Assessment of mediastinal mass

Overview
Summary Aetiology

Emergencies
Urgent considerations

Diagnosis
Step-by-step Differential diagnosis Guidelines

Resources
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Summary
Mediastinal anatomy
The mediastinum is the thoracic space between the visceral pleura of the lungs. The boundaries of the mediastinum are the visceral pleura, thoracic inlet (spine, first ribs, and manubrium), diaphragm, sternum, and anterior spinal ligaments. View image The contents of the mediastinum include the heart, great vessels, trachea, oesophagus, lymphatic tissue, and thymus gland. Tumours may arise from any of these organs. The mediastinum is divided into 4 compartments: superior, anterior, middle, and posterior. View image

Mediastinal contents
Superior mediastinal contents include: Upper third of the thoracic oesophagus Great vessels Trachea Upper poles of the thymus gland Paratracheal lymph nodes Descended thyroid.

Anterior mediastinal contents include: Mediastinal fat Lymph nodes Body and lower poles of the thymus Extracardiac aorta. Middle mediastinal contents include: Pericardium and heart Trachea and carina Lymph nodes. Posterior mediastinal contents include: Oesophagus Descending aorta Thoracic duct Sympathetic nerve chain.

Aetiology
The aetiology of a mediastinal mass can be limited based on its location within the mediastinal compartments. A mass may extend beyond the boundaries of these radiographically-defined compartments as it grows or

invades.
mediastinal mass limited by locationCreated by BMJ Evidence Centre

Aetiology of

Thyroid masses (goitre, neoplasm)

Located in the anterior mediastinum, a thyroid neoplasm can be benign or malignant. Follicular adenoma is the most common benign neoplasm in substernal goitres. [1] View image Malignant thyroid cancer is present in 10% to 15% of substernal goitres. [2] Follicular cells give rise to follicular adenocarcinoma, papillary carcinoma, and anaplastic carcinoma, while parafollicular cells (C-cells) give rise to medullary thyroid cancer. Medullary thyroid cancer is associated with multiple endocrine neoplasia type 2 syndrome (MEN 2), which comprises medullary thyroid cancer, phaeochromocytoma, and parathyroid hyperplasia.

Lymphadenopathy (metastatic, lymphoma)

Lymphadenopathy may result in a mediastinal mass in the superior, anterior, or middle mediastinum. Malignant aetiology is more commonly found in older patients and patients with a prior history of cancer. In general practice, the prevalence of undiagnosed malignant lymphadenopathy is about 1%. [3] Haematological malignancies such as Hodgkin's and non-Hodgkin's lymphomas and chronic lymphocytic leukaemia may have associated B symptoms, including fever, rash, and weight loss. Acute lymphocytic leukaemia presents as acute onset of symptoms due to cytopenias such as fatigue, bleeding, and recurrent infections.

Thoracic aortic aneurysm

Thoracic aortic aneurysm is a localised or diffuse dilation of the aorta involving all layers of the vessel. It may present as a mediastinal mass in the superior, middle, or posterior mediastinum. Ascending aortic aneurysms are often caused by cystic medial degeneration or necrosis, which is often associated with collagen vascular disorders. Descending aortic aneurysms are most often associated with atherosclerotic disease. The natural history of thoracic aortic aneurysms involves gradual expansion and eventual rupture if untreated. [4] [5]

Thymic masses (thymic neoplasm, thymic hyperplasia)

Thymic neoplasms account for 30% of anterior mediastinal masses in adults [6] and 15% of anterior mediastinal masses in children. [7] WHO classification of thymic tumours is commonly used to classify thymic neoplasms into Type A (benign thymoma), Type B, and Type C (thymic carcinoma). [8] Thymic masses occur in no particular age group, although they have a higher incidence in older people and have a slight male predominance. [9] [10]

Mediastinal germ cell tumours

Extragonadal germ cell tumours are found along the body's midline and correspond to the embryological urogenital ridge. Mediastinal germ cell tumours constitute 50% to 70% of all extragonadal germ cell tumours, and present in the anterior mediastinum. [11] They are classified as benign or malignant. Benign mediastinal germ cell tumours include mature teratoma. Malignant mediastinal germ cell tumours include seminomas (dysgerminomas) and non-seminomas. Mature teratomas can occur in any age group but are more common in children or young adults. There is no gender predilection for mature teratoma. Pure mediastinal seminoma germ cell tumours account for 35% of malignant germ cell tumours. [12] They occur in younger adults 20 to 40 years old, with a male predominance. Non-seminoma germ cell tumours include choriocarcinoma, embryonal carcinoma, teratoma, and endodermal sinus tumours. [13] They occur in younger adults 20 to 40 years old and have a strong male predominance. They are associated with Klinefelter's syndrome. [14]

