– a group of morphologically heterogeneous neoplasms located in the mediastinal space chest cavity. The clinical picture consists of symptoms of compression or germination of a mediastinal tumor into neighboring organs (pain, superior vena cava syndrome, cough, shortness of breath, dysphagia) and general manifestations (weakness, fever, sweating, weight loss). Diagnosis of mediastinal tumors includes x-ray, tomographic, endoscopic examination, transthoracic puncture or aspiration biopsy. Treatment of mediastinal tumors is surgical; for malignant neoplasms it is supplemented with radiation and chemotherapy.

General information

Tumors and cysts of the mediastinum account for 3-7% in the structure of all tumor processes. Of these, in 60-80% of cases benign tumors of the mediastinum are detected, and in 20-40% - malignant (mediastinal cancer). Tumors of the mediastinum occur with equal frequency in men and women, mainly at the age of 20-40 years, i.e., in the most socially active part of the population.

Tumors of mediastinal localization are characterized by morphological diversity, the likelihood of primary malignancy or malignancy, the potential threat of invasion or compression of vital mediastinal organs ( respiratory tract, great vessels and nerve trunks, esophagus), technical difficulties of surgical removal. All this makes mediastinal tumors one of the pressing and most difficult problems of modern thoracic surgery and pulmonology.

Anatomy of the mediastinum

The anatomical space of the mediastinum is limited anteriorly by the sternum, retrosternal fascia and costal cartilages; behind - the surface of the thoracic spine, the prevertebral fascia and the necks of the ribs; on the sides - by the layers of the mediastinal pleura, below - by the diaphragm, and above - by a conventional plane passing along the upper edge of the manubrium of the sternum.

Within the boundaries of the mediastinum are the thymus gland, the upper parts of the superior vena cava, the aortic arch and its branches, the brachiocephalic trunk, carotid and subclavian arteries, thoracic lymphatic duct, sympathetic nerves and their plexuses, branches of the vagus nerve, fascial and cellular formations, lymph nodes, esophagus, pericardium, tracheal bifurcation, pulmonary arteries and veins, etc. There are 3 floors in the mediastinum (upper, middle, lower) and 3 sections (anterior, middle, posterior). The floors and sections of the mediastinum correspond to the localization of neoplasms emanating from the structures located there.

Classification

All mediastinal tumors are divided into primary (initially arising in the mediastinal space) and secondary (metastases of tumors located outside the mediastinum).

Primary mediastinal tumors are formed from different tissues. According to their genesis, mediastinal tumors are divided into:

• neurogenic neoplasms (neurinomas, neurofibromas, ganglioneuromas, malignant neuromas, paragangliomas, etc.)
• mesenchymal neoplasms (lipomas, fibromas, leiomyomas, hemangiomas, lymphangiomas, liposarcoma, fibrosarcoma, leiomyosarcoma, angiosarcoma)
• lymphoid neoplasms (lymphogranulomatosis, reticulosarcoma, lymphosarcoma)
• dysembryogenetic neoplasms (teratomas, intrathoracic goiter, seminomas, chorionepitheliomas)
• tumors thymus gland(benign and malignant thymomas).

Also in the mediastinum there are so-called pseudotumors (enlarged conglomerates of lymph nodes in tuberculosis and Beck’s sarcoidosis, aneurysms large vessels etc.) and true cysts (coelomic pericardial cysts, enterogenic and bronchogenic cysts, hydatid cysts).

In the upper mediastinum, thymomas, lymphomas and substernal goiter are most often found; in the anterior mediastinum - mesenchymal tumors, thymomas, lymphomas, teratomas; in the middle mediastinum - bronchogenic and pericardial cysts, lymphomas; in the posterior mediastinum - enterogenous cysts and neurogenic tumors.

Symptoms of mediastinal tumors

The clinical course of mediastinal tumors is divided into an asymptomatic period and a period of severe symptoms. The duration of the asymptomatic course is determined by the location and size of mediastinal tumors, their nature (malignant, benign), growth rate, and relationships with other organs. Asymptomatic tumors of the mediastinum usually become a finding during preventive fluorography.

General symptoms of mediastinal tumors include weakness, fever, arrhythmias, bradycardia and tachycardia, weight loss, arthralgia, pleurisy. These manifestations are more characteristic of malignant tumors of the mediastinum.

Pain syndrome

Most early manifestations Both benign and malignant tumors of the mediastinum are pain in the chest caused by compression or growth of the tumor into the nerve plexuses or nerve trunks. The pain is usually moderately intense and can radiate to the neck, shoulder girdle, and interscapular area.

