Clinical Challenges in Thoracic Surgery: Anterior Mediastinal Masses

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 10 November 2022

⏱️ 29 minutes

🔗️ Recording | iTunes | RSS

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Summary

In this episode, our team provides a comprehensive review of the differential diagnosis for mediastinal masses, their workup, and biopsy considerations. Listen as we dive deeper into the perioperative planning and operative approach for resection of these masses with special considerations for patients with thymoma.

Learning Objectives:

-Discuss the differential diagnosis of a mediastinal mass

-Review the workup of a mediastinal mass

-Outline indications for biopsy and describe the various approaches

-Describe the operative techniques for thymectomy, pearls & potential pitfalls

Hosts:

Megan Lenihan MD, Kelly Daus MD, Peter White MD, and Brian Louie MD

Referenced Material

https://pubmed.ncbi.nlm.nih.gov/21847052/

Detterbeck FC, Nicholson AG, Kondo K, Van Schil P, Moran C. The Masaoka-Koga stage classification for thymic malignancies: clarification and definition of terms. J Thorac Oncol. 2011 Jul;6(7 Suppl 3):S1710-6. doi: 10.1097/JTO.0b013e31821e8cff. PMID: 21847052.

https://pubmed.ncbi.nlm.nih.gov/33468329/

Ahmad U. The eighth edition TNM stage classification for thymic tumors: What do I need to know? J Thorac Cardiovasc Surg. 2021 Apr;161(4):1524-1529. doi: 10.1016/j.jtcvs.2020.10.131. Epub 2020 Nov 13. PMID: 33468329.

https://pubmed.ncbi.nlm.nih.gov/34695605/

Marx A, et al. The 2021 WHO Classification of Tumors of the Thymus and Mediastinum: What Is New in Thymic Epithelial, Germ Cell, and Mesenchymal Tumors? J Thorac Oncol. 2022 Feb;17(2):200-213. doi: 10.1016/j.jtho.2021.10.010. Epub 2021 Oct 22. PMID: 34695605.

https://pubmed.ncbi.nlm.nih.gov/22882218/

Meriggioli MN, Sanders DB. Muscle autoantibodies in myasthenia gravis: beyond diagnosis? Expert Rev Clin Immunol. 2012 Jul;8(5):427-38. doi: 10.1586/eci.12.34. PMID: 22882218; PMCID: PMC3505488.

https://pubmed.ncbi.nlm.nih.gov/34339670/

Raja SM, Guptill JT, McConnell A, Al-Khalidi HR, Hartwig MG, Klapper JA. Perioperative Outcomes of Thymectomy in Myasthenia Gravis: A Thoracic Surgery Database Analysis. Ann Thorac Surg. 2022 Mar;113(3):904-910. doi: 10.1016/j.athoracsur.2021.06.071. Epub 2021 Jul 30. PMID: 34339670.

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If you liked this episode, check out other clinical challenge episodes here: https://behindtheknife.org/podcast-series/clinical-challenges/

Transcript

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0:00.0	Behind the Night, the Surgery Podcast, relevant and engaging content designed to help you dominate the day.
0:13.0	Hello and welcome back to another thoracic surgery clinical challenge with your Swedish Medical Center thoracic surgery team.
0:29.0	I'm Megan Lennahan, joined by the grand doctors Brian Louis, Peter White, and Kelly Dawes.
0:38.0	Hey, hey, hey.
0:39.0	Today we are going to be talking about anterior mediasdinal masses.
0:43.0	You have surely heard of your terrible teas of the anterior mediasdinum,
0:48.0	thymoma, teratoma, ectopic thyroid tissue, terrible lymphoma, and parathyroid.
0:55.0	So while we will touch on the workup for these, we're going for a deeper dive on thymoma specifically because it is Peter White's favorite.
1:03.0	He loves it. He really does.
1:05.0	Let's start off with a case.
1:07.0	So a 64-year-old man is referred by his PCP to your office for a mediasdinal mass.
1:12.0	He's pretty healthy, and he had a chest CT to rule out a PE for what turned out to be some virus associated shortness of breath.
1:20.0	This CT, however, noted a 3.4 by 1.8 centimeter anterior mediasdinal mass.
1:26.0	His symptoms are solved, but now he's sitting in your office asking what's next?
1:31.0	So, Kelly, let's start with thinking about what your differential is going to be for this patient.
1:37.0	Absolutely.
1:38.0	So when I think about the differential for a mass and the mediasdinum, I like to divide it into the three main compartments.
1:44.0	Anterior, middle, and posterior.
1:46.0	And then think about what structures lie within each of these.
1:50.0	The anterior mediasdinum is located between the sternum and paracardium and contains thymic, lymphoid, and residual embryonic tissue.
1:58.0	This makes the differential diagnosis for an anterior mediasdinal mass, including such as thymoma, lymphoma, or germ cell tumors.
2:07.0	Now, the middle mediasdinum includes all the visceral structures, the paracardium, heart, great vessels, trachea, esophagus.
	...

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