γ (PPARγ), insulin-like growth factor 1 receptor (IGF1R), epidermal growth factor receptor (EGFR), estrogen receptor (ER), progesterone receptor (PgR), androgen receptor (AR), human epidermal growth factor type 2 (HER2)/neu, CD44, and L-type amino acid transporter 1 (LAT1), in thymic tumors. Immunohistochemical analysis showed that the PPARγ positivity rate in thymic carcinoma was 32 %, which was significantly higher than that in thymoma (4 %). The IGF1R positivity rate in thymic carcinoma was 73 %, which was significantly higher than that in thymoma (27 %). Therefore, by examining the expressions of PPARγ and IGF1R, it would be possible to identify therapy-responsive patients and to improve results of thymic carcinoma treatment.

Radioactive seed implantation for the treatment of mediastinal malignant tumors and lymph node metastases in 43 cases

背景与目的纵隔内恶性肿瘤位置深邃、隐匿, 手术切除可能性极小。由于其紧邻心包、主气管、大血管等重要解剖结构, 氩氦刀冷冻及热消融同样受到限制。本文比较43例放射性125Ⅰ粒子植入患者的影像复查资料和生存质量, 探讨其操作安全性和临床疗效。 方法2010年7月-2011年7月经病理证实并完成随访的43例患者, 其中原发纵隔型肺鳞癌21例, 原发食管癌9例, 淋巴结转移癌13例。合并主气道50%以上狭窄18例, 食管梗阻9例, 上腔静脉回流障碍6例。每个病灶植入125Ⅰ粒子10枚-60枚, 平均(30.79±14.23)枚。治疗后2个月、4个月、6个月及12个月复查CT观察局部病灶控制情况, 并对患者生存质量及生存期进行随访。 结果全部操作技术成功率100%, 最长随访时间12个月, 6个月生存37例, 6个月生存率为85.0%, 局部病灶PR 30个, NC 7个, 临床有效率为81.08%, 临床受益率为100%。12个月生存31例, 1年生存率为60.5%, 局部病灶CR 16个, PR 7个, NC 2个, PD 6个, 临床有效率为74.19%, 临床受益率为80.65%。6个月、12个月KPS评分提高且差异明显。穿刺导致气胸3例(6.98%), 无大血管、主气管、喉返神经及心包损伤等严重并发症。结论放射性125Ⅰ粒子植入治疗纵隔内恶性肿瘤, 技术成功率高且相对安全, 临床疗效肯定。

Palliative Surgery for Malignant Mediastinal Tumor Invading the Superior Vena Cava and Right Atrium

Intra-atrial extension of a superior vena cava (SVC) tumor is rare and it is associated with high mortality rates. An 80-year-old woman presented with malignant mediastinal tumor invading the superior vena cava and right atrium. The unresectable tumor caused uncontrolled SVC syndrome and led to the risk of pulmonary artery tumor thrombosis. Palliative surgery for the intracaval and atrial tumor was performed. Presently, 6 months after surgery, the patient remains free from SVC syndrome and has received effective adjuvant chemotherapy to reduce the size of the tumor.

Cisplatin and irinotecan combination chemotherapy for advanced thymic carcinoma: Evaluation of efficacy and toxicity

BackgroundThymic carcinoma is a rare, malignant mediastinal tumor that is definitively distinguished from thymoma by its wide extensiveness and poor prognosis. At present, cisplatin-based triplet or quartet chemotherapy with the second generation antitumor agents, referred to as Einhorn's protocol for germ cell tumors, is used as first-line chemotherapy for advanced thymic carcinoma, though an optimal chemotherapeutic regimen has not yet been established. In this retrospective study, the effectiveness and toxicity of cisplatin and irinotecan combination chemotherapy were evaluated over a nine-year period. Patients and methodsPatients with advanced thymic carcinoma who were treated with cisplatin and irinotecan combination chemotherapy between January 1, 2002 and December 31, 2010, were retrospectively identified from our database and medical records. The endpoints in this study were disease control, response rate, progression-free survival (PFS), and overall survival (OS). Significant hematological and non-hematological toxicities were also assessed. ResultsAmong identified nine patients, disease control was achieved in 8 patients (88.9%), and a clinical response was achieved in 5 (55.6%). The median PFS was 7.9 months, and the median OS was 33.8 months. One- and two-year OS were 77.7% and 55.6%, respectively. Grade 3/4 hematological toxicities were observed in 2 patients (22.2%), and Grade 3/4 non-hematological toxicities were seen in 2 patients (22.2%). No febrile neutropenia or toxic death was recorded. ConclusionCisplatin and irinotecan combination chemotherapy appears to be acceptable for advanced thymic carcinoma as first-line chemotherapy with respect to efficacy, toxicity, and usage in the clinical setting.

