Muhammadiahkuliah Blk 12 CA Paru Dan Meiastinal

LUNG AND MEDIASTINAL LUNG AND MEDIASTINAL CANCERCANCER

1.1. LUNG CANCERLUNG CANCER2.2. MEDIASTINAL CANCERMEDIASTINAL CANCER

AHMAD RASYIDAHMAD RASYID

Sub Bagian PulmonologiSub Bagian PulmonologiBagian Ilmu Penyakit DalamBagian Ilmu Penyakit DalamRS. Moh.Hoesin / FK UnsriRS. Moh.Hoesin / FK Unsri

1.LUNG CANCER1.LUNG CANCER

HISTOLOGICAL TYPES OF LUNG HISTOLOGICAL TYPES OF LUNG CANCERCANCER

- - SMALL CELL LUNG CANCER (SCLC) : 20% SMALL CELL LUNG CANCER (SCLC) : 20%

(OAT CELL) (OAT CELL)

- NON SMALL CELL LUNG CANCER (NSCLC) :- NON SMALL CELL LUNG CANCER (NSCLC) :

1. Squamous cell carcinoma : 40%1. Squamous cell carcinoma : 40%

2. Adenocarcinoma : 20%2. Adenocarcinoma : 20%

3. Large cell carcinoma : 15%3. Large cell carcinoma : 15%

4. Bronchioalveolar carcinoma : 5%4. Bronchioalveolar carcinoma : 5%

Kanker paru bukan sel kecil

KLASIFIKASI WHO CARCINOMA PARUKLASIFIKASI WHO CARCINOMA PARU ::

1. Ca epidermoid = Ca squamous cell 1. Ca epidermoid = Ca squamous cell = spindel cell = spindel cell

2. Ca sel kecil = Ca small cell 2. Ca sel kecil = Ca small cell

= Oat cell = intermediate cell= Oat cell = intermediate cell

3. Adeno carcinoma3. Adeno carcinoma

4. Ca sel besar = Ca giant cell 4. Ca sel besar = Ca giant cell

=clear cell=clear cell

5. Bronchioalveolar Ca5. Bronchioalveolar Ca

Indonesia (1984-1988) :Indonesia (1984-1988) :

1. Adeno Ca :1. Adeno Ca : 49,1%49,1%

2. Ca epidermoid :2. Ca epidermoid : 40,2%40,2%

3. Ca sel kecil :3. Ca sel kecil : 6,9% 6,9%

4. Ca sel besar :4. Ca sel besar : 3,8% 3,8%

I.I. Ca sel skuamosa=epidermoid CaCa sel skuamosa=epidermoid Ca

– Asal : hiperplasi sel basal epithel Asal : hiperplasi sel basal epithel bronkus bronkus → metaplasi sel squamosa→ metaplasi sel squamosa

– Lokasi : 75-90% : bronkus besar atau Lokasi : 75-90% : bronkus besar atau letaknya di sentral → shg sering letaknya di sentral → shg sering obstruksi bronkusobstruksi bronkus

– Sitologi sputum sangat membantu di Sitologi sputum sangat membantu di samping bronkoskopisamping bronkoskopi

II. II. AdenokarsinomaAdenokarsinoma

– Asal : epithel bronkusAsal : epithel bronkus– Lokasi : umumnya perifer, jarangLokasi : umumnya perifer, jarang

obstruksi bronkus.obstruksi bronkus.– Sering mrp nodule paru soliter, < 4cmSering mrp nodule paru soliter, < 4cm

III. III. Ca sel kecil :Ca sel kecil :

– Ukuran sel 6-8 mikron, banyak Ukuran sel 6-8 mikron, banyak intiinti

– Disebut juga Oat sel, bila tidakDisebut juga Oat sel, bila tidak ditemukan sitoplasmaditemukan sitoplasma– Letak : umumnya sentral, sputumLetak : umumnya sentral, sputum sitologi 90%sitologi 90%– Penyebaran : sangat cepat.Penyebaran : sangat cepat. Saat ter diagnosa, penyebaran sudahSaat ter diagnosa, penyebaran sudah jauhjauh

