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Mediastinal organs examination. Benign neoplasms of the mediastinum

In the section on diseases of the mediastinum, usually only diseases of the lymph nodes, tissue, and partly the mediastinal pleura are considered, mainly from the point of view of the compression phenomena they cause; purulent mediastinitis is primarily of surgical interest.
When considering the symptoms of compression, it is advisable to conditionally divide the mediastinum (minus the main organs - the heart and cardiac membrane) into upper, posterior, anterior. The upper mediastinum contains the aortic arch, thoracic (lymphatic) duct, esophagus, vagus, sympathetic, phrenic nerve; posterior descending aorta, lower part of the trachea, main bronchi, lower part of the esophagus, vena cava (superior and lower), thoracic duct, vagus, sympathetic, phrenic nerve; anterior - mainly the thymus gland.
Severe, even fatal signs of compression can be caused in the mediastinum (as well as in the brain) by any tumor (in the broad sense of the word), not only malignant, but even benign and inflammatory.
The most common complaints with compression of the mediastinal organs are shortness of breath, cough with sputum, change in voice, pain, dysphagia; Objective signs include impaired local circulation with edema, roundabout circulation, local cyanosis, etc.
Shortness of breath is most often caused by compression of the trachea or bronchi, stagnation of blood in the lungs, including due to compression of the pulmonary veins at the point where they flow into the heart, compression of the recurrent nerve, etc.
It should be imagined that in the origin of shortness of breath in diseases of the mediastinum, the neuroreflex effect on the part of the respiratory tract receptors, as well as vascular baroreceptors, etc., is of primary importance.
Congestive cough, the formation of roundabout venous circulation and other mediastinal compression signs are of the same origin. Representing the manifestation of adaptive mechanisms for the restoration of various aspects of impaired organ activity, shortness of breath, cough, etc., at the same time, often achieve excessive Strength; in these cases, it is advisable to strive to alleviate them.

Shortness of breath develops in several periods - first only after physical exertion or during excitement, then it becomes
constant, is inspiratory or also expiratory in nature, often accompanied by stridor (with compression of the trachea); as the disease progresses, orthopnea takes on the character, the patient cannot lie down, shortness of breath greatly disrupts sleep; It is not so rare that death occurs from strangulation.

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The cough is often paroxysmal, convulsive or whooping cough-like in nature when irritated by enlarged lymph nodes or when the process spreads to the mucous membrane of the tracheal bifurcation. Cough can also be a consequence of congestive or inflammatory bronchitis, irritation of the vagus nerve. The cough, like the voice, can be hoarse, weak or silent, with a particular hue from swelling or paralysis of the vocal cords (due to compression of the recurrent nerve). The cough is initially dry or with sputum, mucous from excessive secretion and retention of mucus or mucopurulent, sometimes, with the development of bronchiectasis from compression of the bronchus, very copious. Often the sputum is stained with blood (congestion, bronchiectasis, rupture of blood vessels).
Particularly painful are pains that occur either in the form of attacks radiating to the neck or arm due to pressure on the brachial plexus or in the form of a feeling of numbness or pressure in one arm.
Difficulty swallowing (dysphagia) rarely reaches the degree that is observed with diseases of the esophagus itself.
When the superior vena cava or its main branches are compressed, swelling of the cervical tissue and shoulder girdle in the form of a cape and upper limbs, even swelling of the face, or one right or left arm, is observed. Blood from the superior vena cava system penetrates into the inferior
through the veins of the anterior wall of the body or mainly through the deeply embedded azygos and semi-gypsy vein (if they have escaped compression); with unilateral compression of the subclavian vein, collaterals lead from this side of the chest to the collectors of the superior vena cava of the opposite side; Due to swelling of the veins of the orbit and swelling of the tissue, bulging eyes may develop. Small skin veins on the face and chest are dilated. Superficially located veins have the appearance of blue-purple, “leech” cords. Venous stagnation is accompanied by extremely sharp local cyanosis due to stretching of the veins and slow blood outflow.
Disruption of blood flow through the arterial trunks is observed less frequently, mainly with an aortic aneurysm.
An objective examination reveals other signs of compression of the mediastinal organs: uneven pupils or complete compression syndrome of the upper cervical sympathetic nerve with miosis, eye retraction, drooping eyelid, sweating and facial hyperemia on the affected side, persistently recurrent herpes zoster on the chest simultaneously with intercostal neuralgia due to compression of the roots, high standing of the diaphragm and other signs
unilateral paralysis of the phrenic nerve, effusion into the pleural cavity as a result of accumulation of the contents of the milk vessels - chylothorax with compression of the thoracic (lymphatic) duct. Compression of the bronchus produces the usual symptoms of bronchial obstruction up to massive atelectasis.
Other mediastinal signs are characteristic of mediastino-pericarditis: multicostal systolic retraction in the atrium, lack of forward movement of the lower part of the sternum during inspiration due to fusion with the spine, paradoxical pulse, systolic retraction of the laryngeal cartilage.
X-ray examination easily establishes congestion in the lungs, impaired patency of the esophagus (when contrast is given), high standing and paralysis of the diaphragm on the left or right side, displacement of the trachea (ascertained clinically), atrophy of the vertebral bodies, leading to transverse myelitis; examination with a laryngeal mirror - paralysis of the plus ligaments.
Signs of the disease itself that causes compression are easily detected, for example, enlarged lymph nodes in the neck or in the mediastinum (with lymphogranulomatosis, etc.), signs of mediastinal pleurisy, aortic aneurysm, mitral stenosis (causing compression of the lower laryngeal nerve in the case of a sharp increase in the left atrium), scarring tuberculous process with calcification, etc.

The mediastinum is the space in the middle parts of the chest cavity. At first glance, it seems that there can be no problems with it. But, if you study medical statistics, you can note that in 3-7% of cases of diagnosis of tumor formations, a diagnosis is made as a mediastinal tumor. It is equally common among men and women. At the same time, 60-80% of formations are benign in nature. In other situations, we can talk about cancer.

Important! Most often, formations are diagnosed in people aged 20-40 years, that is, in the working population.

Features of the classification of neoplasms

All mediastinal tumors are initially divided into two large groups: primary and secondary. The former develop in tissues as an independent pathology, the latter become metastases of already existing formations.

Primary tumors can be formed from different tissues. Depending on this, the following types are distinguished:

neurogenic;
mesenchymal;
lymphoid;
dysembryogenetic;
thymus tumors.

In some cases, doctors diagnose pseudotumors, which are lymph nodes that are enlarged for some reason. True cysts also occur.

We mentioned above that neoplasms can be malignant and benign. The latter are characterized by fairly slow growth and do not metastasize. The former increase in size very quickly and metastasize, which causes additional symptoms to appear.

