MEDIASTINUM

From Big Medical Encyclopedia

MEDIASTINUM [mediastinum (PNA, JNA), septum mediastinale (BNA)] — the part of a chest cavity limited to a back surface of a breast — in front, chest department of a backbone — behind, the right and left mediastinal pleurae — on the parties, an upper aperture of a thorax — from above and a diaphragm — from below. Topografoanatoma define S. as a complex of the bodies located in a chest cavity between the right and left mediastinal pleurae.

The anatomy

S.'s Projection in front matches a breast (without xiphoidal shoot), behind it is the share of the I—X (XI) chest vertebrae. A. A. Bobrov (1890) suggested to divide S. on the horizontal plane which is carried out through the upper edge of the III edge on top and bottom (mediastinum sup. et inferius). Are in the lower S. heart (see) and pericardium (see). The conditional plane passing frontally through a trachea and primary bronchi, S. divide on front and back (mediastinum ant. et post.). Sometimes speak about average S. (mediastinum med.), meaning a trachea and primary bronchi.

Fig. 1. Mediastinum. Anterior aspect. Front edges of pleural bags and the lungs concluded in them are turned off in the parties; cellulose of an upper mediastinum is partially removed together with lymph nodes; 1 — the left clavicle (is sawn off); 2 — the left thymic branches of an internal chest artery and the veins accompanying them; 3 — the left brachiocephalic vein; 4 — the left share of a thymus; 5 — the left phrenic nerve, a perikardodiafragmalny artery and a vein; 6 — a first line of the left pleural bag; 7 — a pericardium; 8 — a diaphragm; 9 — a first line of the right pleural bag; 10 — the right phrenic nerve, a perikardodiafragmalny artery and a vein; 11 — a fatty tissue; 12 — the right share of a thymus; 13 — the right brachiocephalic vein; 14 — the right thymic branches of an internal chest artery and the veins accompanying them; 15 — the right clavicle (is sawn off).
Fig. 2. Mediastinum. Back view. The backbone, parts of edges and cellulose is removed: 1 — the II chest vertebra; 2 — the right III edge (is sawn off); 3 — a gullet; 4 — a chest channel; 5 — the right sympathetic trunk; 6 — the intercostal nerve (is dissected away); 7 — a connecting branch; 8 — a back intercostal artery; 9 — an unpaired vein; 10 — a big splanchnic nerve; 11 — the XI chest vertebra; 12 — a pleura; 13 — a chest part of an aorta; 14 — the left sympathetic trunk; 15 — the left III edge (is sawn off).

In front S. are located (in front back): thymus (see), or the cellulose replacing it, an upper vena cava and its sources — veins brachiocephalic and unpaired (partially) (see. Venas cava ), the ascending part and an aortic arch with its branches (see. Aorta ), pulmonary trunk (see) and its branches, pulmonary veins (see. Lungs ), phrenic nerves, limf. nodes, trachea (see) and main bronchial tubes (see); in its lower part — heart and a pericardium (tsvetn. fig. 1). In back S. are located gullet (see), limf. chest channel (see), a chest part of an aorta (see. Aorta ), unpaired and semi-unpaired veins (see. Vienna ), vagus nerves (see), sympathetic trunks and their branches, chest aortal texture (tsvetn. fig. 2).

Cross sectional dimension of top and bottom S. is more, than an average. The Perednezadny size increases from top to down. The form C. depends on a form thorax (see).

Fig. 3. Mediastinum. Right-side view. The mediastinal pleura, a part of a costal and diaphragmal pleura are removed, partially removed cellulose and lymph nodes: 1 — trunks of a brachial plexus (are dissected away); 2 — the left subclavial artery and a vein (are dissected away); 3 — an upper vena cava; 4 — the II edge (is sawn off); 5 — the right phrenic nerve, a perikardodiafragmalny artery and a vein; 6 — the right pulmonary artery (is dissected away); 7 — a pericardium; 8 — a diaphragm; 9 — the costal pleura (is dissected away); 10 — a big splanchnic nerve; 11 — the right pulmonary veins (are dissected away); 12 — a back intercostal artery and a vein; 13 — a lymph node; 14 — the right bronchial tube; 15 — an unpaired vein; 16 — a gullet; 17 — the right sympathetic trunk; 18 — the right vagus nerve; 19 — a trachea.
Fig. 4. Mediastinum. Left-side view. The mediastinal pleura, a part of a costal and diaphragmal pleura, and also cellulose are removed: 1 — the clavicle (is sawn off); 2 — the left sympathetic trunk; 3 — a gullet; 4 — a chest channel; 5 — the left subclavial artery; 6 — the left vagus nerve; 7 — a chest part of an aorta; 8 — a lymph node; 9 — a big splanchnic nerve; 10 — a semi-unpaired vein; 1 1 — a diaphragm; 12 — a gullet; 13 — the left phrenic nerve, a perikardodiafragmalny artery and a vein; 14 — pulmonary veins (are dissected away); 15 — the left pulmonary artery (is dissected away); 16 — the left general carotid artery; 17 — the left brachiocephalic vein.