Apparent diffusion coefficient values of mediastinal masses in children

Compare apparent diffusion coefficient (ADC) values between benign and malignant mass lesions in a cohort of children referred for imaging of a mediastinal mass. Prospective study including 24 consecutive children (11 boys, 13 girls aged 5 months to 16 years). All underwent echo planar diffusion weighted MR imaging of the mediastinum with b-factors of 0 and 600 s/mm(2). Apparent diffusion coefficient (ADC) values were calculated and correlated with the surgical finding or biopsy. The mean ADC value of malignant mediastinal tumors was 0.91 (S.D., 0.17) × 10(-3) mm(2)/s and of benign lesions 1.8 (S.D., 0.33) × 10(-3) mm(2)/s. There was significant different in the ADC value between malignant tumors and benign mediastinal tumors (P<0.001). Selection of 1.2 × 10(-3) mm(2)/s as a threshold value for differentiating malignant from benign mediastinal masses has an accuracy of 93%, sensitivity of 92%, specificity of 94%, positive predictive value of 94%, negative predictive value of 92% and area under the curve of 0.962. Apparent diffusion coefficient value is a promising non-invasive parameter for assessment of mediastinal mass in children.

Role of diffusion-weighted imaging in the differential diagnosis of benign and malignant lesions of the chest-mediastinum

We retrospectively evaluated the role of diffusion-weighted imaging (DWI) with fat and background signal suppression in the differential diagnosis of benign and malignant lesions of the chest-mediastinum by calculating the mean apparent diffusion coefficient (ADC) values. Thirty-four patients with lung nodules/mediastinal masses underwent magnetic resonance (MR) imaging of the chest with conventional and DWI sequences. All patients had been previously studied with computed tomography (CT). After magnetic resonance (MR) imaging the patients underwent transthoracic CT-guided biopsy or mediastinoscopy. After the histopathological diagnosis had been obtained, the lesions were retrospectively divided into five groups: adenocarcinomas (n=16), squamous cell carcinomas (n=12), chronic pneumonias (n=2), malignant mediastinal tumours (n=2) and typical carcinoids (n=2). We compared ADC values in the different lesion groups using the Mann-Whitney U test. There were statistically significant differences (p<0.05) between ADC values of benign and malignant lesions. Using an ADC value of 1.25×10⁻³ mm²/s as a threshold, we were able to differentiate malignant from benign lesions with 91% diagnostic accuracy, 90% sensitivity, 100% specificity, 100% positive predictive value and 57% negative predictive value. Short-tau inversion-recovery echo-planar imaging (STIR-EPI) sequences applied to the chest-mediastinum provided potentially useful images for the differential diagnosis of benign and malignant lesions.

Les sarcomes primitifs du médiastin

Primary sarcomas of the mediastinum are rare and account for 2 to 8% of malignant mediastinal tumours. The aim of this study is to describe their clinical and pathological characteristics.Fifteen cases of primary mediastinal sarcoma, diagnosed between 1993 and 2009, were reviewed retrospectively, noting the clinical, radiological and pathological findings, and the treatment given.The patient population consisted of eight females and seven males with mean age of 40 years (14 to 73 years). The symptomatology was predominately respiratory. Imaging showed a mediastinal mass invading adjacent organs in nine cases. The diagnosis was made in all cases by histological examination. These 15 mediastinal sarcoma comprised 12 malignant peripheral nerve tumours, two liposarcomas and one angiosarcoma. Three were grade III, six grade II and six grade I. Ten were treated surgically, of which seven had radical resections. Associated treatments were neoadjuvant (one case) or adjuvant (one case) chemotherapy and postoperative radiotherapy (five cases). Radiotherapy was undertaken alone in three inoperable tumours. Eight patients (53%) had died.Management of primary mediastinal sarcoma needs a multidisciplinary approach, and is based mainly on radical resection. The prognosis is poor and depends mainly on surgical excision and histological grade.

Surgical Resection of a Posterior Mediastinal Tumor That Was Previously Treated with Aortic Stent-graft under the Misdiagnosis of Aortic Aneurysm -A case report-

A 70-year-old man was transferred to our center due to severe epigastric and back pain with the impression of a ruptured thoracic aortic aneurysm. Six months previously, he had undergone insertion of stent graft into the descending thoracic aorta at another hospital. The findings of the computed tomographic scan suggested a rapidly growing malignant mediastinal tumor rather than a ruptured aneurysm. Exploratory thoracotomy confirmed the diagnosis and the tumor was resected along with the portion of the aorta contained in it. This exemplary case should raise the concern against overzealous application of endovascular aortic repair.