Important! Most often we have to deal with neurogenic formations, which account for 15-20% of the total number of mediastinal tumors. They are formed from cells of nervous tissue and are found in several types. The classification depends on the type of tissue from which the formation arose - the nerve tissue itself or the peripheral nerve sheath.

If we talk about the International Classification of Mediastinal Tumors, there are also several points here. The disease in question can be indicated by the following ICD10 codes:

malignant primary formation – C38;
malignant secondary formation – C78.1;
benign formations of the mediastinum – D15.2.

This classification is largely designed to facilitate reporting and statistics. It does not play a special role in treatment.

Why do formations appear in the mediastinum?

Many experts believe that most neoplasms are congenital. But, they remain in an inactive state for a long time, and when favorable conditions are created, they begin to develop, and appear already in adolescence or earlier. Here we are talking about germinogenic formations, the cause of which is the primary germ cell. Such tumors are diagnosed in children and adolescents. There is also a list of the most common localizations. In it, cysts and tumors of the mediastinum in children are one of the first places. Even if the disease does not manifest itself at this age, it will make itself felt later, when the person reaches working age.

It is not yet possible to name the exact reasons. There is an opinion that the development of mediastinal tumors is a consequence of irradiation of the body, the negative impact of the environment on it and other similar factors. Heredity also plays a role. If someone in your family has been diagnosed with similar diseases, the risk of their occurrence increases in the child.

Serious viral infections that affect the body are also considered causes. They cause the launch of pathological processes in cells, which result in the appearance of a tumor.

Clinical manifestations of the disease

The earlier the disease is detected, the easier it is to treat it, including when it comes to mediastinal tumors. Particular attention should be paid to the fact that even with a benign course, which is observed in 60% of cases, most of the formations can degenerate into cancer, thereby worsening further prognosis. Early diagnosis will help to minimize the likelihood of such a development of events and have a high chance of a full recovery. That is why it is so important to carefully study the symptoms of a mediastinal tumor, which appear quite clearly.

Let us immediately note that there is a certain period during which the disease does not show clinical manifestations. Its duration differs in each case and depends on the following factors:

size of the tumor;
location features;
character – malignant or benign;
growth intensity;
influence on the functioning of other organs.

In such situations, tumors and mediastinal cysts are detected accidentally as a result of preventive fluorography. But, given that most people undergo it systematically, the size of the tumors is usually quite small.

When the tumor reaches a sufficiently large size or becomes malignant, a person begins to notice vivid symptoms. The first thing that appears is periodic pain in the chest area. They are triggered by compression or growth of a tumor into nerve endings and trunks. Pain varies in intensity and can spread to the neck, shoulder, and interscapular area.

Adults also have additional symptoms of a mediastinal tumor, they include the following:

pain in the heart area. In fact, the organ can be completely healthy, but pain appears due to the peculiarities of the localization of the formation, its location on the left side of the cavity;
superior vena cava syndrome. In this case, symptoms appear as a result of impaired blood flow from the upper body. As a result, a person notices frequent occurrence of tinnitus and headaches. Blueness of the skin and shortness of breath are also observed. Swelling of the face and chest appears, veins in the neck swell;
if the trachea and bronchi are compressed, the person begins to suffer from coughing and shortness of breath;
when the esophagus is compressed, dysphagia is noted.

There are a number of clinical signs by which tumor formation can be noticed, these are:

increased fatigue and weakness;
heart rhythm disturbances;
fever;
sudden weight loss for no apparent reason;
joint pain, which can be localized even in several joints;
inflammation of the serous membrane of the lungs or pleura.

The listed signs are for the most part characteristic of malignant neoplasms. The latter can also manifest as night sweats, itchy skin, decreased blood glucose levels, increased blood pressure, and even diarrhea. It all depends on the type of education that takes place in a particular case.

In any situation, if the listed symptoms are noted, it is necessary to urgently seek medical help. It is important to do this as soon as possible, because postponing a visit to the doctor will only complicate treatment.

What diagnostic methods are used to make a diagnosis?

First of all, the doctor collects anamnesis and conducts an initial examination. It is important for the doctor to know the features of the clinical picture, the time and frequency of symptoms. Also in this case, family history is important, because with a genetic predisposition, the risk of developing tumor formation increases significantly.

If we talk directly about diagnostic methods, they will be as follows:

Chest X-ray	This is the first thing to do. It allows you to see the tumor, determine its location, and obtain information about its size and shape.
CT scan	It allows you to confirm previously received information and obtain information about the condition of tissues and lymph nodes. Using this technique, metastases can be detected if they occur.
MRI	It is used to confirm or refute data obtained from previous studies; today it is considered one of the most accurate and informative techniques.
Bronchoscopy	It is becoming one of the endoscopic diagnostic methods, allowing you to assess the condition of the bronchi and trachea, to understand whether there are cancerous formations here. The study is performed using a special instrument - an endoscope, and is carried out if indicated.
Biopsy	It is needed to determine the nature of the tumor and involves taking tissue for histological examination. This is a very important procedure that has a great impact on determining the treatment regimen.

Of course, blood tests are required: general, biochemical, and for tumor markers. They allow you to assess the state of a person’s health, identify inflammatory processes, if any, in the body, and understand what kind of formation you are dealing with - malignant or benign.

How is tumor formation treated?

Let us immediately note that treatment of mediastinal tumors is carried out exclusively by surgical methods. Conservative therapy turns out to be useless and sometimes dangerous, given the risk of benign tumors developing into malignant ones. Therefore, in the absence of contraindications, the patient will be scheduled for surgery in any case. To carry it out, thoracoscopic and open methods can be used. The choice is influenced by the following factors:

tumor size and features of its location;
depth of germination in tissue;
the nature of the formation - malignant or benign;
presence of metastases;
equipment available in the clinic;
general health of the patient.

If the tumor of the anterior mediastinum or other parts of it is malignant, the issue of additional use of radiation or chemotherapy will be decided. These techniques can be used independently if a person has contraindications for surgery. They are also combined with surgical treatment. Therapy with anticancer drugs can be carried out before surgery, if the tumor is large enough and needs to be made operable, and also after removal of the tumor in order to destroy cancer cells that may have remained in the body. This is very important, because it is known that cancer very often relapses. Tumors can be located in other organs, but the fact itself is confirmed by statistics.

Chemotherapy is one of the treatment options

For greater effectiveness, doctors carry out polychemotherapy, combining 2-3 types of antitumor drugs. The duration of courses and their number are determined individually, depending on the patient’s health condition.

After a person has undergone full treatment, he is recommended to periodically visit a doctor and undergo some diagnostic procedures, such as X-rays, CT or MRI, and donate blood, including for tumor markers. This will allow you to monitor the healing process and notice the tumor in time if a relapse occurs. During the first year, diagnostics are carried out quite often; in the subsequent period, the time intervals between procedures increase.

