《外科教学资料》6mediastinum mass lesions纵隔肿瘤申林课件

Contents Mediastinal mass lesion (纵隔肿瘤) MEDIASTINUM MASS LESIONS 纵隔肿瘤 Department of Cardiothoracic Surgrey,Second Affiliated Hospital of Chongqing Medical University Shen Lin 教学大纲要求 v了解纵隔肿瘤的分类,临床表现,诊断和治疗原则 (1)纵隔临床解剖分区 (2)常见的纵隔肿瘤及好发部位 (3)纵隔肿瘤的临床表现和诊断 (4)纵隔肿瘤的治疗原则 原发性纵隔肿瘤好发部位 v 原发性纵隔肿瘤多有其好发部位,了解纵隔的 解剖与包含的组织器官有助与不同肿瘤的诊断和 鉴别 (1)前上纵隔以胸腺瘤和胸骨后甲状腺肿常见 (2)畸胎溜和皮样囊肿多位于前纵隔 (3)后纵隔肿瘤多数为神经源性肿瘤 (4)纵隔囊肿较常见的有支气管囊肿、食管囊 肿和心包囊肿 (5)淋巴源性肿瘤可位于前、中、后纵隔 纵隔肿瘤的临床表现 v纵隔肿瘤的临床表现与肿瘤的大小、部位、生长 速度、性质等有关,常见症状包括: v(1)胸闷,胸痛等 v(2)周围器官,组织受压症状:肿瘤压迫神经系统如 颈交感神经、喉返神经、臂丛神经、脊髓产生相 应症状;压迫呼吸系统引起咳嗽、呼吸困难、发绀 等;压迫食道引起吞咽困难；压迫腔静脉产生上腔 静脉综合征等。 v(3)掌握某些肿瘤的特异性症状:如畸胎瘤破入肺内 可咳出皮质腺分泌物或毛发,胸腺瘤可合并重症肌 无力的表现,胸骨后甲状腺肿随吞咽上下运动等. 主要辅助检查手段 v 胸部X线检查 v CT扫描 v 核磁共振 v 内镜检查 v 活检 原发性纵隔肿瘤治疗原则 v对多数纵隔肿瘤,诊断确立,即应外科手术治疗 v恶性肿瘤无法切除或已有远处转移,可辅助以放射 治疗或化学药物治疗等 v恶性淋巴源性肿瘤一般不适宜手术,宜进行放射治 疗或化学药物治疗 Anatomy of Mediastinum Mediastinum Anteroposterior View Anatomy of Mediastinum vThe mediastinum(纵隔) is the compartment between the pleural cavities. vThe mediastinum itself is defined laterally by the mediastinal pleura of each lung;superiorly and inferiorly by the thoracic inlet and diaphragm, respectively; anteriorly by the sternum; and posteriorly by the vertebral bodies. vthe mediastinum is divided loosely into three main compartments. Anatomy of Mediastinum (纵膈的分区) Divisions of Mediastinum (纵膈的分区) v The anterosuperior mediastinum（前纵膈） contains the thyroid, thymus gland,the lymph nodes,the ascending aorta and transverse aorta. v The middle mediastinum（中纵膈） contains the heart,the pericardium,the trachea,the hila of the lungs,the phrenic nerves,lymph nodes,and areolar tissue. v The posterior mediastinum（后纵膈） contains the sympathetic chains（交感链）,the vagus nerves（迷走神经）,the esophagus,the thoracic duct,lymph nodes,and the descending aorta. Anatomy of Mediastinum .上纵隔 .下纵隔 2.前纵隔 3.中纵隔 4.后纵隔 纵 隔 分 区 B Anatomy of Mediastinum 上纵隔 下纵隔 Distribution of tumors in the mediastinum v All parts of mediastinum Lymph node lesions v Middle mediastinum Vascular lesions (Aneurysms )(血管疾病,如血管瘤) Lipoma(脂肪瘤) myxoma(粘液瘤) Bronchogenic cysts(支气管囊肿) Esophageal lesions(食管病变) v Anterosuperior mediastinum Thymoma（胸腺瘤） Lymphoma(淋巴肿瘤) Teratoma(畸胎瘤) Stem cell tumor(干细胞肿瘤) Thyroid(甲状腺) lesions Parathyroid(甲状旁腺) Lipoma v Posterior mediastinum Neurogenic tumors （神经源性肿瘤） Pathology v Lesions within the mediastinum represent an interesting variety of masses,both malignant (恶 性)and benign(良性).mediastinum malignancies constitute less than 20% of all thoracic tumors. v Neurogenic tumors constitute 26%of mediastinal masses, cysts 21%,teratoma 16%, thymomas 12%, lymphomas 12%,and all other lesions 12%. Clinical findings v Symptoms are more frequent in malignant than benign lesions.About one-third of patients have no symptoms. Fifty percent of patients have respiratory symptoms such as cough, wheezing, dyspnea, and recurrent pneumonias. Hemoptysis and, arely, expectoration of cyst contents may found with equal frequency, each in about 10% of patients. Myasthenia（重症肌无力）(15-25% with thymoma), fever,and superior vena caval obstruction are each found in about 5%of patients. v The following symptoms suggest cancer and thus imply a poorer prognosis（预后）:hoarseness（哮喘）, Horners syndrome, severe pain, and superior vena caval obstruction. Assistant examination v Standard posteroanterior and especially lateral chest films (正侧位胸片)often provide much useful information; however, contrast CT scanning has become the diagnostic test of choice. MRI is helpful for assessing vascular or spinal cord extension. v Bronchoscopy(气管镜) and esophagoscopy (食管 镜)are occasionally useful to identify primary lung lesions or lesions of the esophagus. Some common mediastinal masses vNeurogenic tumors（神经源性肿瘤） Neurogenic tumors almost always occur in the posterior mediastinum often the superior portionarising from intercostal or sympathetic nerves.Ten percent of neurogenic tumors are malignant.Malignant tumors occur more frequently in children. Some common mediastinal masses vMediastinal cystic lesions（囊肿性病变） Cysts of the mediastinum may arise from the pericardium,bronchi,esophagus,or thymus. Pericardial cysts are also called mesothelial cysts.Seventy-five percent are located near the cardiophrenic angles,and 75%of these are on the right side. Some common mediastinal masses vGerm cell tumors（干细胞肿瘤） Germ cell tumors are common mass lesions of the anterior mediastinum.Historically,they are both solid and cystic, and the more differentiated ones may contain hair or teeth. Microscopically, ectodermal, endodermal,and mesodermal elements are present. These tumors occasionally rupture into the pleural space,lung,pericardium,or vascular structures. Some common mediastinal masses vLymphomas（淋巴瘤） Lymphomas are usually associated with disseminated disease(弥散性病变) metastatic to the mediastinum. They are typically identified in the anterior compartment but can present anywhere through the mediastinum. They are the second most common mass in the anterior mediastinum. Occasionally,lymphosarcoma(淋巴 肉瘤), Hodgkins disease(霍奇金病), or reticulum cell sarcoma (网状细胞肉瘤)arises as a primary mediastinal lesion. Treatment v Treatment is tailored to the specific disease process causing the mediastinal mass. In almost all cases, tissus diagnosis is imperative for guiding appropriate therapy. Mediastinal masses are treated usually with initial surgical resection. v Surgical approaches include ： median sternotomy (anterior masses), posterolateral thoracotomy (posterior and middle mediastina