Mediastinal Mass
Charles Bailey, MD, PhDDon E. Eslin, MD, PhD (4th Edition)
Mediastinal Mass - BASICS
Mediastinal Mass - description
Space-occupying lesion of the mediastinum:
- Anterior mediastinum includes the thymus and other structures anterior to the pericardium.
- Middle mediastinum is a vascular space that contains the pericardium, heart, great vessels, ascending aorta, and aortic arch.
- Posterior mediastinum contains the tracheobronchial tree, esophagus, descending aorta, and neural structures.
Mediastinal Mass - pathophysiology
Morbidity is due to compression of adjacent normal structures, particularly large airways, heart, and great vessels.
Mediastinal Mass - DIAGNOSIS
General goal is to establish diagnosis promptly and begin treatment as indicated, because condition may progress rapidly and become life threatening. If you suspect a malignancy, the child should be immediately referred to an oncologist.
Mediastinal Mass - signs & symptoms
- Superior vena cava syndrome (superior mediastinal syndrome):
- Edema/suffusion of face and neck
- Jugular venous distension
- Conjunctival injection
- Altered mental status
- Airway compression:
- Cough (nonproductive)
- Orthopnea or dyspnea
- Stridor or wheezing
- Cardiac tamponade/diastolic dysfunction:
- Quiet heart sounds
- Hypotension, narrowed pulse pressure, or pulsus paradoxus
Mediastinal Mass - history
- Systemic symptoms (fever, weight loss, night sweats, fatigue) associated with infection and malignancies
- Cough, wheeze, dyspnea on exertion (DOE), orthopnea may indicate early airway compromise.
- Face/Neck swelling suggests superior mediastinal syndrome (SMS).
Mediastinal Mass - physical exam
- Check for signs and symptoms noted above.
- Pulse oximetry
- Lymphadenopathy or hepatosplenomegaly suggests malignancy or infection. Ecchymoses, petechiae, and mucosal bleeding suggest thrombocytopenia, which can be seen in leukemia.
- Horner syndrome can be seen in neuroblastoma, typically with a posterior mediastinal mass.
Mediastinal Mass - tests
Consider pulmonary function tests (PFTs) if respiratory reserve is in question.
Mediastinal Mass - lab
- CBC with differential: Anemia, thrombocytopenia, neutropenia, or circulating blasts frequently noted in leukemia or lymphoma; leukocytosis in infection
- Tumor lysis screen: Lactate dehydrogenase, uric acid, electrolytes, blood urea nitrogen, creatinine
- Purified protein derivative skin test for tuberculosis
Mediastinal Mass - imaging
- Chest radiograph (lateral film required) to establish size and location of mass
- CT of the chest (if patient can tolerate semirecumbent positioning) to define size, location, and consistency of mass
- ECG to assess diastolic filling and vascular patency
Mediastinal Mass - diag proced-surgery
- Goal is rapid diagnosis using least invasive/painful procedure, to minimize need for sedation/anesthesia.
- Bone marrow aspiration/biopsy: Simplest procedure if CBC is suspicious
- Lymph node biopsy: If adenopathy at easily accessible site
- Biopsy of mass: Consider radiologically guided needle biopsy.
- Pleurocentesis, pericardiocentesis, or excision of isolated mass may have both diagnostic and therapeutic roles.
- Lumbar puncture may be combined with other procedures if meningitis or hematologic malignancy is suspected.
Recumbent positioning, sedation, or positive pressure ventilation may lead to catastrophic respiratory or cardiovascular collapse in patients with partial compromise. Procedures may need to be done with local anesthesia or minimal sedation in these patients.
