Mediastinal tumors

[Andjela]

My husband is 32.  He has had a recurrent pain in the front part of his left rib cage area.  The pain started at least a year ago and would come, last for a few days, then go away.  He thought it was a rib injury, because he did wrestling type sports so he didn't see a doctor.  He finally went to a doctor 2 days ago, a chest xray showed something cloudy on the left side of his rib cage.  He had a contrast CT today which, per his MD, showed a mediastinal tumor.  He will see a cardio-thoracic surgeon for consultation and probably a biopsy in 4 days.  We are obviously scared due to lack of information, not knowing if this can be benign or not.  The pain in his ribs was in the anterior, mid portion of left rib cage area, slightly more towards the bottom.  Does this automatically mean it's anterior tumor?  We read about those and they seem very likely malignant.  Our questions are, what are the chances of this type of tumor being benign vs. malignant?  If malignant, what are his chances for treatment, considering he has none of the symptoms we saw on websites (i.e. fever, chills, night sweats, etc).  The only symptom he ever had was the pain.  His doctor did do an ekg and blood work to rule out cardiac cause, and those were all normal.  Not sure what lab work was done.  Could the CT be wrong and there's nothing there?  This seems unlikely to me, since he is having pain in the area.  We just can't wait for next week to find out.  Any info will help (hopefully).  We are stressed and the timing can't be worse cause we're expecting a baby any week now.

[KatyG1982]

Hi. I am very interested in how the diagnosis/prognosis worked out for your husband. I had a similar situation this year and I am trying to research as much information as I can. I am a 33 year old female with a very large anterior mediastinal tumor which was unfortunately extremely PET avid. I had all of the classic "B" symptoms such as debilitating night sweats, daily fevers, weight loss, and chills. I was sent to an oncologist and infectious disease doctor who both stated I was looking at hodkins lymphoma. I underwent a bronchoscopy and mediastinoscopy with no successful biopsy. A couple of months ago I underwent a right lateral thoracotomy. The tumor was negative for lymphoma but positive for chronic histoplasmosis and late effects of fibrosis mediastinitis. Post histoplasmosis FM is rare. So rare none of my doc's know how to treat me.
I hope all is well and you and your husband had a successful outcome.

[Lexu7]

Hi,  I am very interested in how this man's tests/surgery turned out.  Did it turn out to be Synovial Cell Sarcoma?  My 44-year-old son had a large mediastinal tumor taken out 4 weeks ago.  The CT scan showed an encapsulated tumor (thymoma), but when they did surgery, they found an invasive thymoma tumor had wrapped around two nerves, a vein and had invaded the pericardiium of the heart and one lung.  The surgeon had to remove the vein, but because the tissue samples he sent to the lab during surgery were said to be benign, he left the two nerves intact (recurrent laryngeal and right phrenic) after removing as much tumor from them as possible.  He also removed part of the pericardium and a little slice of lung tissue.  (Now my son has nerve damage to his larynx and diaphagm.)  The final dx is stage 3 invasive thymoma, type B2.  He is getting radiation treatment to kill any residual cells.  Any advice or thoughts as to the DX or treatment?  I have read that some studies show that recurrence is less likely if chemo is done before surgery and radiation after surgery.  Is this your conclusion also?  In our case, the CT scan showed an encapsulated tumor, so a decision was made to go in after it with a sternotomy (open chest procedure).  It turned out to be very invasive.  Any explanation for this?  (No chemo was done.)

[Fernando Roque, MD]

Hi.  You may wish to have those slides reviewed by a second pathologist, just to make sure that it is indeed Synovial Cell Sarcoma.  You're right, this kind of tumor is not usually found in the chest wall/ mediastinal area, so it may be wise to have the biopsy slides rechecked before proceeding with the surgery. This is merely a suggestion, based on what you've posted in this forum. If your husband's doctor is reasonably certain of the diagnosis, then just go ahead with the operation.

[Andjela]

My husband had a biopsy last week and they definitely ruled out Lymphoma and Thymoma.  They couldn't figure out what it was so they had to send the specimen out for a special stain.  Today we found out it was a Synovial Cell Sarcoma, which, apparently, is weird to have in the chest wall.  The surgeon told my husband that he doesn't think the classification is quite precise, but it must be the closest they could get.  The good news is that the tumor is low grade and slow growing.  It will require surgery with no chemo or radiation.  It will be quite an extensive surgery with partial rib removal and a muscle flap.  Based on the CT scan, the surgeon feels that the cancer has not spread to other organs.  They will do an MRI scan tomorrow for a better picture.  

