外科学教学课件：MEDIASTINUM MASS LESIONS纵隔肿瘤

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1、Company LogoContentsMediastinal mass lesion(纵隔肿瘤)MEDIASTINUM MASS LESIONS纵隔肿瘤纵隔肿瘤Company Logo教学大纲要求教学大纲要求v了解纵隔肿瘤的分类了解纵隔肿瘤的分类,临床表现临床表现,诊断和治疗原则诊断和治疗原则 (1)纵隔临床解剖分区纵隔临床解剖分区 (2)常见的纵隔肿瘤及好发部位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纵隔肿瘤的临床表现和诊断 (4)纵隔肿瘤的治疗原则纵隔肿瘤的治疗原则 Company Logo原发性纵隔肿瘤好发部位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原发性

2、纵隔肿瘤多有其好发部位,了解纵隔的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解剖与包含的组织器官有助与不同肿瘤的诊断和鉴别鉴别 (1)前上纵隔以胸腺瘤和胸骨后甲状腺肿常见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、食管囊纵隔囊肿较常见的有支气管囊肿、食管囊肿和心包囊肿肿和心包囊肿 (5)淋巴源性肿瘤可位于前、中、后纵隔淋巴源性肿瘤可位于前、中、后纵隔Company Logo纵隔肿瘤的临床表现纵隔肿瘤的临床表现v纵隔肿瘤的临床表现

3、与肿瘤的大小、部位、生长纵隔肿瘤的临床表现与肿瘤的大小、部位、生长速度、性质等有关速度、性质等有关,常见症状包括常见症状包括:v(1)胸闷胸闷,胸痛等胸痛等v(2)周围器官周围器官,组织受压症状组织受压症状:肿瘤压迫神经系统如肿瘤压迫神经系统如颈交感神经、喉返神经、臂丛神经、脊髓产生相颈交感神经、喉返神经、臂丛神经、脊髓产生相应症状应症状;压迫呼吸系统引起咳嗽、呼吸困难、发绀压迫呼吸系统引起咳嗽、呼吸困难、发绀等等;压迫食道引起吞咽困难；压迫腔静脉产生上腔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。静脉综合征等。v(3)掌握某些肿瘤的特异性症状掌握某些肿瘤的特异性症状:如畸胎瘤破入肺

4、内如畸胎瘤破入肺内可咳出皮质腺分泌物或毛发可咳出皮质腺分泌物或毛发,胸腺瘤可合并重症肌胸腺瘤可合并重症肌无力的表现无力的表现,胸骨后甲状腺肿随吞咽上下运动等胸骨后甲状腺肿随吞咽上下运动等.Company Logo主要辅助检查手段主要辅助检查手段v 胸部胸部X线检查线检查v CT扫描扫描v 核磁共振核磁共振v 内镜检查内镜检查v 活检活检Company Logo原发性纵隔肿瘤治疗原则原发性纵隔肿瘤治疗原则v对多数纵隔肿瘤对多数纵隔肿瘤,诊断确立诊断确立,即应外科手术治疗即应外科手术治疗v恶性肿瘤无法切除或已有远处转移恶性肿瘤无法切除或已有远处转移,可辅助以放射可辅助以放射治疗或化学药物治疗等治疗

5、或化学药物治疗等v恶性淋巴源性肿瘤一般不适宜手术恶性淋巴源性肿瘤一般不适宜手术,宜进行放射治宜进行放射治疗或化学药物治疗疗或化学药物治疗Company LogoAnatomy of MediastinumMediastinumAnteroposterior ViewCompany LogoAnatomy of MediastinumvThe mediastinum(纵隔)is the compartment between the pleural cavities.vThe mediastinum itself is defined laterally by the mediastinal p

6、leura 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.Company LogoAnatomy of Mediastinum(纵膈的分区)Company LogoDivisions of Mediastin

7、um(纵膈的分区)vThe anterosuperior mediastinum（前纵膈）contains the thyroid,thymus gland,the lymph nodes,the ascending aorta and transverse aorta.vThe 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.vThe posterior me

8、diastinum（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.Company LogoAnatomy of Mediastinum.上纵隔上纵隔.下纵隔下纵隔2.前纵隔前纵隔3.中纵隔中纵隔4.后纵隔后纵隔纵隔分区BCompany LogoAnatomy of Mediastinum上纵上纵隔隔下纵下纵隔隔Company LogoDistribution of tumors

9、 in the mediastinumvAll parts of mediastinum Lymph node lesions vMiddle 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)vAnterosuperior 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)lesion

10、s Parathyroid(甲状旁腺)Lipomav Posterior mediastinum Neurogenic tumors（神经源性肿瘤）Company LogoPathologyv 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 cons

11、titute 26%of mediastinal masses,cysts 21%,teratoma 16%,thymomas 12%,lymphomas 12%,and all other lesions 12%.Company LogoClinical findingsv 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

12、 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 sy

13、mptoms suggest cancer and thus imply a poorer prognosis（预后）:hoarseness（哮喘）,Horners syndrome,severe pain,and superior vena caval obstruction.Company LogoAssistant examinationv Standard posteroanterior and especially lateral chest films(正侧位胸片)often provide much useful information;however,contrast CT s

14、canning 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.Company LogoSome common mediastinal massesvNeurogenic tumors（神

15、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.Company LogoSome common mediastinal massesvMediastinal c

16、ystic lesions（囊肿性病变）（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.Company LogoSome common mediastinal

17、massesvGerm cell tumors（干细胞肿瘤）（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 occa

18、sionally rupture into the pleural space,lung,pericardium,or vascular structures.Company LogoSome common mediastinal massesvLymphomas（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 pr

19、esent 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.Company LogoTreatmentvTreatment is tailored to the specific disease

20、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.vSurgical approaches include：mediansternotomy(anteriormasses),posterolateral thoracotomy(posterior and middle

21、 mediastinal masses)as well as VATS or bilateral anterior thoracotomy(all mediastinal compartments).Company LogoTreatmentv Adjuvant chemotherapy（辅助化疗）is important for malignant germ cell lesions,malignant neurogenic tumors,and bulky or advanced thymomas.Postoperative radiation therapy（术后放疗）decreases

22、 local recurrence in higher-stage thymoma and in other incompletely resected lesions.Radiation and chemotherapy constitutes the principal therapy for primary mediastinal lymphoma.Company LogoTreatmentPericardial CystPericardial CystCompany LogoTeratomaCompany LogoCompany LogoTreatmentResection of thymoma through VATS Company LogoTreatmentResection of thymoma through VATS