Cyst (bronchogenic, pericardial, oesophageal)

Bronchogenic, pericardial, and oesophageal cysts may present as a mass in the middle mediastinum. Bronchogenic cysts are embryonic bronchopulmonary foregut malformations. Oesophageal cysts are congenital anomalies that arise during early embryonic development. Pericardial cysts are thin-walled cysts that arise from the pericardium. View image

Tracheal tumours (benign or malignant)

Primary tracheal tumours can be benign or malignant and may present in the middle mediastinum. The majority of tracheal tumours are malignant, with adenoid cystic carcinoma and squamous cell carcinoma being the most common histology. The most common benign tumours include squamous papilloma. Ninety percent of tracheal tumours in adults are malignant, compared with 10% to 30% in children. [15]

Neurogenic tumours (paraganglioma)

Neurogenic tumours arise from peripheral nerves, autonomic ganglia, and embryonic remnants of the neural tube. They may be benign or malignant and may present in the posterior mediastinum. Neurogenic tumours in children are often malignant, while tumours in adults tend to be benign. [16] Children and young adults are more prone to tumours of autonomic ganglia (two-thirds of which are malignant). Adults are more prone to nerve sheath tumours, which are almost all benign. Benign tumours include benign neurolemmoma schwannoma, phaeochromocytoma, neurofibroma, ganglioneuroma, and granular cell tumour. Malignant tumours include malignant schwannoma and neuroblastoma.

Lung cancer
Lung cancer comprises a group of malignant epithelial tumours arising from cells lining the lower respiratory tract. Lung cancer is divided into 2 categories: non-small cell lung cancer (NSCLC) and small cell lung cancer. NSCLC accounts for more than 85% of all lung cancers.[17] Tobacco exposure continues to be the most important cause of lung cancer, and approximately 90% of lung cancer is directly attributable to smoking. [18]

Urgent considerations
See Differential Diagnosis for more details

Superior vena cava syndrome

Superior vena cava (SVC) syndrome occurs when the SVC is occluded or compressed by a tumour in the anterior and/or superior mediastinum. Malignant tumours are commonly associated with SVC syndrome. [19] In most cases, SVC syndrome is not a medical emergency unless neurological symptoms are present. [20] A biopsy should be obtained prior to the initiation of therapy. Biopsies can often be obtained from more accessible synchronous lesions or via mediastinoscopy. [21] Treatment is directed at the underlying disease process.

Horner's syndrome
Horner's syndrome (oculosympathetic paresis) may be caused by a tumour in the superior mediastinum affecting the sympathetic ganglion. The syndrome consists of miosis (pupil constriction), ptosis (drooping eyelid), and anhidrosis (absence of sweating). [22] A biopsy should be obtained prior to the initiation of therapy. Biopsies can often be obtained from more accessible synchronous lesions or via mediastinoscopy. Treatment is directed at the underlying disease process.

Tracheal obstruction
Tracheal obstruction could occur from intrinsic or extrinsic tumour compression. The majority of tracheal tumours are malignant, with squamous cell carcinoma and adenoid cystic carcinoma being the most common histology. [23] Extrinsic tracheal compression can occur from tumours of surrounding tissues such as thyroid, oesophagus, lymph nodes, and lung. [24][25] Symptoms include dyspnoea, cough, haemoptysis, and stridor. Acute respiratory distress may not be present until the trachea is almost completely occluded, and may be rapidly fatal. Standard chest radiograph is insensitive in the detection of tracheal tumours. CT scan is the imaging modality of choice. Rapid surgical intervention is required for tracheal obstruction. [26]

Bronchial obstruction
Bronchial obstruction could occur from intrinsic or extrinsic tumour compression. Intraluminal bronchial tumours are often malignant, with small cell carcinoma and squamous cell carcinoma being the most common histology. Extrinsic bronchial compression can occur from tumours of surrounding tissues such as lymph nodes and lung or occasionally from an aneurysm. Symptoms include dyspnoea, cough, haemoptysis, and wheezing. Standard chest radiograph may identify a mass lesion with associated unilateral lung collapse. CT scan is the imaging modality of choice. [27] Bronchial obstruction may be addressed surgically or with radiotherapy after the underlying tumour is diagnosed.