[Fernando Roque, MD]

Hi.  Thymoma has an excellent prognosis when properly treated.  Even stage 3 tumors have a ten year survival rate of around 80%, and a 10% overall recurrence rate, although recurrence was noted to be higher (20%) in those with invasive disease.

[Andjela]

Thank you so much for all your expertise.  We actually got to see a cardio-thoracic surgeon today.  He says the mass is left of sternum and it's just behind the front of the ribs.  It's very large, about size of a baseball.  They will do a biopsy tomorrow morning.  If it's Lymphoma, he wants to treat it with chemo and radiation.  If it's something else, he wants to remove it with surgery.  Either way it's not great, but it sounds like we at least have some options.  The surgeon thinks Lymphomas are very treatable nowadays.  Surgery would be pretty major, but my husband is young and strong.  The surgeon thinks   this is the primary site, not metastasis.  It's scary because of the size of the mass.  It's amazing that he's not having trouble breathing as this mass is compressing his left lung.  It is only on one side, so it sounds like that's better.  You mentioned prognosis for germ cell tumor and lymphoma.  What's the prognosis with thymoma?  Thank you again.

[Fernando Roque, MD]

Hi.  If the tumor is in the anterior mediastinum, then we're probably dealing with either a thymoma, a germ cell tumor, or a lymphoma.  Neurogenic tumors don't usually occur in the anterior mediastinum and is not a primary consideration.  Mediastinal germ cell tumors are very responsive to chemotherapy, and this is the preferred first line treatment for this disease (not surgery).  Long term disease free survival for these patients when given chemotherapy is around 80%, and most are curable.  Mediastinal lymphoma is also very responsive to chemotherapy, even when the mass is large and bulky.  The "success rate" for treating lymphomas depends on its specific type, but generally, masses which are confined in the mediastinum, or are found in only one side of the diaphragm, have a better prognosis.  I'm not aware of any blood test which reliably diagnoses lymphoma.  Specific lymphoma types are diagnosed by looking at the appearance of tumor cells under the microscope, and by the use of immunohistochemistry staining methods.  These procedures do not use blood but tissue samples from the mass itself (by means of a biopsy).

[Andjela]

Thank you Dr. Roque.  My husband's regular physician did tell him it was an anterior tumor.  We will see a cardiothoracic surgeon in 2 days.  Do you think he will be able to tell us anything at all, based on location?  I'm just worried that treatment, for instance surgery, will be difficult because of size or location of the tumor.  As long as there is some sort of a treatment, we'll feel slightly better.  Do you know the success rate of treatment for the malignant tumors?  It probably depends of the stage.  Is it ever possible to remove malignant tumors, if they haven't spread?  Also, we heard there was a blood test which can rule in or out Lymhoma.  Do you know if that's correct?
Thank you!

[Fernando Roque, MD]

Hi.  The four most common types of tumor found in the mediastinum are the following:  neurogenic tumors (accounting for 25.3% of all mediastinal tumors), thymoma (23.3%), lymphoma (15.3%), and germ cell tumors (12.2%).  Thymoma is usually a benign condition, but may degenerate into an invasive tumor in some cases. Neurogenic tumors which occur in infants and children are frequently malignant, but the majority of those found in adults are benign.  Germ cell tumors and lymphomas are malignant but very treatable diseases, and a lot of these cases are curable.

Neurogenic tumors originate from nerves found near or around the mediastinum, like the vagus nerve, brachial plexus and sympathetic ganglia.  These tumors are usually found in the posterior mediastinum, accounting for 75% of masses in this location.  Thymomas originate from the thymus gland, which is a gland found in the anterior mediastinum, and which is involved in the maturation of T-lymphocytes.  Germ cell tumors are similar in origin to those found in the gonads (e.g. testicles), and lymphomas are malignancies involving lymphocytes and lymph nodes.

The character of your husband's pain cannot accurately tell us whether that tumor is located in the anterior or posterior mediastinum.  It is also hard to tell, at this point, if that mass is benign or malignant, or what specific type it is, since your husband doesn't have other symptoms aside from the pain.

As for treatment, it really depends on what type of tumor it is, so you'll just have to wait for the biopsy results to come out.  Feel free to post updates regarding your husband's condition, so we can discuss it further.