The friable connecting fabric surrounding S.'s bodies is a whole. Above she unites to retro and previstseralny kletchatochny spaces of a neck (see. Kletchatochny spaces ), below — through openings of a diaphragm on the course of periesophagal and paravazalny cellulose — with retroperitoneal space (see). Friable connecting fabric immediately of a kpereda from a backbone and directly behind the handle of a breast, least — between leaves mediastinal is most expressed pleurae (see) and bodies of the Village. Between the bodies which are located in S. allocate a number of kletchatochny spaces. The Pozadigrudinny (retrosternal) space is between a back surface of a breast and an aortic arch. In it the thymus and brachiocephalic veins, limf are located. nodes, superficial noncardiac neuroplex. The pretracheal kletchatochny space is between a front surface of a trachea and an aortic arch, an upper vena cava and pulmonary arteries. It contains deep noncardiac neuroplex. The right paratracheal space is limited to a trachea and a mediastinal pleura on each side, and in front an upper vena cava. In it nodes, partially unpaired vein, the right phrenic and upper part of a chest part of the right vagus nerve lie limf (tsvetn. fig. 3). The left paratracheal space is limited medially to a trachea and a gullet. lateralno — an aortic arch, the left general sleepy and subclavial arteries. It contains partially left vagus nerve, a chest channel and limf, nodes (tsvetn. fig. 4). In the preesophageal kletchatochny space created behind by a gullet, in front — a back surface of a trachea, and its bifurcations — a back surface of a pericardium (this part of space call pozadiserdechny) are lower, are located limf. nodes. The retroesophageal kletchatochny space is kzad from a gullet. In it esophageal neuroplex and limf, nodes are placed. The retroesophageal space passes into the juxtaspinal spaces located on each side bodies of chest vertebrae; in them there are sympathetic trunks, unpaired and semi-unpaired veins.

The innervation of bodies of S. is carried out by a chest aortal texture (plexus aorticus thoraci-cus) and its derivatives — cordial (plexus cardiacus), esophageal (plexus esophageus) and pulmonary textures (plexus pulmonalis).

S.'s blood supply is carried out by the numerous arterial branches originating as directly from an aorta — mediastinal (rr. mediastinales), bronchial (rr. bronchiales), esophageal (rr. esophagea-les), pericardiac (rr. pericardiaci), and from its branches — back intercostal arteries (aa. intercostales post.), from internal chest arteries — mediastinal, thymic (rr. thymici), bronchial branches. Outflow of a venous blood happens in unpaired, semi-unpaired and in internal chest veins.

Limf, vessels from S.'s bodies go to the following limf, to nodes: near - sternal (nodi lymphatici paraster-nales), prepericardiac (nodi lymphatici prepericardiales), lateral pericardiac (nodi lymphatici pericardiales lat.), pre-vertebral (nodi lymphatici pre-vertebrales), front and back mediastinal (nodi lymphatici medi-astinales ant. et post.).

Radioanatomy

Fig. 1. The roentgenogram of a thorax is normal (a side projection): 1 — retrosternal space; 2 — a shadow of heart and the main vessels; 3 — retrocardial space; the dashed line designated conditional border between front and a postmediastinum.

In a direct projection of a condition for studying of a radioanatomy of S. are less favorable since all its bodies merge in a uniform intensive shadow. The best conditions for rentgenol. researches C. are created in slanting and side projections. On the roentgenogram in a side projection the shadow of heart and the main vessels occupying average department of the image of a thorax (fig. 1) is visible. Kperedi from this shadow to a back wall of a breast located retrosternal space in the form of a light strip. Kzadi from a shadow of heart and the main vessels to a backbone is traced retrocardial space in "a type of an enlightenment of the irregular polosovidny shape. Here back S.'s bodies and back departments of lungs are displayed. At elderly people the shadow of the descending aorta is well visible.

For rentgenol. studying the upper part C. since the level of the first mezhreberye shaded by imposing of muscles, bones of a shoulder girdle is especially difficult (belts of an upper extremity, T.) and containing large blood vessels. On the rear edge of a vascular shadow in an upper part the light strip of a trachea crossing a shadow of an aortic arch is visible. The conditional line drawn on a back contour of a trachea divides upper S. into front and back departments. Normal at a usual rentgenol. a research a gullet, limf, nodes and nerves are not visible.

Methods of inspection

At inspection of the patient need to be considered that patol. the processes developing in S. cause a heavy symptom complex — a so-called mediastinal syndrome: cyanosis, short wind, disturbance of cordial activity, pain behind a breast, hypostasis of a neck, person and upper extremities, expansion of saphenas of a thorax, etc. (see. Mediastinal syndrome ). In addition to these symptoms, general for all diseases of S., there are also others, connected with character or localization patol. process at this patient. So, purulent processes of S. are followed by a feverish state, a high leukocytosis, dynamics gematol is characteristic of a lymphogranulomatosis. changes, for an echinococcosis — an eosinophilia, positive an agglutination test with latex, Kasoni's test. Influence of features of localization patol. process on a wedge, a picture it is the most noticeable at

S. V tumors recognition patol. S.'s processes such methods of a research as radiological, bronkhologichesky, surgical, etc. are of great importance.

Radiological methods: mediastinografiya (see), pnevmomediastinografiya (see), imposing of diagnostic pheumothorax (see), angiocardiography (see), contrast X-ray inspection top and bottom hollow veins (see. Kavografiya ), aortografiya (see). Pnevmomediastinografiya, and especially the tomopnevmomediastinografiya, allows to receive a symptom of an enveloping gas patol. shadows to find the «leg» connecting a new growth with S. or lack of usual gas layers in its cellulose. Diagnostic pheumothorax, to-ry it is possible to impose in the presence of a pleural cavity, free from unions, allows to distinguish S.'s new growth from a tumor or a cyst of a lung. More convincing data usually manage to be obtained at the new growths located in verkhnezadny departments of S. Angiokardiografiya and an aortografiya are important in differential diagnosis between S.'s new growths and congenital anomalies of arterial system, aneurisms of a pulmonary trunk and an aorta.

Contrasting of venas cava is important for assessment of prevalence of tumoral process in S., and also identification of a prelum and germination of the next educations.

A tracer technique — scanning (see) areas of a neck and thorax after introduction radio pharmaceutical drug (see) apply to diagnosis of pathology of a thyroid gland at a retrosternal craw.