Thoracic aortic aneurysm rupture

The natural history of thoracic aortic aneurysms involves gradual expansion and eventual rupture if untreated. [4] [5] When a thoracic aortic aneurysm ruptures, sudden death may ensue. Patients may present with sudden-onset severe chest pain that may have a tearing character and radiation to the back. Syncope, lightheadedness, and a feeling of impending doom may be present. Presenting signs include tachycardia,

hypotension, and shock. Chest x-ray is an important first test and may show widened mediastinum. [28] Contrast-enhanced CT chest is the test of choice to diagnose a suspected rupture. Emergent vascular or cardiothoracic surgery referral should be made if the diagnosis is suspected on clinical grounds, and critical care maintained until surgery. [29]

Aortic dissection
Aortic dissection occurs when an intimal tear causes blood to enter into the intima-media space of the aorta, resulting in a false lumen. The false lumen may extend in an anterograde (towards the descending aorta) or retrograde (towards the aortic valve) direction. The most common causes of aortic dissection are hypertension, congenital bicuspid aortic valve, and collagen vascular disorder. [30] Location of dissection: ascending aorta 65%, descending aorta 20%, aortic arch 10%, and abdominal aorta 5%. Signs and symptoms depend on location of dissection, vascular branch involvement, and presence of rupture. Pain is almost universal and often described as tearing or shearing with radiation to the back or neck. [31] Regional ischaemia may occur from branch vessel involvement. Chest x-ray may show widened mediastinum and/or displacement of aortic intimal calcium, but a normal chest x-ray does not exclude the diagnosis. ECG is useful to exclude concomitant myocardial infarction. Trans-oesophageal echocardiography, MRI, and contrast-enhanced CT scan are the diagnostic modalities of choice. [32] In unstable patients who cannot be taken to the scanner, trans-oesophageal echocardiography can rapidly make the diagnosis. In more stable patients, a CT scan or MRI can make the diagnosis as well as give more information regarding extent of dissection and arch involvement, which is critical in operative planning. [33] Once an aortic dissection is suspected, critical care and cardiothoracic surgery services should be activated.[29]

Red flags
Thoracic aortic aneurysm Non-Hodgkin's lymphoma Metastatic cancer Thymoma Lung cancer Aortic dissection Hodgkin's lymphoma Mediastinal germ cell tumour: seminoma Mediastinal germ cell tumour: non-seminoma Thymic carcinoma Primary tracheal tumours Neurogenic tumour Thyroid neoplasm Acute lymphocytic leukaemia Chronic lymphocytic leukaemia Mediastinal germ cell tumour: mature teratoma

Step-by-step diagnostic approach

Most mediastinal tumours may be asymptomatic (incidental finding) or associated with vague complaints. The likelihood of malignancy depends on mass location, patient's age, and the presence of symptoms. [34] [35] Malignant masses are found in the anterior, middle, and posterior mediastinum in approximately 60%, 30%, and 15% of cases, respectively. [6]Symptoms are present in 80% to 90% of patients with malignant mediastinal tumours at presentation, compared to 46% of patients with benign masses. [6] Approximately 10% to 15% of patients with myasthenia gravis have a thymoma. [36] Neurogenic tumours are commonly observed in children. Acute lymphocytic leukaemia may occur in children (commonly <5 years) or adults. Lymphoma, chronic lymphocytic leukaemia, thymomas, and thyroid tumours tend to occur in adults. [37] [38]

History
Although some mediastinal tumours may be asymptomatic, certain symptoms may raise concern for a mediastinal tumour and relate to its location. These include the following:
Airway compression: dyspnoea, stridor, haemoptysis, cough Oesophageal compression: dysphagia, odynophagia, weight loss Recurrent laryngeal nerve compression: hoarse voice Superior vena cava obstruction: facial swelling, headache Sympathetic ganglion involvement: Horner's syndrome, in which the patient may note pupillary constriction, drooping eyelids, and absence of sweating Chest wall invasion: myasthenic pain, palpable mass Myasthenic symptoms: easy fatigability, drooping eyelid, double vision, dysarthria Constitutional symptoms of malignancy: weight loss, night sweats, fever.