Tumors of the mediastinum with left-sided localization can simulate pain resembling angina pectoris. When there is compression or invasion of the mediastinal border by a tumor sympathetic trunk Horner's symptom often develops, including miosis, ptosis of the upper eyelid, enophthalmos, anhidrosis and hyperemia of the affected side of the face. If you have pain in the bones, you should think about the presence of metastases.

Compression syndrome

Compression of the venous trunks is primarily manifested by the so-called superior vena cava syndrome (SVVC), in which the outflow is disrupted venous blood from the head and upper half of the body. SVC syndrome characterized by heaviness and noise in the head, headache, chest pain, shortness of breath, cyanosis and swelling of the face and chest, swelling of the veins of the neck, and increased central venous pressure. In case of compression of the trachea and bronchi, cough, shortness of breath, and wheezing occur; recurrent laryngeal nerve - dysphonia; esophagus - dysphagia.

Specific manifestations

In some mediastinal tumors, specific symptoms. Thus, with malignant lymphomas, night sweats and skin itching are observed. Mediastinal fibrosarcomas may be accompanied by a spontaneous decrease in blood glucose levels (hypoglycemia). Mediastinal ganglioneuromas and neuroblastomas can produce norepinephrine and epinephrine, leading to attacks of hypertension. Sometimes they secrete a vasointestinal polypeptide that causes diarrhea. With intrathoracic thyrotoxic goiter, symptoms of thyrotoxicosis develop. Myasthenia gravis is detected in 50% of patients with thymoma.

Diagnostics

The variety of clinical manifestations does not always allow pulmonologists and thoracic surgeons to diagnose mediastinal tumors based on anamnesis and objective examination. Therefore, the leading role in identifying mediastinal tumors is played by instrumental methods.

• X-ray diagnostics. A comprehensive x-ray examination in most cases allows one to clearly determine the location, shape and size of the mediastinal tumor and the extent of the process. Mandatory tests for suspected mediastinal tumors include chest x-ray, polyposition x-ray, and x-ray of the esophagus. Data x-ray examination are clarified using a bone marrow puncture with a myelogram study.
• Surgical biopsy. The preferred methods of obtaining material for morphological research are mediastinoscopy and diagnostic thoracoscopy, which allow biopsy under visual control. In some cases, there is a need to perform a parasternal thoracotomy (mediastinotomy) for revision and biopsy of the mediastinum. If there are enlarged lymph nodes in the supraclavicular region, a pre-scaling biopsy is performed.

Treatment of mediastinal tumors

In order to prevent malignancy and the development of compression syndrome, all mediastinal tumors should be removed as far as possible. early dates. For radical removal of mediastinal tumors, thoracoscopic or open ways. When the tumor is located retrosternally and bilaterally, longitudinal sternotomy is predominantly used as a surgical approach. For unilateral localization of the mediastinal tumor, an anterolateral or lateral thoracotomy is used.

Patients with a severe general somatic background can undergo transthoracic ultrasound aspiration of a mediastinal tumor. In case of a malignant process in the mediastinum, radical extended removal of the tumor or palliative removal of the tumor is performed in order to decompress the mediastinal organs.

The question of the use of radiation and chemotherapy for malignant tumors The mediastinum is decided based on the nature, extent and morphological features tumor process. Radiation and chemotherapy treatment is used both independently and in combination with surgical treatment.

A mediastinal tumor is a neoplasm in the mediastinal space of the chest, which can vary in morphological structure. Often diagnosed benign neoplasms, but approximately every third patient is diagnosed with cancer.

There are a large number of predisposing factors that determine the appearance of a particular formation, ranging from addiction to bad habits and dangerous working conditions, ending with metastasis cancerous tumor from other organs.

The disease manifests itself in large numbers clearly severe symptoms, which are quite difficult to ignore. The most characteristic external signs include severe cough, shortness of breath, headaches and increased body temperature.

The basis diagnostic measures consists of instrumental examinations of the patient, the most informative of which is considered to be a biopsy. In addition, a medical examination and laboratory tests will be required. Treatment of the disease, regardless of the nature of the tumor, is only surgical.

Etiology

Despite the fact that tumors and cysts of the mediastinum are quite rare disease, its occurrence in most cases is caused by the spread of the oncological process from other internal organs. However, there are a number of predisposing factors, among which it is worth highlighting:

• long-term addiction to bad habits, in particular smoking. It is worth noting that the more experience a person has of smoking cigarettes, the greater the likelihood of acquiring such an insidious disease;
• decreased immune system;
• contact with toxins and heavy metals– this includes both working conditions and unfavorable environmental conditions. For example, living near factories or industrial enterprises;
• constant exposure to ionizing radiation;
• prolonged nervous overstrain;
• poor nutrition.