Malignant mediastinal germ cell tumors: Clinical findings and diagnostic and therapeutic problems

縦隔悪性胚細胞性腫瘍（MGCT）の診断および治療アプローチを再確認するために，切除例の検討を行い，臨床上の問題点を明らかにした．対象は，1993～2006年に昭和大学関連3病院で切除したMGCT8例で，21～69歳，すべて男性．部位は前縦隔6例，中縦隔2例．AFP高値2例，HCG高値1例，両マーカーとも高値1例，上昇なし4例であった．組織検査は，CT下針生検4例，傍胸骨生検1例，縦隔鏡1例，未施行2例で，生検を行った6例中5例で，最終病理と一致した．初回治療は，化療4例（CR2例，PR2例），放治1例（NC），手術3例で，最終病理診断は，Seminoma3例，Yolk sac tumor1例，Adenocarcinoma with teratoma1例，Embryonal carcinoma1例，その他2例であった．MGCTの治療に際しては，化療の効果は良好であることからマーカー陽性例は速やかな抗癌剤治療が必要である．MGCTのなかに比較的高齢者，あるいは中縦隔発生例があることは留意すべき点である．

Malignant pulmonary and mediastinal tumors in children: differential diagnoses

Conventional chest radiography is the most common imaging procedure in children. When a chest mass is discovered, cross-sectional imaging is often required to accurately localize and characterize the lesion in order to narrow the differential diagnosis. Knowledge of the differential diagnostic possibilities for chest tumors in children is important for both the pediatric and general radiologist because they differ from adults. The more common pediatric, malignant, mediastinal and pulmonary tumors and the characteristic imaging and clinical features that are useful in distinguishing between them are discussed in this review.

Characteristics associated with complete surgical resection of primary malignant mediastinal tumors

To identify preoperative characteristics associated with complete surgical resection of primary malignant mediastinal tumors. Between 1996 and 2006, 42 patients with primary malignant mediastinal tumors were submitted to surgery with curative intent at a single facility. Patient charts were reviewed in order to collect data related to demographics, clinical manifestation, characteristics of mediastinal tumors and imaging aspects of invasiveness. The surgical resection was considered complete in 69.1% of the patients. Cases of incomplete resection were attributed to invasion of the following structures: large blood vessels (4 cases); the superior vena cava (3 cases); the heart (2 cases); the lung and chest wall (3 cases); and the trachea (1 case). Overall survival was significantly better among the patients submitted to complete surgical resection than among those submitted to incomplete resection. The frequency of incomplete resection was significantly higher in cases in which the tumor had invaded organs other than the lung (as identified through imaging studies) than in those in which it was restricted to the lung (47.6% vs. 14.3%; p = 0.04). None of the other preoperative characteristics analyzed were found to be associated with complete resection. Preoperative radiological evidence of invasion of organs other than the lung is associated with the incomplete surgical resection of primary malignant mediastinal tumors.

Assessment of mediastinal tumors with diffusion‐weighted single‐shot echo‐planar MRI

To assess the role of diffusion-weighted single-shot echo-planar magnetic resonance imaging (MRI) in patients with mediastinal tumors. Prospective study was conducted on 45 consecutive patients (29 male, 16 female, age 22-66 years, mean 41 years) with mediastinal tumor. They underwent diffusion-weighted single-shot echo-planar MRI of the mediastinum with a b-factor of 0, 300, and 600 sec/mm(2). The apparent diffusion coefficient (ADC) value of the mediastinal tumor was correlated with the histopathological findings. The mean ADC value of malignant mediastinal tumors was 1.09 +/- 0.25 x 10(-3) mm(2)/sec, and of benign tumors was 2.38 +/- 0.56 x 10(-3) mm(2)/sec. There was a significant difference in the mean ADC value between malignant and benign tumors (P = 0.001) and within different grades of malignancy (0.001). When an ADC value of 1.56 x 10(-3) mm(2)/sec was used as a threshold value for differentiating malignant from benign tumor, the best results were obtained with an accuracy of 95%, sensitivity of 96%, specificity of 94%, positive predictive value of 94%, negative predictive value of 96%, and area under the curve of 0.938. The ADC value is a noninvasive parameter that can be used for differentiation of malignant from benign mediastinal tumors and grading of mediastinal malignancy.