A perspective diagnostic method at various forms of pathology of a mediastinum is the ultrasonic biolocation (see. Ultrasonic diagnosis ).

A highly effective method of a research C. is the computer tomography (see. Tomography computer ). Bronkhologichesky methods — bronkhoskopiya (see) and bronchography (see) — apply to an exception of intra pulmonary localization of a tumor or a cyst.

Surgical methods — a puncture biopsy through a chest wall or the bronchoscope, mediastinoskopiya (see) or torakoskopiya (see) with a biopsy — hl are directed. obr. on receiving from a new growth of material for a cytologic or histologic research also provide the most exact diagnosis. The puncture through a chest wall is reasonable at new growths, to-rye prilezhat to it closely. Via the bronchoscope punktirut generally new growths, coming from adjacent to a trachea and bronchial tubes limf, nodes. Mediastinoskopiya — the diagnostic operation which is carried out under an endotracheal anesthesia, allowing to make front S.'s audit by means of the special endoscopic device — a mediastinoskop.

The roentgenoscopy, a X-ray analysis, a tomography, and at pathology in back S. — a X-ray contrast research remain standard methods gullet (see). The best rentgenol. documentation of new growths of S. is often reached not by a X-ray analysis, and electrox-ray analysis (see). Exact presurgical diagnosis of new growths of S. from them morfol. verification works well not always even during the use of numerous special methods of a research. In these cases the final diagnosis is established only during operation.

Pathology

S.'s Pathology includes malformations of bodies of S., damage, inflammatory diseases, cysts and tumors.

Malformations S.'s bodies meet rather seldom (see. Aorta , Gullet , Heart ).

Damages

Distinguish the opened and closed damages of Page.

The closed damages can arise at a heavy bruise or a prelum of a thorax, at the closed fractures of a breast, sometimes in combination with the general contusion (see). At the closed S.'s injury the nature of changes depends generally on hemorrhage in cellulose C., on penetration of air and contagiums (at a rupture of bronchial tubes, a gullet). Hemorrhages and S.'s emphysema arise at the same time more often.

At a small hematoma of S. bleeding stops spontaneously. A moderate asthma, stethalgias, slight cyanosis, insignificant swelling of cervical veins which are observed in the first 2 — 5 days after an injury gradually pass. The rupture of larger vessels of S. leads to formation of an extensive hematoma and an imbibition blood of bodies and fabrics C. The imbibition blood of vagus nerves which is followed by disturbance of breath and a decompensation of blood circulation (a vagal syndrome) is especially dangerous. The last often meets at the progressing mediastinal hematomas. Quite often in similar cases heavy drain pneumonia (so-called vagal pneumonia) are observed. Occasionally S.'s hematoma suppurates with development of diffusion mediastinitis (see) or formation of abscess. At extensive hematomas of S. its punctures, removal of the streamed blood and introduction of antibiotics are shown.

The remote effects of a mediastinal hematoma are the hems, unions leading to a sclerosis of cellulose, a prelum of nerves and vessels, a mediastinopericarditis. In nek-ry cases there is a perineuritis of vagus nerves that leads to disturbances of secretion, motility and a trophicity went. - kish. path.

Mediastinal emphysema is observed at a rupture of bronchial tubes, the segments of a lung forming its mediastinal surface, a gullet is more rare zabryushinno than the located departments of intestines. Emphysema without substantial increase of pressure in S. proceeds usually asymptomatically (see. Pneumomediastinum ). The progressing mediastinal emphysema develops hl. obr. at internal valve pheumothorax (see). The sharp asthma arising at the same time, cyanosis, disturbance of blood circulation, the accruing hypodermic emphysema of the person, neck, breast sharply worsen a condition of the patient. Treatment — an urgent puncture of a pleural cavity and S. with continuous aspiration of air, novocainic cervical vagosympathetic blockade, a thoracotomy and sewing up of a rupture of a bronchial tube.

Open damages (wounds) of S. and its bodies in peace time arise usually at open injuries of a thorax. Accumulation of blood and blood clots in the wound channel and cellulose C. can be combined with hemorrhages in pleural cavities, a pericardium, an abdominal cavity (see. Torakoabdominalny damages ). These hematomas in the absence of wound of a large vessel and an infection proceed the same as at the closed injury of Page.

Wounds of a large vessel usually are followed by heavy symptoms of a prelum of bodies of S. and most often come to an end adversely. The infection of a wound of S. causes development of the mediastinitis proceeding as phlegmon or abscess.

The special group is made by nonperforating wounds of S. (about 0,5 all wounds of this area). Even at originally favorable current and a smooth wound repair stay of a foreign body in S. quite often leads further to infection of cellulose, a prelum of nerves, vessels and S.'s bodies that serves as the indication to its operational removal.

S.'s wounds can be followed by damage of vagus nerves and sympathetic trunks, heart and vessels, bronchial tubes, a chest channel. Especially it is necessary to allocate a so-called syndrome of an upper vena cava, to-ry arises at a prelum a hematoma, fibrinferment or a rupture of this vein with full or its partial obstruction (see. Venas cava ). Treatment operational — imposing of a bypass anastomosis or shunting by plastic corrugated prostheses.

Fighting damages of S. are, as a rule, combined with the getting wounds of a breast and damages of its bodies. The volume of the first pre-medical and first medical assistance given at these damages is identical to that at the getting wounds of a breast. The nature of the qualified and specialized help, the indication to an operative measure depend on damage of these or those bodies of a mediastinum and complications.

See also Aorta , Breast , Heart , Trachea .

Inflammatory diseases — see. Mediastinitis .

