ContentsMediastinalmasslesion(縱隔腫瘤)MEDIASTINUMMASSLESIONS

縱隔腫瘤教學大綱要求了解縱隔腫瘤的分類,臨床表現(xiàn),診斷和治療原則

(1)縱隔臨床解剖分區(qū)

(2)常見的縱隔腫瘤及好發(fā)部位

(3)縱隔腫瘤的臨床表現(xiàn)和診斷(4)縱隔腫瘤的治療原則

原發(fā)性縱隔腫瘤好發(fā)部位

原發(fā)性縱隔腫瘤多有其好發(fā)部位,了解縱隔的解剖與包含的組織器官有助與不同腫瘤的診斷和鑒別(1)前上縱隔以胸腺瘤和胸骨后甲狀腺腫常見(2)畸胎溜和皮樣囊腫多位于前縱隔(3)后縱隔腫瘤多數(shù)為神經(jīng)源性腫瘤(4)縱隔囊腫較常見的有支氣管囊腫、食管囊腫和心包囊腫(5)淋巴源性腫瘤可位于前、中、后縱隔縱隔腫瘤的臨床表現(xiàn)縱隔腫瘤的臨床表現(xiàn)與腫瘤的大小、部位、生長速度、性質(zhì)等有關(guān),常見癥狀包括:(1)胸悶,胸痛等(2)周圍器官,組織受壓癥狀:腫瘤壓迫神經(jīng)系統(tǒng)如頸交感神經(jīng)、喉返神經(jīng)、臂叢神經(jīng)、脊髓產(chǎn)生相應(yīng)癥狀;壓迫呼吸系統(tǒng)引起咳嗽、呼吸困難、發(fā)紺等;壓迫食道引起吞咽困難；壓迫腔靜脈產(chǎn)生上腔靜脈綜合征等。(3)掌握某些腫瘤的特異性癥狀:如畸胎瘤破入肺內(nèi)可咳出皮質(zhì)腺分泌物或毛發(fā),胸腺瘤可合并重癥肌無力的表現(xiàn),胸骨后甲狀腺腫隨吞咽上下運動等.主要輔助檢查手段胸部X線檢查CT掃描核磁共振內(nèi)鏡檢查活檢原發(fā)性縱隔腫瘤治療原則對多數(shù)縱隔腫瘤,診斷確立,即應(yīng)外科手術(shù)治療惡性腫瘤無法切除或已有遠處轉(zhuǎn)移,可輔助以放射治療或化學藥物治療等惡性淋巴源性腫瘤一般不適宜手術(shù),宜進行放射治療或化學藥物治療AnatomyofMediastinumMediastinumAnteroposteriorViewAnatomyofMediastinumThemediastinum(縱隔)isthecompartmentbetweenthepleuralcavities.Themediastinumitselfisdefinedlaterallybythemediastinalpleuraofeachlung;superiorlyandinferiorlybythethoracicinletanddiaphragm,respectively;anteriorlybythesternum;andposteriorlybythevertebralbodies.themediastinumisdividedlooselyintothreemaincompartments.AnatomyofMediastinum

(縱膈的分區(qū))DivisionsofMediastinum

(縱膈的分區(qū))

Theanterosuperiormediastinum（前縱膈）

containsthethyroid,thymusgland,thelymphnodes,theascendingaortaandtransverseaorta.

Themiddlemediastinum（中縱膈）

containstheheart,thepericardium,thetrachea,thehilaofthelungs,thephrenicnerves,lymphnodes,andareolartissue.

Theposteriormediastinum（后縱膈）

containsthesympatheticchains（交感鏈）,thevagusnerves（迷走神經(jīng)）,theesophagus,thethoracicduct,lymphnodes,andthedescendingaorta.AnatomyofMediastinum