Um caso raro de tumores torácicos malignos sincrônicos

Malignant neurogenic mediastinal tumors in adults are uncommon and extremely aggressive. We report the case of a 61-year-old male patient with the simultaneous occurrence of malignant mediastinal schwannoma and bronchioloalveolar carcinoma. Although bronchioloalveolar carcinoma is present in 4-7% of the resected synchronous thoracic tumors, this association has never been reported in the literature. However, it is a common finding in patients presenting apparently inflammatory infiltrates and ground-glass opacities, as in the case presented here.

Primary malignant germ cell tumours

Study objectives : the aim of this enquiry was to perform a retrospective review on patients treated for primary malignant mediastinal germ cell tumours (PMMGCT) between 1992-2008, to specify their clinical characteristics, their prognostic factors and to evaluate the current therapeutic strategies.Patients: we report a study about 8 patients with seminoma in 3 cases, yolk sac tumour (YST) in 2 cases, embryonal carcinoma (EC) in 1 case, choriocarcinoma in 1 case and teratocarcinoma in 1 case. Pathologic diagnoses were confirmed in all cases by surgical biopsy and a resection of the residual mass in 2 cases.Results: all the patients were male with a mean age of 32 years (range, 16 to 63 years). Only one patient was asymptomatic. The most frequent symptoms were cough (87.5%), chest pain (50%) and dyspnea (50%). The 8 tumours were located in the anterior mediastinum. One patient with EC didn’t received any treatment because of the rapid evolution of the disease. The 7 others received pre-operative chemotherapy and 3 patients received a second-line chemotherapy because of the persistence of viable tumours in one case (YST) and a resistance to the first chemotherapy in 2 cases (seminoma and teratocarcinoma). The overall 2-year survival of patients with seminoma was 100% towards 25% for those with nonseminomatous tumours. The patients with satge I disease survived for a mean period of 3 years.Conclusion: The PMMGCT cause generally a diagnostic challenge because of the difficulty of their resection and the little size of the biopsy specimen. Besides, the absence of a primary gonadal localization may be difficult to establish. These tumours have a worse prognosis than their gonadal counterparts. Prognostic factors are multiple and not accurate. The most relevant ones seem to be the histological type and the disease stage.

Intracranial germ cell tumors: association with Klinefelter syndrome and sex chromosome aneuploidies

Intracranial germ cell tumors (ICGCTs) occur mainly in male children and adolescents. Polyploidy of the X chromosome and X hypomethylation have been suggested as mechanisms of malignant transformation independently of the histological tumor type. On the other hand, several reports associate these tumors with Klinefelter’s syndrome (KS). Recent reports indicate that KS patients have an increased relative risk for development of malignant mediastinal germ cell tumors and also around 8% of male patients with primary mediastinal tumors have KS. In an attempt to explore the frequency of KS amongst patients with ICGCTs and to confirm the presence of X chromosome polyploidies in these tumors, we studied 13 young male patients with ICGCTs. Paraffin-embedded tumoral and normal tissues were studied by FISH. KS was found in 15% of the cases, demonstrating that this constitutive aneuploidy may be related to carcinogenesis. When tumor and non-tumor tissues were compared, statistically significant X and Y chromosome polyploidies in tumors were revealed. These results emphasize that aneuploidies are involved in ICGCT tumorigenesis.

Radical Excision of Thymic Adenocarcinoma with Selective Cerebral Perfusion

Most cases of thymic carcinoma have some invasion to neighboring organs when diagnosed, and it is generally difficult to completely remove. We adopted selective cerebral perfusion as a cerebral protection and successfully performed resection of a thymic adenocarcinoma that involved the superior vena cava, left brachiocephalic vein, right brachiocephalic artery and vein, and left common carotid artery in a 47-year-old woman. Even if multiple great vessels were involved by mediastinal malignant tumor, complete resection with selective cerebral perfusion could be safely performed.

CISPLATINUM-BASED CHEMOTHERAPY IN MALIGNANT MEDIASTINAL TERATOMA

Five patients with primary malignant mediastinal non-seminomatous germ cell tumours have been treated with a multimodality approach, including cisplatinum-containing chemotherapy, at this institution over the past 7 years. All patients had bulky disease (greater than 10 cm maximum diameter) at presentation and showed raised serum concentrations of human chorionic gonadotrophin or alpha-fetoprotein. Two patients are alive with no evidence of disease at 22 months and 6 years, respectively, from initial diagnosis; two patients have died from progressive disease and one from acute non-lymphocytic leukaemia without evidence of residual germ cell tumour. Long-term survival is achievable for these poor risk patients with a combined modality approach.