Surgical Science, 2011, 2, 212-214
doi:10.4236/ss.2011.24047 Published Online June 2011 (http://www.SciRP.org/journal/ss)
Copyright © 2011 SciRes. SS
Mediastinal Masses: Pathophysiological Issues and
Management Challenges in a Developing World
Martins Oluwafemi Thomas, Ezekiel O. Ogunleye
Lagos University Teaching Hospital/College of Medicine of University of Lagos, Lagos, Nigeria
Received January 10, 2011; revised March 24, 201 1; acce pted April 12, 20 1 1.
Context: Mediastinal masses occur worldwide. Compartmental occurrence and pathological variants vary
widely, hence, the need for more studies. AIM: The study was conducted to further shed light on patho-
physiological and current management challenges of mediastinal masses. Settings and Design: It was a pro-
spective hospital based study spanning a period of 5 years. Methods and Materials: We gathered patients in
series noting their ages and sex, presenting symptoms, investigation reports, treatment modalities and associ-
ated postoperative complications. Statistical Analysis Used: Data was analysed manually looking at fre-
quency distribution, correlation of malignancy with compartment involved and duration of symptoms against
incidence of malignancy. Results: We saw 38 patients with significant male preponderance. Most tumours
were in anterior mediastinum and population distribution was leptokurtic. Conclusions: Population distribu-
tion of mediastinal masses is leptokurtic. The second to the fourth decades of life are mostly affected. There
was no correlation between occurrence of malignancy and the mediastinal compartment involved. Most be-
nign tumours are symptomatic and duration of symptoms is not discriminatory between benign and malig-
nant variants. Occurrence of malignancy had no bearing with duration of symptoms. If less than two months,
it became significant at sixth month when benignity was positively correlated with long duration of symp-
Keywords: Mediastinal Masses Management Challenges
The mediastinum is the space between the two lungs.
The space is protected by the rigid anterior and posterior
chest walls. Much of the space is occupied by the heart
and the great vessels. The other components include
lymph nodes and thoracic ducts to mention a few. Any of
these component organs can become enlarged thereby
becoming symptomatic or even asymptomatic. Mediasti-
nal tumours benign or malignant may be primary or sec-
ondary, congenital or acquired [1-4]. Most benign tu-
mours are primary to the mediastinum in location but
cervico-mediastinal tumours are also fairly common.
They are mostly solid tumours, but may be cystic or
Benign masses present mostly with pressure symp-
toms. They also present with endocrine symptoms. Ma-
lignant masses may present with pressure or constitu-
tional symptoms. However some tumours may present
with atypical symptoms. Ankermann and his colleagues
 found three paediatric cases that presented like bron-
chial asthma. Critical mediastinal mass with propensity
to cause respiratory symptoms in children is associated
with the followings: anterior location of the mediastinal
mass, histological diagnosis of lymphoma, presence of
superior vena caval obstruction, radiological evidence of
vessel compression or displacement, pericardial effusion
and pleu ral effusi on .
The histological patterns al so vary wi dely . The common
benign tumours of the antero-superior mediastinum in-
clude thyroid masses, thymomas and vascular tumours to
mention a few. The middle mediastinum is dominated by
the pericardial masses while the posterior mediastinum is
dominated by neurogenic t umours like gangl ioneurom as.
While an earlier report from Ibadan, southwest Nigeria
confirmed lymphomas as the commonest primary medi-
astinal masses,  Lam and his colleagues  in Singa-
pore found neurogenic tumour as the commonest his-
M. O. THOMAS ET AL.
tologic variant. Some of the rare tumours of the medi-
astinum include sarcoma of follicular dendritic cells in
the posterior mediastinum, non seminomatous germ cell
tumour, adenomatoid tumour, mediastinal extrame-
dullary haemopoietic tumour, thoracic duct cysts and
cervicothoracic schwannoma. [8-12]
In view of the internal location of most mediastinal
masses, symptomatology has to be supported by imaging
techniques to define the tumours. Diagnosis was based
mainly on clinical features and standard chest radio-
graphs in Nigeria till about a decade ago . Fine nee-
dle aspiration has been tried by authors from Saudi Ara-
bia  and another team in Ibadan.  Personal ex-
perience, though not published shows that the gold stan-
dard nowadays for the diagnosis of mediastinal masses is
imaging, and it has reduced the incidence of diagnostic
thoracotomy in the management of such ma sse s.