A similar disease in equally occurs in both sexes. The main risk group consists of people of working age - from twenty to forty years. IN in rare cases, malignant or benign neoplasms of the mediastinum can be diagnosed in a child.

The danger of the disease lies in the wide variety of tumors, which may differ in their morphological structure, damage to vital organs and the technical complexity of their surgical excision.

The mediastinum is usually divided into three floors:

• upper;
• average;
• lower.

In addition, there are three sections of the lower mediastinum:

• front;
• rear;
• average.

Depending on the part of the mediastinum, the classification of malignant or benign neoplasms will differ.

Classification

By etiological factor Mediastinal tumors and cysts are divided into:

• primary – originally formed in this area;
• secondary – characterized by the spread of metastases from malignant tumors that are located outside the mediastinum.

Since primary neoplasms are formed from various tissues, they will be divided into:

• neurogenic tumors of the mediastinum;
• mesenchymal;
• lymphoid;
• thymus tumors;
• dysembryogenetic;
• germ cell - develop from the primary germ cells of the embryo, from which sperm and eggs should normally be formed. It is these tumors and cysts that are found in children. There are two peaks of incidence - in the first year of life and in adolescence - from fifteen to nineteen years.

There are several most common types of neoplasms, which will differ in their location. For example, tumors of the anterior mediastinum include:

• neoplasms thyroid gland. They are often benign, but sometimes they are cancerous;
• thymoma and thymic cyst;
• mesenchymal tumors;

In the middle mediastinum the most frequent formations are:

• bronchogenic cysts;
• lymphomas;
• pericardial cysts.

A tumor of the posterior mediastinum manifests itself:

• enterogenous cysts;
• neurogenic tumors.

In addition, clinicians usually distinguish between true cysts and pseudotumors.

Symptoms

For quite a long period of time, tumors and cysts of the mediastinum can occur without expressing any symptoms. The duration of this course is determined by several factors:

• place of formation and volume of neoplasms;
• their malignant or benign nature;
• the rate of tumor or cyst growth;
• relationship with other internal organs.

In most cases, asymptomatic mediastinal tumors are discovered completely by accident - during fluorography for another disease or for preventive purposes.

As for the period of expression of symptoms, regardless of the nature of the tumor, the first sign is pain in the chest area. Its appearance is caused by compression or germination of the formation into the nerve plexuses or endings. The pain is often moderate. The possibility of pain radiating to the area between the shoulder blades, shoulders and neck cannot be ruled out.

Against the background of the main manifestation, other symptoms of mediastinal neoplasms begin to appear. Among them:

• fatigue and malaise;
• increased body temperature;
• severe headaches;
• bluish lips;
• dyspnea;
• swelling of the face and neck;
• cough - sometimes with blood;
• uneven breathing, even attacks of suffocation;
• heart rate instability;
• profuse sweating, especially at night;
• causeless weight loss;
• increase in the volume of lymph nodes;
• hoarseness of voice;
• night snoring;
• increased blood pressure;
• slurred speech;
• disruption of the process of chewing and swallowing food.

In addition to the above symptoms, myasthenic syndrome very often appears, which is manifested by muscle weakness. For example, a person cannot turn his head, open his eyes, or raise his leg or arm.

Similar clinical manifestations are typical for mediastinal tumors in children and adults.

Diagnostics

Despite the variety and specificity of the symptoms of such a disease, it is quite difficult to establish a correct diagnosis based on them. For this reason, the attending physician prescribes a whole range of diagnostic examinations.

Primary diagnosis includes:

• a detailed interview with the patient will help determine the first time of onset and the degree of intensity of symptom expression;
• a clinician’s examination of the patient’s medical history and life history to determine the primary or secondary nature of the neoplasms;
• a thorough physical examination, which should include auscultation of the patient’s lungs and heart using a phonendoscope, examination of the condition of the skin, and measurement of temperature and blood pressure.

General laboratory diagnostic techniques do not have any special diagnostic value However, a clinical and biochemical blood test is necessary. A blood test is also prescribed to determine tumor markers that will indicate the presence of a malignant neoplasm.

In order to determine the location and nature of the neoplasm according to the classification of the disease, it is necessary to carry out instrumental examinations, including:

Treatment

After confirming the diagnosis, a benign or malignant mediastinal tumor should be surgically removed.

Surgical treatment can be carried out in several ways:

• longitudinal sternotomy;
• anterolateral or lateral thoracotomy;
• transthoracic ultrasound aspiration;
• radical extended surgery;
• palliative removal.