IV. IV. Ca cell besar :Ca cell besar :

– Asal : epithel bronkus, mikroskopisAsal : epithel bronkus, mikroskopis

mirip dg gambaran Adeno Ca atau mirip dg gambaran Adeno Ca atau

Ca epidermoidCa epidermoid– Letak : 40% sentral, 60% perifer, Letak : 40% sentral, 60% perifer,

ukuran > 4 cmukuran > 4 cm– Penyebaran/pertumbuhan sangatPenyebaran/pertumbuhan sangat

ganas melalui pemb. darah/lympheganas melalui pemb. darah/lymphe

ETHIOLOGI KARSINOMA PARU :ETHIOLOGI KARSINOMA PARU :

– Penyebab pasti tidak diketahuiPenyebab pasti tidak diketahui– Hubungan erat dengan kebiasaanHubungan erat dengan kebiasaan

merokokmerokok– Zat-zat dari pabrik/industri, Zat-zat dari pabrik/industri,

misalnya :misalnya :

nikel, asbestos, arsen, dllnikel, asbestos, arsen, dll– Industri yg menggunakan isotopIndustri yg menggunakan isotop

radioaktif, mis. uraniumradioaktif, mis. uranium

GEJALA KLINIS :GEJALA KLINIS : tergantung dari :tergantung dari :

– Lokasi tumorLokasi tumor– Invasi ke organ sekitarInvasi ke organ sekitar– Ada/tidaknya penyebaran :Ada/tidaknya penyebaran :

lymphogen, hematogenlymphogen, hematogen

Umumnya gejala dibagi :Umumnya gejala dibagi :

– Intra thorakalIntra thorakal : - intra : - intra pulmoner pulmoner

- ekstrapulmonar- ekstrapulmonar

– Ekstra thorakalEkstra thorakal : - non : - non metastasismetastasis

- metastasis- metastasis

I. Intra thorakal intra pulmoner :I. Intra thorakal intra pulmoner :

1. Batuk kering dan lama1. Batuk kering dan lama2. Batuk darah ringan (bercak2. Batuk darah ringan (bercak²)²)

3. Sesak nafas3. Sesak nafas4. Mengi/ wheezing terlokalisir4. Mengi/ wheezing terlokalisir5. Nyeri dada karena invasi ke 5. Nyeri dada karena invasi ke

pleura atau tumor menempati pleura atau tumor menempati daerah sukus superior parudaerah sukus superior paru

II. Intra thorakal extra pulmonal :II. Intra thorakal extra pulmonal : Desakan tumor ke rongga mediastinum, Desakan tumor ke rongga mediastinum,

sehingga menekan/merusak syaraf & organ yg sehingga menekan/merusak syaraf & organ yg ada di dalamnyaada di dalamnya : :

- - N. RekurensN. Rekurens : Parese/paralisis pita suara shg suara serak : Parese/paralisis pita suara shg suara serak - - N. FrenikusN. Frenikus : Parese/paralisis diafragma : Parese/paralisis diafragma - - N. Simpatis servikalisN. Simpatis servikalis : Sindroma Horner ( : Sindroma Horner (ipsilateralipsilateral miosis, ptosis, endopthalmus dan anhidrosis)miosis, ptosis, endopthalmus dan anhidrosis) -- EsofagusEsofagus : disfagia, atau asfiksia bila ada fistula : disfagia, atau asfiksia bila ada fistula bronkoesofagusbronkoesofagus - - V. Cava Superior sindromaV. Cava Superior sindroma : sesak nafas, bullneck dan : sesak nafas, bullneck dan venektasis dinding dada akibat bendungan v. cava venektasis dinding dada akibat bendungan v. cava

superiorsuperior - - Pleksus BrakialisPleksus Brakialis : nyeri pada lengan yang dipersyarafi : nyeri pada lengan yang dipersyarafi n. ulnarisn. ulnaris - - Dinding dadaDinding dada : tumor menempati sulkus superior/apeks : tumor menempati sulkus superior/apeks paru shg terjadi sindroma Pancoast (nyeri dada danparu shg terjadi sindroma Pancoast (nyeri dada dan batuk2 darah)batuk2 darah) - - Jantung – PerikardiumJantung – Perikardium : Pada efusi perikardial dapat : Pada efusi perikardial dapat mengakibatkan tamponade jantung mengakibatkan tamponade jantung

