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AJR. American Journal of Roentgenology Nov 2019The purpose of this article is to provide a primer for radiologists focused on integrating the radiologic, pathologic, and clinical features of primary mediastinal... (Review)
Review
The purpose of this article is to provide a primer for radiologists focused on integrating the radiologic, pathologic, and clinical features of primary mediastinal large B-cell lymphoma (PMLBCL). PMLBCL is a unique subtype of lymphoma that poses diagnostic and therapeutic challenges to the fields of radiology and oncology. Knowledge of this distinctive clinical-pathologic entity and its associated imaging and clinical features is critical for radiologists.
Topics: Humans; Lymphoma, Large B-Cell, Diffuse; Mediastinal Neoplasms
PubMed: 31414888
DOI: 10.2214/AJR.19.21225 -
American Journal of Clinical Pathology Sep 2021Primary mediastinal (thymic) large B-cell lymphoma (PMBL) is an uncommon large B-cell neoplasm recognized by the World Health Organization as a distinct entity on the... (Review)
Review
OBJECTIVES
Primary mediastinal (thymic) large B-cell lymphoma (PMBL) is an uncommon large B-cell neoplasm recognized by the World Health Organization as a distinct entity on the basis of its unique clinical features, histogenesis, phenotype, and pathogenetic mechanisms. The diagnosis of PMBL can be challenging because of features that may overlap with other (Hodgkin and non-Hodgkin) lymphoma types. This review describes our approach to the diagnosis of PMBL.
METHODS
Two cases are presented to illustrate how we diagnose PMBL and separate PMBL from related histologic and biological mimickers, such as Hodgkin lymphoma and gray zone lymphoma.
RESULTS
A diagnosis of PMBL requires correlation of morphology and immunophenotype with clinical and staging data. Gene expression analysis is not typically performed in clinical labs but has expanded our understanding of the functional pathways underlying this disease and helped identify biomarkers that can be translated to diagnostic practice and possibly to future therapeutic options.
CONCLUSIONS
PMBL and closely related entities can pose diagnostic challenges. It is important to understand the borders between PMBL and other closely related lymphoma types so that patients receive successful primary treatment with curative intent.
Topics: Humans; Immunophenotyping; Lymphoma, Large B-Cell, Diffuse; Mediastinal Neoplasms; Mediastinum
PubMed: 34398178
DOI: 10.1093/ajcp/aqab122 -
Clinical Radiology Dec 2023Anterior mediastinal masses can be difficult to characterise on computed tomography (CT) due to the wide spectrum of normal appearances of thymic tissue as well as the... (Review)
Review
Anterior mediastinal masses can be difficult to characterise on computed tomography (CT) due to the wide spectrum of normal appearances of thymic tissue as well as the challenge of differentiating between benign and malignant pathologies. Additionally, attenuation of cystic mediastinal lesions can be misinterpreted on CT due to varying attenuation values. Anecdotally, non-vascular magnetic resonance imaging (MRI) of the thorax is underutilised across radiology departments in the UK, but has been shown to improve diagnostic certainty and reduce unnecessary surgical intervention. T2-weighted MRI is useful in confirming the cystic nature of lesions, whereas chemical shift techniques can be utilised to document the presence of macroscopic and intra-cellular fat and thus help distinguish between benign and malignant pathologies. In this review article, we present a practical approach to using MRI for the characterisation of anterior mediastinal lesions based on our clinical experience in a UK district general hospital.
Topics: Humans; Mediastinal Neoplasms; Magnetic Resonance Imaging; Thymus Gland; Tomography, X-Ray Computed; Mediastinum
PubMed: 37709611
DOI: 10.1016/j.crad.2023.08.015 -
Magnetic Resonance in Medical Sciences... Oct 2023The anterior mediastinum is the most common location of mediastinal tumors, and thymic epithelial tumors are the most common mediastinal tumors. It is important to...
The anterior mediastinum is the most common location of mediastinal tumors, and thymic epithelial tumors are the most common mediastinal tumors. It is important to differentiate thymic epithelial tumors from malignant lymphomas and malignant germ cell tumors because of the different treatment strategies. Dynamic contrast-enhanced MRI and diffusion-weighted imaging can provide additional information on the differential diagnosis. Chemical shift imaging can detect tiny fat tissues in the lesion and is useful in differentiating thymic hyperplasia from other solid tumors such as thymomas. MRI findings reflect histopathological features of mediastinal tumors, and a comprehensive evaluation of MRI sequences is important for estimation of the histopathological features of the tumor. In this manuscript, we describe the MRI findings of anterior mediastinal solid tumors and the role of MRI in the differential diagnosis.
Topics: Humans; Mediastinum; Mediastinal Neoplasms; Diagnosis, Differential; Thymus Neoplasms; Magnetic Resonance Imaging; Neoplasms, Glandular and Epithelial
PubMed: 35296589
DOI: 10.2463/mrms.rev.2021-0098 -
Cirugia Espanola Oct 2022
Topics: Humans; Mediastinal Neoplasms; Soft Tissue Neoplasms; Solitary Fibrous Tumors
PubMed: 35753574
DOI: 10.1016/j.cireng.2022.06.037 -
The American Surgeon Feb 2022Mediastinal masses are commonly encountered by the thoracic surgeon. Few studies have reported on the frequency and characteristics of symptoms at presentation. The...
