Radiology Examination of

Radiology Examination of
Mediastinum
Mediastinum
Arlavinda A. Lubis
Arlavinda A. Lubis
Radiology Department,Ulin Hospital / Radiology Department,Ulin Hospital /
Faculty of Medicine, Lambung Mangurat University Faculty of Medicine, Lambung Mangurat University
Introduction
Introduction

The
The
mediastinum
mediastinum
is the region in
is the region in
the chest
the chest
between the
between the
pleural cavities
pleural cavities
that contain the
that contain the
heart and other
heart and other
thoracic viscera
thoracic viscera
except the lungs
except the lungs
Mediastinal anatomy
Mediastinal anatomy
Boundaries Boundaries

Lateral Lateral - parietal pleura - parietal pleura

Anterior Anterior - sternum - sternum

Posterior Posterior - vertebral column and - vertebral column and

paravertebral gutters paravertebral gutters

Superior Superior - thoracic inlet - thoracic inlet

nferior nferior - diaphragm - diaphragm

!elson !elson "Radiologists" "Radiologists"

Anterior mediastinal# Anterior mediastinal# is bounded anteriorly is bounded anteriorly

by the sternum and posteriorly by a line by the sternum and posteriorly by a line
drawn from the anterior aspect of the drawn from the anterior aspect of the
trachea and along the posterior heart trachea and along the posterior heart border border

Middle Middle mediastinal compartment lies mediastinal compartment lies

between the anterior and posterior between the anterior and posterior
mediastinum mediastinum

Posterior Posterior mediastinal, anterior mediastinal, anterior

border is defned by a line that is 1 border is defned by a line that is 1
cm posterior to the anterior edge cm posterior to the anterior edge
of the vertebral bodies of the vertebral bodies
Mediastinal compartment
Mediastinal compartment
by Felson
by Felson
(Meschan, 1981;
resited by Lange & Walsh, 2007)
Diseases of the
Diseases of the
Mediastinum
Mediastinum

Pneumomediastinum Pneumomediastinum

Mediastinitis Mediastinitis

eoplasma eoplasma

Pneumomediastinum
Pneumomediastinum

!ir in the mediastinum is a common !ir in the mediastinum is a common

complication of mechanical ventilation is also complication of mechanical ventilation is also
commonly encountered in some conditions commonly encountered in some conditions

Pain is the most common symptom Pain is the most common symptom

"esults from stretching of the mediastinal "esults from stretching of the mediastinal
tissues tissues

#ubsternal and aggravated by breathing and #ubsternal and aggravated by breathing and
changing position changing position

Dyspnea, dysphagia, subcutaneous Dyspnea, dysphagia, subcutaneous

crepitation crepitation

Mediastinitis
Mediastinitis

!cute in$ammation of the mediastinum !cute in$ammation of the mediastinum

#ubsternal chest pain, chills, high fever, #ubsternal chest pain, chills, high fever,
prostration prostration

%hronic mediastinitis %hronic mediastinitis

eoplasma
eoplasma
%linical Presentation
%linical Presentation

!symptomatic mass !symptomatic mass

Incidental discovery & most common Incidental discovery & most common

'() of all mediastinal mass are asymptomatic '() of all mediastinal mass are asymptomatic

*() of such mass are benign *() of such mass are benign

More than half are malignant if with More than half are malignant if with
symptoms symptoms
%linical Presentation
%linical Presentation

+,ects on %ompression or invasion of ad-acent tissues +,ects on %ompression or invasion of ad-acent tissues

%hest pain %hest pain, from traction on mediastinal mass, tissue , from traction on mediastinal mass, tissue
invasion, or bone erosion is common invasion, or bone erosion is common

%ough %ough, because of e.trinsic compression of the trachea , because of e.trinsic compression of the trachea
or bronchi, or erosion into the airway it self or bronchi, or erosion into the airway it self

/emoptysis, hoarseness or stridor /emoptysis, hoarseness or stridor

Pleural e,usion, invasion or irritation of pleural space Pleural e,usion, invasion or irritation of pleural space

Dysphagia, invasion or direct invasion of the esophagus Dysphagia, invasion or direct invasion of the esophagus

Pericarditis or pericardial tamponade Pericarditis or pericardial tamponade

"ight ventricular out$ow obstruction and cor "ight ventricular out$ow obstruction and cor
pulmonale pulmonale
%linical Presentation
%linical Presentation