III. Ekstra torakal non metastasis :III. Ekstra torakal non metastasis :

1. Manifestasi neuromuskuler :1. Manifestasi neuromuskuler : - - Gejala berupa neuropati karsinoma : sindroma Gejala berupa neuropati karsinoma : sindroma

berupaberupa miopati, neuropati perifer, degenerasi serebelermiopati, neuropati perifer, degenerasi serebeler subakuta, ensefalomiopati dan mielopati nekrotiksubakuta, ensefalomiopati dan mielopati nekrotik

2. Manifestasi endokrin metabolik :2. Manifestasi endokrin metabolik : - - Hiperparatitiroid dengan hiperkalsimea, sekresi Hiperparatitiroid dengan hiperkalsimea, sekresi insulin dengan hipoglikemi, sindroma Cushing,insulin dengan hipoglikemi, sindroma Cushing, sindroma karsinoid, sekresi berlebihan gonadotropinsindroma karsinoid, sekresi berlebihan gonadotropin disertai ginekomastidisertai ginekomasti

3. Manifestasi jaringan ikat / tulang :3. Manifestasi jaringan ikat / tulang : - - Peningkatan kadar Growth hormon plasma ditandaiPeningkatan kadar Growth hormon plasma ditandai hipertrofi osteoartropati baruhipertrofi osteoartropati baru

4. 4. Kadang2 migratori thrombophlebitis,Kadang2 migratori thrombophlebitis, purpura & anemiapurpura & anemia

IV. Ekstra Thorakal metastasis :IV. Ekstra Thorakal metastasis :

Melalui sirkulasi arterial ke : Melalui sirkulasi arterial ke :

- Hati : - Hati : Nyeri hipokondrial dan ikterikNyeri hipokondrial dan ikterik

- Tulang- Tulang dan paralisis ektermitas bawah dan paralisis ektermitas bawah

- Otak : - Otak : pusing, sakit kepala, bingungpusing, sakit kepala, bingung

- Glandula supra renal- Glandula supra renal

DIAGNOSIS :DIAGNOSIS :

1. Sitologi sputum1. Sitologi sputum : 82,8%: 82,8%

2. Bronkhoskopi2. Bronkhoskopi

- Washing- Washing : 76% : 76%

- Brushing- Brushing : 74% : 74%

- Biopsi- Biopsi : 82% : 82%

- Kombinasi- Kombinasi : 94% : 94%

3. Aspirasi transbronkhial3. Aspirasi transbronkhial : 71% : 71%

4. Aspirasi transthorakal4. Aspirasi transthorakal : 53% : 53%

Lain-lain : - pungsi & biopsi pleuraLain-lain : - pungsi & biopsi pleura

- fluoroskopi, - fluoroskopi,

- tomografi,- tomografi,

- mediastinoskopi, - mediastinoskopi,

- CT scan, MRI,- CT scan, MRI,

- torakoskopi - torakoskopi

Diagnosis kanker paru (rontgen)

Bayangan padat (putih) pada bagian paru yang terkena

Diagnosis kanker paru (CT Scan)

Diagnosis kanker paru (bronkoskopi)

Bronkoskopi

STAGING SYSTEM OF LUNG CANCER :STAGING SYSTEM OF LUNG CANCER :

T : PRIMARY TUMORT : PRIMARY TUMOR

T1 T1 : Tumor 3 cm or less : Tumor 3 cm or less T2T2 : Tumor > 3,0 cm : Tumor > 3,0 cm T3 T3 : Tumor any size, location ≤2 cm : Tumor any size, location ≤2 cm

distal carina, no pleural effusiondistal carina, no pleural effusion T4T4 : Tumor any size, extension into : : Tumor any size, extension into :

- chest wall,- chest wall, - mediastinum,- mediastinum, - diafragma, - diafragma, - pleura, pleural effusion- pleura, pleural effusion

The trachea (wind pipe) – The trachea (wind pipe) – Cont.Cont.