If we talk about the prognosis for a mediastinal tumor, only a doctor can voice it. Each case is individual, just like the human body. Several important factors influence future life forecasts:

the nature of the formation and its size;
depth of tissue germination, number of affected organs;
presence of metastases;
type of operation performed;
general health.

Thus, we can conclude that with the capabilities of modern medicine, the chances of a successful cure are significantly increased. But it also depends on the timeliness of detection of the disease. Therefore, if there are signs of health problems, you should not put off visiting a doctor. You need to contact a good specialist as soon as possible and undergo a full diagnosis. This will help make the treatment more successful and the prognosis as positive as possible in a particular situation. Under no circumstances should you self-medicate by reading abstracts, forums and topical publications. It is very dangerous.

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of issues of anesthesia, surgical techniques, diagnosis of various mediastinal processes and neoplasms. New diagnostic methods make it possible not only to accurately establish the localization of a pathological formation, but also make it possible to assess the structure and structure of the pathological focus, as well as obtain material for pathomorphological diagnosis. Recent years have been characterized by the expansion of indications for surgical treatment of mediastinal diseases, the development of new highly effective, low-traumatic treatment methods, the introduction of which has improved the results of surgical interventions.

Classification of mediastinal disease.

Mediastinal injuries:

1. Closed trauma and wounds of the mediastinum.

2. Damage to the thoracic lymphatic duct.

Specific and nonspecific inflammatory processes in the mediastinum:

1. Tuberculous adenitis of the mediastinum.

2. Nonspecific mediastinitis:

A) anterior mediastinitis;

B) posterior mediastinitis.

According to the clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

B) chronic mediastinitis.

Mediastinal cysts.

1. Congenital:

A) coelomic pericardial cysts;

B) cystic lymphangitis;

B) bronchogenic cysts;

D) teratomas

D) from the embryonic embryo of the foregut.

2. Purchased:

A) cysts after hematoma in the pericardium;

B) cysts formed as a result of the disintegration of a pericardial tumor;

D) mediastinal cysts arising from the border areas.

Mediastinal tumors:

1. Tumors arising from the organs of the mediastinum (esophagus, trachea, large bronchi, heart, thymus, etc.);

2. Tumors arising from the walls of the mediastinum (tumors of the chest wall, diaphragm, pleura);

3. Tumors arising from the tissues of the mediastinum and located between organs (extraorgan tumors). Tumors of the third group are true tumors of the mediastinum. They are divided according to histogenesis into tumors of nervous tissue, connective tissue, blood vessels, smooth muscle tissue, lymphoid tissue and mesenchyme.

A. Neurogenic tumors (15% of this location).

I. Tumors arising from nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

B) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

B) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

D) tumors arising from blood vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus gland:

A) thymoma;

B) thymus cysts.

D. Tumors from reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) retrosternal goiter;

B) intrathoracic goiter;

B) adenoma of the parathyroid gland.

The mediastinum is a complex anatomical formation located in the middle of the thoracic cavity, enclosed between the parietal layers, spinal column, sternum and lower diaphragm, containing fiber and organs. The anatomical relationships of the organs in the mediastinum are quite complex, but knowledge of them is mandatory and necessary from the standpoint of the requirements for providing surgical care to this group of patients.

The mediastinum is divided into anterior and posterior. The conventional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum there are: the thymus gland, part of the aortic arch with branches, the superior vena cava with its sources (brachiocephalic veins), the heart and pericardium, the thoracic part of the vagus nerves, the phrenic nerves, the trachea and the initial sections of the bronchi, nerve plexuses, lymph nodes. In the posterior mediastinum there are: the descending aorta, azygos and semi-gypsy veins, the esophagus, the thoracic part of the vagus nerves below the roots of the lungs, the thoracic lymphatic duct (thoracic region), the border sympathetic trunk with the splanchnic nerves, nerve plexuses, lymph nodes.

To establish a diagnosis of the disease, localization of the process, its relationship to neighboring organs, in patients with mediastinal pathology, it is first necessary to conduct a full clinical examination. It should be noted that the disease in the initial stages is asymptomatic, and pathological formations are an accidental finding during fluoroscopy or fluorography.

The clinical picture depends on the location, size and morphology of the pathological process. Typically, patients complain of pain in the chest or heart area, interscapular area. Painful sensations are often preceded by a feeling of discomfort, expressed in a feeling of heaviness or foreign formation in the chest. Shortness of breath and difficulty breathing are often observed. When the superior vena cava is compressed, cyanosis of the skin of the face and upper half of the body and their swelling may be observed.

When examining the mediastinal organs, it is necessary to conduct thorough percussion and auscultation and determine the function of external respiration. Important during the examination are electro- and phonocardiographic studies, ECG data, and X-ray studies. Radiography and fluoroscopy are carried out in two projections (direct and lateral). When a pathological focus is identified, tomography is performed. The study, if necessary, is supplemented with pneumomediastinography. If the presence of a substernal goiter or an aberrant thyroid gland is suspected, ultrasound examination and scintigraphy with I-131 and Tc-99 are performed.

In recent years, when examining patients, instrumental research methods have been widely used: thoracoscopy and mediastinoscopy with biopsy. They allow a visual assessment of the mediastinal pleura, partly the mediastinal organs, and collection of material for morphological examination.

Currently, the main methods for diagnosing mediastinal diseases, along with radiography, are computed tomography and nuclear magnetic resonance.

Features of the course of individual diseases of the mediastinal organs:

Damage to the mediastinum.

Frequency - 0.5% of all penetrating chest wounds. Damage is divided into open and closed. Features of the clinical course are caused by bleeding with the formation of a hematoma and compression of organs, vessels and nerves.

Signs of mediastinal hematoma: slight shortness of breath, mild cyanosis, swelling of the neck veins. X-ray shows darkening of the mediastinum in the area of the hematoma. Often a hematoma develops against the background of subcutaneous emphysema.

When the vagus nerves are imbibited by blood, vagal syndrome develops: respiratory failure, bradycardia, deterioration of blood circulation, and confluent pneumonia.

Treatment: adequate pain relief, maintaining cardiac activity, antibacterial and symptomatic therapy. With progressive mediastinal emphysema, puncture of the pleura and subcutaneous tissue of the chest and neck with short and thick needles to remove air is indicated.

When the mediastinum is injured, the clinical picture is complemented by the development of hemothorax and hemothorax.

Active surgical tactics are indicated for progressive impairment of external respiratory function and ongoing bleeding.

Damage to the thoracic lymphatic duct can occur with:

1. closed chest injury;
2. knife and gunshot wounds;
3. during intrathoracic operations.

