MEDIASTINAL CASE STUDIES Patricia K. Abbott MHS PA-C Senior Physician’s Assistant Division of Thoracic Surgery Hospital of University of Pennsylvania

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Mediastinal Case Study A mediastinum is an area, a cavity, between 2 portions of an organ The thoracic mediastinum is the area that includes the organs and tissues which separates the right and left lungs

Mediastinal Case Study

Mediastinal Case Study

Mediastinal Case Study

Mediastinal Case Study

Mediastinal Case Study

Mediastinal Case Study

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Purpose of procedure • Diagnosis • treatment

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Approach • Mediastinoscopy • Mediastinotomy • Cervical mediastinoscopy • Mediansternotomy • Video thoracoscopy • Thoracotomy

Mediastinal Case Study

In Thorascopic Surgery, ed. Kaiser LR, Daniel LR.Little, Brown and Co. 1993

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32yo male with diagnosis of stage I mediastinal seminoma 2005; s/p radiation therapy Follow up radiographic studies reveal decrease in size of anterior mediastianal mass, but persistant Patient is asymptomatic

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PMHx: above PSHx: right foot surgery x2 ROS: negative Tobacco History: none Social Hx: Married „ Engineer „

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CT Scan of the Chest with contrast 8x3cm mass in anterior mediastinum No mediastinal, hilar or axillary lymph nodes No pulmonary nodules seen Visualized upper abdomen WNL PET Scan reveals intense metabolic activity with an SUV=6.2

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Pre Operative Risk factors Tobacco Use a. Smokeless b. Cigarettes: When patient quit smoking: never smoked c. Tobacco use: select no (vs. yes) d. a + d

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Answer: c. No –patient never smoked

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Clinical Staging a. No b. Yes: Clinical Stage TI

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Answer: a. No – clinical staging in the STS data base is only applicable to lung and esophageal cancers.

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Mediastinal /Neck (Yes) (No) – Yes a. b. c. d. e.

Anterior mediastinotomy Biopsy, mediastinal mass Resection, mediastinal mass Median sternotomy (for approach) c+d

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Answer: e. (c + d) The approach is mediansternotomy PLUS the reason for surgery in the mediastinum is to resect the mass in the chest

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80yo female found to have a 2.5cm right upper lung lesion during evaluation for shortness of breath PET scan is + in RUL and also in mediastinum and hilum TTNA: +NSCLC

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Symptoms: „ „

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Risk Factors: „

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Tobacco history: 1ppdx33yrs; quit 1979

PMHx: „

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20lb weight loss over 3months No cough, sputum production or hemoptysis

Hypertension, h/o TIA

PSHx: „ „ „ „ „

Bilateral breast bx (benign) TAH/BSO Cataract procedure Cholecystectomy hemorrhoidectomy

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9/5/06 patient taken to the operating room for invasive staging Flexible bronchoscopy Transverse incision was made overlying the sternal notch Samples of lymph nodes were taken and forwarded to pathology Patient recovered from anesthesia and was discharged to home

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Weight loss over last 3 month? a. b. c. d.

20lbs 0 44kg unkown

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Answer c. 44kgs – weight is recorded in kg and lbs weight loss is recorded in kg

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Category of Disease a. b. c. d.

Trachea – malignant Lung – primary Lung – benign mediastinum

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Answer: b. Lung - primary

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Tobacco Use: Yes a. b. c. d.

Cigarettes: 33pack-years Cigarettes: 27pack-years Quit smoking: >12 months preop Quit smoking: Never smoked (