What is a Mediastinal Mass?

Podcast Transcript

Announcer:

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Monisha Sudarshan, MD:

Hello everyone. My name is Monisha Sudarshan. I'm one of the thoracic surgeons at Cleveland Clinic in the Department of Cardiovascular and Thoracic Surgery. I do surgery on everything in the chest except the heart. The lungs, the esophagus, and the mediastinal space. And today we'll be talking about anterior mediastinal masses. The mediastinum is the space that is basically between your breastbone and your back or your spine, and between the lungs. And today we'll be specifically talking about the anterior mediastinal space, which is basically the space behind your breastbone and in front of your heart.

When patients come to me with a mediastinal mass, one of their first questions is, "What could this anterior mediastinal mass be?" And it could be as simple as a residual thymus gland, which is, we're all born with a thymus gland, and as we age, it gets smaller and smaller and even disappears. But in some patients, we have a thymus gland that has not completely disappeared, and we often see this in the younger population.

An anterior mediastinal mass could be a cyst, which is a fluid-filled structure, and this could be benign or something that's not cancerous, or it could be cancerous. Then an anterior mediastinal mass can be a slow-growing tumor of the thymus gland called thymoma, or something more aggressive, such as a thymic cancer. It could even be something in your thyroid that has enlarged and come down into your mediastinal face. Other things that an anterior mediastinal mass can be is a lymphoma or enlarged lymph node glands from something else.

What kind of symptoms can an anterior mediastinal mass give? The majority of patients with such a mass do not have any symptoms. This is because the chest is a large space and a mass can grow quite large before it becomes symptomatic or before it gives any signs or symptoms.

If the mediastinal mass is giving symptoms, it's because of compression of the organs that are surrounding it, or it's because of invasion of the organs. The symptoms that one might have when having such a mass is coughing or shortness of breath or difficulty breathing. It could be swelling of the neck, swelling of the upper arms. It could be fevers, weight loss, fatigue, so sometimes it can be very general symptoms.

What kind of tests are expected when one gets the diagnosis of an anterior mediastinal mass? As I mentioned before, oftentimes these are not symptomatic. Many of my patients come in with an anterior mediastinal mass discovered on a CT scan that was done for other reasons. That could be a car accident or something completely unrelated. And once you have that CT scan, it really depends on how the mass looks on that. If it looks like a small thymoma, as we talked about before, then perhaps nothing more is required and surgery can be directly discussed.

Or if the question of what this is is unclear, then it could be doing more imaging such as an MRI that can tell us what this mass is, but also whether it's invading the other structures. Certain types of masses may require biopsy to understand what is going on. Other blood work can also give us an understanding of what this anterior mediastinal mass is.

There's a variety of treatments out there. In general, these could be chemotherapy, surgery, radiation, starting with just monitoring. Sometimes if your doctor is fairly confident that this anterior mediastinal mass is just a residual thymus gland, nothing more than just monitoring with a CT scan may be required. If this looks like a thymoma on a CT scan, and if the patient is a good surgical candidate or safe for surgery, then we could progress directly to surgery. If this looks like a lymphoma and a biopsy has been done and a lymphoma has been confirmed, then most likely it's going to be chemotherapy. And sometimes we need a combination of different things such as surgery, chemotherapy, and radiation. And we sometimes see that in patients who have a thymic cancer and who require all three.

Within surgery, what kind of surgical techniques can be used to remove this anterior mediastinal mass? If surgery is appropriate, we want to try to remove the mass using as small incisions as possible so that your recovery is fast. This is called a minimally invasive approach, and for a minimally invasive approach, we often use the robotic approach to remove the mass that is sitting behind your breastbone. These could be small incisions that are as small as eight millimeters, and sometimes we can go only on one side, which is the right side or the left side, or sometimes we need to go on both sides because your spot is sitting right in the middle.

Sometimes minimally invasive surgery is not possible, and this could be because the mass is really big or because it's invading structures that need to come out and need to be reconstructed. That bigger incision is called a sternotomy, and that involves splitting of the breastbone. And oftentimes you may have heard about a sternotomy when thinking about open-heart surgery. If you are a candidate for minimally invasive surgery, then the recovery in the hospital can be as short as one or two nights stay, depending on how complex the surgery was and your other medical conditions.

What are the key questions that you should bring up with your doctor when faced with an anterior mediastinal mass diagnosis? Well, the number one question of course, is what do they think it looks like? What do they think it is? The second question would be, what additional tests do you require? And this could be imaging, blood work or a biopsy. If you do require a biopsy, ask how will the biopsy be done? If you're going to get surgery, an important question will be, how would the surgery be approached? Will it be minimally invasive? Will it be an open incision? Are you a good candidate for the minimally invasive surgery?

And then finally, if you have already had your mediastinal mass removed, one of the other questions would be, is this something that can come back? Do you need any additional therapy such as chemotherapy or radiation? Do you need monitoring CT scans? And if so, how often? For how many years, or for the rest of your life?

I hope this has answered some of your questions. An anterior mediastinal mass is a very rare diagnosis. If you do have a diagnosis of an anterior mediastinal mass, make sure you're seeing a specialized center who's able to handle this. At Cleveland Clinic, we have a multidisciplinary approach to anterior mediastinal masses with specialists, not just in surgery, but also in oncology and in radiation oncology that manage this all together. So we'd be happy to see you and provide you with specialized and tailored care for your diagnosis because not every mediastinal mass is the same and not every patient is the same. Thank you.

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