Cysts and tumors

Before opening of x-ray emission of a cyst and S.'s tumor were distinguished only at a pathoanatomical research. Implementation rentgenol. a method of a research in a wedge, practice allowed Ya. A. Lovtsky by 1908 to generalize a wedge, overseeing by 520 patients with S. Chastot's pathology of tumors and S.'s cysts is made by 1 — 3% in relation to all localizations of tumors. They are observed equally often at men and women; meet preferential at young and mature age. According to V. R. Braytsev, most of them belongs to inborn dizontogenetichesky new growths (see. Dizontogenetichesky tumors ). Benign tumors and S.'s cysts considerably prevail over malignant.

Classification of the main forms of cysts and S.'s tumors: 1) cysts — coelomic (pericardiac), epithelial (bronchogenic), enterogenous (ezofagealny, gastrogenic), parasitic (echinococcal) and meningeal (are observed extremely seldom); 2) benign tumors — neurogenic, a mesenchymal origin (a lipoma, fibroma, a hemangioma, a lymphangioma, a ganglionic hyperplasia limf, nodes — a syndrome Kastl exchange, an osteoma, a chondroma, a hibernoma), thymomas, a retrosternal craw, teratoid educations; 3) malignant tumors — primary (a lymphogranulomatosis, lymphosarcomas, malignant vascular tumors, osteoblastomas, chondrosarcomas, neuroblastomas, malignant thymomas) and metastatic (metastasises of cancer and sarcomas of various bodies, metastasises of a melanoma). Most of scientists, besides, distinguish group of pseudoneoplasms the, or granulomas specific and nonspecific.

According to L. A. Giterman and N. I. Malyukov, patients with specific defeats intrathoracic limf, nodes make about a half of all patients with S.'s diseases, at patients aged up to 40 years bronchadenites and S.'s tuberculomas prevail (see. Tuberculosis extra pulmonary ).

In a wedge, practice primary tumors and cysts most often meet. They are observed more than at 90% of patients with new growths S.: a retrosternal craw — 17%, neurogenic tumors — 15% (at children to 51%), teratoid educations — 8%, new growths of a thymus (thymoma) — 12%, pericardiac cysts — 7%, lipomas — 7%. Seldom fibromas, hibernomas, hemangiomas and lymphangiomas meet.

A bit different data are provided by A. R. Wychulis from clinic of Mayo (USA): benign cysts make 16,2%, tumors of a thymus — 21,7%, teratomas and dermoid cysts — 9,3%, neurinoma — 19,9%, malignant lymphoma — 10,1%.

Cysts. Coelomic pericardiac cysts — roundish, oval or irregular shape the thin-walled educations filled with colorless or yellowish transparent liquid. They result from disturbance of process of merge of embryonal lacunas in a zone of formation of a pericardiac tselom (see. Pericardium ). The sizes of cysts usually of 4 — 5 cm in the diameter, they are transparent, are sometimes reported with a cavity of a pericardium. Walls of a cyst are covered by a mesothelium from cubical or epithelial-like cells from within, and outside covered with a pleura. At 30% of patients the wedge, manifestations at these cysts are absent, at the others dull aches in heart, cough, short wind can be noted, and at cysts of the big sizes — severe pains and other heavy symptoms, a prelum of bodies of the Village. Ruptures of coelomic cysts, development in them suppurative process or a malignancy are observed seldom. At differential diagnosis it is necessary to exclude first of all an aortic aneurysm (see) and to aneurysm of heart (see), and also a tumor of a lung (see), a dermoid cyst (see. Dermoid ), phrenic hernia (see. Diaphragm ). In diagnosis of coelomic cysts of a pericardium their characteristic localization in a lower part of front S. (more often on the right), accurate and equal contours, identification of communication with a pericardium on pneumomedia-stinogrammakh are important. At localization in upper or back S. differential diagnosis with other cystous educations is difficult, and is often impossible. A coelomic cyst operation is simple and consists in transpleural removal of a cyst. Results of intervention usually good.

In group of bronchogenic (bronchial) cysts S.'s cysts and cysts of a thymus since they are similar on an embryogenesis, a form and a wedge, to manifestations are described also enterogenous (ezofagealny and gastrogenic). All these cysts are inborn and are formed of malrelated rudiments of an epithelium of primary gut. The mixed options of a structure of their wall containing fabric elements of respiratory system are sometimes observed and went. - kish. path. These are the roundish rather thin-walled cysts filled with liquid viscous light contents. Sometimes in a cyst find blood or pus, is more often at the message of a cyst with a gleam of a bronchial tube.

The wedge, symptomatology of a bronchogenic and accessory stomach (enterokist) in many respects depends on their size. Often the wedge, symptoms are shown already at children's age and are caused by a prelum of a trachea, bronchial tubes, a gullet, large veins. Serious complications of cysts — suppuration with the subsequent break of their contents in a gleam of airways, pleural and pericardiac cavities, a gullet, bleeding from a wall of a cyst, and also development of massive unions. Cases of development of cancer in a wall of a cyst are known. At enterogenous, in particular gastrogenic, cysts in connection with secretory activity of glands perhaps also an ulceration of a wall with perforation or a penetration in the next bodies.

In rentgenol. to diagnosis of a bronchogenic and accessory stomach an important role is played by their localization in back S. Naiboley a reliable symptom of a bronchogenic cyst detection on pnevmomediastino-grams of the «leg» connecting a cyst with a trachea or a bronchial tube is.

Cysts of a thymus meet at children more often. They can partially be located on a neck and, being restrained in an upper aperture of a thorax, to lead to a prelum of a trachea and disturbances of external respiration.

Treatment consists cysts at a distance, a cut it is necessary to make as soon as possible.

S.'s echinococcus meets seldom, as a rule at the disseminated echinococcosis. Most often it strikes cellulose C. and a pericardium. M. Yu. Gilevich and V. S. Krishtopin described the patient with a pechenochno-me-diastinalny form of an echinococcosis of a liver, at to-rogo migration of a cyst in S. through an esophageal opening of a diaphragm was observed.