#uperior vena cava #uperior vena cava

0ulnerable to e.trinsic compression and obstruction 0ulnerable to e.trinsic compression and obstruction
because it is thin walled and its intravascular because it is thin walled and its intravascular
pressure is low, and relatively confned by lymph pressure is low, and relatively confned by lymph
nodes and other rigid structures nodes and other rigid structures

#uperior vena cava syndrome #uperior vena cava syndrome

"esults from the increase venous pressure in the "esults from the increase venous pressure in the
upper thora. , head and nec1 upper thora. , head and nec1

characteri2ed by dilation of the collateral veins in the characteri2ed by dilation of the collateral veins in the
upper portion of the head and thora. and edema and upper portion of the head and thora. and edema and
phlethora of the face, nec1 and upper torso, phlethora of the face, nec1 and upper torso,
su,usion and edema of the con-unctiva and cerebral su,usion and edema of the con-unctiva and cerebral
symptoms such as headache, disturbance of symptoms such as headache, disturbance of
consciousness and visual distortion consciousness and visual distortion

3ronchogenic carcinoma and lymphoma are 3ronchogenic carcinoma and lymphoma are
the most common etiologies the most common etiologies
%linical Presentation
%linical Presentation

/oarseness, invading or compressing the nerves /oarseness, invading or compressing the nerves

/orners syndrome, involvement of the /orners syndrome, involvement of the

sympathetic ganglia 4dropping eyelid, decreased sympathetic ganglia 4dropping eyelid, decreased
pupil si2e,decreased sweating on the ipsilateral pupil si2e,decreased sweating on the ipsilateral
face5 face5

Dyspnea, from phrenic nerve involvement causing Dyspnea, from phrenic nerve involvement causing
diaphragmatic paralysis diaphragmatic paralysis

Tachycardia, secondary to vagus nerve Tachycardia, secondary to vagus nerve

involvement involvement

%linical manifestations of spinal cord compression %linical manifestations of spinal cord compression
%linical Presentation
%linical Presentation

#ystemic symptoms and syndromes #ystemic symptoms and syndromes

Fever, anore.ia, weight loss and other non Fever, anore.ia, weight loss and other non
specifc symptoms of malignancy and specifc symptoms of malignancy and
granulomatous in$ammation granulomatous in$ammation
Techni6ues for visuali2ing the
Techni6ues for visuali2ing the
mediastinum and its content
mediastinum and its content
"adiographic techni6ue "adiographic techni6ue

%hest .7ray8 #tandard postero antero and %hest .7ray8 #tandard postero antero and
lateral views lateral views

Most mediastinal tumors are discovered Most mediastinal tumors are discovered

Fluoroscopy and tomography Fluoroscopy and tomography

%omputed tomography
%omputed tomography

%an identify normal anatomic variations and %an identify normal anatomic variations and
$uid flled cyst $uid flled cyst

#ite of the origin of the mass can be better #ite of the origin of the mass can be better
identifed identifed

1(() specifcity for the %T appearance of 1(() specifcity for the %T appearance of
teratomas, thymolipoma, omental fat teratomas, thymolipoma, omental fat
herniation herniation

9verall accuracy for predicting mediastinal 9verall accuracy for predicting mediastinal
mass is only :*) mass is only :*)
%omputed tomography
%omputed tomography

;imitation ;imitation

/ori2ontal oriented structures and boundaries /ori2ontal oriented structures and boundaries
are di<cult to evaluate are di<cult to evaluate

!bnormalities in the aortopulmonary window !bnormalities in the aortopulmonary window

area and the subcarinal area area and the subcarinal area

%T has become the initial imaging %T has become the initial imaging
procedure of choice for evaluation of procedure of choice for evaluation of
mediastinum in patients with primary mediastinum in patients with primary
mediastinal mass or with lung cancer mediastinal mass or with lung cancer
Magnetic "esonance
Magnetic "esonance
Imaging
Imaging

!ssesses tissue by measuring the !ssesses tissue by measuring the

radiofre6uency induced nuclear resonance radiofre6uency induced nuclear resonance
instead of measuring the attenuation of instead of measuring the attenuation of
transmitted ioni2ing radiation transmitted ioni2ing radiation