Physical examination
The mediastinum is inaccessible to direct physical examination except during surgery. Specific physical findings, which also relate to location of the tumour

and should be sought in examining a patient with mediastinal mass, include the following:
Airway compression: stridor, prolonged inspiration/expiration, haemoptysis Recurrent laryngeal nerve compression: hoarseness Superior vena cava obstruction: facial swelling, collateral veins, plethora Sympathetic ganglion involvement: Horner's syndrome, with miosis, ptosis, and anhidrosis Myasthenic symptoms: ptosis, diplopia, dysarthria Evidence of haematological malignancy: fever, pallor, petechiae, hepatosplenomegaly, abdominal mass.

Laboratory tests
Certain laboratory testing is indicated depending on the suspected aetiology as follows:
Suspected thymoma: FBC and acetylcholine receptor antibody Suspected mediastinal goitre: Thyroid function tests Suspected parathyroid adenoma: Serum calcium, phosphate, and parathyroid hormone Suspected germ cell tumour: Alpha-fetoprotein and beta-human chorionic gonadotrophin Suspected phaeochromocytoma: 24-hour urinary metanephrines and catecholamines, and plasma free metanephrines Suspected neurogenic tumour: 24-hour urinary homovanillic acid and vanillylmandelic acid Suspected haematological malignancy: FBC and blood film, flow cytometry, HIV serology, and hepatitis B and C serology.

Radiological tests
Chest x-ray with posteroanterior and lateral views is indicated in all cases. It provides information on the size, anatomical location, density, and composition of the mass. CT scan with intravenous contrast enhancement provides information concerning the vascularisation of the mass and its relationship to adjacent structures. It can also determine the content (calcium, fat, or necrotic

tissue View image ) and characteristics (cystic or solid) of the mass. View imageView image CT scan is a useful test and is indicated in most cases to further evaluate a mediastinal mass. MRI provides useful information in evaluating spinal, vascular, or cardiac invasion. It is also useful to assess the relationship of the mass to vascular structures. In the evaluation of the posterior compartment of the mediastinum, MRI chest and thoracic spine may be needed to further assess the relationship of the mass to vascular structures, thoracic spine, spinal canal, and spinal cord. MRI is useful for evaluation of thyroid masses when iodinated contrast is contra-indicated. Trans-oesophageal echocardiogram is the preferred initial test for diagnosis of aortic aneurysms and aortic dissection, especially during emergencies. Barium swallow is indicated in cases of oesophageal cyst and demonstrates the presence of communication between the cyst and oesophagus lumen. Endoscopic ultrasound is used to differentiate between an intramural or extramural mass and delineate the relation of the cyst to surrounding structures. Testicular ultrasound has a high sensitivity and is able to detect intratesticular lesions as small as 2 mm.

Radionuclide studies
Nuclear scans and biochemical studies are useful in diagnosing and evaluating the following conditions.
Suspected substernal thyroid: radioactive iodine thyroid scan to define the nature and extent of thyroid gland; toxic multinodular goitre shows multiple hot and cold areas consistent with areas of autonomy and suppression; malignant thyroid nodules are also cold. Suspected catecholamine-secreting tumour: metaiodobenzylguanidine (MIBG) scan to define the nature and extent of the tumour. Malignancy: FDG-PET scan to define the extent and stage of a malignancy. FDG uptake occurs in most malignancies including lymphomas, metastatic carcinomas, thymic carcinomas, and lung cancers.

Biopsy techniques
While clinical judgement in combination with radiographic imaging can often narrow the diagnostic possibilities, definitive pathological diagnosis is

required prior to initiating therapy. There are many modalities to obtain a pathological diagnosis, and each modality has its advantages and limitations. Image-guided percutaneous needle biopsy
This type of biopsy is performed with either CT or ultrasound, using local anaesthesia and light sedation. Samples are taken using either a fine needle or a core needle. It is mainly indicated for anterior mediastinal masses. The advantages of using an image-guided percutaneous needle biopsy are that it is minimally invasive, associated with low risk, and can be done as an outpatient procedure. The disadvantage is that tissue may be insufficient to render a definitive diagnosis, especially with lymphoma and thymoma.

