Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
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Transcript of Surgical treatment of mediastinal tumor by dr. innocent kingsley asogwa
SURGICAL TREATMENT
OF
MEDIASTINAL TUMOR
BY
DR. INNOCENT KINGSLEY ASOGWA
ML - 608
USUAL LOCATION OF MEDIASTINAL LESIONS
TREATMENTOF THYMOMA
Surgery
Complete surgical resection
Median sternotomy with a vertical or submammary incision is most commonly
used
bilateral anterolateral thoracotomies with transverse sternotomy, or “clam-
shell procedure”, preferred with advanced or laterally displaced large tumors
Patients with MG and thymoma have a 56% to 78% 10-year survival rate and
a 3% recurrence rate with 4.8% (1.7% since 1980) operative mortality after
extended thymectomy
Radiation
In stage II and III invasive disease, adjuvant radiation can decrease
recurrence rates after complete surgical resection from 28% to 5%
Radiation therapy has proven beneficial in the treatment of extensive disease
CONT’D
Systemic Therapy
Steroids have been shown to be active in the management of thymomas
Both single-agent and combination therapy have demonstrated activity in the
adjuvant and neoadjuvant settings
Doxorubicin, cisplatin, ifosfamide, corticosteroids, and cyclophosphamide all
have been used as single-agent therapy
Molecularly Targeted Therapy
Overexpression of c-kit is common in thymic carcinoma
Coamplification of the HER-2/neu topoisomerase 2-alpha gene may correlate
with response to the CAP chemotherapy regimen
antitumor activity has been reported with dasatinib, a small molecule oral,
multitargeted kinase inhibitor of Bcr-Abl and src kinases, ephrin receptor
kinases, platelet-derived growth factor receptor, and c-kit, in thymoma
Branches of the internal thoracic arteries are divided to permit the en bloc specimen to be rotated upward, exposing the undersurface of the gland and the draining veins. The exposed brachiocephalic and thymic veins are isolated and divided between ligatures or clips (inset).
PREOPERATIVE
Initial workup:
careful history and physical examination the neck and particularly the thyroid gland require careful palpation
Investigation:
complete blood count,
serum electrolytes,
thyroid function tests,
acetylcholine-receptor antibody assay,
pulmonary function tests,
electromyographic studies,
immunoglobulin assay,
bone marrow biopsy,
cervical lymph node biopsy
CONT’D
Radiographic Investigation:
Plain Chest X Ray 2 plane: posteroanterior and left lateral view
CT Scan
MRI
Patient's strength and respiratory status should be optimized with the
use of pyridostigmine and immunosuppressive agents when indicated
Preoperative plasmapharesis or IV immunoglobulin therapy may be
beneficial in patients with a vital capacity of less than 2 L
POSTOPERATIVE
Usually are extubated in the OR within 30 minutes of the conclusion of
the operation
Kept in a monitored setting overnight
If the patient does not have an epidural catheter in place, parenteral
analgesia can be administered in small intermittent doses of
hydromorphone or morphine
On the morning after the operation, oral medication and a clear liquid
diet are begun and advanced as tolerated
The chest tubes are removed when no air leak or significant output is
present and the lungs are fully expanded on chest x-ray 2nd
postoperative day
CONT’D
Antibiotics and the continuous epidural infusion are discontinued, and
oral narcotic analgesics are started once the chest tubes are removed
Patients with MG are discharged when their symptoms are adequately
controlled with oral medication and they are well able to tolerate a
regular diet
Most patients are able to return to normal activity and work within 2–3
weeks after transsternal thymectomy
Tapering of medications in patients with MG begins at various times
after operation depending on the judgment of the neurologist
TREATMENT OF Substernal Goiter
CONSIDERATION FOR THORACOTOMY
Atypical anatomy
Extramediastinal extension with known malignancy
Posterior location or extension of tumor
Goiters that extend to the tracheal carina
Adherence to visceral or intrathoracic parietal pleura
CONSIDERATION FOR MEDIAN STERNOTOMY
Primary retrosternal/ectopic
goiter
Atypical anatomy
Dense adhesions from prior
surgery
Inability to deliver the gland into
the neck
Extracapsular extension or
known mediastinal malignancy
Recurrent intrathoracic goiter
Prior thyroid surgery, especially
for cancer
Goiters that extend to the
tracheal carina
Goiters that cause life-
threatening compression of
mediastinal structures
Significant intraoperative
mediastinal bleeding
Adherence to mediastinal pleura
Goiters usually can be removed via cervical incision with the use of carefulblunt finger dissection to mobilize the gland from its attachment tomediastinal structures. Most large goiters can be removed through a 2-cmcollar incision.