In addition, if the tumor is malignant, treatment is supplemented with chemotherapy, which is aimed at:

• reduction of the volume of malignant formation - carried out before the main operation;
• final liquidation cancer cells, which may not have been completely removed during surgery;
• elimination of a tumor or cyst - in cases where surgical therapy cannot be performed;
• maintaining the condition and prolonging the patient’s life – when diagnosing a severe form of the disease.

Along with chemotherapy, radiation treatment can be used, which can also be the main or auxiliary technique.

There are several alternative methods to combat benign tumors. The first of them consists of a three-day fast, during which you need to refuse any food, and you are allowed to drink only purified water without gas. When choosing such treatment, you must consult with your doctor, since fasting has its own rules.

The therapeutic diet, which is part of complex therapy, includes:

• frequent and fractional food consumption;
• complete rejection of fatty and spicy foods, offal, canned food, smoked meats, pickles, sweets, meat and dairy products. It is these ingredients that can cause the degeneration of benign cells into cancerous ones;
• enriching the diet with legumes, fermented milk products, fresh fruits, vegetables, cereals, dietary first courses, nuts, dried fruits and herbs;
• cooking food only by boiling, steaming, stewing or baking, but without adding salt and fat;
• plenty of drinking regime;
• control over the temperature of food - it should not be too cold or too hot.

Besides this, there are several folk remedies that will help prevent the onset of cancer. The most effective of them include:

Potato flowers will help
prevent cancer

• potato flowers;
• hemlock;
• honey and mumiyo;
• golden mustache;
• apricot kernels;
• sagebrush;
• white mistletoe.

It is worth noting that starting such therapy on your own can only aggravate the course of the disease, which is why you should consult with your doctor before using traditional recipes.

Prevention

There are no specific preventive measures that can prevent the appearance of a tumor in the anterior mediastinum or any other location. People need to follow a few general rules:

• give up alcohol and cigarettes forever;
• follow safety rules when working with toxins and poisons;
• If possible, avoid emotional and nervous stress;
• follow nutritional recommendations;
• strengthen immunity;
• undergo fluorographic examination annually for preventive purposes.

There is no unambiguous prognosis for such a pathology, since it depends on several factors - localization, volume, stage of development, origin of the tumor, age category the patient and his condition, as well as the possibility of surgery.

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Neoplasms of the mediastinum (tumors and cysts) in the structure of all oncological diseases make up 3-7%. Most often, mediastinal neoplasms are detected in persons 20-40 years old, i.e., in the most active socially part of the population. About 80% of detected mediastinal tumors are benign, and 20% are malignant.
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: thymus gland, upper section of the superior vena cava, brachiocephalic veins, aortic arch and its branches, brachiocephalic trunk, left common carotid artery, left subclavian artery.
In the posterior part of the superior mediastinum are located: esophagus, thoracic lymph duct, trunks of sympathetic nerves, vagus nerves, nerve plexuses of organs and vessels of the thoracic cavity, fascia and cellular spaces.
In the anterior mediastinum are located: fiber, spurs of the intrathoracic fascia, the leaves of which contain the internal mammary vessels, retrosternal lymph nodes, anterior mediastinal nodes.
In the middle part of the mediastinum there are: pericardium with the heart enclosed in it and intrapericardial sections of large vessels, tracheal bifurcation and main bronchi, pulmonary arteries and veins, phrenic nerves with accompanying phrenic-pericardial vessels, fascial-cellular formations, lymph nodes.
In the posterior part of the mediastinum are located: 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 mediastinal organs.
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 posterior section the mediastinum along its entire length are neurogenic tumors.

Clinical picture
Mediastinal neoplasms 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 mediastinal neoplasms, an asymptomatic period and a period of pronounced clinical manifestations can be distinguished. The duration of the asymptomatic period depends on the location and size of the neoplasm, its nature (malignant, benign), growth rate, relationship with organs and formations of the mediastinum. Very common mediastinal neoplasms long time They are asymptomatic and are accidentally discovered during a routine chest x-ray.
Clinical signs of mediastinal neoplasms 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 prolapse 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.
On late stages the development of neoplasms occurs: 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, cardiac arrhythmia.
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, clinical signs neoplasms, mediastinum are very diverse, however, they manifest themselves 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.