Endoscopic biopsy with or without ultrasonography

Endoscopic biopsy with ultrasonography can be performed bronchoscopically (EBUS) or through the oesophagus (EUS) using a fine needle. The accessible areas are those immediately adjacent to the tracheobronchial tree and oesophagus, which limits what can be biopsied. The American Thoracic Society has standardised the nomenclature of lymph nodes in the chest. There are 14 numbered nodal stations; lymph nodes considered to be in the mediastinum are stations 1 to 9. EBUS can access nodal stations 2, 4, 7, and sometimes 10, while EUS can access nodal stations 5, 7, 8, and 9. The advantages of EBUS are that it is minimally invasive, associated with low risk, and can be done as an outpatient procedure. [39] Use of EBUS may also reduce the need for surgical staging. [40]The disadvantages are that only limited areas are amenable to biopsy, and it requires special equipment and technical expertise (both endoscopes and cytopathologist), which are not available at all institutions.

Mediastinoscopy
This is an invasive procedure requiring general anaesthesia. Incision is made just above the manubrium, and a mediastinoscope is passed along the pretracheal plane into the mediastinum. The superior middle mediastinum (pretracheal and paratracheal spaces) and the subcarinal space can be explored. It is generally used for diagnosis and staging of lung cancer and lymphoma. Mediastinoscopy has a high diagnostic yield. It is associated with low risk and usually done as an outpatient procedure. However, the assessed area is limited to superior middle mediastinum and subcarinal space, and it can be life-threatening if vascular injury occurs.

Mediastinotomy/Chamberlain procedure
Typically used for masses of the anterior mediastinum. It allows excellent exposure (costal cartilage removed) and has a high diagnostic yield. However, it is an invasive procedure requiring general anaesthesia and overnight hospitalisation and only allows sampling of anterior mediastinum.

Thoracoscopy
Video-assisted thoracoscopic surgery (VATS) is a valuable tool in the diagnosis and management of mediastinal masses. Almost all traditionally open procedures can be performed via VATS, including thymectomy,

duplication cyst excision, pericardial cyst excision, and posterior mediastinal mass resection. It allows excellent exposure of all compartments of the mediastinum for diagnostic biopsy and therapeutic excision of mediastinal masses and for accurate determination of local invasion or intrapleural metastatic spread. It is an invasive procedure and requires general anaesthesia and hospitalisation.

Open biopsy sternotomy or thoracotomy

Sternotomy gives excellent exposure to the anterior mediastinum, and thoracotomy gives excellent exposure to the middle and posterior mediastinum. Open biopsy is done less often than VATS to biopsy lesions. It is useful when excision of large lesions (>5 to 7 cm) are required and when anatomical considerations make VATS not feasible. It is an invasive procedure requiring general anaesthesia and a longer hospital stay, and is associated with a higher morbidity rate.

Bone marrow biopsy

Indicated if clinical features are suggestive of an underlying haematological malignancy such as lymphoma or acute or chronic lymphocytic leukaemia.

Peripheral lymph node biopsy

Haematological and metastatic malignancies may have abnormal lymph nodes peripherally. Excision of a complete lymph node provides valuable information on the malignant cell type based on histological appearance or immunohistochemical staining.

Differential diagnosis
Sort by: common/uncommon or category Commonhide all Thoracic aortic aneurysm

History
often asymptomatic; may present with chest with associated hypotension and shock may

Exam
signs of heart failure (elevated venous distress); signs of aortic insufficiency

1st test

trans-oesophageal echocardiography : assess size, location of aneurysm, and the presence of a dissection; assess co-existing aortic valvular abnormalitiesMore

or back pain; sudden-onset chest or back pain pressure, ankle oedema, respiratory be caused by aneurysm dissection or rupture; (diastolic murmur, collapsing pulse); signs compression of adjacent structures may cause of aneurysm dissection or rupture dysphagia or dyspnoea; vascular compromise (hypotension and shock); associated signs may lead to anginal symptoms, orthopnoea, Marfan's syndrome of Marfan's syndrome (arm span exceeding and ankle oedema; may have associated hx of height, arachnodactyly, joint hypermobility)

