Masses in the anterior portion of the mediastinum can include thymoma, lymphoma, pheochromocytoma and germ cell tumors including teratoma. Lung cancer typically spreads to the lymph nodes in the mediastinum.
Anterior mediastinal compartment, also known as anterosuperior compartment, is anterior to the pericardium. Masses in this area is more likely to be malignant than those in other compartments.[1][2] Most common masses found here include thymomas, germ cell tumors, lymphomas, thyroid tissue, and parathyroid lesions.
Diagnosis
In several editions of Physical Diagnosis,[3] concerning mediastinal tumors the author writes:
- According to Christian1 the mediastinal neoplasms which are neither so rare nor so obscure as to make diagnosis practically impossible are: (1) Sarcoma (including lymphosarcoma, leucaemic growths, and Hodgkins' disease; (2) Teratoma and cyst.
Many signs and symptoms of a mediastinal tumor do not distinguish between these two principle classes of mediastinal tumor. However, on a radiograph usually the former class will have an irregular shape and the latter class will have a smooth spherical or ovoid shape. A large minority of patients with a mediastinal teratoma (including dermoid cyst) will cough up hair.[3] For a differential diagnosis, the key is to exclude aneurism.
Thymoma
Most common primary anterior mediastinal tumor (20%) in adults but rarely seen in children. It can be classified as lymphocytic, epithelial, or spindle cell histologies, but the clinical significance of these classifications is controversial.[4] Tonofibrils seen under electron microscopy can differentiate thymoma from other tumors such as carcinoid, Hodgkin's, and seminoma. Patients are usually asymptomatic but can present with myasthenia gravis-related symptoms, substernal pain, dyspnea, or cough. Invasive tumors can produce compression effects such as superior vena cava syndrome. (3,4) Thymomas are diagnosed with CT or MRI revealing mass in anterior mediastinum. Therapy in stage I tumors consists of surgical ressection with good prognosis. Stage II-III requires maximal resection possible followed by radiation. Stage IV disease requires addition of cisplatin-based chemotherapy in addition to those in stage II and III. For those with invasive thymoma, treatment is based on induction chemotherapy, surgical resection, and post-surgical radiation. 5-year survival for invasive thymoma is between 12-54% regardless of any myasthenia gravis symptoms (5,6).
Lymphoma
Secondary most common primary anterior mediastinal mass in adults. Most are seen in the anterior compartment and rest are seen in middle compartment. Hodgkin's usually present in 40-50's with nodular sclerosing type (7), and non-Hogdkin's in all age groups. Can also be primary mediastinal B cell lymphoma with exceptionally good prognosis.[5][6][7] Common symptoms include fever, weight loss, night sweats, and compressive symptoms such as pain, dyspnea, wheezing, SVC syndrome, pleural effusions (10,11). Diagnosis usually by CT showing lobulated mass. Confirmation done by tissue biopsy of accompanying nodes if any, mediastinoscopy, mediastinotomy, or thoracotomy. FNA biopsy usually not adequate. (12,13,14) Treatment of mediastinal Hodgkin's involves chemotherapy and/or radiation. 5 year survival is now around 75%. (15) Large-cell type may have somewhat better prognosis. Surgery is generally not performed because of invasive nature of tumor.
Of all cancers involving the same class of blood cell, 2% of cases are mediastinal large B cell lymphomas.[8]
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