TUMOR

MEDIASTINUM Pembimbing :
dr. Qonita, Sp.Rad
dr. Farid Wadjdi Khafidz, Sp. Rad
dr. Dina H Susanti, Sp. Rad
Disusun Oleh : Alif Riadi

SMF RADIOLOGI RSUD KABUPATEN JOMBANG

L/O/G/
FAKULTAS KEDOKTERAN UNIVERSITAS
MUHAMMADIYAH MALANG O
Tumor Mediastinum

1 Pendahuluan

2 Anatomi mediastinum

3 Diagnosis  Gambaran klinis dan pem. penunjang

4 Klasifikasi Tumor Mediastinum

5 Penatalaksanaan

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 Pendahuluan
Tumor Mediastinum Massa

Rongga Mediastinum

Sempit Penekanan pd organ

sekitarnya
Lambat Silent in early phase

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 Pendahuluan
• Gejala utama  penekanan pd organ
sekitar
• Insidentil pd pemeriksaan Ro thorak rutin
• Gambaran khusus penyakit  sesuai
dengan anatomi dan asal embriologi
• Ganas  anak (50%)
 dewasa (25%)

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 Anatomi Mediastinum
Anatomical Surgical

Schwartz et al., 1999

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 Anatomi Mediastinum

Albert: Clinical Respiratory Medicine, 2nd ed, p. 790 www.themegallery.com

 Anatomi Mediastinum; potongan
melintang

Mediastinum Anterior

Mediastinum Medial

Mediastinum Posterior

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http://mywebpages.comcast.net/wnor/thoraxlesson3.htm
 Anatomi
Anterior Superior Media Posterior

• Esophagus
•Thymus Gland •Pericardium • Vagus nerves
•Aortic Arch •Heart • Sympathetic
• Superior Vena •Great Vessels Chain
•Trachea • Thoracic duct
Cava • Thoracic
•Lymph Node • Trachea
desending
• Parathyroid Bifurcation • Aorta
Gland •Main
• Azygos
•Ectopic Thyroid Bronchi • Hemiazygosve
Tissue •Phrenic in
Nerve • Paravertebral
• Hilar Lymph Lymphnode
Node www.themegallery.com
•Neural tumours 40% •Neural tumours 20-27%
•Lymphoma 20% •Thymic 19-26%
•Teratomas & Cysts 15-25% •Cyst 18-21%
•Thymic rare •Teratoma \ lymphoma 11-15%
•Posterior Mediastinum •Anterior Mediastinum
•Most often benign •Often Malignant
•2/3 of tumors symptomatic •1/3 of tumors symptomatic
•Ages 30 – 50

A CHILDREN B
ADULT
Perbedaan Tumor Mediastinum
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 Etiologi

Fisik Genetik Kimiawi

Nutrisi Bioorganisme Hormon

 Patofisiologi

EN
MUTASI G

SEL Kompensasi SEL

NORMAL tubuh: ABNORMAL
APOPTOSIS
/
erusak
Agen p n Lin
ge
karsino me gkun
ma gan
da
i tidak

NEOPLASMA
Gambaran Klinis
ANAMNESIS
• Tanpa gejala

>> •Terdeteksi saat pemeriksaan Ro

toraks rutin

• Penekanan pada organ sekitar

Jinak

• Penekanan & invasi organ sekitar

Ganas
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Gambaran Klinis

Batuk, sesak/stridor  trakea-bronkus

Disfagia  esofagus

SVCS  >> tumor ganas

Suara serak & batuk  n laringeus

Paralisis n. frenikus  n frenikus

Nyeri dinding dada  tumor neurogenik

dan penekanan sistem syaraf
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Pemeriksaan Fisik

•  informasi  sesuai lokasi, ukuran

dan keterbatasan organ lain

• Dapat dikaitkan dg beberapa keadaan

klinis spt:
- miastenia gravis  timoma
- limfadenopati  limfoma

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Pemeriksaan Penunjang
• Rontgen toraks
 Lokasi tumor  anterior, medial atau posterior
 Tumor besar  sulit

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Pemeriksaan Penunjang

• CT scan toraks dgn kontras

 lokasi tumor  perkiraan jenis
 Menentukan stage invasi sekitar
+/-
 Guiding  sampel sitologi
 Untuk menentukan luas radiasi

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Klasifikasi
 Timoma

Definisi:
• Timoma adalah tumor mediastinum anterior  kelenjar timus.

