A mediastinal mass

,; ,

Photo Rounds

A mediastinal mass

J Fam Pract. 2010 June;59(6):347-350

PDF Download

References

1. Singh B, Lucente FE, Shaha AR. Substernal goiter: a clinical review. Am J Otolaryngol. 1994;15:409-416.

2. Strollo DC, Rosado de Christenson ML, Jett JR. Primary mediastinal tumors. Part 1: tumors of the anterior mediastinum. Chest. 1997;112:511-522.

3. Hoffman OA, Gillespie DJ, Aughenbaugh GL, et al. Primary mediastinal neoplasms (other than thymoma). Mayo Clin Proc. 1993;68:880-891.

4. Davis RD, Jr, Oldham HN, Jr, Sabiston DC, Jr. Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management, and results. Ann Thorac Surg. 1987;44:229-237.

5. den Bakker MA, Oosterhuis JW. Tumours and tumour-like conditions of the thymus other than thymoma; a practical approach. Histopathology. 2009;54:69-89.

6. Gerein AN, Srivastava SP, Burgess J. Thymoma: a ten year review. Am J Surg. 1978;136:49-53.

7. van Heerden JA, Harison EG, Jr, Bernatz PE, et al. Mediastinal malignant lymphoma. Chest. 1970;57:518-529.

8. Hoppe RT. The non-Hodgkin’s lymphomas: pathology, staging, treatment. Curr Probl Cancer. 1987;11:363-447.

9. Luna MA, Valenquela-Tamariz J. Germ cell tumors of the mediastinum: postmortem findings. Am J Clin Pathol. 1976;65:450-454.

10. Moran CA, Suster S, Koss MN. Primary germ cell tumors of the mediastinum: III. Yolk sac tumor, embryonal carcinoma, choriocarcinoma, and combined nonteratomatous germ cell tumors of the mediastinum—a clinicopathologic and immunohistochemical study of 64 cases. Cancer. 1997;80:699-707.

11. Polansky SM, Barwick KW, Ravin CE. Primary mediastinal seminoma. AJR Am J Roentgenol. 1979;132:17-21.

12. Jennings A. Evaluation of substernal goiters using computed tomography and MR imaging. Endocrinol Metab Clin North Am. 2001;30:401-414, ix.

13. Wright CD, Mathisen DJ. Mediastinal tumors: diagnosis and treatment. World J Surg. 2001;25:204-209.

14. Park HM, Tarver RD, Siddiqui AR, et al. Efficacy of thyroid scintigraphy in the diagnosis of intrathoracic goiter. AJR Am J Roentgenol. 1987;148:527-529.

Mediastinal cysts are common benign lesions of the mediastinum of pericardial, enteric, bronchogenic, or thymic origin, and are easily detected by CT or MRI studies. In addition, growth of parathyroid tissue can result in a retrosternal tumor, but such tumors are rarely of significant size.

Diagnosis hinges primarily on the CT scan

CT imaging is the method of choice to determine whether a mediastinal mass is thyroidal in origin and to define the extent of substernal goiter and the potential impingement on adjacent structures.¹² These scans drive the need for and choice of therapy.¹³ An MRI of the thyroid gland may be helpful in distinguishing the thyroid from other tissue; ultrasonography is more accurate for defining thyroid anatomy in the anterior neck.

FAST TRACK

Thyroid radionuclide imaging with 123-iodine can be misleading because of impaired radioiodine uptake in some substernal goiters.

In the case of our patient, we used thyroid ultrasonography to confirm the CT findings. Further diagnostic tests included measurements of serum thyroid-stimulating hormone, triiodothyronine, and thyroxine, showing euthyroidism. Thyroid radionuclide imaging with 123-iodine was not performed in this case. While it can identify a substernal tumor as being thyroid tissue, the method can also be misleading because of impaired radioiodine uptake in some substernal goiters.¹⁴

Given our patient’s lack of pain, tenderness, or firmness in the cervical goiter and the results of his imaging studies, a fine-needle aspiration biopsy was not performed to rule out a malignant disorder like thyroid cancer.

Treatment ranges from watch and wait to surgery

Treatment of asymptomatic retrosternal goiter remains controversial. Levothyroxine suppression has a limited role in reducing the size or stopping the growth of the thyroid. Surgery is the method of choice in patients with obstructive symptoms, given the risk of progressive tracheal compression.

In the present case, we decided to watch and wait because of the patient’s age, history, and lack of any signs of obstruction of the trachea, esophagus, or mediastinal vessels. We recommended that the patient come back for a follow-up visit in 6 to 12 months.

CORRESPONDENCE: Christian S. Haas, MD, University Hospital Schleswig-Holstein–Campus Luebeck, Department of Medicine I, Ratzeburger Allee 160, 23538 Luebeck, Germany; cs_haas@yahoo.com

A mediastinal mass

References

Pages

Recommended Reading