As a rule, they are accompanied by a severe and dangerous complication: chylothorax. If conservative therapy is unsuccessful, surgical treatment is required within 10-25 days: ligation of the thoracic lymphatic duct above and below the injury, in rare cases, parietal suturing of the duct wound, implantation into the azygos vein.

Inflammatory diseases.

Acute nonspecific mediastinitis- inflammation of the mediastinal tissue caused by a purulent nonspecific infection.

Acute mediastinitis can be caused by the following reasons.

Open mediastinal injuries.
1. Complications of operations on the mediastinal organs.
2. Contact spread of infection from adjacent organs and cavities.
3. Metastatic spread of infection (hematogenous, lymphogenous).
4. Perforation of the trachea and bronchi.
5. Perforation of the esophagus (traumatic and spontaneous rupture, instrumental damage, damage by foreign bodies, tumor disintegration).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the varying severity of which leads to a variety of its clinical manifestations. The first symptom complex reflects the manifestations of severe acute purulent infection. The second is associated with the local manifestation of a purulent focus. The third symptom complex is characterized by the clinical picture of damage or disease that preceded the development of mediastinitis or was its cause.

General manifestations of mediastinitis: fever, tachycardia (pulse - up to 140 beats per minute), chills, decreased blood pressure, thirst, dry mouth, shortness of breath up to 30 - 40 per minute, acrocyanosis, agitation, euphoria with transition to apathy.

With limited posterior mediastinal abscesses, the most common symptom is dysphagia. There may be a dry barking cough up to suffocation (involvement of the trachea), hoarseness of voice (involvement of the recurrent nerve), as well as Horner's syndrome - if the process spreads to the sympathetic nerve trunk. The patient's position is forced, semi-sitting. There may be swelling in the neck and upper chest. On palpation there may be crepitus due to subcutaneous emphysema, as a result of damage to the esophagus, bronchus or trachea.

Local signs: chest pain is the earliest and most persistent sign of mediastinitis. The pain intensifies when swallowing and throwing the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the location of the process.

Anterior mediastinitis	Posterior mediastinitis
Chest pain	Chest pain radiating into the interscapular space
Increased pain when tapping the sternum	Increased pain with pressure on the spinous processes
Increased pain when tilting the head - Gehrke's symptom	Increased pain when swallowing
Pastiness in the sternum area	Pastosity in the area of the thoracic vertebrae
Symptoms of compression of the superior vena cava: headache, tinnitus, cyanosis of the face, swelling of the veins of the neck	Symptoms of compression of the paired and semi-gypsy veins: dilation of the intercostal veins, effusion in the pleura and pericardium
With CT and NMR - a darkened zone in the projection of the anterior mediastinum	With CT and NMR - a darkened zone in the projection of the posterior mediastinum
X-ray - shadow in the anterior mediastinum, presence of air	X-ray - shadow in the posterior mediastinum, presence of air

When treating mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists of providing optimal access, exposing the injured area, suturing the rupture, draining the mediastinum and pleural cavity (if necessary) and applying a gastrostomy tube. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the method of N.N. Kanshin (1973): drainage of the mediastinum with tubular drainages, followed by fractional rinsing with antiseptic solutions and active aspiration.

Chronic mediastinitis divided into aseptic and microbial. Aseptic include idiopathic, posthemorrhagic, coniotic, rheumatic, dysmetabolic. Microbial diseases are divided into nonspecific and specific (syphilitic, tuberculous, mycotic).

What is common to chronic mediastinitis is the productive nature of inflammation with the development of sclerosis of the mediastinal tissue.

Idiopathic mediastinitis (fibrous mediastinitis, mediastinal fibrosis) is of greatest surgical importance. In a localized form, this type of mediastinitis resembles a tumor or mediastinal cyst. In the generalized form, mediastinal fibrosis is combined with retroperitoneal fibrosis, fibrous thyroiditis and orbital pseudotumor.

The clinical picture is determined by the degree of compression of the mediastinal organs. The following compartment syndromes are identified:

Superior vena cava syndrome
Pulmonary vein compression syndrome
Tracheobronchial syndrome
Esophageal syndrome
Pain syndrome
Nerve compression syndrome

Treatment of chronic mediastinitis is mainly conservative and symptomatic. If the cause of mediastinitis is determined, its elimination leads to a cure.

Mediastinal tumors. All clinical symptoms of various mediastinal masses are usually divided into three main groups:

1. Symptoms from the mediastinal organs, compressed by the tumor;

2. Vascular symptoms resulting from compression of blood vessels;

3. Neurogenic symptoms developing due to compression or sprouting of nerve trunks

Compression syndrome manifests itself as compression of the mediastinal organs. First of all, the brachiocephalic and superior vena cava veins are compressed - superior vena cava syndrome. With further growth, compression of the trachea and bronchi is noted. This is manifested by cough and shortness of breath. When the esophagus is compressed, swallowing and passage of food are impaired. When the tumor of the recurrent nerve is compressed, phonation disturbances, paralysis of the vocal cord on the corresponding side. When the phrenic nerve is compressed, the paralyzed half of the diaphragm stands high.

When the borderline sympathetic trunk is compressed, Horner's syndrome causes drooping of the upper eyelid, narrowing of the pupil, and retraction of the eyeball.

Neuroendocrine disorders manifest themselves in the form of joint damage, heart rhythm disturbances, and disturbances in the emotional-volitional sphere.

The symptoms of tumors are varied. The leading role in making a diagnosis, especially in the early stages before the appearance of clinical symptoms, belongs to computed tomography and x-ray methods.

Differential diagnosis of mediastinal tumors themselves.

		Location		Content		Malignancy	Density
Teratoma	The most common tumor of the mediastinum	Anterior mediastinum	Significant	Mucous membrane, fat, hair, organ rudiments	Slow		Elastic
Neurogenic	Second most common	Posterior mediastinum	Significant	Homogeneous	Slow			Fuzzy
Connective tissue	Third most common	Various, most often anterior mediastinum	Various	Homogeneous	Slow
Lipoma, hibernoma		Various	Various	Mixed structure	Slow			Fuzzy
Hemangioma, lymphangioma		Various						Fuzzy

Thymomas (tumors of the thymus) are not classified as mediastinal tumors themselves, although they are considered together with them due to the peculiarities of localization. They can behave both benign and malignant tumors, giving metastases. They develop either from epithelial or lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis. The malignant variant occurs 2 times more often, is usually very severe and quickly leads to the death of the patient.

Surgical treatment is indicated:

with an established diagnosis and suspicion of a tumor or mediastinal cyst;
for acute purulent mediastinitis, foreign bodies in the mediastinum causing pain, hemoptysis or suppuration in the capsule.

The operation is contraindicated for:

established distant metastases to other organs or cervical and axillary lymph nodes;
compression of the superior vena cava with transition to the mediastinum;
persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness;
dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
the general serious condition of the patient with symptoms of cachexia, hepatic-renal failure, pulmonary and heart failure.