%oronal and sagittal planes are better viewed, %oronal and sagittal planes are better viewed,
vertical structures and boundaries are better vertical structures and boundaries are better
evaluated evaluated

#uperior sulcus tumors, lesions invading the #uperior sulcus tumors, lesions invading the
medistinum, chest wall and diaphragm medistinum, chest wall and diaphragm

!nd possible invasion of the brachial ple.us, !nd possible invasion of the brachial ple.us,
and for evaluating vertebral invasion and for evaluating vertebral invasion
Magnetic "esonance
Magnetic "esonance
Imaging
Imaging

;imitations ;imitations

Distinguish poorly between hilar mass and Distinguish poorly between hilar mass and
ad-acent collapsed or consolidated lung ad-acent collapsed or consolidated lung

%annot distinguish between a benign and a %annot distinguish between a benign and a
malignant causes for lymph node enlargement malignant causes for lymph node enlargement
=ltrasonography
=ltrasonography

For cystic nature of mediatinal mass For cystic nature of mediatinal mass

=seful in guiding endoscopic biopsy =seful in guiding endoscopic biopsy

techni6ue techni6ue
"adionuclide imaging
"adionuclide imaging

"ely on the locali2ation of mar1ers based "ely on the locali2ation of mar1ers based
on specifc metabolic or immunologic on specifc metabolic or immunologic
properties of the target tissue properties of the target tissue

Potential ability to diagnose and stage a Potential ability to diagnose and stage a
malignancy and identify distant metastasis malignancy and identify distant metastasis

Planar imaging with gallium >? and Planar imaging with gallium >? and
thallium7@(1 thallium7@(1
P9#IT"9 +MI##I9
P9#IT"9 +MI##I9
T9M9A"!P/B
T9M9A"!P/B

The single most notable addition to the staging The single most notable addition to the staging
armamentarium for the evaluation of lung cancer armamentarium for the evaluation of lung cancer

Based on the Based on the biologic activity of neoplastic cells biologic activity of neoplastic cells

PET is a metabolic imaging technique based on the PET is a metabolic imaging technique based on the
function of a tissue rather than its anatomy function of a tissue rather than its anatomy

Lung cancer cells demonstrate increased cellular Lung cancer cells demonstrate increased cellular
uptake of glucose and a higher rate of glycolysis when uptake of glucose and a higher rate of glycolysis when
compared to normal cells compared to normal cells

The radiolabeled glucose analogue [18F !uoro"#" The radiolabeled glucose analogue [18F !uoro"#"
deoxy"d"glucose undergoes the same cellular uptake deoxy"d"glucose undergoes the same cellular uptake
as glucose$ but after phosphorylation is not further as glucose$ but after phosphorylation is not further
metaboli%ed and becomes trapped in cells metaboli%ed and becomes trapped in cells

&ccumulation of the isotope can then be identi'ed &ccumulation of the isotope can then be identi'ed
using a ()T camera using a ()T camera
Specific criteria for an abnormal PET scan are either a standard
uptake value of greater than 2.5 or uptake in the lesion that is greater
than the background activity of the mediastinum
It has proved useful in differentiating neoplastic from normal tissues
P9#IT"9 +MI##I9
P9#IT"9 +MI##I9
T9M9A"!P/B
T9M9A"!P/B

The techni6ue is not infallible because

The techni6ue is not infallible because
certain non7neoplastic processes, including
certain non7neoplastic processes, including
granulomatous and other infammatory
granulomatous and other infammatory
diseases as well as infections
diseases as well as infections
,
,
may also
may also
demonstrate positive P+T imaging
demonstrate positive P+T imaging

Size limitations
Size limitations
are also an issue, with the
are also an issue, with the
lower limit of resolution of the study being
lower limit of resolution of the study being
appro.imately
appro.imately
7 to 8 mm
7 to 8 mm
depending on the
depending on the
intensity of upta1e of the isotope in
intensity of upta1e of the isotope in
abnormal cells
abnormal cells

9ne should not rely on a negative P+T

9ne should not rely on a negative P+T
fnding for lesions less than 1 cm on %T scan
fnding for lesions less than 1 cm on %T scan
Dealing with mediastinal mass
Dealing with mediastinal mass
%onventional radiographic signs
%onventional radiographic signs