Non-Hodgkin's lymphoma

see our comprehensive coverage of Non-Hodgkin's lymphoma

History
persistently enlarged lymph nodes, constitutional or B symptoms (fevers, night sweats, and/or weight loss)

Exam
lymphadenopathy in one or more regions, hepatosplenomegaly may be present, fever

1st test

peripheral lymph node excision biopsy: type and grade of nonHodgkin's lymphomaMore

Other tests

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History
prior cancer hx in the presence of new lymphadenopathy should raise suspicion for recurrent or metastatic disease; patients may complain of fatigue, weight loss, and other constitutional symptoms

Exam
weight loss, occasionally fever, pallor; other physical examination findings vary according to the cancer type

1st test

biopsy: identification of malignant cells in lymph node More

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Thymoma see our comprehensive coverage of Thymic tumour

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History
growth rate, and paraneoplastic syndromes; half of patients with thymomas are asymptomatic; in symptomatic patients, 40% have myasthenic symptoms; [47]paraneoplastic syndromes include myasthenia gravis, limbic encephalitis, pure red cell aplasia; symptoms include chest pressure, hoarseness, chest wall pain, dysphagia, and dyspnoea related to tumour compression or invasion; myasthenic manifestations include easy fatigability, ptosis, diplopia, dysarthria; limbic encephalitis manifestation

Exam
(stridor, prolonged inspiration/expiration); recurrent laryngeal nerve compression (hoarseness); superior vena cava obstruction (facial swelling, collateral veins, plethora); myasthenic manifestations (easy fatigability, ptosis, diplopia, dysarthria); limbic encephalitis (cognitive dysfunction, complex partial seizures, hyperthermia)

1st test

CT scan of chest: enlarged thymus often with

presenting symptoms depend on tumour location, size, often asymptomatic; airway compression

well-defined borders and preservation of fat planes; local invasion may be presentMore

includes mood or behavioural changes, cognitive dysfunction

Lung cancer see our comprehensive coverage of Non-small cell lung cancer

History
may present with cough, dyspnoea, haemoptysis, chest pain, weight loss; fatigue, hoarseness, suspected if bone pain and/or fractures; brain metastases suspected if confusion, personality changes, nausea and vomiting, headache, seizures present

Exam
wheeze, rales, decreased breath sounds, and dullness to percussion; cervical or supraclavicular adenopathy, osteoarthropathy; in SVC syndrome: facial swelling, dilated neck or chest/abdominal wall veins

1st test

CXR: NSCLC: variable; may detect a solitary pulmonary nodule, mass, pleural effusion, lung collapse, or mediastinal or hilar fullness; SCLC: central mass, hilar lymphadenopathy, pleural effusion

Other tests

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dysphagia; bone metastases finger clubbing, hypertrophic

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Uncommonhide all
Aortic dissection see our comprehensive coverage of Aortic dissection

History
sudden-onset chest pain, usually

Exam
hypertension may result from a

1st test

trans-oesophageal echocardiography: diagnostic of aortic dissection and assesses aortic valvular abnormalitiesMore

Othe

described as ripping or tearing; pain is catecholamine surge or underlying often maximal at onset and changes as essential hypertension; hypotension may the dissection evolves; pain radiating into the neck or jaw may indicate that the dissection involves the aortic arch and extends into the great vessels of the arch; pain that is felt in the intrascapular area may indicate that be the result of excessive vagal tone, cardiac tamponade, or hypovolaemia from rupture of the dissection; neurological deficits occur in 20% of cases; most common neurological findings are syncope and altered mental status;

CT scan of chest with contrast enhancement: detects aortic dissection and determines its sizeMore

the dissection involves the descending dyspnoea may be caused by congestive aorta; aortic dissection can be painless heart failure or tracheal or bronchial in about 10% of patients and especially in patients with collagen vascular disorder [42] compression; new diastolic murmur from aortic insufficiency; asymmetrical pulses and blood pressure measurements

Hodgkin's lymphoma see our comprehensive coverage of Hodgkin's lymphoma

History
constitutional or B symptoms (fevers, night sweats, and/or

Exam
regions, hepatosplenomegaly may be present, fever

1st test

peripheral lymph node excision biopsy: type of

Other tests

persistently enlarged lymph nodes, lymphadenopathy in one or more

FBC: a

present

weight loss)