Diagnostics
The main method for diagnosing mediastinal tumors 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.
To mandatory X-ray methods Examinations of a patient with a mediastinal tumor include: -fluoroscopy, radiography and tomography of the chest, contrast study 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, transbronchial or transtracheal needle biopsy mediastinal formations localized in the area of ​​tracheal bifurcation. In some cases, mediastinoscopy and videothoracoscopy, in which the biopsy is carried out 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 you suspect systemic diseases(leukemia, lymphogranulomatosis, reticulosarcomatosis, etc.), as well as for immature neurogenic tumors, a bone marrow puncture is performed with the study of a myelogram.

Tumors of nervous tissue
Neurogenic tumors are the most common and account for about 30% of all primary mediastinal tumors. 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.
Neuroma- the most common neurogenic tumor, develops from nerve sheath cells. Neurofibroma is somewhat less common. They are usually localized in the posterior mediastinum, equally often on both the right and left. Tumors are characterized by slow growth, but can reach large sizes. Cases of their malignancy have been described. At the same time neurofibromas more prone to malignant transformation. Malignant tumors of the nerve sheaths - neurogenic sarcomas, are characterized by rapid growth.

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, pain in the chest. But characteristic of lymphogranulomatosis are skin itching, enlargement of the liver and spleen, changes in the blood and bone marrow are often absent at this stage. Primary lymphogranulomatosis of the mediastinum can be asymptomatic for a long time, with enlargement of the mediastinal lymph nodes for a long time may remain the only manifestation of the process.
With 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.

Tumors from the thymus gland
The thymus gland is formed in the first month of pregnancy. At birth, it consists of two lobes connected by an isthmus. Each lobe has a number of lobules separated from each other by connective tissue layers. The lobules consist of two layers: cortical and medulla. The cortical layer contains compact masses of small cells, histologically similar to lymphocytes, these are the so-called thymocytes. In the medulla, epithelial elements predominate; among them, Hassall's bodies, characteristic of the thymus, are located concentrically, originating from the endothelium of arterioles. IN childhood The thymus gland is located in the lower part of the neck and the anterior part of the upper mediastinum, behind the sternum, from which it is separated by loose tissue. During puberty, i.e. at the age of 12-15 years, the involution of the thymus gland begins. Gradually, the gland tissue is replaced by adipose tissue and, ultimately, it turns into a fatty and connective tissue lump, the mass of which in an adult is 5-10 g. During histological examination, specific thymic elements can be detected between fat cells and fibrous cords.
Tumors developing from the thymus gland or its remnants are called thymomas - this is a collective term that includes several various types tumors. There are tumors arising from the medulla and cortical layers of the thymus: epithelioid thymoma (epidermoid, spindle cell, lymphoepithelial, granulomatous) and lymphoid thymola. In addition, hyperplasia and delayed involution of the thymus gland are distinguished. Depending on the degree of cell differentiation, thymomas can be benign or malignant. However, the concept of “benign thymoma” is very arbitrary, since in some cases those tumors that are regarded as benign upon histological examination often tend to infiltrative growth, metastasis and relapse after their removal. The typical location of thymomas is in the anterior part of the superior mediastinum.
Thymomas are equally common in men and women. They are found at any age - from early childhood to old age. In children, thymic hyperplasia is quite often observed, which can even lead to the development of compression syndrome of the mediastinal organs. Benign thymomas can be asymptomatic for a long time, sometimes reaching significant sizes. Large thymomas are manifested by a feeling of heaviness in the chest, shortness of breath, and palpitations; in children they can cause chest deformation - bulging of the sternum. Malignant tumors of the thymus gland are characterized by rapid infiltrative growth, early and extensive metastasis. In 10-50% of patients with thymomas and delayed thymic involution, symptoms of myasthenia gravis are detected, which can occur in two forms: ocular myasthenia and generalized.
Isolated ocular myasthenia is manifested by weakness of the muscles of the eyeball and eyelids, which leads to ptosis and diplopia. This form of the disease does not pose a threat to the patient’s life and leads to only moderate disability. However, in some cases, ocular myasthenia can develop into a generalized form, being the first manifestation of the disease.
Generalized myasthenia gravis is characterized by severe muscle weakness skeletal muscles, disturbances in chewing, swallowing, speech, breathing, development of muscle wasting. Dysphagia (impaired swallowing) and dysarthria (impaired speech), as a consequence of damage to the muscles of the soft palate, pharynx and esophageal muscles, are often early symptoms of the disease and are usually found in 40% of all patients. The most severe manifestation of myasthenia gravis is the development of myasthenic crisis, in which there is a dysfunction of the respiratory muscles, up to the development of apnea (complete cessation of breathing movements. Myasthenia gravis can develop with both malignant and benign tumors thymus gland, disruption of the processes of its physiological involution.