Access to the mediastinum is usually through a thora-
cotomy or sternotomy incision but a cervical approach
may suffice for some cervicomediastinal lesions. More
recently, endoscopic computer-enhanced mediastinal
mass resection using robotic technology is being done
thorough minimal access . This is associated with
shorter hospitalisation because surgical trauma is mini-
This work was done to study the pathophysiological
issues and management challenges of m edi astinal masses.
2. Subjects and Methods
The design of the study was for a prospective and hospi-
tal based setting spanning five years in the metropolitan
Lagos, Nigeria. We created a protocol for entering the
relevant data. These data included patients’ demography
with special note of age and sex. We took note of the
presenting symptoms, report of investigations stating the
location of the mass, treatment modality and specific
associated operative and postoperative complications.
We excluded vascular masses like thoracic aneurysms
and all masses that were treated with chemotherapy and
radiotherapy. We only included the surgically treated
The data was subsequently analysed. We looked at the
frequency di st r i but i o n of the d at a .
We also looked at the duration of symptoms vis-à-vis
the incidence of malignancy and we sought correlation
between mediastinal compartment involved and occur-
rence of malignancy.
There were 38 patients with Mediastinal masses in 5
years. They consisted of 29 males and 9 females giving a
Male: Female ratio of 3.2:1.
The antero-superior Mediastinal masses dominated
with 29 patients (76.3%) while 18.4% and 2.6% were
found in the posterior and middle mediastinum respec-
tively (Table 1). The sample population had a mean age
of 33.7 ± 10.0 years. The median of 32.7 was close to the
mean and it was marginally leptokurtic. This means that
the distribution was close to normal with a Pearson
Skewness of +0.30
We saw 17 thyroid masses constituting 44.7%, 10 pa-
tients had lymphomas constituting 26.3% and 7cases of
neurogenic tumour 18.4%. Others were 3 thymic tu-
mours (7.9%) and only one pericardial cyst (2.6%).
The asymptomatic patients were 13 (34.2%) in all.
They were incidental findings on chest radiographs.
There was no correlation between occurrence of ma-
lignancy and the mediastinal compartment involved. This
correlation could not be tested with the middle mediasti-
num because we saw only one middle mediastinal mass.
There was also no correlation between duration of
symptoms and occurrence of malignancy as tested with
arbitrary durations of one and two month durations re-
spectively. The position changed at the 6th month where
87.3% were fo un d t o be benign.
Tumours of the mediastinum are either primary or sec-
ondary. Management of mediastinal tumours can be
challenging. The reasons for this have to do with the
need for complex or sophisticated facilities for diagnosis
and treatment. This often limits the diagnosis and treat-
ment of such tumours.
In our study, we saw 38 patients who had mediastinal
masses in five years. This constituted an annual hospi-
tal-based occurrence of 7.6 cases and it was nearly dou-
ble the occurrence of mediastinal masses in Ibadan, a
centre 120 kilometres North-east of our cen tre  within
Table 1. Age & sex distribution and locations.
(yrs) MFAntero-superior Middle PosteriorTotal
<10 1-1 - - 1
11 - 20 1-1 - - 1
21 - 30 10211 - 1 12
31 - 40 13413 1 3 17
41 - 50 233 - 2 5
51 - 60 1-- - 1 1
>60 1-- - - 1
Total 29929 1 7 38
Copyright © 2011 SciRes. SS
M. O. THOMAS ET AL.
Copyright © 2011 SciRes. SS
the same period. We have no good explanation for the
increased occurren c e at o u r centre.
Our study showed a male preponderance of 76.3%.
This is very close to the finding of 71.4% in the same
study (vide supra) conducted over a 24-year period.
The mean age in our series was 33.7 ± 10 years. It is
fairly close to the mean of 35.2 ± 22.1 years found in a
similar report for the same region . Cumulatively,
76.3% of the affected patients in our series were in the
3rd and 4th decades of life with a skew towards the 4th
More than 2/3 of the tumours were in the an-
tero-superior mediastinum, followed by less than 20 % in
the posterior mediastinum and the middle mediastinum
harboured only one case. This distribution is quite simi-
lar to positions held by earlier authors [7,13].
Thyroid masses contributed 44.7% of the tumours
while lymphomas and neurogenic tumours were 26.3%
and 18.4% respectively. This contrasts with earlier posi-
tions where lymphomas, thymic tumours and thyroid
masses were found in reducing order [7,13].
Majority of our patients were symptomatic at presen-
tation. In all, 65.8% presented with varying symptoms
leaving only 34.2% as incidental findings. Even at that,
the asymptomatic group is still very significant and it
might constitute a good reason for routine screening of
patients in the 2nd and 3rd decades of life.