The Csilhouette signD The Csilhouette signD

The hilar overlay sign The hilar overlay sign

The hilar convergence sign The hilar convergence sign

The cervicothoracic sign The cervicothoracic sign

Foto thora1s normal
Foto thora1s normal
The Csilhouette signD
The Csilhouette signD

Ehen a mass abuts a normal Ehen a mass abuts a normal

mediastinal structure of mediastinal structure of
similar radiodensity, the similar radiodensity, the
margins of the @ structures margins of the @ structures
will be obliterated will be obliterated

This apparent loss of the This apparent loss of the

margin of the normal margin of the normal
structure can be used to structure can be used to
locali2e a mediastinal mass locali2e a mediastinal mass
to the same compartment as to the same compartment as
the normal structure the normal structure
The hilar overlay sign
The hilar overlay sign

especially useful in especially useful in

distinguishing an distinguishing an
anterior mediastinal anterior mediastinal
mass from a prominent mass from a prominent
cardiac silhouette cardiac silhouette

If the bifurcation of the If the bifurcation of the

main pulmonary artery is main pulmonary artery is
F1 cm medial to the F1 cm medial to the
lateral border of the lateral border of the
cardiac silhouette, it is cardiac silhouette, it is
strongly suggestive of a strongly suggestive of a
mediastinal mass mediastinal mass
Imaging of the mediastinum in oncology
Michele Lesslie, DO; Marvin H. Chasen, MD, MSEE; Reginald F. Munden, MD,
DMD
The hilar convergence
The hilar convergence
sign
sign

is used to distinguish between a prominent is used to distinguish between a prominent

hilum and an enlarged pulmonary artery hilum and an enlarged pulmonary artery

If the pulmonary arteries converge into the If the pulmonary arteries converge into the
lateral border of a hilar mass, the mass lateral border of a hilar mass, the mass
represents an enlarged pulmonary artery represents an enlarged pulmonary artery

! hilar mass may have the appearance of an ! hilar mass may have the appearance of an
enlarged pulmonary artery, but the vessels will enlarged pulmonary artery, but the vessels will
not arise from the marginG instead they will not arise from the marginG instead they will
seem to pass through the margins as they seem to pass through the margins as they
converge on the true artery converge on the true artery
an enlarged
pulmonary arery
Hillar mass
The cervicothoracic sign
The cervicothoracic sign

is used to determine the location of a mediastinal is used to determine the location of a mediastinal
lesion in the upper chest lesion in the upper chest

The uppermost border of the anterior mediastinum The uppermost border of the anterior mediastinum
ends at the level of the claviclesH ends at the level of the claviclesH

the medial and posterior mediastinum e.tends the medial and posterior mediastinum e.tends
above the claviclesH ! mediastinal mass that above the claviclesH ! mediastinal mass that
pro-ects superior to the level of the clavicles must pro-ects superior to the level of the clavicles must
therefore be located either within the middle or therefore be located either within the middle or
posterior mediastinumH posterior mediastinumH

the more cephalad the mass e.tends, the more the more cephalad the mass e.tends, the more
posterior the location posterior the location

The anterior mediastinum contains the following

structures* thymus$ lymph nodes$ ascending aorta$
pulmonary artery$ phrenic nerves and thyroid+

The four T,s make up the mnemonic for anterior

mediastinal masses**
1+ Thymus
#+ Teratoma -germ cell.
/+ Thyroid
0+ Terrible Lymphoma
Sanjeev Bhalla, Marieke Hazewinkel and o!in Smithuis
1ardiothoracic 2maging 3ection of the 4allinckrodt 2nstitute of 5adiology$ 3t+ Louis$ 63&
and the 5adiology department the 4edical 1entre &lkmaar and the 5i7nland 8ospital$
Leiderdorp$ the 9etherlands
;esions typically in the
;esions typically in the
!nterior Mediastinum
!nterior Mediastinum

Thymic neoplasm
Thymic neoplasm

Thymoma is the most common neoplasm Thymoma is the most common neoplasm
occuring in the anterior mediastinum occuring in the anterior mediastinum

"ecogni2ed more often recently because of "ecogni2ed more often recently because of
increase aggresiveness in evaluating patients increase aggresiveness in evaluating patients
with myasthenia gravis with myasthenia gravis

%omposed of lymphocytes and epithelial cells %omposed of lymphocytes and epithelial cells
Thymoma
Thymoma