Tumors from tissues displaced into the mediastinum
These formations include teratomas(from the Greek teratos - miracle), or, as they are often called, mediastinal dermoids are tumors containing various tissues that are usually absent in the part of the body where they arise. Among primary mediastinal neoplasms, teratomas, in frequency, occupy second place after neurogenic tumors and account for 10 - 15%. Teratomas consist of tissues or tissue elements belonging to all three germ layers. These neoplasms are congenital in nature and arise during the process of disturbed embryogenesis.
The existing hypotheses of the origin of teratomas are of interest. According to one of them, during pregnancy one fetus receives abnormal development and finds itself inside another, developing until a certain period, and then undergoing degenerative changes. Another hypothesis explains the appearance of teratomas by parthenogenetic development of germ cells. And finally, according to the third, teratomas originate from the “remnants” of pluripotent cells, “forgotten” during the process of embryogenesis, possibly due to disruption of the mechanism of cell differentiation.
Teratomas can reach significant sizes and cause compression of the mediastinal organs. Activation of the growth of mediastinal teratomas can occur after injury, during pregnancy, under the influence of neurohumoral changes during puberty. They are located predominantly in the anterior mediastinum and in the anterior section of the superior mediastinum. The development of these neoplasms can be complicated by suppuration and malignancy. Immature or malignant teratomas (teratoblastomas) are characterized by rapid infiltrative growth, a tendency to tumor disintegration and development purulent complications.
Neoplasms that develop from tissues displaced into the mediastinum include mediastinal goiter. It is classified as a tumor conditionally, since in the precise sense of this concept it is not one. Mediastinal goiter is more common in women. As a rule, people over 40 years of age become ill.
Mediastinal goiter can be retrosternal, diving and intrathoracic. A goiter is called retrosternal, the upper pole of which can be palpated from the side of the jugular fossa. A “diving” goiter is located behind the sternum. When swallowing, coughing, or straining, the goiter moves upward, but does not completely come out from behind the manubrium of the sternum. At this moment it is possible to palpate only the surface of its upper pole. The intrathoracic goiter is completely located behind the sternum and is not accessible to palpation. Mediastinal goiter develops from the thyroid gland that has descended behind the sternum or comes from accessory thyroid glands displaced into the mediastinum during embryogenesis. A goiter that develops from the rudiments of the thyroid gland displaced into the mediastinum is called aberrant. A goiter that is completely separated from the thyroid gland and has independent mobility can be considered aberrant.
Mediastinal struma can be euthyroid, hypo and hyperthyroid. Nodular forms are more common, diffuse forms are less common. A malignant tumor can develop in struma developing both from the normal thyroid gland and from aberrant thyroid rudiments. Nodular hypo- and euthyroid forms undergo malignancy more often.
Diagnosis of retrosternal and diving goiter, in cases where it is possible to palpate its upper pole, does not present any great difficulties. Intrathoracic goiter is much more difficult to diagnose. Its typical location is the anterior part of the upper mediastinum, behind the manubrium of the sternum to the right or left of the trachea, depending on its original zone - the lower parts of the right or left lobe of the thyroid gland. Right-sided localizations are more common. Sometimes a downward displacement and hyperplasia of the angle of the isthmus of the thyroid gland develops. In cases of diffuse intrathoracic goiter, which are relatively rare, the trachea is enclosed in a kind of coupling on almost all sides.
Rare malignant tumors of the mediastinum include mediastinal seminoma and chorionepithelioma of the mediastinum. Seminoma occurs exclusively in men. Chorionepithelioma also predominantly affects men, mainly aged 15-35 years. The pronounced hormonal activity of chorionepithelioma leads to mammary hyperplasia and testicular atrophy in men; in women - to engorgement of the mammary glands, as during pregnancy, and the release of colostrum. These extragenital tumors are extremely malignant, give numerous hematogenous metastases early, and have rapid infiltrative growth. Tumors rarely reach large sizes, since patients die as a result of early and extensive hematogenous metastasis. The prognosis is usually unfavorable.

Treatment of mediastinal tumors - 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 only be justified if early stages diseases when the process locally affects a certain group of lymph nodes, which is not so common in practice. IN recent years A 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 high efficiency this method of treatment and the possibility of carrying out intervention even in patients with severe concomitant diseases and low functional reserves.

is a group of malignant tumors that originate from organs and tissues located in this area. The mediastinum is bounded laterally by the lungs, in front and behind by the sternum, spinal column and ribs, and below by the diaphragm. Here are the large blood vessels and lymphatic vessels Therefore, mediastinal cancer often occurs secondary to metastasis from other parts of the body. The mediastinal organs themselves also serve as a source of neoplasm - it is caused by proliferation of cells of the thymus, trachea, esophagus, bronchi, nerve trunks, pericardium, adipose or connective tissue. There are also atypia, the cytology of which resembles embryonic tissue.

