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The Mediastinum Edited by Alberto M Cambridge University Press 978-1-107-03153-1 - Pathology of the Mediastinum Edited by Alberto M. Marchevsky, Mark R. Wick Excerpt More information Chapter1 The mediastinum Alberto M. Marchevsky, MD, and Mark R. Wick, MD The mediastinum is the chest cavity region located as a – Anatomic classifications of the mediastinum “septum” between the two pleural cavities 1 5. It is an area of great interest to internists, pulmonologists, imaging specialists, It has become customary in clinical practice to divide the thoracic surgeons, and pathologists because it can be the site of mediastinum into anatomic compartments separated by arbi- origin of numerous pathologic processes 6. Indeed, the medi- trary lines. There are several anatomic classifications of astinum has been compared to a “Pandora’s box” full of the area, but the most widely used scheme is a simple one that divides the mediastinum into four compartments: super- surprises for physicians concerned with chest diseases. 1–3 Many interesting clinical problems associated with medias- ior, anterior, middle, and posterior (Fig. 1.3) . This classifi- cation is useful in that certain pathologic lesions are most tinal lesions have become apparent in the last few decades with 3–5,11 the development of very sensitive new radiologic techniques frequently located in particular compartments . For such as computerized tomography (CT scan), magnetic reson- example, thymic and thyroid tumors are usually in the anterior mediastinum, whereas most neurogenic lesions are found in ance imaging (MRI), and the extensive use of invasive diagnos- 3 tic procedures such as mediastinoscopy, limited thoracotomy, the posterior compartment . This scheme, however, has sev- transthoracic fine needle aspiration biopsy, ultrasound guided eral drawbacks such as the fact that there is no agreement in transesophageal fine needle aspiration biopsy (EUS), and ultra- the literature on whether the posterior mediastinum should – sound guided transbronchial fine needle aspiration biopsy 7 10. extend backward only to the anterior margins of the vertebral These techniques enable the detection, localization and biopsy bodies or more posteriorly into what some authors term the of mediastinal lesions hitherto located in “blind spots” of chest paraspinal area. X-rays. However, the diagnosis of most mediastinal lesions is Heitzman tried to overcome the limitations of this over- often rendered pathologically, a task that is often not simple, as simplified view of the mediastinum by proposing a much more the mediastinum contains numerous organs such as the detailed classification of the area based on anatomic landmarks thymus, lymph nodes, ganglia, ectopic thyroid and parathyroid that can be recognized on chest roentgenograms. In his tissues, soft tissues, and others that can become involved in scheme, the mediastinum can be divided into thoracic inlet, 6 anterior mediastinum, supraaortic area, infraaortic area, various pathologic processes . 7 The aim of this volume is to review the clinicopathologic supraazygous area, infraazygous area, and hila . aspects of all mediastinal lesions of interest to the surgical The thoracic inlet marks the cervicothoracic junction and is pathologist, with the exception of pathologic processes in the the area above and below a plane drawn transversely through esophagus. Although the esophagus is located in the medias- the first rib. The anterior mediastinum is the region extending tinum, a detailed description of its pathology is generally from the thoracic inlet to the diaphragm in front of the included in books dealing with the gastrointestinal tract. pericardium, ascending aorta, and superior vena cava. The supraaortic area is the region located behind the left side of the anterior mediastinum. It extends from the aortic arch to Anatomy of the mediastinum the thoracic inlet. The infraaortic area is the region located The mediastinum extends anteroposteriorly from the sternum behind the left side of the anterior mediastinum. It extends to the spine and sagitally from the thoracic inlet to the dia- from below the aortic arch to the diaphragm. The supraazy- phragm (Fig. 1.1) 1,2,5,9,11,12. Its boundaries include the ster- gous area is the region located behind the right side of the num anteriorly, the thoracic vertebra posteriorly, the first anterior mediastinum. It extends from the arch of the azygous thoracic rib, first thoracic vertebra, and manubrium super- vein to the thoracic inlet. The infraazygous area is the region iorly, and the diaphragm inferiorly. It contains the thymus, extending behind the right side of the anterior mediastinum the heart and other structures shown in Figs 1.1 and 1.2. from below the arch of the azygous vein to the diaphragm. The Pathology of the Mediastinum, ed. Alberto M. Marchevsky and Mark R. Wick. Published by Cambridge University Press. © Cambridge University Press 2014. 