OBJECTIVE
Mediastinal masses are commonly encountered by the thoracic surgeon. Few studies have reported on the frequency and characteristics of symptoms at presentation. The primary objective of this study is to determine how often patients present with symptoms from a mediastinal mass. The secondary objective is to determine if the presence of symptoms has an effect on outcomes after surgery.
METHODS
A retrospective review of an institutional database was performed. All patients who underwent surgical resection of a mediastinal mass from 2013 to 2019 were included in the analysis. Medical records were reviewed for the presence or absence of symptoms preoperatively, and these cohorts were compared. Multivariable analysis was performed, adjusting for clinical variables to assess for differences between these cohorts.
RESULTS
70 patients underwent surgery for a mediastinal mass. The average age was 49.2 years, and 46 patients (65.7%) presented with symptoms. There were no significant differences in demographics between the symptomatic and asymptomatic groups. The most common symptom was dyspnea in 18 patients (22%), followed by chest pain (15 patients, 19%) and dysphagia (8 patients, 10%). When comparing symptomatic and asymptomatic patients, symptomatic patients had a larger tumor size (5.8 cm vs 3.8 cm, = .04) and a longer length of stay (2.0 days vs 1.2 days, = .02).
CONCLUSIONS
The majority of patients with mediastinal masses present with symptoms, with the most common symptom being dyspnea. Symptomatic patients are more likely to have a larger tumor and tend to have a longer length of hospital stay postoperatively compared to asymptomatic patients.
Topics: Asymptomatic Diseases; Chest Pain; Databases, Factual; Deglutition Disorders; Dyspnea; Female; Humans; Length of Stay; Male; Mediastinal Neoplasms; Middle Aged; Multivariate Analysis; Retrospective Studies; Symptom Assessment; Tumor Burden
PubMed: 33522269
DOI: 10.1177/0003134821989038 -
Korean Journal of Radiology Jan 2023As the majority of incidentally detected lesions in the anterior mediastinum is small nodules with soft tissue appearance, the differential diagnosis has typically... (Review)
Review
As the majority of incidentally detected lesions in the anterior mediastinum is small nodules with soft tissue appearance, the differential diagnosis has typically included thymic neoplasm and prevascular lymph node, with benign cyst. Overestimation or misinterpretation of these lesions can lead to unnecessary surgery for ultimately benign conditions. nonsurgical anterior mediastinal lesions. The pitfalls of MRI evaluation for anterior mediastinal cystic lesions are as follows: first, we acknowledge the limitation of T2-weighted images for evaluating benign cystic lesions. Due to variable contents within benign cystic lesions, such as hemorrhage, T2 signal intensity may be variable. Second, owing to extensive necrosis and cystic changes, the T2 shine-through effect may be seen on diffusion-weighted images (DWI), and small solid portions might be missed on enhanced images. Therefore, both enhancement and DWI with apparent diffusion coefficient values should be considered. An algorithm will be suggested for the diagnostic evaluation of anterior mediastinal cystic lesions, and finally, a management strategy based on MRI features will be suggested.
Topics: Humans; Mediastinum; Magnetic Resonance Imaging; Thymus Neoplasms; Diffusion Magnetic Resonance Imaging; Diagnosis, Differential; Mediastinal Neoplasms
PubMed: 36606621
DOI: 10.3348/kjr.2022.0606 -
Respiratory Medicine Sep 2023Paragangliomas are rarely found in the mediastinum, where they account for a small proportion of mediastinal masses. This study aimed to better characterize the...
BACKGROUND
Paragangliomas are rarely found in the mediastinum, where they account for a small proportion of mediastinal masses. This study aimed to better characterize the presenting features and relevant aspects in optimizing the diagnosis and treatment of mediastinal paragangliomas.
METHODS
A computer-assisted search of electronic health records was performed to identify adult patients (≥18 years) who underwent evaluation for a primary mediastinal paraganglioma at Mayo Clinic between January 2000 and April 2022. Medical charts, laboratory tests and radiology images were reviewed to collect data.
RESULTS
The study included 51 patients, each with a single mediastinal paraganglioma. The median age was 47 years (IQR: 39-67), 67% females. Symptoms of catecholamine excess were manifest in 39% of patients, and 14% presented with mass effect, while the remaining 47% had no paraganglioma-related symptoms. Genetic testing was performed in 35 patients; 66% harbored a pathogenic variant in the succinate dehydrogenase enzyme complex. Most paragangliomas (71%) were in the middle mediastinum and showed uptake of intravenous contrast on chest imaging. Biopsies were performed in 30 (59%) patients; 27% were inconclusive and 10% resulted in major complications. Surgical resection occurred in 75%, primarily for relief of symptoms (50%) followed by proximity to critical structures (45%). Perioperative complications were common (66%), but there were no cases of local tumor recurrence during the follow-up period (median 8 years; IQR: 4-13).