Mediastinal Mass - differencial diagnosis
- Congenital/Anatomic:
- Thoracic meningocele (posterior)
- Large normal thymus in neonate (anterior)
- Bronchogenic, pericardial, or foregut cyst (middle)
- Aortic aneurysm and other vascular anomalies (middle)
- Infectious (may cause mediastinal adenopathy and/or pulmonary nodules) (middle/posterior):
- Tuberculosis
- Histoplasmosis
- Aspergillosis
- Coccidioidomycosis
- Blastomycosis
- Foreign body in the trachea or esophagus
- Sarcoidosis
- Tumor:
- Benign:
- Thymoma (anterior)
- Teratoma/Dermoid cyst (anterior)
- Lymphangioma/Cystic hygroma (middle/posterior)
- Hemangioma (posterior/middle)
- Pheochromocytoma (posterior)
- Ganglioneuroma (posterior)
- Neurofibroma (posterior)
- Malignant:
- Hodgkin lymphoma (anterior/middle)
- Non-Hodgkin lymphoma or leukemia (anterior/middle)
- Neuroblastoma (posterior)
- Pheochromocytoma (posterior)
- Rhabdomyosarcoma or pleuropulmonary blastoma (any)
- Ganglioneuroblastoma (posterior)
- Neurofibrosarcoma (posterior)
- Ewing sarcoma or osteogenic sarcoma (anterior/posterior)
- Malignant germ cell tumor (anterior)
Mediastinal Mass - TREATMENT
Mediastinal Mass - general measures
Definitive therapy will be based on the diagnosis.
- Do not treat a patient who has no history of asthma with steroids without obtaining a chest radiograph to confirm that there is no mediastinal mass.
- If symptoms are progressing rapidly or there is evidence of superior vena cava syndrome, tracheal compression, or spinal cord compression, emergent steroids or radiation may be required, if possible, following rapid diagnostic procedures.
Mediastinal Mass - diet
NPO until respiratory and cardiovascular stability established
Mediastinal Mass - nursing
Monitor vital signs, pulse oximetry, mental status closely.
Mediastinal Mass - special therapy
Mediastinal Mass - radiotherapy
May be indicated for emergent management of malignancies
Mediastinal Mass - medication
Mediastinal Mass - first line
- Steroids may be given after diagnosis is obtained to treat hematologic malignancies or decrease edema/inflammation.
- Additional therapy depends on diagnosis (e.g., chemotherapy, antibiotics).
Mediastinal Mass - surgery
- May be required for diagnostic biopsy
- Excision may relieve acute compression, and may be primary therapy for isolated benign mass.
Mediastinal Mass - FOLLOW UP
Mediastinal Mass - complications
- Superior vena cava syndrome
- Tracheal compression
- Spinal cord compression
- Pleural and pericardial effusions
- Secondary infection
- Horner syndrome: Ptosis, miosis, and anhydrosis resulting from compression of the cervical sympathetic nerve trunk
- Esophageal narrowing or erosion: May result in feeding difficulty or bleeding
Mediastinal Mass - bibliography
- Franco A, Mody NS, Meza MP. Imaging evaluation of pediatric mediastinal masses. Radiol Clin North Am. 2005;43:325–353.
- Hammer BG. Anaesthetic management for the child with a mediastinal mass. Paediatr Anaesth. 2004;14:95–97.
- Jaggers J, Balsara K. Mediastinal masses in children. Semin Thorac Cardiovasc Surg. 2004;16:201–208.
- Kelly KM, Lange B. Oncologic emergencies. Pediatr Clin North Am. 1997;44:809–829.
Mediastinal Mass - CODES
Mediastinal Mass - icd9
786.6 Swelling, mass, or lump in chest
Mediastinal Mass - FAQ
- Q: What should be done if the child is asymptomatic and a mediastinal mass is an incidental finding on chest x-ray?
- A: Careful history and physical with specific attention to pulmonary, cardiac, and hematologic systems.
Vital signs to include temperature and pulse oximetry
CBC, differential, ESR, tumor lysis labs
(PPD), anergy panel
CT of chest
Referral to oncologist, surgeon, or infectious disease specialist pending above results
- Q: When should an oncologist be consulted?
- A: With any of the following:
Rapidly enlarging mass
Signs and symptoms of tracheal compression, superior vena cava (SVC) syndrome, or spinal cord compression Hepatomegaly, lymphadenopathy, bruises, or petechiae on physical examination
Anemia, thrombocytopenia, or leukocytosis suggesting bone marrow involvement
Malignant histology is demonstrated with biopsy
When help is needed in establishing diagnosis
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
Other Book Chapters Related to Breast lump
Read excerpts from these other book chapters related to Breast lump:
Medical Books Excerpts
- Breast Mass
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Mediastinal Mass
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Scrotal Mass
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- FACE MASS
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.
More About Causes of Breast lump
|
|
More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
|
|
» Next page: Medications causing Breast lump
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