1 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-03153-1 - Pathology of the Mediastinum Edited by Alberto M. Marchevsky, Mark R. Wick Excerpt More information Chapter 1: The mediastinum Clavicle First rib Brachial plexus Subclavian artery and vein Intercostal arteries, veins and nerves Brachiocephalic arterial trunk Brachiocephalic nerves Right brachiocephalic vein Vagus nerve Left brachiocephalic vein Azygous vein Trachea Sympathetic neural trunk Superior vena cava and thoracic ganglia Phrenic nerve Superior lobar bronchus Thymus Pulmonary artery Pericardium Confluence of right middle lobe and right lower lobe bronchi Right pulmonary veins Esophagus Pericardiophrenic artery and vein; phrenic nerve Major splanchnic nerve Parietal pleura Intercostal arteries, veins and nerves Diaphragm Intercostal muscles Fig. 1.1 Diagram of the mediastinum showing different structures. Fig. 1.3 Diagram of the mediastinum illustrating the various mediastinal compartments. • Heart (H) T • Trachea (T) GV • Great vessels (GV) GV • Thymus gland (G) GV • Sympathetic nerves and ganglia G • Thoracic duct, lymphatic ducts, and lymph nodes H Fig. 1.2 Diagram of the mediastinum showing the heart and other mediastinal structures of interest. 2 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-03153-1 - Pathology of the Mediastinum Edited by Alberto M. Marchevsky, Mark R. Wick Excerpt More information Chapter 1: The mediastinum hila include both major bronchi and surrounding bronchopul- azygous vein, pulmonary artery, and superior division of the monary structures. right pulmonary artery), nerves (right recurrent laryngeal This classification is useful from the imaging point of view nerve, vagus nerve), and bronchi (right main bronchus and because it enables imaging specialists to localize lesions with right upper lobe bronchus); (c) to the left of the trachea, blood accuracy and aids in suggesting differential diagnosis, but is of vessels (thoracic duct, aortic arch, bronchial artery, pulmonary relatively little value to a surgical pathologist faced with the arteries), left recurrent laryngeal nerve, esophagus, and left task of establishing the pathologic diagnosis of a particular main bronchus; and (d) inferior to the trachea, carinal lymph mediastinal lesion that could arise in more than one area. nodes, esophagus, and tracheal bifurcation. Therefore, throughout this volume we utilize the simpler and The middle mediastinum strictly should include only the more widely used classification of the mediastinum into four pericardium and its contents. For convenience, however, compartments: superior, anterior, middle, and posterior. most anatomy textbooks describe the hila of the lungs in this compartment and include in the middle mediastinum import- Anatomic compartments ant bronchopulmonary lymph nodes classified by Nagaishi The superior mediastinum extends above a line drawn from the as follows: bronchopulmonary, pulmonary ligament, manubrium of the sternum through the lower edge of the Botallo’s ligament, tracheal bifurcation, tracheobronchial, fourth thoracic vertebral body (Fig. 1.3) 5,12. The anterior paratracheal, pretracheal, aortic arch, and innominate vein – mediastinum lies below the superior compartment, between angle nodes 1 3. the sternum and the pericardium. The posterior mediastinum The anterior mediastinum merges at its upper end with the extends behind a coronal plane through the posterior aspect of superior compartment and reaches inferiorly to the dia- the pericardium. The middle compartment lies between the phragm. It contains the thymus gland, blood vessels (e.g., the anterior and posterior divisions of the mediastinum. internal mammary artery and vein), lymph nodes (internal The superior mediastinum contains the phrenic nerves and mammary and diaphragmatic lymph nodes), connective tissue, the superficial and deep cardiac plexuses (Fig. 1.1). In addition, and fat. Occasionally it can contain thyroid and parathyroid the superior and middle mediastina contain a large number of tissue. structures that can be explored with the mediastinoscope and The posterior mediastinum is the space located behind the are usually classified according to their relationship to the pericardium and above the diaphragm. It merges directly with trachea, as the mediastinoscopist follows its pathway in order the superior mediastinum and includes important structures – to explore the paratracheal areas 8,9,13 16. They include (a) the such as the descending portion of the thoracic aorta, esopha- soft tissues anterior
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