Pea1 incidence is :(7>( yIo Pea1 incidence is :(7>( yIo

+6ual gender predilection +6ual gender predilection

"are in children "are in children

@IJ assymptomatic at the time of diagnosis @IJ assymptomatic at the time of diagnosis

!nterior mediastinal mass may be discovered !nterior mediastinal mass may be discovered
incidentally incidentally

%hest pain, cough, dyspnea %hest pain, cough, dyspnea

:(7?() of patients can have systemic syndromes :(7?() of patients can have systemic syndromes
Thymoma
Thymoma

Myasthenia gravis is the most common Myasthenia gravis is the most common
syndrome syndrome

9ccurs in 1(7'() of patients 9ccurs in 1(7'() of patients

/ow thymoma produced myasthenia is /ow thymoma produced myasthenia is

un1nown but autoantibodies to the post un1nown but autoantibodies to the post
synaptic acetylcholine receptor appears to synaptic acetylcholine receptor appears to
e.plain the dysfunction of the e.plain the dysfunction of the
neuromuscular -unction neuromuscular -unction
Thymoma
Thymoma

Found near the -unction of the heart and Found near the -unction of the heart and
great vessels great vessels

"ound or oval, smooth or lobulated as "ound or oval, smooth or lobulated as

compared with thymic hyperplasia which is compared with thymic hyperplasia which is
symmetrical symmetrical

=sually distorts the gland normal shaped =sually distorts the gland normal shaped
Thymoma
Thymoma

Thymomas are neoplastic but most are Thymomas are neoplastic but most are
benign benign

Invasive tumors have a poorer prognosis Invasive tumors have a poorer prognosis

' year ' year K '(7??) survival rate K '(7??) survival rate

1( year K J(7'') survival rate 1( year K J(7'') survival rate

"ecurrence after resection occurs in 1IJ of "ecurrence after resection occurs in 1IJ of
patients patients

Presence of thymoma7associated systemic Presence of thymoma7associated systemic

syndrome is a poor prognostic sign syndrome is a poor prognostic sign
Thymoma
Thymoma

May respond to hormonal therapy May respond to hormonal therapy

Manage by resection via median sternotomy Manage by resection via median sternotomy
approach or 0!T# approach or 0!T#

!d-unctive treatment with post operative !d-unctive treatment with post operative
radiotherapy radiotherapy

!ddition of perioperative radiotherapy is !ddition of perioperative radiotherapy is

provided provided
thymoma
thymoma
9ther thymic mass
9ther thymic mass

Thymic hyperplasia, thymic cyst and Thymic hyperplasia, thymic cyst and
lipothymoma lipothymoma

Thymic carcinoma is a malignant process Thymic carcinoma is a malignant process

that invades locally and fre6uently that invades locally and fre6uently
metastasi2ed metastasi2ed

Prognosis is poor Prognosis is poor

"esection followed by ad-uvant "esection followed by ad-uvant

chemoradiotherapy is advocated chemoradiotherapy is advocated
Aerm cell tumors
Aerm cell tumors

1(71@ ) of primary mediastinal tumors are 1(71@ ) of primary mediastinal tumors are
derived from germinal tissues both in adults derived from germinal tissues both in adults
and in children and in children

Teratoma and teratocarcinoma Teratoma and teratocarcinoma

#eminoma #eminoma

+mbryonal cell carcinoma +mbryonal cell carcinoma

%horiocarcinoma %horiocarcinoma

They are believed to arise from remnant They are believed to arise from remnant
multipotent germ cells that have migrated multipotent germ cells that have migrated
abnormally during embryonic development abnormally during embryonic development
Teratomas
Teratomas

Most common germ cell tumors Most common germ cell tumors

Made up of tissues foreign to the area in Made up of tissues foreign to the area in
which they occur which they occur

+ctodermal derivatives predominate +ctodermal derivatives predominate

Ehen only the epidermis and its derivatives Ehen only the epidermis and its derivatives
are present, the term dermoid cyst are present, the term dermoid cyst
Teratomas
Teratomas

Boung adults Boung adults

3ut reported in all age groups 3ut reported in all age groups

Men and women a,ected e6ually Men and women a,ected e6ually

*() are benign *() are benign

1IJ are asymptomatic 1IJ are asymptomatic

Pain, cough, dyspnea Pain, cough, dyspnea

/emoptysis if tumor erodes into a bronchus /emoptysis if tumor erodes into a bronchus