The urgency of the problem is that middle age sick people are 20-40 years old. It occurs in adolescents (girls and boys), and even in children. Elderly people also suffer from this disease. The incidence in Russia is 0.8-1.2%, or a fifth of all tumors in this area. Epidemiology shows that it occurs in both men and women throughout the world, although there are epidemiologically unfavorable areas. For example, female thyrotoxic goiter is common in mountainous regions, where the incidence of cancer in the anterior part of the mediastinum is high.

It is possible to find out how dangerous education is only by histological examination, making differentiation difficult. Even a benign nature does not exclude malignancy. Mediastinal cancer is deadly, the prognosis is unfavorable, the mortality rate is high, and not only because of the difficulties of diagnosis, but also because it is often inoperable due to the involvement of large vessels, nerves, and vital organs. However, this does not mean that it is incurable - there is a chance to survive, you need to continue to fight.

Types of mediastinal cancer

Classification of mediastinal cancer is difficult, since there are descriptions of more than 100 types of neoplasms, including primary and secondary types.

Based on the cytological picture, the following types are distinguished::

• . small cell - rapidly progresses, as it metastasizes hematogenously and lymphogenously;
• . squamous - develops over a long period of time, arises from mucous membranes (pleura, pericardium, vascular walls);
• . embryonic, or germiogenic - formed from embryonic membranes due to pathologies of fetal embryogenesis;
• . low differentiated.

Forms are distinguished by origin and localization:

• . angiosarcoma;
• . liposarcoma;
• . synovial sarcoma;
• . fibrosarcoma;
• . leiomyosarcoma;
• . rhabdomyosarcoma;
• . malignant mesenchymoma.

International TNM classification used to determine the prevalence of the disease.

Mediastinal cancer, symptoms and signs with photos

The very beginning of mediastinal cancer is asymptomatic, which is expressed by the absence of complaints from the patient until the size of the tumor increases. You should pay attention to weakness, fatigue, weight loss, which amounts to 10-12 kilograms in 1-2 months.

With primary involvement of the bronchi and trachea, the disease is expressed by respiratory failure (shortness of breath, cough). In the early stages of pericardial damage, the first obvious manifestations are arrhythmia, bradycardia, and rapid pulse. Pain syndrome severe, pain behind the sternum, pain and burning are localized on the developmental side and radiate to the back to the scapula.

External, visible changes in the body occur if the central veins are compressed. When pressure is applied to the superior vena cava, cyanosis is observed; it also appears when the tumor compresses the lungs and tracheobronchial tree. Red spots on the skin, face, dermographism, increased sweating, drooping of the eyelid, dilation of the pupil, retraction of the eyeball - characteristic one-sided symptoms of germination of the sympathetic trunk.

Initial signs of germination of the recurrent laryngeal nerve are hoarseness of voice, change in timbre; spinal cord - paresthesia (pins and needles sensation). Oncological alertness should also arise when isolated pleurisy or pericarditis is detected.

Late symptoms include: fever without visible inflammation and infectious process, cachexia, exhaustion. Bone pain indicates metastases.

The warning signs of mediastinal cancer are so varied that not every doctor can suspect its development. In this case, you cannot simply palpate the lump or see the ulcer, so instrumental examination methods remain the main methods of diagnosis.

Causes of mediastinal cancer

The causes of mediastinal cancer are varied; it is difficult to determine what triggers it. oncological process. Psychosomatics, one of the branches of medicine, believes that oncology is formed due to changes in a person’s psycho-emotional state.

Genetics blames heredity, when the gene that provokes the formation of atypia is inherited. A predisposition may arise during embryo formation due to impaired fetal embryogenesis.

There is also a viral theory, according to which a pathogen (for example, papilloma virus, AIDS or herpes) causes the appearance of gene mutations. However, mediastinal cancer is not contagious to others; it is impossible to become infected by airborne droplets or other means.

Doctors identify factors that cause cancer degeneration, the main of which are:

• . age—the body’s immunological defense gradually decreases;
• . carcinogens coming from food or environmental pollution;
• . radiation and exposure;
• . pregnancy pathologies;
• . chronic diseases.

Stage characterizes the extent of spread of mediastinal cancer:

• . zero, or in situ (0) - at an early stage the pathology is practically not detected;
• . the first (1) is an encapsulated tumor without invasion into the mediastinal tissue;
• . second (2) - there is infiltration of fatty tissue;
• . third (3) - germination of several mediastinal organs and lymph nodes;
• . fourth and last (4) - there are distant organs affected by metastases.

