Tumors of the Mediastinum and Chest Wall

Mediastinal masses are a common reason for referral. Accurate diagnosis is important, but in this relatively inaccessible location, also challenging. Malignant node involvement by carcinoma must be distinguished from various primary mediastinal tumors including lymphoma, as well as from a wide variety of nonmalignant causes of lymphadenopathy and benign enlargement of mediastinal structures. Metastasis to mediastinal or hilar lymph nodes by cancer is among the commonest causes of intrathoracic node enlargement in adults, especially those with risk factors for lung and other cancers. The clinical evaluation of mediastinal masses requires knowledge of anatomy, radiology, pathology, and a systematic differential diagnostic approach.

Epidermal inclusion cysts (EIC) are common lesions formed by the invagination and cystic expansion of the epidermis or hair follicle. We present an unusual case of an epidermal inclusion cyst masquerading as a soft tissue sarcoma based on initial clinical presentation and radiographic findings. Mischaracterization of this type of lesion may lead to unnecessary diagnostic modalities or invasive, overly-aggressive surgery.

El mediastino es un espacio anatómico que contiene el corazón y el resto de vísceras torácicas excepto los pulmones. Las masas mediastínicas comprenden una amplia variedad de lesiones malignas y benignas. Normalmente, se presentan como un hallazgo incidental en una radiografía de tórax, aunque en algunas ocasiones los pacientes pueden presentar síntomas secundarios a la compresión que la masa ejerce sobre las estructuras mediastínicas adyacentes, o bien síntomas sistémicos secundarios a síndromes paraneoplásicos. Se puede hacer una buena aproximación diagnóstica inicial para cada lesión considerando la edad del paciente, la localización de la masa, la presencia o ausencia de síntomas, la asociación con enfermedades sistémicas específicas, la presencia de marcadores bioquímicos tumorales y los hallazgos radiológicos. Para el diagnóstico definitivo, se requerirán muestras de tejido obtenidas bien por biopsia o como parte de una intervención terapéutica prevista.

The mediastinum is the anatomical space that contains the heart and other thoracic viscera except the lungs. Mediastinal masses encompass an extensive variety of malignant and benign lesions. Typically, these lesions present as an incidental finding in chest radiography, although occasionally patients experience symptoms secondary to the compression exerted by the mass on the adjacent mediastinal structures and even systemic symptoms secondary to paraneoplastic syndromes. A good initial diagnostic approach can be performed for each lesion by considering the patient's age, the location of the mass, the presence or absence of symptoms, the association with specific systemic diseases, the presence of biochemical tumor markers and radiological findings. For the definitive diagnosis, tissue samples are needed from either a biopsy or as part of a scheduled therapeutic surgery.

Los tumores primarios mediastínicos son un grupo heterogéneo de enfermedades neoplásicas, congénitas e inflamatorias. Dependiendo de su localización (mediastino anterior, medio y posterior) podemos hablar de distintas causas. Desde el punto de vista clínico pueden producir síntomas generales (tos, dolor torácico, fiebre, disnea), síntomas de localización (disfagia, parálisis/paresia, disfonía, síndrome de Horner, síndrome de vena cava superior) o síntomas sistémicos por liberación de substancias por el tumor (miastenia gravis, aplasia pura de la serie roja, síndrome de Cushing, diarrea, hipercalcemia, etc.). En muchos casos, la sospecha diagnóstica deriva de la radiografía simple de tórax, pero para una correcta valoración es necesario realizar una TC torácica. El tratamiento es, salvo en el linfoma, fundamentalmente quirúrgico.

Mediastinal primary tumors are a heterogeneous group of neoplastic, congenital and inflammatory diseases. Regarding its location (anterior mediastinum, medium mediastinum and posterior mediastinum) there are diferent causes of mediastinal masses. Clinically the symptoms can be: generals (cough, chest pain, fever and dyspnea), by location (dysphagia, paralysis/paresis, dysphonia, Horner's syndrome, superior vena cava syndrome) or systemic ones caused by substances released by the tumor (myasthenia gravis, pure red cell aplasia, Cushing's syndrome, diarrhea, hyperkalemia, etc.). In many cases, diagnostic suspicion is based in plain chest radiography. However, a proper diagnosis requires a thoracic CT. Except lymphoma, the treatment is principally surgical.

With the rising number of cancer cases and increasing survival times, cancer patients with critical illness are increasingly presenting to the intensive care unit. This article considers the unique challenges they pose in terms of oncological-specific disease processes and treatment and reviews current trends in outcome prediction. We also consider the ethical standpoints surrounding the treatment of patients for whom there may be no cure and their subsequent transition to palliative care, should it become necessary.