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Diagnostical and therapeutical problems of mediastinal tumors are reported, and their management is described. Lethality was 9% (causes related to the operation, including final stages of advanced tumors).
Most important for the diagnosis of mediastinal tumors are X-ray methods (incl. tomography and pneumomediastinum). Early operation is important for all kinds of tumors. The lateral thoracotomy (Perelman) is recommended. Longterm results are good with benign tumors. This can not be said for malignancies because of their usually late discovery.
OBJECTIVE: To evaluate the accuracy of intraoperative diagnosis of mediastinal lesions using touch imprints and frozen sections. DESIGN: We studied touch imprints and frozen sections from 21 anterior mediastinal lesions retrospectively. The lesions included six cases of non-Hodgkin's lymphoma, eight thymomas, two thymic carcinomas, three Hodgkin's disease cases, and two seminomas. Slides were reviewed independently by each of the three authors, and diagnoses were recorded. RESULTS: Depending on the observer, the correct diagnosis was obtained on touch imprints alone in 76% to 81% of cases. On frozen sections alone, the correct diagnosis was made in 67% to 86% of cases. In 86% to 100% of cases, the correct diagnosis was made on either touch imprint or frozen section. CONCLUSIONS: As with frozen sections, the most common significant error in interpreting cytology preparations was in distinguishing thymic epithelial tumors (thymoma and thymic carcinoma) from lymphoma. On a modified Wright-Giemsa-stained imprint, epithelial cells in a thymoma may be inconspicuous. Clues to their presence include cells with a spindled nuclear shape or a small distinct nucleolus. The epithelial cells have scant cytoplasm with indistinct cell borders. Clumping of cells is often not prominent in lymphocytic thymomas, but may be present in epithelial or mixed lymphocytic and epithelial tumors. With practice, one can learn to recognize thymic epithelial cells on touch imprints. Familiarity with this simple inexpensive technique could improve the accuracy of intraoperative diagnosis of anterior mediastinal lesions.
The clinical and histological diagnosis of mediastinal tumors has to be completed with an appreciation of the biological relationship between the tumor and its host. This is most important for neurogenic and thymic tumors. Successful removal is sometimes possible even after a long time of observation. Auxillary use of radiation and cystostatics is recommended.
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A series of 6 mediastinal tumors of mesenchymal origin is presented. This type of tumors is very heterogeneous in its histology, depending on the differentiation of the primary mesenchymal cell. Presenting symptoms are not diagnostic: nevertheless malignant neoplasms are often revealed by vague thoracic pain, while benign masses usually show the tendency to a slow non infiltrating growth accompanied by faint symptoms of mediastinal compression syndrome. Mesotheliomas and liposarcomas are the most frequent malignant neoplasms, while lipomas are the most represented among the benign ones. Preoperative diagnosis is often casual, based on plain X-ray examination of the chest: subsequent thoracic CAT is of utmost advantage, providing the exact definition of the limits of the mass and of its ability to invade visceral and vascular structures of the mediastinum. Lipomas are well identified by CAT because of their characteristic attenuation value. Surgical operation is mandatory, because benign neoplasms can be effectively cured and infiltrating masses correctly staged and identified by histological examination.
The results of radical and partial surgical treatment of 146 patients with mediastinal tumors have been assessed. All patients were operated at the Specialistic Hospital in Zakopane from the 1st January, 1967 to the 31st December, 1989. Hundred twenty one patients (82.9%) suffered from malignancy and 25 (17.1%) from non-malignant mediastinal tumors. Mortality rate was 2.0%. Late results have been expressed in terms of survival period, and they have been as follows: 44.4% of patients survived 20 years after surgery, 36.5% of patients survived 15 years, 42.9% of patients--10 years, and 56.1% of patients survived 5 years. More than 50% of operated patients resumed their previous work.
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We evaluated the reliability of intraoperative frozen section histology in 149 mediastinal tumours of which 106 lesions were localized in the anterior, 18 in the central and 25 in the posterior mediastinum. Gross non-resectability was ruled out by preoperative imaging. No preoperative cytological or histological diagnosis was obtained in any case. At thoracotomy, 3 biopsies from 3 different sites of the tumour were processed for frozen section as well as for paraffin histology and immunohistochemistry. In 67 of 73 benign lesions (91%), the intraoperative diagnosis was correct, 5 cases could not be classified by frozen section and 1 case had to be revised. Only 28 of 76 malignant lesions (36.8%) were diagnosed correctly by intraoperative frozen section. In 27 cases (35.5%), no intraoperative classification was possible and in 21 patients (27.6%), the diagnosis was wrong with the consequence of surgical overtreatment for lymphoma misinterpreted as thymic cancer in 3 cases. In patients in whom preoperative investigations suggest borderline resectability, a staged procedure to obtain histology prior to definitive surgery could prevent overtreatment.
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