Diagnosis of an echinococcus of S. is simple if there is primary cyst in a liver or a lung. Matter rentgenol. these, positive agglutination tests with latex and Kasoni's test. Treatment — operational (see. Echinococcosis ).

The forecast at timely operational treatment of cysts of S. favorable.

Tumors. Distinguish benign and malignant tumors S. Klien, symptoms of high-quality new growths of S. depend on many factors — growth rates and the size of a tumor, its localization, degree of a prelum of the next anatomic educations, etc. The course of the majority of tumors of S. in an initial stage asymptomatic. Symptoms arise only at increase in a tumor and the fabrics, adjacent to them, connected with this removal, a prelum and destruction of bodies of S., and also others and bodies of a chest cavity.

Allocate two main syndromes at S.'s pathology — compression and neuroendocrinal. Extent of manifestation of a compression mediastinal syndrome depends on localization (front or back S., the central or regional arrangement), a form and intensity of growth, high quality or a zlokachestvennost of process. At a regional arrangement and slow growth a tumor the long term can be shown by nothing. The most frequent symptoms of significant growth patol. educations serve feelings of completeness and pressure behind a breast, and also dull aches. Then signs of dysfunction of these or those bodies of S. as a result of their compression follow.

Allocate three types of compression symptoms: organ (shift and a prelum of heart, trachea, primary bronchi, a gullet), vascular (a prelum brachiocephalic and upper hollow veins, a chest channel, the shift of an aortic arch) and neurogenic (a prelum with disturbance of conductivity wandering, phrenic and intercostal nerves, a sympathetic trunk). Most often at neurogenic tumors are shown nevrol. symptoms (pain, a hypesthesia or a hyperesthesia, vegetative disturbances), a syndrome of an upper vena cava at tumors of front department of upper Page.

The neuroendocrinal syndrome is shown by the damage of joints reminding a pseudorheumatism (see) and also damage of big and small tubular bones — Bamberger's syndrome — Mari (see. Bambergera — Mari a periostosis ). Various changes of a cordial rhythm are noted, stenocardia (see).

During S.'s new growths distinguish two periods — asymptomatic and the period about a wedge, manifestations. Benign tumors develop asymptomatically a long time, sometimes years and even decades.

Diagnosis of tumors of S. presents the known difficulties. At the same time, first, exclude various processes (tumoral and inflammatory) in a pleural cavity, segments of lungs, adjacent to S., a chest wall, and also diseases of bodies of S., a diaphragm, a thyroid gland, to-rye can simulate S.'s tumor (an aortic aneurysm, hearts, phrenic hernia, a retrosternal and intrathoracic craw); secondly, establish the nature of tumoral process (high-quality or malignant); thirdly, on the basis of the analysis of clinicoradiological features of a disease specify a type of a tumor.

Neurogenic tumors of S. evolve from the remained embryonal elements, from to-rykh nerves and their covers are formed. More often tumors develop from a sympathetic trunk and intercostal nerves and are located in back S., more precisely in costovertebral deepening (a pulmonary furrow, T.). On morfol. to structure neurogenic tumors can be neurinoma (see), neurofibromas (see), ganglioneuromas (see). Pheochromocytomas (see) and hemodektoma are among rare tumors of S. (see. Paraganglioma ).

At neurogenic tumors symptoms are more expressed, than at all other high-quality new growths of S. Otmechayutsya of pain behind a breast, in spin, headaches, in some cases — sensitive, secretory, vasculomotor, pilomotor and trophic frustration on skin of a thorax from an arrangement of a tumor. These changes well are registered by means of test of the Minor (see Sweating). Bernard's syndrome — Horner is less often observed (see. Bernard — Horner a syndrome ), signs of a prelum of a recurrent guttural nerve, etc.

Radiological neurogenic tumors are characterized by the homogeneous intensive oval or roundish shadow which is closely adjoining a backbone. Also the symptom of peeling of a pleura is important, to-ry sometimes comes to light on tomograms. Pressure of a tumor upon adjacent bone educations leads to expansion of intervertebral foramens, emergence uzur on edges and vertebras.

Ganglioneuromas can have the form of hourglasses if a part of a tumor is located in the spinal channel and connects a narrow leg to a tumor in S. V similar cases with mediastinal symptoms signs of a prelum of a spinal cord are combined (see) up to paralyzes. Tumors, coming from wandering and returnable guttural nerves, meet seldom, are followed by hoarseness of a voice. Tumors of a phrenic nerve are also rare. At a number of patients neurogenic tumors of S. arise as manifestation neurofibromatosis (see).

Treatment — operational. Standard quick access for removal of neurogenic tumors of S. is side thoracotomy (see). At tumors like hourglasses make a thoracotomy and a laminectomy (see) for simultaneous removal of a new growth from S. and the spinal channel (the vertebral channel, T.).

From tumors of a mesenchymal origin lipomas are more often observed (see. Lipoma ), fibromas (see Fibroma), hemangiomas are more rare (see. Hemangioma ), lymphangiomas (see), are even more rare — a chondroma (see. Chondroma ), an osteoma (see. Osteoma ) and hibernomas (see). Each of such tumors meets not often, but totally they form quite big group.

Lipomas are in most cases observed at the women inclined to completeness. Typical localization of lipomas — the right kardiodiafrag-malny corner though they can be located also in other departments of Page. On localization they can be divided into five groups: mediastinal (located only in S.), cervical and mediastinal, abdomino-mediastinal, intramural (in S. and in bodies of a thorax), parasternalno - mediastinal (are located in the form of hourglasses in front S.).