+.pectoration of di,erentiated tissue such as hair +.pectoration of di,erentiated tissue such as hair
LtrichoptysisM or sebaceous materials can occur LtrichoptysisM or sebaceous materials can occur

%an rupture in the pleural space and can cause !"D# or %an rupture in the pleural space and can cause !"D# or
enter the pericardium causing Pericardial Tamponade enter the pericardium causing Pericardial Tamponade
Teratomas
Teratomas

9n %N", Teratomas are smooth, rounded

9n %N", Teratomas are smooth, rounded
and well circumscribed if they are cystic
and well circumscribed if they are cystic
and more lobulated and asymmetric if
and more lobulated and asymmetric if
they are solid
they are solid

#oft tissue, fat and calcifcation

#oft tissue, fat and calcifcation
Loccasionally fully formed teeth and
Loccasionally fully formed teeth and
boneM can be seen on %T images
boneM can be seen on %T images

!ll teratomas should be resected as to the

!ll teratomas should be resected as to the
uncertainty whether it is benign and
uncertainty whether it is benign and
possibility of further enlargement and
possibility of further enlargement and
impingement on ad-acent structures
impingement on ad-acent structures
Aerm cell tumor
Aerm cell tumor
Smooh, !ell"de#ined anerior mediasinal umor !ih
heerogeneous aenuaion associaed !ih calci#ic
inraumoral nodules suggess a mediasinal eraodermoid
$enign eraoma. % &'"year"old man developed mild ches
discom#or. (Atlas of diagnostic oncology, Arthur T.
Skarin,2009)
#eminomas
#eminomas

#eminoma LdysgerminomaM #eminoma LdysgerminomaM

9ccurs almost e.clusively in men 9ccurs almost e.clusively in men

=sually in the J =sually in the J

rd rd
decade of life decade of life

%hest pain, dyspnea, cough, hoarseness and %hest pain, dyspnea, cough, hoarseness and
dysphagia dysphagia

#0% syndrome can occur #0% syndrome can occur

They are aggressive malignant tumors that They are aggressive malignant tumors that
e.tend locally and metastasi2ed distantly, e.tend locally and metastasi2ed distantly,
usually to the s1eletal bones usually to the s1eletal bones
#eminoma
#eminoma

They may secrete /%A, but not !FP They may secrete /%A, but not !FP

Poor prognosis Poor prognosis

!ge FJ' yIo !ge FJ' yIo

#0% syndrome #0% syndrome

#upraclavicular, clavicular or hilar adenopathy #upraclavicular, clavicular or hilar adenopathy

Presentation with fever Presentation with fever

+.tremely radiosensitive and may respond +.tremely radiosensitive and may respond
dramatically with chemotherapy even in dramatically with chemotherapy even in
cases of dissemination cases of dissemination

%isplatin based regimen is used %isplatin based regimen is used

;ong term survival is *() ;ong term survival is *()

;ymphomas
;ymphomas

%ommon cause in both adults and children %ommon cause in both adults and children

1(7@() of cases 1(7@() of cases

/odg1inOs disease occurs bimodally in /odg1inOs disease occurs bimodally in

adolescents and young adults and in those over adolescents and young adults and in those over
'( '(

on7/odg1inOs occurs in older adults on7/odg1inOs occurs in older adults

'(7>() of /D have mediastinal lymph node '(7>() of /D have mediastinal lymph node
involvement at the time of diagnosis involvement at the time of diagnosis

9nly @() of /; have mediastinal involvement 9nly @() of /; have mediastinal involvement
;ymphoma
;ymphoma

Incidental discovery of a mass on %N" is a Incidental discovery of a mass on %N" is a

common presentation of lymphoma common presentation of lymphoma

#ystemic and locali2ed symptoms #ystemic and locali2ed symptoms

Tracheal compromise and #0% are common Tracheal compromise and #0% are common

Pericardial and pleural involvement Pericardial and pleural involvement

"esection is not a necessary part of therapy, "esection is not a necessary part of therapy,
but anterior thoracotomy or but anterior thoracotomy or
mediastinoscopy is re6uired to confrm the mediastinoscopy is re6uired to confrm the
diagnosis if adenopathyis not evident diagnosis if adenopathyis not evident
outside the mediatinum outside the mediatinum

Obliterated retrosternal clear space

On the PA film there is a lobulated widening of

the superior mediastinum.
On the lateral chest film the retrosternal clear
space is obliterated.