N : NODAL INVOLVEMENTN : NODAL INVOLVEMENT

N0N0 : No metastasis to regional : No metastasis to regional limonudilimonudi N1 N1 : Metastasis Limfonudi : : Metastasis Limfonudi : - peribronchial,- peribronchial, - ipsilateral hilar region,- ipsilateral hilar region, - both- both N2N2 : Metastasis Limfonudi : : Metastasis Limfonudi : - ipsilateral mediastinal- ipsilateral mediastinal - subcarinal- subcarinal

N3N3 : Metastasis Limfonudi : : Metastasis Limfonudi :

- contralateral mediastinal,- contralateral mediastinal,

- contralateral hilar,- contralateral hilar,

- ipsilateral or contralateral - ipsilateral or contralateral

scalene or supraclavicularscalene or supraclavicular

M : DISTANT METASTASISM : DISTANT METASTASIS

M0M0 : No distant metastasis : No distant metastasis M1 M1 : Distant metastasis present: Distant metastasis present liver, bone, brain, etcliver, bone, brain, etc

STAGE = STADIUM :STAGE = STADIUM : II : T1 N0 M0, or T2 N0 M0: T1 N0 M0, or T2 N0 M0 II II : T1 N1 M0, or T2 N1 M0: T1 N1 M0, or T2 N1 M0 III aIII a : T 1,2,3 N2 M0: T 1,2,3 N2 M0 III bIII b : T4 any N M0, or any T N3 M0: T4 any N M0, or any T N3 M0 IV IV : any T any N M1: any T any N M1

PENATALAKSANAAN :PENATALAKSANAAN :

Terdiri dari :Terdiri dari :

- Operasi- Operasi

- Radioterapi- Radioterapi

- Kemoterapi- Kemoterapi

Pengobatan• Paliatip

• Kuratif

Bedah Radiasi Kemoterapi Imunoterapi

• Tergantung staging dan tipe kanker

OperasiOperasi

Ca epidermoid (NSCLC) Stad. I, II, IIIACa epidermoid (NSCLC) Stad. I, II, IIIA

AdenocarcinomaAdenocarcinoma

Ca Sel besarCa Sel besar

Ca Sel kecil : - ganas, metastasis >Ca Sel kecil : - ganas, metastasis >

- jarang operasi- jarang operasi

- sensitif : sitostatika- sensitif : sitostatika

radioterapiradioterapi

RadiotherapyRadiotherapyDefinitif/kuratifDefinitif/kuratif

PaliatifPaliatif

Umumnya Ca yang terdiagnose Umumnya Ca yang terdiagnose sudah stadium lanjut sudah stadium lanjut → > 75% → > 75% perlu radioterapiperlu radioterapi

Indikasi RadioterapiIndikasi Radioterapi

I. Berdasarkan I. Berdasarkan sifat radioterapisifat radioterapi

I.a Definitif:I.a Definitif:Ca operable, tapi toleransi operasi Ca operable, tapi toleransi operasi sangat rendahsangat rendahTumor primer, KGB hilus, KGB Tumor primer, KGB hilus, KGB mediastinummediastinum

I.b Paliatif:I.b Paliatif:MeningkatkanMeningkatkan kualitas hidupkualitas hidupTumor primer sajaTumor primer saja

KemoterapiKemoterapiPilihan pada yang sudah alami Pilihan pada yang sudah alami metastasismetastasis