It should be noted that when choosing the scope of surgical intervention in cancer patients, one should take into account not only the growth pattern and extent of the tumor, but also the general condition of the patient, age, and the condition of vital organs.

Surgical treatment of malignant tumors of the mediastinum gives poor results. Hodgkin's disease and reticulosarcoma respond well to radiation treatment. For true mediastinal tumors (teratoblastomas, neuromas, connective tissue tumors), radiation treatment is ineffective. Chemotherapy methods for the treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires emergency surgical intervention as the only way to save the patient, regardless of the severity of his condition.

To expose the anterior and posterior mediastinum and the organs located there, various surgical approaches are used: a) complete or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, in which both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavity; d) diaphragmotomy with and without opening the abdominal cavity; e) opening the mediastinum through an incision in the neck; f) the posterior mediastinum can be penetrated extrapleurally from behind along the lateral surface of the spine with resection of the heads of several ribs; g) the mediastinum can be entered extrapleurally after resection of the costal cartilages at the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Work ability examination.

Clinical examination of patients

To determine the ability of patients to work, general clinical data are used with a mandatory approach to each person examined. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - disease or tumor, age, complications from the treatment, and in the presence of a tumor - possible metastasis. It is common to be placed on disability before returning to professional work. For benign tumors after radical treatment, the prognosis is favorable. The prognosis for malignant tumors is poor. Tumors of mesenchymal origin are prone to relapses followed by malignancy.

Subsequently, the radicality of the treatment and complications after treatment are important. Such complications include lymphostasis of the extremities, trophic ulcers after radiation treatment, and disturbances in the ventilation function of the lungs.

Control questions

1. Classification of mediastinal diseases.
2. Clinical symptoms of mediastinal tumors.
3. Methods for diagnosing mediastinal tumors.
4. Indications and contraindications for surgical treatment of tumors and mediastinal cysts.
5. Operative approaches to the anterior and posterior mediastinum.
6. Causes of purulent mediastinitis.
7. Clinic of purulent mediastinitis.
8. Methods for opening ulcers with mediastinitis.
9. Symptoms of esophageal rupture.

10. Principles of treatment of esophageal ruptures.

11. Causes of damage to the thoracic lymphatic duct.

12. Chylothorax clinic.

13. Causes of chronic mediastinitis.

14. Classification of mediastinal tumors.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Ill for 2 years. The thyroid gland is not enlarged. Basic exchange +30%. A physical examination of the patient did not reveal any pathology. An X-ray examination reveals a rounded formation 5x5 cm with clear boundaries in the anterior mediastinum at the level of the second rib on the right, the lung tissue is transparent.

What additional studies are needed to clarify the diagnosis? What is your tactic in treating a patient?

2. Patient, 32 years old. Three years ago I suddenly felt pain in my right arm. She was treated with physiotherapy - the pain decreased, but did not go away completely. Subsequently, I noticed a dense, lumpy formation on the right side of the neck in the supraclavicular region. At the same time, the pain in the right side of the face and neck intensified. At the same time I noticed a narrowing of the right palpebral fissure and a lack of sweating on the right side of the face.

Upon examination, a dense, lumpy, immobile tumor and an expansion of the superficial venous section of the upper half of the body in front were discovered in the right clavicular region. Slight atrophy and decreased muscle strength in the right shoulder girdle and upper limb. Dullness of percussion sound over the apex of the right lung.

What kind of tumor can you think of? What additional research is needed? What's your tactic?

3. Patient, 21 years old. She complained of a feeling of pressure in her chest. Radiologically, on the right, an additional shadow is adjacent to the upper part of the mediastinal shadow in front. The outer contour of this shadow is clear, the inner one merges with the shadow of the mediastinum.

What disease can you think of? What is your tactics in treating the patient?

4. Over the past 4 months, the patient has developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. An X-ray examination on the right revealed a shadow in the right lung, which is located behind the heart, with clear contours about 10 cm in diameter. The esophagus at this level is compressed, but its mucous membrane is not changed. Above the compression there is a long delay in the esophagus.

What is your presumptive diagnosis and tactics?

5. A 72-year-old patient immediately after fibrogastroscopy developed substernal pain and swelling in the neck area on the right.

What complication can you think of? What additional studies will you perform to clarify the diagnosis? What is your tactics and treatment?

6. Sick 60 years. A day ago in the hospital, a fish bone was removed at level C 7. After which swelling appeared in the neck area, temperature up to 38°, abundant salivation, palpation on the right began to detect an infiltrate of 5x2 cm, painful. X-ray signs of phlegmon of the neck and expansion of the mediastinal body from above.

What is your diagnosis and tactics?

1. To clarify the diagnosis of intrathoracic goiter, it is necessary to carry out the following additional examination methods: pneumomediastinography - in order to clarify the topical location and size of tumors. Contrast study of the esophagus - to identify dislocation of mediastinal organs and displacement of tumors during swallowing. Tomographic examination - in order to identify narrowing or pushing aside of the vein by a neoplasm; scanning and radioisotope study of thyroid function with radioactive iodine. Clinical manifestations of thyrotoxicosis determine the indications for surgical treatment. Removal of a retrosternal goiter in this location is less traumatic to be carried out using a cervical approach, following the recommendations of V.G. Nikolaev to cross the sternohyoid, sternothyroid, and sternocleidomastoid muscles. If there is a suspicion of fusion of the goiter with surrounding tissues, transthoracic access is possible.

2. You can think about a neurogenic tumor of the mediastinum. Along with a clinical and neurological examination, radiography in direct and lateral projections, tomography, pneumomediastinography, diagnostic pneumothorax, angiocardiopulmography is necessary. In order to identify disorders of the sympathetic nervous system, the Linara diagnostic test is used, based on the use of iodine and starch. The test is positive if, during sweating, starch and iodine react, taking on a brown color.

Treatment of a tumor that causes compression of nerve endings is surgical.

3. You can think about a neurogenic tumor of the posterior mediastinum. The main thing in diagnosing a tumor is to establish its exact location. Treatment consists of surgical removal of the tumor.

4. The patient has a tumor of the posterior mediastinum. The most likely neurogenic character. The diagnosis can be clarified by a multifaceted X-ray examination. At the same time, it is possible to identify the interest of neighboring authorities. Considering the location of the pain, the most likely cause is compression of the phrenic and vagus nerves. Treatment is surgical, in the absence of contraindications.

5. One can think about iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After an X-ray examination and X-ray contrast examination of the esophagus, an urgent operation is indicated - opening and drainage of the rupture zone, followed by sanitation of the wound.