CONCLUSION
Mediastinal paragangliomas are most located in the middle mediastinum and can often be diagnosed noninvasively using a combination of clinical, biochemical, and radiological features.
Topics: Adult; Female; Humans; Middle Aged; Male; Retrospective Studies; Paraganglioma, Extra-Adrenal; Paraganglioma; Mediastinal Neoplasms; Mediastinum
PubMed: 37257785
DOI: 10.1016/j.rmed.2023.107296 -
Anesthesiology Jan 2022Central airway occlusion is a feared complication of general anesthesia in patients with mediastinal masses. Maintenance of spontaneous ventilation and avoiding... (Observational Study)
Observational Study
BACKGROUND
Central airway occlusion is a feared complication of general anesthesia in patients with mediastinal masses. Maintenance of spontaneous ventilation and avoiding neuromuscular blockade are recommended to reduce this risk. Physiologic arguments supporting these recommendations are controversial and direct evidence is lacking. The authors hypothesized that, in adult patients with moderate to severe mediastinal mass-mediated tracheobronchial compression, anesthetic interventions including positive pressure ventilation and neuromuscular blockade could be instituted without compromising central airway patency.
METHODS
Seventeen adult patients with large mediastinal masses requiring general anesthesia underwent awake intubation followed by continuous video bronchoscopy recordings of the compromised portion of the airway during staged induction. Assessments of changes in anterior-posterior airway diameter relative to baseline (awake, spontaneous ventilation) were performed using the following patency scores: unchanged = 0; 25 to 50% larger = +1; more than 50% larger = +2; 25 to 50% smaller = -1; more than 50% smaller = -2. Assessments were made by seven experienced bronchoscopists in side-by-side blinded and scrambled comparisons between (1) baseline awake, spontaneous breathing; (2) anesthetized with spontaneous ventilation; (3) anesthetized with positive pressure ventilation; and (4) anesthetized with positive pressure ventilation and neuromuscular blockade. Tidal volumes, respiratory rate, and inspiratory/expiratory ratio were similar between phases.
RESULTS
No significant change from baseline was observed in the mean airway patency scores after the induction of general anesthesia (0 [95% CI, 0 to 0]; P = 0.953). The mean airway patency score increased with the addition of positive pressure ventilation (0 [95% CI, 0 to 1]; P = 0.024) and neuromuscular blockade (1 [95% CI, 0 to 1]; P < 0.001). No patient suffered airway collapse or difficult ventilation during any anesthetic phase.
CONCLUSIONS
These observations suggest a need to reassess prevailing assumptions regarding positive pressure ventilation and/or paralysis and mediastinal mass-mediated airway collapse, but do not prove that conventional (nonstaged) inductions are safe for such patients.
Topics: Adult; Aged; Airway Obstruction; Anesthesia, General; Bronchoscopy; Female; Humans; Male; Mediastinal Neoplasms; Middle Aged; Prospective Studies; Video-Assisted Techniques and Procedures
PubMed: 34724550
DOI: 10.1097/ALN.0000000000004011 -
Cancer Journal (Sudbury, Mass.) 2020Diffuse large B-cell lymphoma (DLBCL) encompasses a group of aggressive B-cell non-Hodgkin lymphomas with striking genetic heterogeneity and variable clinical... (Review)
Review
Diffuse large B-cell lymphoma (DLBCL) encompasses a group of aggressive B-cell non-Hodgkin lymphomas with striking genetic heterogeneity and variable clinical presentations. Among these is primary mediastinal B-cell lymphoma (PMBL), which has unique clinical and molecular features resembling Hodgkin lymphoma. Treatment of DLBCL is usually curative, but identifiable subsets at highest risk for treatment failure may benefit from intensified chemotherapy regimens and/or targeted agents added to frontline therapy. Recent comprehensive genomic analyses have identified distinct genetic subtypes of DLBCL with characteristic genetic drivers and signaling pathways that are targetable. Immune therapy with chimeric antigen receptor T cells and checkpoint inhibitors has revolutionized the treatment of relapsed or refractory disease, and antibody drug conjugates have weaponized otherwise intolerable cytotoxic agents. Ongoing clinical trials are further refining the specificity of these approaches in different genetic subtypes and moving them from the setting of recurrent disease to frontline treatment in high-risk patient populations.
Topics: Antineoplastic Combined Chemotherapy Protocols; Clinical Decision-Making; Clinical Trials as Topic; Disease-Free Survival; Drug Resistance, Neoplasm; Humans; Immune Checkpoint Inhibitors; Immunoconjugates; Immunotherapy, Adoptive; Lymphoma, Large B-Cell, Diffuse; Mediastinal Neoplasms; Molecular Targeted Therapy; Neoplasm Recurrence, Local; Progression-Free Survival; Receptors, Chimeric Antigen
PubMed: 32496453
DOI: 10.1097/PPO.0000000000000450