Photos and images of computer and magnetic resonance imaging, which are attached to the diagnostician’s report, will help determine the degree.

If there is a suspicion of mediastinal cancer, to check it, identify a tumor and make a diagnosis, use:

• . survey, acquaintance with the medical history;
• . examination (finger percussion, palpation);
• . tumor marker test;
• . Ultrasound - reveals other lesions;
• . X-ray examination and fluorography (the main method of diagnosis);
• . endoscopic examinations (bronchoscopy, esophagoscopy, thoracoscopy);
• . PET-CT scan to determine distant metastasis;
• . computer or magnetic resonance imaging to obtain layer-by-layer photographs of tumor formation.

Treatment of mediastinal cancer

Mediastinal cancer is curable if patients consult a specialist in time. Thoracic surgery offers an effective remedy that will help defeat and get rid of cancer. The surgeon’s actions are aimed at complete removal involved structures under general anesthesia. Operable mediastinal cancer and all affected tissue are removed by thoracotomy, after which radiation and chemotherapy are prescribed. The goal is to stop the growth of the tumor and slow down the spread. Radiation and chemotherapy are also used if there are contraindications to surgery. Symptomatic therapy can help alleviate the condition at all stages - the patient takes strong painkillers and cardiovascular drugs.

Sometimes clinical remission does not last long. When the disease occurs again (relapses), the patient’s life expectancy is reduced and treatment tactics change. If mediastinal cancer is not treated, its consequences are death. Advanced mediastinal cancer and the disintegration of the cancerous tumor also affect the time allotted to the patient. The survival rate is 35%, it is influenced by the speed, time and dynamics of the process. Recovery is possible with timely detection of the tumor, which often happens when contacting medical institution for other diseases with similar symptoms, or for preventive examinations.

Prevention of mediastinal cancer

Since the etiology of mediastinal cancer varies and it is not possible to completely exclude the damaging factor, in order to prevent it, it is recommended to general recommendations, which reduce the chance of getting sick and to some extent protect against cancer:

• . active lifestyle;
• . absence bad habits(smoking, alcohol);
• . normal sleep;
• . daily routine;
• . healthy eating.

You should avoid stress, overwork, strong physical exertion, and undergo preventive examinations and fluorography, which can show formation. Only timely medical assistance will help avoid death.

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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 therapeutic techniques, 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 non-specific 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 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) substernal 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, thoracic part vagus nerves, phrenic nerves, trachea and initial parts 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), border sympathetic trunk with 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 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 to determine the function 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. Peculiarities 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 chest and neck with short and thick needles to remove air.

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

As a rule, they are accompanied by 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.

1. 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 abscesses of the posterior mediastinum, the most common symptom is dysphagia. May be dry barking cough up to suffocation (involvement of the trachea in the process), hoarseness (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: dilatation 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:

1. Superior vena cava syndrome
2. Pulmonary vein compression syndrome
3. Tracheobronchial syndrome
4. Esophageal syndrome
5. Pain syndrome
6. 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 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. A leading role in making a diagnosis, especially in the early stages before the appearance of clinical symptoms, belongs computed tomography and the X-ray method.

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:

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

The operation is contraindicated for:

1. established distant metastases to other organs or cervical and axillary lymph nodes;
2. compression of the superior vena cava with transition to the mediastinum;
3. persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness;
4. dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
5. 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 saving 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 their 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.

Security questions

1. 1. Classification of mediastinal diseases.
2. 2. Clinical symptoms mediastinal tumors.
3. 3. Methods for diagnosing mediastinal tumors.
4. 4. Indications and contraindications for surgical treatment mediastinal tumors and cysts.
5. 5. Operative approaches to the anterior and posterior mediastinum.
6. 6. Causes of purulent mediastinitis.
7. 7. Clinic of purulent mediastinitis.
8. 8. Methods for opening ulcers with mediastinitis.
9. 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. Thyroid gland 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 hand. 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 decline muscle strength right shoulder girdle And upper limb. Dullness percussion sound above 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. X-ray to the right upper section An additional shadow is adjacent to 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. X-ray examination on the right revealed a shadow in 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 methods examinations: pneumomediastinography - 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 research functions of the thyroid gland with radioactive iodine. Clinical manifestations thyrotoxicosis determines 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 applies diagnostic test Linara, 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 tumors.

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, you can identify interest neighboring organs. Considering the localization of pain, the most probable cause- compression of the diaphragmatic and vagus nerve. 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.