These tumors grow slowly and only at very big sizes or at bilateral distribution lead to a prelum of vitals and vessels of a chest cavity. The malignancy them is noted extremely seldom.

Rentgenol. the picture at lipomas of a cardiophrenic corner is characterized by the semicircular shadow adjoining a shadow of heart, a diaphragm and a front chest wall. Differential diagnosis between S.'s lipoma, a coelomic cyst of a pericardium and phrenic hernia of Larrey (see. Diaphragm ) it is carried out generally by means of imposing of a pneumomediastinum: gas surrounds a lipoma and stratifies it on segments. This symptom of lobation and lack of the leg leaving under a diaphragm, patognomonichna for lipomas of Page.

As well as all tumors of S., a lipoma, as a rule, are subject to removal. However at a typical rentgenol. a picture and absence a wedge, manifestations it is admissible to refrain from operation and to be limited annual rentgenol. control. Operation does not present great difficulties, except for removal of tumors in the form of hourglasses, at to-rykh the bilateral or combined accesses sometimes are required.

S.'s fibroma meets quite seldom. Most often these tumors are localized in front Page. They come from fibrous layers of a pleura, a pericardium, a stroma of a thymus, etc. The sizes usually small (4 — 5 cm in dia.), the consistence dense, rounded shape, a tumor is encapsulated. Wedge. current generally favorable. At the small sizes of a tumor symptoms are a little expressed. Increase in a tumor leads to a prelum of a sympathetic trunk and development of a syndrome of Bernard — Horner. The oncotomy, as a rule, leads to recovery.

Vascular tumors of S. — a lymphangioma, a hemangioma — meet seldom. Their presurgical diagnosis is extremely difficult. Gistol. the structure does not differ from a structure of vascular tumors of other localizations. Treatment — operational. Forecast, as a rule, favorable. Are seldom observed bone (osteoma) and cartilaginous (chondroma) tumors S.

Kastlmen (V. of Castleman) described rather rare disease — a ganglionic hyperplasia of lymph nodes of S. (an angiofollikulyarny lymphoma). Also the mixed its intermediate forms meet plazmotsitarny (apprx. 10%), vascular and hyaline, actually lymphocytic (to 90%). Tumors usually have the ovoidny or spherical form, the big sizes, are encapsulated. Treatment consists the struck adenoid tissue, a cut at a distance in spite of the fact that the tumor is usually encapsulated, presents sometimes difficulties in connection with plentiful vascularization. A recurrence does not happen.

For designation of various tumors of a thymus (see) the umbrella term «thymoma» is applied. Gistol. the structure of thymomas is very various. Revealed at gistol. a research of line of a maturity (high quality) often there do not correspond tendencies of thymomas to infiltriruyushchy growth, innidiation and a recurrence after removal. All thymomas need to be considered potentially malignant tumors. Usually they represent big, irregular shape of a tumor, localized, as a rule, in upper or average part of front Page. At rentgenol. a research the pnevmomediastinografiya and a puncture biopsy through a chest wall have the greatest diagnostic value.

— thymomas — it is necessary to distinguish a hyperplasia of a thymus from true tumors, edges arises at children and adults at disturbance of its processes fiziol. involution.

Tumors of a thymus can be combined with Itsenko's syndrome — Cushing (see. Itsenko — Cushing a disease ) and defeats thyroid gland (see).

The wedge, a current of thymomas usually does not differ from the course of other tumors of Page.

Treatment of a thymoma operational. Usually use intercostal access on the party of defeat. At a median arrangement of a tumor and its big sizes the longitudinal section of a breast is shown. At a combination of a thymoma and myasthenias (see) symptoms of muscular weakness after an oncotomy usually pass. In cases of a hyperplasia of a thymus with unsharply expressed a wedge, manifestations of a myasthenia apply hormonal or radiation therapy.

The retrosternal craw is also carried to S.'s tumors, considering its topography. Allocate three types of a retrosternal craw: «diving», the most part to-rogo is located in S., and smaller — on a neck, acts during the swallowing; actually retrosternal craw which is localized entirely behind a breast (its upper pole is probed behind cutting of the handle of a breast); intrathoracic — is located deeply in S. and is unavailable to a palpation. These types of a retrosternal craw have various a wedge, a current. So, the «diving» craw is characterized by periodically coming phenomenon of the asphyxia connected with deviation of a trachea, and also symptoms of a prelum of a gullet (dysphagy). At a retrosternal and intrathoracic craw symptoms of a prelum of large vessels, especially veins take place. In these cases puffiness of the person and neck, swelling of veins, hemorrhages in scleras, a phlebectasia of a neck and thorax is observed. Venous pressure at these patients is increased, headaches, weakness, an asthma are observed. In diagnosis of a retrosternal and intrathoracic craw the multiaxial roentgenoscopy has essential value. For confirmation of the diagnosis use radio-isotope scanning with 131 I, but negative data of this research do not exclude existence of a «cold» or colloid node.

The retrosternal and intrathoracic craw, in addition to a prelum of a trachea, a gullet and large venous trunks, can malignizirovatsya therefore early radical removal it is obligatory. The retrosternal craw is deleted from cervical access, and intrathoracic — from side intercostal access or a cervical section in combination with a partial longitudinal or longitudinally cross sternotomy.

Fig. 2. A straight line(s) and side tomograms of a thorax of the patient with a dermoid cyst of a mediastinum: shooters specified a shadow of roundish education in a front mediastinum.

Teratoid educations of S. can be referred to tumors, considering them morfol. structure and a possibility of a malignancy (see. Teratoma ). They have an appearance of solid or cystous educations (fig. 2). At suppuration of a dermoid cyst (see. Dermoid ) contents become liquid, putreform. Course of dermoid cysts of S. long. The sizes of a cyst increase slowly. The pathognomonic sign — a vykashlivaniye of kashitseobrazny masses and hair (at break of a cyst in a bronchial tube), contrary to the occurring opinion, meets seldom.