6. The patient has perforation of the esophagus with subsequent formation of phlegmon of the neck and purulent mediastinitis. Treatment is surgical opening and drainage of neck phlegmon, purulent mediastinotomy, followed by wound debridement.

Sometimes chest pain is perceived as a cardiovascular problem or associated with another disease. Due to their location, mediastinal tumors are not immediately noticeable. Often, saving a patient’s life depends on early detection of pathology.

Definition

Formations that arise in the mediastinal area constitute a large group of tumors. They originate in different types of cells and differ morphologically.

The space called the mediastinum is located between four conventionally designated boundaries:

sternum (from its inside) - in front,
thoracic spine with all structural elements (the inner side is considered) - from behind,
pleura, which lines the boundary layer on the sides;
a conventional plane that lies horizontally and passes above the roots of the lungs - the upper border;
the pleura that lines the diaphragm is the lower border.

Classification

Tumors of the mediastinum are often benign in nature; oncological formations of various morphologies occupy 20 ÷ 40%. Tumor formations develop from tissue cells:

that arose in the mediastinum as a result of a pathological process that occurred in the perinatal period;
organs in the mediastinum,
that are between the organs.

Neurogenic formations

A third of tumors in the mediastinal region are neurogenic tumors. With pathology of nerve cells, the following occurs:

sympathagoniomas,
paragangliomas,
ganglioneuromas.

Disease of the nerve sheaths can initiate the following types of formations:

neurogenic sarcomas,

Mesenchymal

The formations occupy a quarter of all mediastinal tumors. Here we combine formations that arise in soft tissues with different morphologies. This:

leiomyoma.

Dysembryogenetic

Pathology arises from three elements of the germ layer. Half of all cases of neoplasms are benign in nature.

This type of pathology includes:

intrathoracic goiter,
chorionepithelioma,

Neoplasms of the thymus gland

In the total number of mediastinal pathologies, tumors associated with the thymus gland are a relatively rare phenomenon. Of these, only five percent are classified as cancer.

Diagnostics may reveal:

mucoepidermoid cancer.

Lymphoid

This type of pathology directly affects lymphoid tissue or lymph nodes. Considered as a disease of the immune system.

lymphosarcoma,
reticulosarcoma,

Pseudotumors

These include this type of problem that resembles a tumor, but is not one:

enlarged lymph nodes.

True Brushes

These are hollow formations and can be acquired or congenital. These include:

hydatid cysts,
coelomic pericardial cysts,
bronchogenic cysts,
enterogenous cysts.

They are also distinguished:

primary formations– pathologies that arise in tissues located in the mediastinum zone;
secondary tumors– appeared as a result of metastases from organs that are outside the mediastinum.

Risk factors and localization

The causes of tumors of the superior and posterior mediastinum arise for the following reasons:

, and the degree of harm increases with experience and the number of cigarettes smoked per day;
With age, the body's protective functions decrease, it is important to lead a healthy lifestyle;
There are many environmental influences that can cause cell mutation:
- ionizing radiation,
- contact with harmful chemicals,
- the effect of radon in enclosed spaces,
- household or industrial dust,
- unfavorable ecology in the place of residence,
stressful situations,
poor nutrition.

The mediastinum area is conventionally divided into floors:

upper,
average,
lower.

Also, the mediastinum area is divided conventionally by vertical planes into sections:

front,
average,
rear.

Accordingly, tumors that arise in specific sections correspond to the pathology of the organs and tissues between them located in these areas.

Front

Tumors of the anterior mediastinum:

teratomas,
mesenchymal tumors,
lymphomas,
thymomas.

Upper

Formations of the upper part of the mediastinum:

retrosternal goiter,
lymphomas,
thymomas.

Rear

Tumors of the posterior mediastinum may be:

neurogenic tumors,
enterogenous cysts.

Symptoms of mediastinal tumors

The onset of the disease often occurs without giving noticeable signals. Since mediastinal pathologies are of a different nature, the signs of each type of disease differ from each other.

Symptoms of the disease also depend on which part of the mediastinum the pathology appears in and its size. As the formation increases, the likelihood also increases that it will begin to put pressure on neighboring organs and tissues and cause problems.

Symptoms that occur most often:

asthenic syndrome manifests itself through signs:
- fatigue,
- the temperature may rise,
- general malaise,
when there is a disease of the nerves there is pain,
myasthenia gravis syndrome causes weakness of a muscle group; it is difficult for the patient, for example:
- turn your head
- raise a hand,
- open eyes,
if the superior vena cava is compressed:
- headache,
- dilated veins,
- dyspnea,
- swelling of the neck and face,
- cyanosis of the lips,
if the formation causes compression of organs located in the mediastinum:
- cough,
- dyspnea,
- hemoptysis.

Diagnostic methods

When examining a patient, a specialist based on his complaints may prescribe an instrumental examination.

One of the main ways to diagnose a patient with a suspected tumor in the mediastinal area is an X-ray examination. This method includes:
- fluorography,
- fluoroscopy
- and other ways.
Using the study, information is obtained about how the tumor is located in space, its size and effect on neighboring tissues.
allows you to examine some types of formations and take material for.
Magnetic resonance imaging provides the most detailed information about soft tissues. The method provides the opportunity to obtain all the pathology data necessary for a doctor.
Mediastinoscopy - allows you to see the condition of some lymph nodes, and it is possible to take material for a biopsy.

Treatment

The most favorable type of treatment for mediastinal tumors is to detect the pathology in time and remove it. This applies to examples when the nature of the formation is malignant and in the case of a benign tumor. Treatment methods for mediastinal tumors in children and adult patients do not differ.

Operation

A non-cancerous tumor can become malignant over time, so early surgical intervention can prevent a negative development.

Oncological formations tend to grow rapidly and metastasize over time. In this case, surgery is even more indicated.

Apply:

The closed method is thoracoscopic. This method is classified as endoscopic interventions. It is safe and low-traumatic, video surveillance is provided. Some types of tumors can be removed thoracoscopically.
Open way:
The method is used in complex cases when it is not possible to perform a closed operation.

Chemotherapy

If the formation is malignant, it is necessary to use it. Drugs are selected that are capable of killing cells of the tumor identified during diagnosis.

The procedure prescribed by a specialist can be carried out:

before surgery to reduce formation;
after it, to deprive the viability of cancer cells that remain after the operation;
a separate method when intervention is not possible.

Chemotherapy, which is carried out without surgery, can support the patient's condition, but not cure it completely.

Radiation therapy

It is used in the same way as the previous method, being an auxiliary tool in the periods before and after surgery. It can also be an independent procedure if surgery is not indicated due to the patient’s condition or the degree of development of the pathology.

Forecast

The hope for a favorable outcome of mediastinal tumors is ambiguous in different cases.