Bukan sel kecil : Bukan sel kecil : – Stadium III lanjut atau menyebarStadium III lanjut atau menyebar– Segera/bersama-sama dengan Segera/bersama-sama dengan

radioterapi atau operasiradioterapi atau operasi

Ca sel kecil : terapi utama selain Ca sel kecil : terapi utama selain radioterapiradioterapi

PrognosisPrognosis Tergantung dari :Tergantung dari :

1. Derajat / staging = stadium1. Derajat / staging = stadium

2. Tampilan umum /2. Tampilan umum /

performance statusperformance status

Performance Status Performance Status berdasarkan berdasarkan Skala KarnofskySkala Karnofsky

Skala 90-100% : Aktivitas normalSkala 90-100% : Aktivitas normal

Skala 70-80% : Ada keluhan umum, tapiSkala 70-80% : Ada keluhan umum, tapi

cukup aktif mengurus diricukup aktif mengurus diri

sendirisendiri

Skala 50-60% : Umumnya aktif, hanyaSkala 50-60% : Umumnya aktif, hanya

sesekali butuh bantuansesekali butuh bantuan

Skala 30-40% : Tidak aktif, perlu banyak Skala 30-40% : Tidak aktif, perlu banyak bantuan bantuan

Skala 10-20% : Sangat lemah, tidak dapat Skala 10-20% : Sangat lemah, tidak dapat meninggalkan tempat meninggalkan tempat

tidur,tidur,

total perlu bantuan orang.total perlu bantuan orang.

NSCLCNSCLCStage I Stage I : Surgical : Surgical resectionresectionStage II Stage II

Stage IIIa : RadioterapiStage IIIa : Radioterapi

Stage IIIbStage IIIb : Radioterapi dan : Radioterapi dan & Stage IV kemoterapi& Stage IV kemoterapi

Survival times NSCLCSurvival times NSCLCThe five years survival by the stagingThe five years survival by the staging

Squamous cellSquamous cell

Stage I : 55%Stage I : 55%

Stage II : 35%Stage II : 35%

Stage IIIa : 15%Stage IIIa : 15%

Stage IIIb : 0%Stage IIIb : 0%

Stage IV : 0%Stage IV : 0%

AdenocarcinomaAdenocarcinoma

Stage I : 45%Stage I : 45%

Stage II : 23%Stage II : 23%

Stage IIIa : 8%Stage IIIa : 8%

Stage IIIb : 0%Stage IIIb : 0%

Stage IV : 0%Stage IV : 0%

Survival times SCLCSurvival times SCLCLimited disease Limited disease → 15 months→ 15 months

Extensive disease → 8 monthsExtensive disease → 8 months

More than 2 years → 13%More than 2 years → 13%

Mayor causes of deaths → 2-5 yearsMayor causes of deaths → 2-5 years

2. 2. MEDIASTINALMEDIASTINALCANCERCANCER

MEDIASTINAL TUMORSMEDIASTINAL TUMORS

MediastinumMediastinum: Region between the : Region between the pleural sacspleural sacs

Tumors arise from anterior, middle & Tumors arise from anterior, middle & posterior compartmentsposterior compartments

ExtentExtentAnteriorAnterior – between sternum – between sternum anteriorly to pericardium & anteriorly to pericardium & brachiocephalic vessels posteriorlybrachiocephalic vessels posteriorly

MiddleMiddle - between the anterior & - between the anterior & posterior compartmentsposterior compartments

PosteriorPosterior - pericardium & trachea - pericardium & trachea anteriorly, to vertebral column anteriorly, to vertebral column posteriorlyposteriorly

BOUNDARIES OF BOUNDARIES OF MEDIASTINUMMEDIASTINUM

AnteriorAnterior - sternum - sternum

Posterior Posterior - Vertebral Column- Vertebral Column

SuperiorSuperior - Thoracic inlet - Thoracic inlet

InferiorInferior - Diaphragm - Diaphragm

** ** MediastinumMediastinum is connected to is connected to neck & retroperitoneum allowing neck & retroperitoneum allowing spread of air & infectionspread of air & infection