There is no particular preference of malignant tumours
for any mediastinal compartment. Also, within a period
of 2months of symptoms, there was no correlation be-
tween occurrence of malignancy and duration of symp-
toms to an extent that 87.3% of cases were found to be
We therefore concluded that long duration of symp-
toms (>6 months) is a pointer to benignity of mediastinal
 Y. Zhang, S. R. Yang, D. U. Cheng and J. Guan “Clinical
and Pathological Features of Congenital Bronchial Cyst,”
Chinese Journal of Tuberculosis and Respiratory, Vol. 26,
No. 10, 2003, pp. 619- 622.
 L. H. Cheng and F. C. Wells, “A Multidisciplinary Ap-
proach to Recurrent Cervicothoracic Cystic Hygroma in
an Adult,” Britain Journal of Maxillofac Surgery, Vol. 42,
No. 1, 2004, pp. 66-68.
 N. S. Adzick “Management of Foetal Lung Lesions,”
Clinics in Perinatology, Vol. 30, No. 3, 2003, pp. 481-
 J. H. Kim, J. M. Goo, H. J. Lee, M. J. Chung, S. I. Jung,
Lim KY, M. W. Lee and J. G. Im, “Cystic Tumours in the
Anterior Mediastinum. Radiologic-Pathological Correla-
tion,” Journal of Computer Assisted Tomography, Vol.
27, No. 5, 2003, pp. 714-723.
 T. Ankermann, A. Claviez and M.Suttorp, “Mediastinal
tumour in Children Initially Misdiagnosed and Treated as
Bronchial Asthma,” Dtsch Med Wochenschr, Vol. 129,
No. 12, 2004, pp. 613-616. doi:10.1055/s-2004-820570
 J. C. Lam, C. H. Chui, A. S. Jacobsen, A. M. Tan and V.
T. Joseph, “When is a Mediastinal Mass Critical in a
Child? An Analysis of 29 Patients,” Pediatric Surgery
International, Vol. 20, 2004, pp. 180-184.
 V. O. Adegboye, A. O. Ogunsehinde, M. O. Obajimi, O.
Ogunbiyi, A. I. Brimmo, O. A. Adebo, “Presentation of
Primary Mediastinal Masses in Ibadan,” East African
Medical Journal, Vol. 80, No. 9, 2003, pp. 484-487.
 S. M. Krober, A. Marx, H. Aebert, B. M. Dohmen, E.
Kaiserling, “Sarcoma of Follicular Dendritic Cells in the
Dorsal Mediastinum,” Human Pathology, Vol. 35, No. 2,
2004, pp. 259-263. doi:10.1016/j.humpath.2003.09.008
 Y. M. Al-Marzooq, A. T. Al-Bahrani, R. Chopra, M. I.
Al-Momatten “Fine Needle Aspiration Biopsy Diagnosis
of Intrathoracic Extramedullary Hematopoiesis Present-
ing as a Posterior Mediastinal Tumour in a Patient with
Sickle-Cell Disease: Case Report,” Diagnostic Cytopa-
thology, Vol. 30, No. 2, 2004, pp. 119-121.
 D. O. Irabor, J. K. Ladipo, F. N. Nwachokor, J. O. Tho-
mas, “Schwannoma of the Left Branchial Plexus Mim-
icking a Cervicomediastinal Gotre in a Young Nigerian
Lady,” West African Journal of Medicine, 21, 3, 2002, pp.
 J. A. Plaza, F. Dominguez, S. Suster, “Cystic Adenoma-
tous Tumour of the Mediastinum,” American Journal of
Surgical Patholo g y , 2004, Vol. 28, No. 1, pp. 132-138.
 C. S. Pramesh, M. S. Deshpande, G. H. Pantvaidya, S.
Sharma, R. K. Deshpande, “Thoracic duct cyst of the
mediastinum,” Annals of Thoracic and Cardiovascular
Surgery, Vol. 9, No. 4, 2003, pp. 264-265.
 V. O. Adegboye, A. I. Brimmo, O. A. Adebo, O. O.
Ogunsehinde, M. O. Obajimi, “The place of clinical fea-
tures and standard chest radiography in evaluation of me-
diastinal masses,” West African Journal of Medicine, Vol.
22, No. 2, 2003, pp. 156-160.
 J. A. Morgan, T. Kohmoto, C. R. Smith, M. C. Oz and M.
Argeziano, “Endoscopic Computer-Enhanced Mediastinal
Mass Resection using Robotic Technology,” Heart Sur-
gery Forum, Vol. 6, No. 6, 2003, pp. E164-166.