Gejala klinis :
• umumnya memberikan gambaran jinak  sering ditemukan tanpa
gejala yang khas dan sulit dideteksi dengan pemeriksaan fisik

Prevalensi:
• tumor yang paling banyak ditemukan, sekitar 47%
• Sekitar 30-50% penderita timoma mengalami miastenia gravis dan
sekitar 10-15% penderita miastenia gravis mengalami timoma
Diagnosis
• Foto rontgen thorax
• Ct scan
• FNAB

X ray normal

Tymoma
Stadium dan terapi
 Teratoma

Definisi:
• Teratoma (Tumor Mediastinum Anterior)
merupakan neoplasma yang terdiri dari beberapa
unsur jaringan yang asing pada daerah dimana
tumor tersebut muncul

Prevalensi:
• 15% dewasa
• 25% anak
 Gejala klinis
The majority of patients are asymptomatic, with the mediastinal mass discovered incidentally
Masses that become symptomatic can do so in a variety of ways:
• mass effect
– respiratory distress (infants)
– respiratory failure
– superior mediastinal syndrome
– neck mass
– Horner syndrome 
• endocrine function
– hormone production, e.g. beta-HCG, insulin
• rupture
– chest pain
– hemoptysis
– respiratory distress
– cardiac tamponade 
– pleural effusions
 Tipe
• Teratomas may either be:
– mature: well differentiated
– immature: poorly differentiated
– with malignant transformation
• mature teratoma with non-germ cell malignancy arising
from one of the components 
 Radiographic features

• The vast majority of

mediastinal teratomas
are located in the
anterior mediastinum
(80%), with most of the
remainder involving
multiple compartments
(13-15%). Isolated
posterior or middle
mediastinal location is
uncommon (2-8%)
 Limfoma
• Limfoma adalah sekumpulan keganasan
primer pada kelenjar getah bening dan limfoid
• Berdasarkan tipe histologiknya dibagi menjadi
Limfoma hodgkin,
Limfoma non hodgkin
 Epidemiologi

• Limfoma bertanggung jawab atas sekitar 15%

dari semua massa mediastinum primer, dan
45% massa mediastinum anterior pada anak-
anak.
 Gejala klinis
• umunya non spesifik:
Penurunan BB > 10% dlm 6 bulan
Demam 38 C > 1 minggu tanpa sebab yg jelas
Keringat malam banyak
Cepat lelah
Kekurangan nafsu makan,
Pembesaran KGB
Terdapat benjolan yang tidak nyeri

• Symptoms directly attributable to the mediastinal component include:

– retrosternal chest pain
– SVC compression with SVC syndrome
– dyspnea
– cough
 Radiographic features
• The majority of patients have anterior
mediastinal and paratracheal involvement.
Isolated hilar nodal involvement is uncommon
• Treatment and prognosis
• Specific treatment depends on the type of
lymphoma and the stage, but broadly requires
chemotherapy and or radiotherapy
• Similarly, the prognosis is very variable. 
Stage I and II Hodgkin lymphoma have the
best prognosis with a greater than 90% cure
rate
 Adenoma paratiroid
• Parathyroid adenomas are benign tumors of the parathyroid glands, and are
the most common cause of primary hyperparathyroidism.
• Epidemiology
Demographics: 75% women, usually in 30s
• Clinical presentation
Patients present with primary hyperparathyroidism: elevated serum calcium levels and
elevated serum parathyroid hormone levels. This results in multisystem effects including
– Osteoporosis,
– renal calculi,
– constipation,
– peptic ulcers,
– mental changes,
– fatigue, and
– depression.
• Location
The majority of parathyroid adenomas are
juxtathyroid and located immediately posterior
or inferior to the thyroid gland. Superior gland
parathyroid adenomas may lie posteriorly in the
tracheo-esophageal groove, paraesophageal
location, or even as inferior as the mediastinum
X ray

Calcified mass in the right paratracheal region

consistent with calcification of the known
thyroid adenoma.
• X-ray is helpful in diagnosis of parathyroid adenoma. Finding in X-ray suggestive of parathyroid adenoma
includes subperiosteal bone resorption, endoosteal bone resorption, subchondral resorption,
subligamentous resorption, intracortical resorption, osteopenia, brown tumors, salt and pepper sign in the
skull (pepper pot skull), and chondrocalcinosis.
USG