The result of treatment depends on:

on the size of education,
localization,
degree of tumor maturity,
whether it has begun to spread into the tissue of other organs,
have metastases appeared?
whether the patient is operable or not.

The best option is early detection of the tumor and its complete removal.

Video about modern surgical technologies in the treatment of malignant tumors of the mediastinum:

Which doctors should you contact if you have malignant neoplasms of the anterior mediastinum?

What are malignant neoplasms of the anterior mediastinum?

Malignant neoplasms of the anterior mediastinum in the structure of all oncological diseases account for 3-7%. Most often, malignant neoplasms of the anterior mediastinum are detected in persons 20-40 years old, i.e., in the most socially active part of the population.

Mediastinum is called the part of the thoracic cavity limited in front by the sternum, partially by the costal cartilages and retrosternal fascia, behind by the anterior surface of the thoracic spine, the necks of the ribs and prevertebral fascia, and on the sides by the layers of the mediastinal pleura. The mediastinum is limited below by the diaphragm, and above by a conventional horizontal plane drawn through the upper edge of the manubrium of the sternum.

The most convenient scheme for dividing the mediastinum, proposed in 1938 by Twining, is two horizontal (above and below the roots of the lungs) and two vertical planes (in front and behind the roots of the lungs). In the mediastinum, therefore, three sections (anterior, middle and posterior) and three floors (upper, middle and lower) can be distinguished.

In the anterior section of the superior mediastinum there are: the thymus gland, the upper section of the superior vena cava, the brachiocephalic veins, the aortic arch and its branches, the brachiocephalic trunk, the left common carotid artery, the left subclavian artery.

In the posterior part of the upper mediastinum there are: the esophagus, the thoracic lymphatic duct, the trunks of the sympathetic nerves, the vagus nerves, the nerve plexuses of the organs and vessels of the thoracic cavity, fascia and cellular spaces.

In the anterior mediastinum there are: fiber, spurs of the intrathoracic fascia, the leaves of which contain the internal mammary vessels, retrosternal lymph nodes, and anterior mediastinal nodes.

In the middle section of the mediastinum there are: the pericardium with the heart enclosed in it and the intrapericardial sections of large vessels, the bifurcation of the trachea and the main bronchi, the pulmonary arteries and veins, the phrenic nerves with the accompanying phrenic-pericardial vessels, fascial-cellular formations, and lymph nodes.

In the posterior part of the mediastinum there are: the descending aorta, azygos and semi-gypsy veins, trunks of sympathetic nerves, vagus nerves, esophagus, thoracic lymphatic duct, lymph nodes, tissue with spurs of the intrathoracic fascia surrounding the organs of the mediastinum.

According to the departments and floors of the mediastinum, certain preferential localizations of most of its neoplasms can be noted. Thus, it has been noticed, for example, that intrathoracic goiter is often located in the upper floor of the mediastinum, especially in its anterior section. Thymomas are found, as a rule, in the middle anterior mediastinum, pericardial cysts and lipomas - in the lower anterior. The upper floor of the middle mediastinum is the most common location of teratodermoids. In the middle floor of the middle part of the mediastinum, bronchogenic cysts are most often found, while gastroenterogenic cysts are detected in the lower floor of the middle and posterior parts. The most common neoplasms of the posterior mediastinum along its entire length are neurogenic tumors.

Pathogenesis (what happens?) during malignant neoplasms of the anterior mediastinum

Malignant neoplasms of the mediastinum originate from heterogeneous tissues and are united by only one anatomical border. These include not only true tumors, but also cysts and tumor-like formations of different localization, origin and course. All mediastinal neoplasms according to their source of origin can be divided into the following groups:
1. Primary malignant neoplasms of the mediastinum.
2. Secondary malignant tumors of the mediastinum (metastases of malignant tumors of organs located outside the mediastinum to the lymph nodes of the mediastinum).
3. Malignant tumors of the mediastinal organs (esophagus, trachea, pericardium, thoracic lymphatic duct).
4. Malignant tumors from tissues limiting the mediastinum (pleura, sternum, diaphragm).

Symptoms of malignant neoplasms of the anterior mediastinum

Malignant neoplasms of the mediastinum are found mainly in young and middle age (20 - 40 years), equally often in both men and women. During the course of the disease with malignant neoplasms of the mediastinum, an asymptomatic period and a period of pronounced clinical manifestations can be distinguished. Duration asymptomatic period depends on the location and size of the malignant neoplasm, growth rate, relationship with organs and formations of the mediastinum. Very often, mediastinal neoplasms are asymptomatic for a long time, and they are accidentally discovered during a preventive X-ray examination of the chest.

Clinical signs of malignant neoplasms of the mediastinum consist of:
- symptoms of compression or tumor growth into neighboring organs and tissues;
- general manifestations of the disease;
- specific symptoms characteristic of various neoplasms;

The most common symptoms are pain resulting from compression or growth of the tumor into the nerve trunks or nerve plexuses, which is possible with both benign and malignant neoplasms of the mediastinum. The pain is usually mild, localized on the affected side, and often radiates to the shoulder, neck, and interscapular area. Pain with left-sided localization is often similar to pain caused by angina pectoris. If bone pain occurs, the presence of metastases should be assumed. Compression or germination of the borderline sympathetic trunk by a tumor causes the occurrence of a syndrome characterized by drooping of the upper eyelid, dilation of the pupil and retraction of the eyeball on the affected side, impaired sweating, changes in local temperature and dermographism. Damage to the recurrent laryngeal nerve is manifested by hoarseness of voice, the phrenic nerve - by a high standing dome of the diaphragm. Compression of the spinal cord leads to dysfunction of the spinal cord.

A manifestation of compression syndrome is compression of large venous trunks and, first of all, the superior vena cava (superior vena cava syndrome). It is manifested by a violation of the outflow of venous blood from the head and upper half of the body: patients experience noise and heaviness in the head, aggravated in an inclined position, chest pain, shortness of breath, swelling and cyanosis of the face, upper half of the body, swelling of the veins of the neck and chest. Central venous pressure rises to 300-400 mmH2O. Art. When the trachea and large bronchi are compressed, coughing and shortness of breath occur. Compression of the esophagus can cause dysphagia, an obstruction in the passage of food.

In the later stages of development of neoplasms, the following symptoms occur: general weakness, increased body temperature, sweating, weight loss, which are characteristic of malignant tumors. Some patients experience manifestations of disorders associated with intoxication of the body by products secreted by growing tumors. These include arthralgic syndrome, reminiscent of rheumatoid polyarthritis; pain and swelling of the joints, swelling of the soft tissues of the extremities, increased heart rate, irregular heart rhythm.

Some mediastinal tumors have specific symptoms. Thus, skin itching and night sweats are characteristic of malignant lymphomas (lymphogranulomatosis, lymphoreticulosarcoma). A spontaneous decrease in blood sugar levels develops with mediastinal fibrosarcomas. Symptoms of thyrotoxicosis are characteristic of intrathoracic thyrotoxic goiter.

