"Cough, feeling of fullness in the chest, shortness of breath, substernal pain, and weight loss are the common symptoms of Mediastinal Cancer."

Diagnosis

 

Imaging

Contrast-enhanced CT chest can confirm the presence of a mediastinal mass, also provides detailed information regarding the mediastinal abnormality, including its location, size, relationship to other structures, and tissue characteristics, particularly involvement/invasion or compression of surrounding structures, which is critical in planning treatment.


  • Magnetic resonance (MR) imaging – MR is useful in distinguishing compression versus invasion, particularly in cases of large anterior mediastinal masses.
  • Positron emission tomography (PET) – For a mediastinal mass that is suspected to be lymphoma, using 18F-fluorodeoxyglucose (FDG) with fused CT may be performed. This modality can be useful to identify a preferred biopsy site. For tumors found to be PET avid on the initial study, it can be useful in monitoring response to treatment. However, it is important to note that FDG-PET imaging can be misleading because nonmalignant conditions such as teratoma and thymic cysts have been shown to have FDG accumulation in 14 to 42 percent of cases. Besides, normal thymus has been shown to have a maximum standardized uptake value (SUV) of 2.00 to 2.09, and the thymic rebound has also been observed, where patients treated with chemotherapy for another malignancy have been found to have increased PET activity with a mean SUV of 2.89 at a mean interval of 10 months after chemotherapy completion.
  • MRI spine – provide a detailed evaluation of posterior mediastinal tumours that are adjacent to the spine.
  • Technetium scan – For a suspected ectopic thyroid tissue or a substernal goiter.
  • MIBG {meta-iodobenzylguanidine} – for mediastinalpheochromocytoma.
  • Scrotal ultrasound – For a mediastinal mass that is suspected or proven to be a germ cell tumour,.
  • Ga-68 DOTATATE) PET/CT scan – in staging neuroendocrine tumours of the thymus.
Biopsy

CT Guided / USG Guided in case of suspicious lymphoma and in borderline operable tumours where neoadjuvant treatment is planned.


EBUS- Endobronchial ultrasound is an outpatient procedure where a small tube is entered into the nostrils and reached into the windpipe to assess the adjacent structures around it. It is a non-invasive procedure where a tissue diagnosis can be obtained from the lymph nodes which helps in diagnosing mediastinal pathology.


Endo-ultrasound ( EUS) in rare occasions where an endoscope is placed in the oral cavity and parao-esophageal tissues like lymph nodes etc can be visualized and biopsied.

Treatment

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Surgical

When a percutaneous or endobronchial biopsy is not possible or cannot provide adequate tissue to definitively establish a diagnosis, a surgical biopsy may be necessary. Surgical options for obtaining a tissue sample are described below:


  • Anterior mediastinotomy for lesions that are substernal(behind the sternum).
  • A cervical mediastinoscopy is an option for lesions in the middle mediastinum. A mediastinoscope is inserted through a small incision just above the sternal notch and directed into the mediastinum. This approach is effective at obtaining tissue from mediastinal masses that are adjacent to the airway.
  • Video-assisted thoracoscopy and video-assisted thoracoscopic surgery (VATS).
Surgical resection

The most appropriate surgical approach for resection of a mediastinal mass depends upon the patient, the location and size of the lesion, the presumptive diagnosis, and the preference and experience of the surgeon performing the resection. Options for surgical resection include minimally invasive approaches.


  • VATS through the chest or via subxiphoid approach, robotic-assisted, transcervical resection).
  • Traditional open approaches (thoracotomy, median sternotomy, thoraco-sternotomy [clamshell], hemi-thoracosternotomy [hemi-clamshell] incisions).
VATS

VATS plays a major role in mediastinal tumours, which is a safe procedure, less morbid and oncologically safe. It can be done either in 1 or 2 or 3 keyhole incisions where most of the patient can go home safely on the next day and in advanced VATS, we do larger tumour excisions with vascular resections and reconstructions.


RATS has a cutting edge over conventional VATS where surgery can be done in inaccessible areas, more precise, HITOC Hyperthermic intrathoracic chemotherapy is local intraoperative perfusion of thoracic cavity with chemotherapy agent after surgical cytoreduction of malignant tumours particularly carried out as an additive procedure in malignant pleural mesothelioma, thymoma with pleural spread and in secondary pleural carcinomatosis in selected patients.

Winning Over Cancer

Mr Mohammed Jamal Uddin from Bangladesh shares his experience about undergoing Proton treatment for his lung tumour at Apollo Proton Cancer Centre.

Watch him speak about his journey.

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Mr. Praboth Palit from Mumbai shares an emotional journey of his treatment at Apollo Proton Cancer Centre. Despite facing a lot of challenges in the beginning, Praboth never lost his hope which is highly commendable.

He thanked Mr. John Chandy ,Dr. Srinivas Chilukuri , and the entire team for their support and guidance.

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