MEDIASTINAL MASSES IN WOMEN WITH MULTINODULAR THYROID DYSEASE

: CASE REPORT
Dewa Nyoman Putra Adiwinata* and I Nyoman Semadi**
*General Surgery Resident, Medical Faculty, Udayana University- Sanglah General Hospital
** Attending Physician, Subdivision of Cardiothoracic and Vascular Surgery,
Department of Surgery, Udayana University-Sanglah General Hospital, Bali-Indonesia

ABSTRACT
Mediastinal masses are a commonly encountered problem in clinic. Even though majority of these are caused by benign conditions,
many of them asymptomatic, a significant proportion of these can be caused by malignant etiology. 1
Benign mass present mostly with pressure symptoms. They also present with endocrine symptoms. Malignant mass may present
with pressure or constitutional symptoms. Howefer some tumours may present with atypical symptoms. Thyroid masses contributed
44,7% of the tumour while lymphomas and neurogenic tumours were 26,3 % and 18,4 respectively.3
More than 2/3 of the tumours were in the antero superior mediastinum, followed by less than 20% in the posterior mediastinum and
the middle mediastinum. 3
In this case, we performed CT Scan Thorak in patient with mediastinal mass. A woman, 59-years old complaind rest pain and in
chest more than Two month. She had history of multinodular Thyroid since 2 years ago. We perform sternotomy with dissection of
tumor, and total thyroidectmy to reduce the rest pain and prevent extend of masses.

INTRODUCTION
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.
Mediastinal tumours benign or malignant may be primary or
secondary, congenital or acquired. Most benign tumor 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
mixed. Benign masses present mostly with pressure symptoms. They
also presents with endocrine symptoms. Malignant masses may present
with pressure or constitutional symptoms.4
The initial radiologic study performed in the evaluation of
mediastinal masses is usually a chest radiograph. Most patients with a
mediastinal mass on chest radiograph should quickly be evaluated with
a chest CT scan. Chest CT is valuable because it shows cross-sectional
views of all the mediastinal compartments. The use of intravenous
contrast medium and the measurement of Hounsfield units during CT
are useful in differentiating vascular structures and fat density. 6
DISCUSSION
From phatological anatomy examination results of
mediastinum mass showed type A of Thymoma. Of the thymic
lesion, thymomas are the most common primary tumor of the
anterior medistinum. Thymomas occur most frequently in
patient between 45-50 years of age and rarely occur in patients
younger than 20 years. They often occur in the upper anterior
mediastinum, are well circumscribed, and may contain of
calcification , necrosis, hemorrhage, or cysts.
Thymoma may be identified radiographically by the
presence of a sulcus sign, which results from resistance of the
neoplasma to flattening by the adjacent heart and great vessels
caused by firmness of the mass. 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
treatment of such tumours. In a study by Davis et al, 85% of
patients with a malignancy were symptomatic, but only 46%
of patients with benign neoplasms had identifiable complaints.
The most common symptoms of presentation of mediastinal
tumours are with cough, dyspnoea, and chest pain.

CASE REPORT SUMMARY

We A woman, 59-years old complained chest pain since 2 months
ago and sometimes she complianed hard to breathe. He just controled
in local health care near his house and got some analgesic. She had
history of multinodular Thyroid since 2 years ago. There is no history
of asthma and heart disease. History of treatment with analgetic
medication. We performed CT-Scan axial slice without contrast first to
diagnose the problem with the pain. Patients CT-Scan of the chest
(Figure 1)
Benign mass present mostly with pressure symptoms.
They also present with endocrine symptoms. Malignant mass
may present with pressure or constitutional symptoms.
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 treatment of such tumour. The CT
scan chest is the single most important diagnostic modality
while evaluating mediastinal masses except for the posterior
mediastinal tumours of ‘‘Neurogenic origin’’ (where MRI
maybe useful).

Figure 1. Radiologic of thorak
After that we perform total thyroidectomy (figure 3) and
sternotomy with dissection of tumor (figure 4), and to reduce the rest
pain and prevent extend of masses.
Figure 3. Thyroid masses
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Figure 4. Thymoma masses