At rentgenol. a research the strip of calcification of a contour of a cyst is sometimes noticeable. Yu. Yu. Dzhanelidze in 1947 described a so-called pseudo-aneurysmal form of a dermoid cyst of Page. At rentgenol. a research the shadow of such cyst pulses, and at auscultation an impression of systolic noise is made.

The malignancy of teratomas noted in 8 — 27% of cases is followed by bystry increase a wedge, symptoms.

The differential diagnosis is carried out with cysts, abscess and cancer of a lung, tumors of a chest wall, exudative pleurisy, an aortic aneurysm and by hearts.

Indications to removal of teratomas of S. are put widely in view of their tendency to a malignancy. The extirpation of a tumor is made from intercostal access or by a median longitudinal section of a breast. The difficulties which are found during removal of these tumors consist in possible lack of the capsule, close ties with a root of a lung, large vessels, S. V bodies these cases it is reasonable to leave a part of an outside cover of a cyst or tumor, and then to process it an acute spoon and to coagulate a surface by a surgical diathermy. At teratomas without signs of a malignancy an operative measure yields the good long-term results.

Malignant tumors of S. can be primary and metastatic. From primary tumors prevail a mediastinal form of a lymphogranulomatosis, lympho-and reticulosarcomas, sarcomas of cellulose C. (fibro - and liposarcomas, malignant hibernomas and mesenchymomas), unripe vascular tumors (angiosarcomas, angioendotelioma and geman-gioperitsitoma), malignant neurinoma (neuroblastomas), tumors of a thymus and a teratoblastoma meet. To draw a clear boundary between a number of benign and malignant tumors of S. on the basis morfol. data it is not always possible as even unripe tumors at children's age can have a high-quality current. However children have a vast majority of unripe tumors, to-rye occur in this age group at 23,9% of patients with tumors and S.'s cysts, are malignant or potentially malignant.

Lymphogranulomatosis (see) in S. meets most often. Primary displays of a disease in the form of defeat intrathoracic limf, nodes, usually in combination with increase in one of groups peripheral limf, nodes of a neck, one of supraclavicular or axillary hollows are noted at 30 — 60% of patients. The isolated defeat only intrathoracic limf, nodes meets much less often.

Lymphosarcoma (see) S. the wedge differs in more bystry, and quite often is followed a current, progressing of a mediastinal compression syndrome by exudative pleurisy. As process is localized in front S., first of all symptoms of a prelum of an upper vena cava, pain behind a breast come to light, then short wind, cough join. At a generalized form of a disease separate groups peripheral limf, nodes increase. The general condition of patients satisfactory during an initial stage of a disease and sharply worsens in process of its progressing. Forecast adverse.

Primary sarcoma of cellulose C. — extremely malignant fast-growing rare tumor (see. Sarcoma ). Extending infiltrative on cellulose C., the tumor covers the bodies located in it, squeezing and even sprouting them. Upon transition of a tumor to a pleura exudate in pleural cavities, in the beginning serous, then hemorrhagic early appears. Forecast adverse.

Metastatic defeat limf, nodes C. is characteristic of cancer of a lung (see Lungs) and a gullet (see), cancer of thyroid and milk glands (see. Mammary gland, Thyroid gland), a seminoma (see) and adenocarcinomas of a kidney (see Kidneys, tumors). Increase limf, nodes C. is noted also at lymphatic, myeloid and other forms of a leukosis (see).

Diagnosis of malignant tumors of S. has the general principles. The lymphogranulomatosis and the reticulosarcoma proceeding with increase limf of nodes C., give similar rentgenol. picture. Primary sarcoma of cellulose C. is shown by the blackout of an uncertain form more often located in a lower part of back Page. In the absence of the increased peripheral limf, nodes or negative data of a biopsy morfol. verification of a disease is possible by means of a puncture biopsy, a mediastinoskopiya or a front parasternal mediastinotomy with capture on a research increased limf, nodes or the site of tumoral fabric.

Developed rentgenol. the research (a direct and side X-ray analysis, a tomography) including if necessary an angiography, pheumothorax and a pnevmomediastinografiya taking into account a wedge, data (a pneumorrhagia and existence of tumor cells in a phlegm at cancer of a lung, quite often characteristic noise at an aortic aneurysm, etc.), results bronkho-and ezofagoskopiya, sometimes mediastino-and torakoskopiya, allows to localize precisely tumoral process in S. Slozhney to establish character of a course of tumoral process. At the same time first of all the wedge, data (intensity of development and the course of a disease, degree of manifestation and character of a compression syndrome, phenomenon of the general intoxication) in combination with results rentgenol are considered. researches. However final establishment of a type of a malignant tumor at suspicion on it perhaps only after a biopsy peripheral limf, a node, a research of pleural exudate, the punctate of a tumor received at a puncture through a chest wall or a wall of a trachea, bronchial tube at a bronkhoskopiya, a mediastinoskopiya or a parasternal mediastinotomy, a thoracotomy as the final stage of diagnosis. In a crust, time radiation therapy and antineoplastic means are not applied without establishment with the help tsitol. or gistol. methods of structure of a malignant new growth.

Radio isotope research (see) S.'s tumors carry out for definition of a form, the sizes, prevalence of tumoral process, and also differential diagnosis between malignant, benign tumors, cysts and inflammatory processes. The method is applied also to assessment of efficiency of beam, chemotherapeutic treatment and identification of a recurrence. The indication for a radio isotope research is existence on S.'s roentgenograms patol. shadows of not clear nature, suspicion on metastasises, a sarcoidosis, the prolonged pneumonia resistant to treatment.