This happened to be a patient with lymphoma.

Thyroid lesions
Thyroid lesions

+ctopic thyrod gland accounts for 1() of +ctopic thyrod gland accounts for 1() of
mediastinal mass mediastinal mass

%ervical goiter e.tends susternally into the %ervical goiter e.tends susternally into the
anterior mediastinum anterior mediastinum

Primary intrathoracic goiter, originating Primary intrathoracic goiter, originating

from the heterotropic thyroid tissue is rare from the heterotropic thyroid tissue is rare

Most are in the anterior mediastinum but Most are in the anterior mediastinum but
can occur in the middle and posterior can occur in the middle and posterior
mediastinum mediastinum
Thyroid lesions
Thyroid lesions

%ommon in women %ommon in women

Middle or older age Middle or older age

!symptomatic !symptomatic

/oarsenessH %ough, swelling of the face /oarsenessH %ough, swelling of the face

"ecogni2ed by radioactive iodine screning "ecogni2ed by radioactive iodine screning

"esected by transcervical approach wihout "esected by transcervical approach wihout

the use of sternotomy approach the use of sternotomy approach
Parathyroid lesions
Parathyroid lesions

Mediastinal parathyroid tissue accounts for Mediastinal parathyroid tissue accounts for
as many as 1() of cases of as many as 1() of cases of
hyperparathyroidism hyperparathyroidism

Mediastinum is the most common site for Mediastinum is the most common site for
ectopic parathyroid adenomas in surgically ectopic parathyroid adenomas in surgically
resistant hyperparathyroidism resistant hyperparathyroidism

Technetium scanning are accurate in Technetium scanning are accurate in

diagnosing parathyroid tissue diagnosing parathyroid tissue

%ured by complete resection %ured by complete resection

Mesenchymal tumors
Mesenchymal tumors

Iipomas, fbroma, mesothelioma, Iipomas, fbroma, mesothelioma,

lymphangiomas, lymphangiomas,

They arise from connective tissue, fat, They arise from connective tissue, fat,
smooth muscle, striated muscle, blood smooth muscle, striated muscle, blood
vessels or lymphatic channels and can occur vessels or lymphatic channels and can occur
in a any region of the mediastinum in a any region of the mediastinum

/istologically they di,er from their /istologically they di,er from their
counterpart counterpart

Presence of symptoms means that the lesion Presence of symptoms means that the lesion
is malignant is malignant
;ipoma
;ipoma

Is the most common mesenchymal tumor Is the most common mesenchymal tumor

Most often anterior Most often anterior

+ncapsulted or unencapsulated +ncapsulted or unencapsulated

#mooth, rounded with sharply defned #mooth, rounded with sharply defned
margins margins
;ipomatosis
;ipomatosis

More common than lipoma More common than lipoma

Aenerali2ed overabundance of histologically Aenerali2ed overabundance of histologically

normal unencapsulated fat normal unencapsulated fat

The presence of some fat in the mediastinum The presence of some fat in the mediastinum
is normal, usually in and around the thymus is normal, usually in and around the thymus

!ccumulation of e.cess fat is associated !ccumulation of e.cess fat is associated

with generali2ed obesity or %ushingPs with generali2ed obesity or %ushingPs
syndrome or with the use of e.ogenous syndrome or with the use of e.ogenous
steroids or drugs steroids or drugs
Middle Mediastinum

The middle mediastinum contains the following

structures* lymph nodes$ trachea$ esophagus$
a%ygos vein$ vena cavae$ posterior heart and the
aortic arch+

The ma7ority of middle mediastinal masses will

consist of foregut duplication cysts -eg
oesophageal duplication or bronchogenic cysts. or
lymphadenopathy+
&ortic arch anomalies can also present as middle
mediastinal masses+
;esions typically in the
;esions typically in the
Middle Mediastinum
Middle Mediastinum

+nlargement of the lymph node +nlargement of the lymph node

Mediatinal lymph node enlargement is most Mediatinal lymph node enlargement is most
often due to three categories of disease often due to three categories of disease
process process