Thus, the clinical signs of neoplasms and mediastinum are very diverse, however, they appear in the late stages of the disease and do not always allow an accurate etiological and topographic-anatomical diagnosis to be established. Data from radiological and instrumental methods are important for diagnosis, especially for recognizing the early stages of the disease.

Neurogenic tumors of the anterior mediastinum are the most common and account for about 30% of all primary mediastinal neoplasms. They arise from nerve sheaths (neurinomas, neurofibromas, neurogenic sarcomas), nerve cells (sympathogoniomas, ganglioneuromas, paragangliomas, chemodectomas). Most often, neurogenic tumors develop from elements of the border trunk and intercostal nerves, rarely from the vagus and phrenic nerves. The usual location of these tumors is the posterior mediastinum. Much less often, neurogenic tumors are located in the anterior and middle mediastinum.

Reticulosarcoma, diffuse and nodular lymphosarcoma(gigantofollicular lymphoma) are also called "malignant lymphomas." These neoplasms are malignant tumors of lymphoreticular tissue, most often affect young and middle-aged people. The tumor initially develops in one or more lymph nodes, followed by spread to neighboring nodes. Generalization occurs early. In addition to the lymph nodes, the metastatic tumor process involves the liver, bone marrow, spleen, skin, lungs and other organs. The disease progresses more slowly in the medullary form of lymphosarcoma (gigantofollicular lymphoma).

Lymphogranulomatosis (Hodgkin's disease) usually has a more benign course than malignant lymphomas. In 15-30% of cases in stage I of the disease, primary local damage to the mediastinal lymph nodes can be observed. The disease is more common between the ages of 20-45 years. The clinical picture is characterized by an irregular wave-like course. Weakness, sweating, periodic rises in body temperature, and chest pain appear. But skin itching, enlargement of the liver and spleen, changes in the blood and bone marrow characteristic of lymphogranulomatosis are often absent at this stage. Primary lymphogranulomatosis of the mediastinum can be asymptomatic for a long time, while enlargement of the mediastinal lymph nodes for a long time may remain the only manifestation of the process.

At mediastinal lymphomas The lymph nodes of the anterior and anterior upper parts of the mediastinum and the roots of the lungs are most often affected.

Differential diagnosis is carried out with primary tuberculosis, sarcoidosis and secondary malignant tumors of the mediastinum. A test of radiation may be helpful in diagnosis, since malignant lymphomas are in most cases sensitive to radiation therapy (the “melting snow” symptom). The final diagnosis is established by morphological examination of the material obtained from a biopsy of the tumor.

Diagnosis of malignant neoplasms of the anterior mediastinum

The main method for diagnosing malignant neoplasms of the mediastinum is x-ray. The use of a comprehensive X-ray examination allows in most cases to determine the localization of the pathological formation - the mediastinum or neighboring organs and tissues (lungs, diaphragm, chest wall) and the extent of the process.

Mandatory X-ray methods for examining a patient with a mediastinal tumor include: - fluoroscopy, radiography and tomography of the chest, contrast examination of the esophagus.

Fluoroscopy makes it possible to identify a “pathological shadow”, get an idea of its location, shape, size, mobility, intensity, contours, and establish the absence or presence of pulsation of its walls. In some cases, one can judge the connection between the identified shadow and nearby organs (heart, aorta, diaphragm). Clarification of the localization of the neoplasm largely makes it possible to predetermine its nature.

To clarify the data obtained during fluoroscopy, radiography is performed. At the same time, the structure of the darkening, its contours, and the relationship of the neoplasm to neighboring organs and tissues are clarified. Contrasting the esophagus helps to assess its condition and determine the degree of displacement or growth of a mediastinal tumor.

Endoscopic research methods are widely used in the diagnosis of mediastinal tumors. Bronchoscopy is used to exclude bronchogenic localization of a tumor or cyst, as well as to determine whether a malignant tumor has invaded the mediastinum of the trachea and large bronchi. During this study, it is possible to perform a transbronchial or transtracheal puncture biopsy of mediastinal formations localized in the area of the tracheal bifurcation. In some cases, mediastinoscopy and videothoracoscopy, in which the biopsy is performed under visual control, turns out to be very informative. Taking material for histological or cytological examination is also possible with transthoracic puncture or aspiration biopsy performed under X-ray control.

If there are enlarged lymph nodes in the supraclavicular areas, they are biopsied, which makes it possible to determine their metastatic lesions or establish a systemic disease (sarcoidosis, lymphogranulomatosis, etc.). If mediastinal goiter is suspected, scanning the neck and chest area after administration of radioactive iodine is used. If compression syndrome is present, central venous pressure is measured.

Patients with mediastinal tumors undergo a general and biochemical blood test, the Wasserman reaction (to exclude the syphilitic nature of the formation), and a reaction with tuberculin antigen. If echinococcosis is suspected, determination of the latexagglutination reaction with echinococcal antigen is indicated. Changes in the morphological composition of peripheral blood are found mainly in malignant tumors (anemia, leukocytosis, lymphopenia, increased ESR), inflammatory and systemic diseases. If systemic diseases are suspected (leukemia, lymphogranulomatosis, reticulosarcomatosis, etc.), as well as immature neurogenic tumors, a bone marrow puncture is performed with the study of a myelogram.

Treatment of malignant neoplasms of the anterior mediastinum

Treatment of malignant neoplasms of the mediastinum- operational. Removal of tumors and mediastinal cysts must be done as early as possible, as this is the prevention of their malignancy or the development of compression syndrome. The only exceptions may be small lipomas and coelomic cysts of the pericardium in the absence of clinical manifestations and a tendency to their increase. Treatment of malignant tumors of the mediastinum in each specific case requires an individual approach. Usually it is based on surgical intervention.

The use of radiation and chemotherapy is indicated for most malignant tumors of the mediastinum, but in each specific case their nature and content are determined by the biological and morphological characteristics of the tumor process and its prevalence. Radiation and chemotherapy are used both in combination with surgical treatment and independently. As a rule, conservative methods form the basis of therapy for advanced stages of the tumor process, when radical surgery is impossible, as well as for mediastinal lymphomas. Surgical treatment for these tumors can be justified only in the early stages of the disease, when the process locally affects a certain group of lymph nodes, which is not so common in practice. In recent years, the videothoracoscopy technique has been proposed and successfully used. This method allows not only to visualize and document mediastinal tumors, but also to remove them using thoracoscopic instruments, causing minimal surgical trauma to patients. The results obtained indicate the high effectiveness of this treatment method and the possibility of carrying out the intervention even in patients with severe concomitant diseases and low functional reserves.