Differential Diagnosis:
The differential diagnosis for a mass in the anterior mediastinum includes the classic 4T's.
The most common primary tumours associated with this location are the following:
Thymoma - (30% of the time)
(Terrible) Lymphoma - (20%)
Teratoma - and other germ cell tumours (18%)
Thyroid cancer (other carcinomas) - (13%)
Secondary tumours are more common in this region and include: lung, esophagus, and testicular cancers.
Clinical Presentation:
The presentation of patients with an anterior mediastinal mass is usually in the 3rd to 5th decade of life.
The main symptoms of a mass in this area include compressive symptoms (stridor, dysphagia, hoarseness) related to the mass impinging on surround structures.
Also, chest pain, cough, dyspnea are all common presenting complaints.
There can also be paraneoplastic phenomena related to the underlying malignancy, and we discussed how hypercalcemia can be associated with with lymphomas, and myasthenia gravis can be associated with thymomas.
The other important consideration is to not miss an aortic dissection in a patient presenting with chest pain and mediastinal fullness on a chest x ray.
Management:
There were a couple of important management considerations that we discussed.
1.) Assessing airway patency - if there is any evidence of stridor, or respiratory distress than a call to anesthesia or ICU to help intubate the patient is warranted.
2.) Ruling out Dissection - CT-angiogram to assess the mass and make sure this is not an aortic dissection.
3.) Obtaining a tissue sample - This can be performed via interventional radiology (IR) or respirology/thoracic surgery via EBUS (Endobronchial Ultrasound) guided biopsy.
Thymic epithelial tumours:
Thymomas have a predilection for females and usually present in the 5th and 6th decades of life. Approximately 35% of patients with thymomas have myasthenia gravis, and 15% of patients with myasthenia gravis will have a thymoma.
Other associations with thymoma include pure red cell aplasia, hypogammaglobuminaemia, and SLE.
The bottom line as Dr. Mark Cheung would say, "When tumour is the rumour, tissue is the issue"
Reference: Imaging of anterior mediastinal tumours. Ching Ching Ong, Lynette L.S. Teo. 2012. Cancer Imaging. 12, 506-515.
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