PREOPERATIVE
Radiographic:
Chest x-ray mediastinal mass, superior mediastinal widening, tracheal
deviation or compression
Chest CT scans define the full extent and anatomic relationships of the
substernal thyroid to surrounding structures and to facilitate preoperative
planning
serum thyroid-stimulating hormone measurement If
hyperthyroidism is present antithyroid medications and beta
blockade should be undertaken before elective resection
Pulmonary functiong testing is useful
discuss these patients with the anesthesiologist in advance of surgery
POSTOPERATIVE
Length of stay for an uncomplicated procedure is overnight
patients can be discharged uneventfully with calcium or calcitriol
supplementation
If a thoracotomy or sternotomy is required, length of stay is increased
major complications injury to the trachea, parathyroid glands, or
recurrent laryngeal nerves
The need for tracheostomy is rare
TREATMENT OF TERATOMAS
For benign tumors that are so large or with involvement of adjacent
mediastinal structures so that complete resection is impossible
partial resection (debulking) can lead to the resolution of symptoms,
frequently without relapse
Malignant teratomas chemotherapy and radiation therapy,
combined with surgical excision
Overall prognosis is poor for malignant teratomas
SEMINOMAS
Sensitive to irradiation and chemotherapy
Treatment consists of systemic and local therapy:
chemotherapy with salvage surgery
combined chemoradiotherapy
Radiation therapy may be considered for early-stage disease, but is not recommended for regional disease
Platinum-based chemotherapy is common
Occasionally, excision is possible without injury to vital structures and can be recommended
When complete resection is possible, the use of adjuvant therapy is unnecessary
MEDIASTINAL NONSEMINOMAS
Current treatment: cisplatin and etoposide-based regimens
When tumor necrosis or a benign teratoma is found during surgical
exploration after chemotherapy excellent or intermediate prognosis
LYMPHOMAS
Surgeon’s primary role is to provide sufficient tissue for diagnosis and
to assist in pathologic staging.
Thoracoscopy, mediastinoscopy, or mediastinotomy and, rarely,
thoracotomy or median sternotomy may be necessary to obtain
sufficient tissue
Lymphoblastic lymphoma occurs predominantly in children,
adolescents, and young adults and represents 60% of cases of
mediastinal non-Hodgkin’s lymphoma.
NEUROGENIC TUMORS: SCHWANNOMA / NEURILIMOMA
During resection, the intraspinal component should be removed first
via a posterior laminectomy minimizes the potential for spinal
column hematoma, cord ischemia, and paralysis
Magnetic resonance image of a neurogenic tumor with extension into the spinal canal via the foramen, which gives a typical dumbbell appearance
Approach for dumbbell tumors. A. Hemilaminectomy (black arrow). B. Resection of intraspinalcomponent of tumor prior to thoracic approach
NEUROBLASTOMAS
Therapy is determined by the stage of the disease
stage I surgical excision
stage II excision and radiation therapy
stages III and IV multimodality therapy using surgical debulking, radiation
therapy, and multiagent chemotherapy
INTERNATIONAL NEUROBLASTOMA STAGING SYSTEM
GANGLION TUMORS
Ganglioneuroblastomas composed of mature and immature ganglion cells
Treatment from surgical excision alone to various chemotherapeutic strategies, depending on:
histologic characteristics,
age at diagnosis,
stage of disease
Ganglioneuromas benign tumors originating from the sympathetic chain that are composed of ganglion cells and nerve fibers
typically present at an early age the most common neurogenic tumors occurring during childhood
usual location: paravertebral region; well encapsulated, cystic degeneration when cross-sectioned
Surgical excision is curative.
PREOPERATIVE
Initial workup:
physical examination and accurate history
Imaging
CT scan to define the morphology and location of the tumor, local invasion, bony or airway involvement
MRI to clarify the relationship of the tumor to the neural foramen and spinal canal
Laboratory test:
serum and urine free catecholamine levels
Insulin and glucose levels
Adjunctive workup:
pulmonary function test
cardiac risk stratification
POSTOPERATIVE
Patients are managed similarly to any patient who has undergone
thoracotomy or thoracoscopy
Chest drains are removed early (i.e., on the day of surgery or
postoperative day 1) based on output and reexpansion of the lung
extubated in the OR, and early mobilization is advocated
Diet may be resumed in short order as tolerated
patients with paragangliomas warrants special attention to heart rate
and blood pressure
REFERENCES
1. Sugarbaker D, Bueno R, Krasna M, Mentzer S, Zellos L. Adult Chest Surgery. McGraw Hill Professional; 2009.
2. DeVita VT, Lawrence TS, Rosenberg SA. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. Lippincott Williams & Wilkins; 2008.
3. Jr CMT, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: Expert Consult Premium Edition: Enhanced Online Features. 19th ed. Elsevier Health Sciences; 2012.
4. Brunicardi F, Andersen D, Billiar T, Dunn D, Hunter J, Matthews J, et al. Schwartz’s Principles of Surgery. 9th ed. McGraw-Hill Education; 2009.
5. Norton JA, Barie PS, Bollinger RR, Chang AE, M.D SFL, M.D SJM, et al. Surgery: Basic Science and Clinical Evidence. Springer; 2009.
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