Fig. 3. Stsintigramma of the patient with a lymphosarcoma of a mediastinum: intensive accumulation of radio pharmaceutical drug in the field of a mediastinum.

The radio isotope research is based on the principle of selectively increased accumulation of radio pharmaceutical drug (RFP) in malignant tumors in comparison with surrounding fabrics. At a research C. two drugs are generally used: citrate of gallium ( 67 Ga) and Bleomycinum, marked indium ( 111 In). Each of these drugs is entered intravenously. The research on the gamma camera or the scanner is begun in 48 — 72 hours after an injection. At malignant tumors of S. (cancer, lymphoma, metastasises) on stsintigramma (skanogramma) the center of the increased accumulation of RFP (fig. 3) is defined, the size to-rogo corresponds to the size of a shadow of a tumor on roentgenograms. Resolving power of a method, i.e. the minimum size of the defined tumor, makes 1,5 — 2 cm. Test-sensitivity depends on a type of a tumor. So, according to Edwards and Heyer (S. of L. Edwards, R. Nauyeg, 1969), at lymphoma it is equal to 85 — 90%, and at cancer and metastasises of 70 — 75%.

At effective treatment of a tumor of S. on repeated stsintigramma accumulation of RFP in S. is not defined, and identification of «the hot center» on skanograkhmma after a course of treatment is the proof of development of a recurrence.

The variety of tumors of S. and opukholepodobny diseases complicates their diagnosis and the choice of a method of treatment.

High radio sensitivity malignant, and first of all limfoproliferativny (a lymphogranulomatosis, a lymphosarcoma, etc.), S.'s tumors proves use of ionizing radiation as independent method of treatment, and in a complex with chemotherapy (see. Chemotherapy of tumors ).

Radiation is carried out on gamma and therapeutic devices (see Gam-ma-apparaty) and linear dynamitrons (see. Particle accelerators ). Opposite fields, a configuration apply to-rykh depends on the volume of defeat and is created individually at each patient by means of the shielding blocks. The single focal dose makes 200 — 220 is glad (2 — 2,2 Gr), week (5 sessions) — 1000 — 1100 is glad (10 — And Gr). At achievement of a dose equal of 2000 I am glad (20 Gr), appoint a week break in radiation for implementation of effect of therapy. After that on the basis of a repeated rentgenol. researches create fields of the smaller sizes. The total focal dose is led up to 4000 — 4500 I am glad (40 — 45 Gr), and in nek-ry cases (at a lymphosarcoma) to 5000 — 5500 I am glad (50 — 55 Gr).

At cancer therapy of a gullet and lungs with metastasises in limf, nodes C. of the field of radiation create defeats according to Topeka. The total focal dose at a radical course makes, as a rule, 6000 is glad (60 Gr), at palliative — 4000 is glad (40 Gr). The attempt of performing radiation therapy is possible also at primary sarcoma of cellulose C. The main complications of radiation therapy are a pulmonitis (see. Pneumonia ), beam fibrosis, a pericardis (see).

The combined treatment of malignant new growths of S. can be planned only at malignant tumors of a thymus or in rare instances at a retrosternal craw.

At all high-quality new growths of S. earlier radical operation is shown. An exception do only at new growths of the right cardiophrenic corner (a coelomic cyst of a pericardium, a mediastinal lipoma) at absence a wedge, symptoms and tendencies to increase patol. shadows at rentgenol. research. Behind such pain-nykhmi can be established dynamic observation with an annual rentgenol. control.

At malignant tumors of S. of the indication to operation are defined by many factors, and first of all — prevalence and morfol. features of process. Even partial removal of a malignant tumor of S. improves a condition of many patients. Besides, the degrowth of a tumor creates the best conditions for the subsequent radiation and chemotherapy.

Contraindications to operation are determined by weight of a condition of the patient (extreme exhaustion, expressed hepatic, renal, the pulmonary heart which is not giving in to therapeutic influence) or signs of explicit not operability (existence of the remote metastasises, dissimination of a malignant tumor by a parietal pleura, etc.).

The forecast depends on a form of a tumor and timeliness of the carried-out treatment.

Operations

Operations on a mediastinum are developed rather well now. The careful preoperative inspection providing a right choice of operational access to S. — transpleural or longitudinal chrezgrudinny shall precede them (see. Mediastinotomy ). After establishment of indications to operation the vigorous preoperative preparation considering specific features of an organism of the patient and the nature of changes in the bodies caused by development patol shall be undertaken. process. Special attention shall be paid to sanitation of an oral cavity and a nasopharynx (a nasal part of a throat, T.) and to treatment of heart diseases and lungs. In the presence of inflammatory process in S. reasonablly short-term intensive introduction of antibiotics.

A rational method of anesthesia is the combined endotracheal anesthesia using muscle relaxants. In some cases use a local infiltration anesthesia according to Vishnevsky.

An operative measure is shown at tumors and S.'s cysts, and also at acute mediastinites and foreign bodys of S. which are followed hron. inflammatory process, pains or pneumorrhagia.

The special attention is deserved by two operations: removal of a big retrosternal craw only from cervical access, i.e. without sternotomy or a thoracotomy (for removal of a craw from a chest cavity on a neck use stage imposing on a node of seams handles); removal of a juxtaspinal neurinoma

in the form of hourglasses from two accesses — a standard side thoracotomy and a lakhminektomiya.

Results of operational removal of tumors and S.'s cysts, and also foreign bodys of S. generally favorable. The operational lethality makes 2 — 4%.



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B. V. Petrovsky; G. D. Baysogolov (I am glad.), R. I. Gabuniya (radio isotope diagnosis), S. S. Mikhaylov (An.), A. I. Pirogov (PMC.), And. X. Rabkin (rents.).

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