Ａ.上縱隔Ｂ.下縱隔

2.前縱隔

3.中縱隔

4.后縱隔縱隔分區(qū)ＡBAnatomyofMediastinum上縱隔下縱隔Distributionoftumorsinthemediastinum

AllpartsofmediastinumLymphnodelesionsMiddlemediastinumVascularlesions(Aneurysms)(血管疾病,如血管瘤)Lipoma(脂肪瘤)myxoma(粘液瘤)Bronchogeniccysts(支氣管囊腫)Esophageallesions(食管病變)AnterosuperiormediastinumThymoma（胸腺瘤）Lymphoma(淋巴腫瘤)Teratoma(畸胎瘤)Stemcelltumor(干細胞腫瘤)Thyroid(甲狀腺)lesionsParathyroid(甲狀旁腺)Lipoma

Posteriormediastinum

Neurogenictumors（神經(jīng)源性腫瘤）

PathologyLesionswithinthemediastinumrepresentaninterestingvarietyofmasses,bothmalignant(惡性)andbenign(良性).mediastinummalignanciesconstitutelessthan20%ofallthoracictumors.Neurogenictumorsconstitute26%ofmediastinalmasses,cysts21%,teratoma16%,thymomas12%,lymphomas12%,andallotherlesions12%.ClinicalfindingsSymptomsaremorefrequentinmalignantthanbenignlesions.Aboutone-thirdofpatientshavenosymptoms.Fiftypercentofpatientshaverespiratorysymptomssuchascough,wheezing,dyspnea,andrecurrentpneumonias.Hemoptysisand,arely,expectorationofcystcontentsmayfoundwithequalfrequency,eachinabout10%ofpatients.Myasthenia（重癥肌無力）(15-25%withthymoma),fever,andsuperiorvenacavalobstructionareeachfoundinabout5%ofpatients.Thefollowingsymptomssuggestcancerandthusimplyapoorerprognosis（預(yù)后）:hoarseness（哮喘）,Horner’ssyndrome,severepain,andsuperiorvenacavalobstruction.AssistantexaminationStandardposteroanteriorandespeciallylateralchestfilms(正側(cè)位胸片)oftenprovidemuchusefulinformation;however,contrastCTscanninghasbecomethediagnostictestofchoice.MRIishelpfulforassessingvascularorspinalcordextension.Bronchoscopy(氣管鏡)andesophagoscopy(食管鏡)areoccasionallyusefultoidentifyprimarylunglesionsorlesionsoftheesophagus.SomecommonmediastinalmassesNeurogenictumors（神經(jīng)源性腫瘤）Neurogenictumorsalmostalwaysoccurintheposteriormediastinum—oftenthesuperiorportion—arisingfromintercostalorsympatheticnerves.Tenpercentofneurogenictumorsaremalignant.Malignanttumorsoccurmorefrequentlyinchildren.SomecommonmediastinalmassesMediastinalcysticlesions（囊腫性病變）Cystsofthemediastinummayarisefromthepericardium,bronchi,esophagus,orthymus.Pericardialcystsarealsocalledmesothelialcysts.Seventy-fivepercentarelocatednearthecardiophrenicangles,and75%oftheseareontherightside.SomecommonmediastinalmassesGermcelltumors（干細胞腫瘤）Germcelltumorsarecommonmasslesionsoftheanteriormediastinum.Historically,theyarebothsolidandcystic,andthemoredifferentiatedonesmaycontainhairorteeth.Microscopically,ectodermal,endodermal,andmesodermalelementsarepresent.Thesetumorsoccasionallyruptureintothepleuralspace,lung,pericardium,orvascularstructures.SomecommonmediastinalmassesLymphomas（淋巴瘤）Lymphomasareusuallyassociatedwithdisseminateddisease(彌散性病變)metastatictothemediastinum.Theyaretypicallyidentifiedintheanteriorcompartmentbutcanpresentanywherethroughthemediastinum.Theyarethesecondmostcommonmassintheanteriormediastinum.Occasionally,lymphosarcoma(淋巴肉瘤),Hodgkin’sdisease(霍奇金病),orreticulumcellsarcoma(網(wǎng)狀細胞肉瘤)arisesasaprimarymediastinallesion.Treatment

Treatmentistailoredtothespecificdiseaseprocesscausingthemediastinalmass.Inalmostallcases,tissusdiagnosisisimperativeforguidingappropriatetherapy.Mediastinalmassesaretreatedusuallywithinitialsurgicalresection.

Surgicalapproachesinclude：

median

sterno