Hodgkin's lymphomaMore

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Mediastinal germ cell tumour: seminoma

History
presenting symptoms depend on tumour tend to grow slowly and metastasise later than non-seminomas, and may reach a larger size at presentation; symptoms include chest pressure, hoarseness, chest wall pain, dysphagia, and dyspnoea; occurs in people aged 20 to 40 years, with male predominance

Exam
often asymptomatic; airway compression may inspiration/expiration; recurrent laryngeal nerve compression may present with hoarseness; superior vena cava obstruction may present with facial swelling, collateral veins, plethora; testicle examination may reveal testicle mass

1st test

CT scan of chest, abdomen, and pelvis: bulky, locally invasive mass; irregular borders; pulmonary and intrathoracic metastases may be seenMore

Other

location, growth rate, and size; seminomas present with stridor and prolonged

Mediastinal germ cell tumour: non-seminoma

History
patients often have symptoms at presentation; symptoms include chest pressure, hoarseness, chest wall pain, dysphagia, and dyspnoea; constitutional symptoms include fever, chills, and weight loss

Exam
signs of airway compression (stridor, prolonged inspiration/expiration); signs of recurrent laryngeal nerve compression (hoarseness); signs of superior vena cava obstruction (facial swelling, collateral veins, plethora); testicle examination may reveal testicle mass; gynaecomastia

1st test

CT scan of chest, abdomen, and pelvis: large lobulated inhomogeneous mass with thin capsule, may contain areas of haemorrhage and necrosis; mediastinal fat invasion commonly seen; pulmonary and intrathoracic metastases may be seen

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Thymic carcinoma

History
majority of patients are symptomatic at

Exam
signs of airway compression (stridor,

1st test

CT scan of chest, abdomen, and

presentation; symptoms may include chest pressure, hoarseness, chest wall pain, dysphagia, and dyspnoea; symptoms from tumour metastases may be present, such as bone pain or lymphadenopathy; may have constitutional symptoms of fever, weight loss, or sweats; paraneoplastic symptoms uncommon

prolonged inspiration/expiration); sign of recurrent laryngeal nerve compression (hoarseness); signs of superior vena cava obstruction (facial swelling, collateral veins, plethora)

pelvis: invasive, poorly defined mediastinal mass with obliteration on mediastinal fat plane; vascular invasion, lymphadenopathy, and extrathymic metastases are common; may also contain calcification and necrosis More

Primary tracheal tumours

History
tracheal obstruction results in dyspnoea, as asthma in children); acute respiratory distress may not be present until the trachea is almost completely occluded; haemoptysis may occur

Exam
tracheal obstruction distress, cough, wheezing, and stridor

1st test

CT scan of chest with contrast enhancement: tumours are often small, solid, and located within the tracheal lumen; extra-tracheal invasion may be presentMore

Other tests

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Neurogenic tumour

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History
no gender predilection; commonly in majority of adults but only 20% of children; [16] children commonly present with respiratory symptoms such as dyspnoea and cough; if associated with neurofibromatosis, multiple skin neuromas are present; depending on size and location, tumours may result in spinal cord compression, pain, numbness, weakness, and muscle atrophy

Exam
hypertension and/or tachycardia, may tumour; classic triad of phaeochromocytoma may present with headache, sweats, and tachycardia; airway compression may present with stridor, prolonged inspiration/expiration; recurrent laryngeal nerve compression may present with hoarseness; superior vena cava obstruction may present with facial swelling, collateral veins, plethora

1st test

CT scan of chest with contrast enhancement: almost always located in posterior mediastinum along costovertebral sulcus; rounded or spindle- or dumbbell-shaped mass; spinal invasion or spinal canal extension; intratumoral calcification may be presentMore

Other tests

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Thyroid neoplasm see our comprehensive coverage of Thyroid cancer

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History
patients often have a known goitre; substernal extension may present with exertional dyspnoea, positional dyspnoea, stridor, wheezing, or cough

Exam
often painless solitary nodules; presence of goitre (80% to 90% of patients with substernal goitres have a visible goitre [1] ); hypertension and tachycardia may be a sign of thyrotoxicosis or phaeochromocytoma; substernal extension suggested by inability to identify the lower pole of thyroid gland; airway compression may present with stridor, prolonged inspiration/expiration; tracheal deviation if goitre is asymmetrical; presence of Pemberton's sign (neck vein distension and facial flushing when arms are held vertically above head - Pemberton's manoeuvre)