ANTERIOR MEDIASTINUM-ANTERIOR MEDIASTINUM-CONTENTSCONTENTS

ThymusThymus

Anterior mediastinal lymph nodesAnterior mediastinal lymph nodes

Internal mammary A & VInternal mammary A & V

Pericardial fatPericardial fat

MIDDLE MEDIASTINUM- MIDDLE MEDIASTINUM- CONTENTSCONTENTS

Heart & Pericardium, ascending Heart & Pericardium, ascending aorta & arch of aorta, vena cavae, aorta & arch of aorta, vena cavae, brachiocephalic A &V ,brachiocephalic A &V ,

Phrenic nervePhrenic nerve

Trachea, main stem bronchi & Trachea, main stem bronchi & contiguous lymph nodescontiguous lymph nodes

Pulmonary A & VPulmonary A & V

POSTEIOR MEDIASTINUM-POSTEIOR MEDIASTINUM-CONTENTSCONTENTS

Descending thoracic aortaDescending thoracic aorta

EsophagusEsophagus

Thoracic ductThoracic duct

Azygos & hemiazygos veinAzygos & hemiazygos vein

Posterior group of mediastinal Posterior group of mediastinal nodesnodes

Sympathetic trunk & intercostal Sympathetic trunk & intercostal nervesnerves

CLASSIFICATIONCLASSIFICATION

DevelopmentalDevelopmental

NeoplasticNeoplastic

InfectiousInfectious

TraumaticTraumatic

Cardiovascular disordersCardiovascular disorders

ANTERIOR MEDIASTINAL ANTERIOR MEDIASTINAL MASSESMASSES

ThymomaThymoma

TeratomaTeratoma

ThyromegalyThyromegaly

LymphomaLymphoma

Lipoma, Fibroma - rareLipoma, Fibroma - rare

MIDDLE MEDIASTINAL MIDDLE MEDIASTINAL MASSESMASSES

Aneurysms - aorta, innominate artery, Aneurysms - aorta, innominate artery, enlarged pulmonary arteryenlarged pulmonary artery

Lymphadenopathy secondary to Lymphadenopathy secondary to carcinoma / metastasis / carcinoma / metastasis / granulomatosisgranulomatosis

Cysts - enteric, bronchogenic, Cysts - enteric, bronchogenic, pleuropericardialpleuropericardial

Dilated azygos, hemiazygos veinsDilated azygos, hemiazygos veins

Hernia of Foramen of MorgagniHernia of Foramen of Morgagni

POSTERIOR MEDIASTINAL POSTERIOR MEDIASTINAL MASSESMASSES

Neurogenic tumorsNeurogenic tumors

Meningo-myelocele, meningoceleMeningo-myelocele, meningocele

Esophageal - tumor, cyst, diverticulaEsophageal - tumor, cyst, diverticula

Hiatus herniaHiatus hernia

Hernia of Foramen of BochdalekHernia of Foramen of Bochdalek

Thoracic spine disease,Thoracic spine disease,

Extramedullary hematopoiesisExtramedullary hematopoiesis

POSTERIOR MEDIASTINAL POSTERIOR MEDIASTINAL NEUROGENIC TUMORSNEUROGENIC TUMORS

NeurilemmomaNeurilemmoma

NeurofibromaNeurofibroma

NeurosarcomaNeurosarcoma

GanglioneuromaGanglioneuroma

PhaeochromocytomaPhaeochromocytoma

CLINICAL FEATURESCLINICAL FEATURES

Nospecific-> mass effect on Nospecific-> mass effect on sorrounding structuressorrounding structures

Insidious onset of retrosternal Insidious onset of retrosternal chest pain, dyspnea , dysphagiachest pain, dyspnea , dysphagia

50% are asypmtomatic50% are asypmtomatic

Mass detected on CXRMass detected on CXR

Physical findings depend on nature Physical findings depend on nature & location of mass& location of mass