Ct scan
MRI
• Differential diagnosis
• parathyroid hyperplasia
• eccentric thyroid nodule
• sequestered thyroid tissue
• lymph node
• vessel
 Lipoma
• Lipoma adalah tumor jaringan lunak yang
paling umum. Tumor lemak jinak yang tumbuh
lambat ini membentuk massa yang lunak,
berlobus, dan dikelilingi oleh kapsul tipis
berserat.
 History and Physical Examination
• Lipomas are most often asymptomatic.
• When they arise from fatty tissue between the skin and
deep fascia,
• typical features include a soft, fluctuant feel; lobulation;
and free mobility of overlying skin.
• A characteristic "slippage sign" may be elicited by gently
sliding the fingers off the edge of the tumor. The tumor will
be felt to slip out from under, as opposed to a sebaceous
cyst or an abscess that is tethered by surrounding induration.
• The overlying skin is typically normal.
 Symptoms
• Symptoms in other sites depend on the location
• Lipomas in the major airways can cause
respiratory distress related to bronchial
obstruction; patients may present with either
endobronchial or parenchymal lesions
• ntramediastinal lipomas may impinge on the
superior vena cava, thereby leading to 
superior vena cava syndrome
 Radiographic feature

A well circumscribed mass (yellow line) is present projecting to the right

of the mediastinum. On the frontal chest x-ray the hilar vessels (red
line) are seen projecting though it indicating the mass is not at the
hilum itself (hilum overlay sign). On MRI the mass can be seen distinct
from the normal mediastinal fat (blue arrows).
 Neurogenic tumors
• Tumor neurogenik adalah penyebab sekitar
90% dari massa mediastinum posterior.
Mereka dapat dibagi menjadi tiga kelompok
berdasarkan lokasi mereka dan keterlibatan
saraf perifer atau rantai simpatik.
– peripheral nerve sheath tumors
– sympathetic ganglia tumors
– paragangliomas
Peripheral nerve origin
                        • Neurofibromas
                        • Neurilemomas (Schwannomas)
Sympathetic nerve origin
                        • Ganglioneuromas—usually benign
                        • Neuroblastomas—usually malignant
                        • Sympathicoblastomas—usually malignant
Paraganglionic cells
                        • Pheochromocytoma
                        • Chemodactomas (paragangliomas)—benign or
malignant
Neurofibromatosis. There is a posterior mediastinal mass seen
on the frontal (white arrow) and lateral views (white arrow). The
mass lies in the paravertebral gutter. There are also multiple
subcutaneous nodules superimposed on the chest (red arrows)
from subcutaneous neurofibromas
 Kista pericardial
• Pericardial cysts are uncommon benign
congenital anomalies of the anterior and
middle mediastinum.
• Clinical presentation
• Usually asymptomatic and discovered
incidentally although occasionally may present
with chest pain and dyspnea
• Plain radiograph
• Typically seen as a mass-like
density at the cardiophrenic
sulcus. They can be of different
shapes and are not always
round. May change in shape and
size with inspiration and
position.

• Foto rontgen
thorax
 Jenis pemeriksaan penunjang lainnya
• Angiografi • Pemeriksaan lab
• Fluoroskopi • Prosedur PS
• Ekokardiografi – Sitologi
• Oesopagografi – Histologi
• USG, MRI
• Prosedur endoskopi
– Bronkoskopi
– Mediastinoskopi
– Torakoskopi
– esofagoskopi
 Tindakan Bedah

Torakotomi eksplorasi
 bila semua upaya diagnostik gagal

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DIAGNOSIS BANDING
berdasarkan lokasi tumor

Bauwmwwa.nthdeCmreagpaol
Anterior mediastinum: “four Ts”— Thymoma, Thyroid tumor, Terrible ylmphwowmw.ath,eTmeergaao
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Penatalaksanaan

JINAK GANAS
Tergantung jenis sel
Operasi
 Limfoma  kemoterapi
 Non limfoma
 multi modalit
o operasi  resisten
radi terapi dan kemo
o Adjuvan terapi
o Neo-adjuvan terapi
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 Penatalaksanaan
Syarat
KEMOTERAPI
BEDAH ELEKTIF
Pilihan RADIOTERAPI
 Spirometri  Hb > 10 mg%
terapi  Leuko
 AGD > 4000- < 10.000
 Tr > 10.000
 PS > 70
Karnofsky

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 Penatalaksanaan

CARA Kemoterapi & Radioterapi

Concuran Alternating Sequential

berbarengan bergantian Kemo > 2 siklus

 radioterapi
Atau
Radioterapi
 kemoterapi

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 Thank you!

Any question?

L/O/G/O