1st test

CT scan of neck and chest without contrast enhancement: determines extent and size of thyroid massMore

Oth

Substernal goitre see our comprehensive coverage of Toxic multinodular goitre

History
history of known goitre; exertional or positional dyspnoea; stridor or wheezing; cough; hyperthyroidism symptoms (heat intolerance, weight loss, insomnia)

Exam
80% to 90% of patients with substernal goitres have a visible goitre; substernal extension suggested by inability to identify lower pole of thyroid gland; airway compression may present with stridor, prolonged inspiration/expiration; signs of thyrotoxicosis (weight loss, hypertension, and tachycardia); tracheal deviation if goitre is asymmetrical, presence of Pemberton's sign (neck vein distension and facial flushing when arms held vertically above head Pemberton's manoeuvre)

1st test

CT scan of neck and chest without contrast enhancement: determines extent and size of thyroidMore

Acute lymphocytic leukaemia see our comprehensive coverage of Acute lymphocytic leukaemia

History
fatigue, dyspnoea, dizziness, bleeding, easy bruising, and recurrent infections

Exam
pallor and ecchymoses, and rarely lymphadenopathy and hepatosplenomegaly

1st test

FBC: anaemia, leukocytosis, leukopenia, and/or thrombocytopenia

Other test

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Chronic lymphocytic leukaemia see our comprehensive coverage of Chronic lymphocytic leukaemia

History
age >60 years; frequently asymptomatic and detected as an incidental finding on blood tests for another reason; B symptoms: fever, chills, night sweats, weight loss, and fatigue

Exam
painless peripheral lymphadenopathy, splenomegaly

1st test

FBC: elevated WBC count with absolute lymphocytosis >5000/microlitre; anaemia and thrombocytopenia may be present

blood film: smudge cells presentMore

Pericardial cyst

History
pericardium; almost always asymptomatic and identified incidentally; signs of congestive heart failure (dyspnoea, oedema, fatigue, and palpitations)

Exam
depending on size and location of lesion; signs of congestive heart failure (oedema, elevated jugular venous pressure); arrhythmia (atrial fibrillation) may also be present

1st test

CT scan of chest with contrast enhancement: non-enhancing, thinwalled, well-defined, homogeneous masses; attenuation is close to water densityMore

Oth

thin-walled cysts that arise from the haemodynamic compromise may occur

Bronchogenic cyst

History
occurs in both adults and children without sexual predilection; may be asymptomatic and identified incidentally; chest pain and dysphagia are most common presenting symptom; consider bronchogenic cyst in patients with recurrent lung infections

Exam
signs of airway compromise (cough, wheezing, dyspnoea, and respiratory distress); signs of infection (fever, purulent sputum, cough)

1st test

CXR: well-defined round mass often located in the vicinity of the carina; air-fluid level may be presentMore

Other tests

CT sca

enhan

walled

masse

secreti

presen

Oesophageal cyst (includes oesophageal duplication cyst)

History
almost always asymptomatic and identified incidentally; [7] often present during childhood; chest tightness or fullness and dysphagia

Exam
almost always asymptomatic

1st test

CT scan of chest with contrast enhancement: nonenhancing, well-defined,

Other tests

barium swallow : de

communication betwe lumenMore

may be present

homogeneous massesMore

endoscopy and end

(EUS): identifies an o

protruding, submucos

epithelium; EUS diffe

extramural mass and

to surrounding structu

Mediastinal germ cell tumour: mature teratoma

History
often asymptomatic and is an incidental finding; presenting symptoms depend on tumour location and size; symptoms include chest pressure, hoarseness, chest wall pain, dysphagia, and dyspnoea; can in children or young adults, with no gender predilection

Exam
often asymptomatic; airway compression (stridor, prolonged inspiration/expiration); recurrent laryngeal nerve compression (hoarseness); superior vena cava obstruction (facial swelling, collateral

1st test

CT scan of chest, abdomen, and pelvis: mass may be solid or cystic; well delineated from surrounding tissue; fat-fluid level or fatty mass with globular calcification may be seen; tumour may have a calcified capsule and occasionally contain teethMore

occur in any age group but more common veins, plethora)