COMMON SYMPTOM OF MEDIASTINALTUMORCOMMON SYMPTOM OF MEDIASTINALTUMOR

Superior vena cava syndromeSuperior vena cava syndrome : cause by : cause by obstruction of superior vena cavaobstruction of superior vena cavaDysphagiaDysphagia : cause by compression of : cause by compression of esophagusesophagusDyspnoe, coughDyspnoe, cough : cause by compression of : cause by compression of tracheobronchial treetracheobronchial treeHoarsenessHoarseness : cause by laryngeal nerve : cause by laryngeal nerve paralysisparalysisHorner’s syndromeHorner’s syndrome (ipsilateral miosis, ptosis,(ipsilateral miosis, ptosis, an/hypohidrosis)an/hypohidrosis) : Cause by compression of : Cause by compression of stellate ganglion/symphatetic pathwaystellate ganglion/symphatetic pathwayWeakness/myasthenia gravisWeakness/myasthenia gravis : cause by : cause by thymomathymomaChest painChest pain : cause by chest wall/neural : cause by chest wall/neural invasioninvasion

NEUROGENIC TUMORSNEUROGENIC TUMORS

Can be ASYPMTOMATICCan be ASYPMTOMATIC

Cord compression, Cord compression,

Chest pain, dyspnea, hoarse Chest pain, dyspnea, hoarse voicevoice

Horner’s syndrome - unusualHorner’s syndrome - unusual

DIAGNOSTIC APPROACHDIAGNOSTIC APPROACHImagingImaging : CT, MRI, Radionuclide : CT, MRI, Radionuclide study,study,

Tissue samplingTissue sampling : Mediastinoscopy, : Mediastinoscopy, Thoracoscopy, Needle aspiration, Thoracoscopy, Needle aspiration, Open BiopsyOpen Biopsy

Barium study for hernia, achalasia, Barium study for hernia, achalasia, diverticuladiverticula

I-131 for intrathoracic goiterI-131 for intrathoracic goiter

DIAGNOSTIC APPROACHDIAGNOSTIC APPROACH

Mediastinoscopy or Mediastinoscopy or anterior mediastinotomy can anterior mediastinotomy can definitively diagnose anterior & definitively diagnose anterior & middle mediastinal massesmiddle mediastinal masses

Video assisted thoracoscopy (VAT) Video assisted thoracoscopy (VAT) plays an important role in diagnosisplays an important role in diagnosis

TREATMENT & TREATMENT & PROGNOSISPROGNOSIS

Dictated by the Dictated by the etio-pathologyetio-pathology of of the massthe mass

TREATMENTTREATMENTResectionResection by Thoracotomy or by Thoracotomy or Video Assisted Video Assisted Thoracoscopic Surgery (VATS)Thoracoscopic Surgery (VATS)

Post-op Post-op radiationradiation for malignant for malignant tumorstumors

REFERENCESREFERENCESFishman’s - Pulmonary Diseases & Disorders, 3rd Fishman’s - Pulmonary Diseases & Disorders, 3rd ed, Ch. 96, Acquired lesions of Mediastinum- ed, Ch. 96, Acquired lesions of Mediastinum- benign & malignant, John R Roberts, Larry R benign & malignant, John R Roberts, Larry R Kaiser, p 1509-1536Kaiser, p 1509-1536

Manual of Clinical Problems in Pulmonary Manual of Clinical Problems in Pulmonary Medicine, 4th ed, 101, Mediastinal masses, Medicine, 4th ed, 101, Mediastinal masses, Stephen P Bradley, p 482-484Stephen P Bradley, p 482-484

Comprehensive Respiratory Medicine, R Albert, Comprehensive Respiratory Medicine, R Albert, S Spiro, J Jett, Sec 18, ch 74. 1-10, Disorders of S Spiro, J Jett, Sec 18, ch 74. 1-10, Disorders of MediastinumMediastinum