;ymphomas ;ymphomas

Metatastic cancer Metatastic cancer

Aranulomatous in$ammation Aranulomatous in$ammation

On he le# a paien !ih a small cell lung
carcinoma.
On he *% #ilm here is a lo+ulaed pararacheal
sripe on he righ.
On he laeral radiograph here is a densiy overlying
he ascending aora and #illing he rerosernal
space.
,hese #indings indicae a mass in he anerior as!ell
as in he middle mediasinum.
C, scanning con#irm o# lymphoma.
Developmental cyst
Developmental cyst

%omprise 1(7@() of all mediatinal mass in %omprise 1(7@() of all mediatinal mass in
both adults and children both adults and children

Pericardial, bronchogenic and enteric cyst Pericardial, bronchogenic and enteric cyst
on the basis of their lining tissue on the basis of their lining tissue

3ronchogenic and enteric cyst are referred 3ronchogenic and enteric cyst are referred
to as foregut duplication cyst because of to as foregut duplication cyst because of
their origin from aberrant portions of the their origin from aberrant portions of the
ventral and dorsal foregut ventral and dorsal foregut
Developmental %ysts
Developmental %ysts

Pericardial cyst Pericardial cyst

!ccounts for 1IJ of cystic masses in adults !ccounts for 1IJ of cystic masses in adults

;ess common in children ;ess common in children

They typically lie against the pericardium, They typically lie against the pericardium,
diaphragm or anterior chest wall on the right diaphragm or anterior chest wall on the right
cardiophrenic angle cardiophrenic angle

It can enlarge to cause right ventricular It can enlarge to cause right ventricular
out$ow tract obstruction, or rupture and out$ow tract obstruction, or rupture and
hemorrhage to cause pericardial tamponade hemorrhage to cause pericardial tamponade
or sudden cardiac death or sudden cardiac death
Developmental %ysts
Developmental %ysts

3ronchogenic cyst
3ronchogenic cyst

Found near the large airways, often posterior Found near the large airways, often posterior
to the carina, may attach to the esophagus or to the carina, may attach to the esophagus or
even inside the pericardium even inside the pericardium

%yst wall often contains cartilages and %yst wall often contains cartilages and
respiratory epithelum respiratory epithelum

Most are discovered incidentally and Most are discovered incidentally and
asymptomatic asymptomatic

They can communicate with the They can communicate with the
tracheobronchial tree and can become infected tracheobronchial tree and can become infected
and cause airway obstruction, pulmonary and cause airway obstruction, pulmonary
artery compression and hemodynamic collapse artery compression and hemodynamic collapse
or rupture with disastrous conse6uences or rupture with disastrous conse6uences
Developmental %ysts
Developmental %ysts

+nteric or entergenous cyst +nteric or entergenous cyst

#imilar in location and appearance with #imilar in location and appearance with
bronchogenic cyst, but have digestive tract bronchogenic cyst, but have digestive tract
epithelum epithelum

=ncommon in adults =ncommon in adults

%ommonly seen in infants and children %ommonly seen in infants and children

!ssociated with spinal e.tension and !ssociated with spinal e.tension and
malformation of the vertebral column called malformation of the vertebral column called
neurenteric cyst neurenteric cyst
Diaphragmatic hernia
Diaphragmatic hernia

The protrusion of omental fat or other The protrusion of omental fat or other
abdominal contents through the diaphragm abdominal contents through the diaphragm
may occur via several potential routes and may occur via several potential routes and
medatinal mass lesion in any compartment medatinal mass lesion in any compartment
may occur may occur

! hernia thorough the foramen of Morgagni ! hernia thorough the foramen of Morgagni
produces a cardiphrenic angle mass, usually produces a cardiphrenic angle mass, usually
on the right side on the right side

3ochdale1Os hernia, in the posterior 3ochdale1Os hernia, in the posterior

mediastinum, generally appears on the left mediastinum, generally appears on the left
side, presumably because the liver prevents side, presumably because the liver prevents
formation on the right formation on the right

They are usually incidental fnding but can They are usually incidental fnding but can
cause complication in some cases cause complication in some cases

Posterior Mediastinum
Posterior Mediastinum

The posterior mediastinum contains the following

structures* sympathetic ganglia$ nerve roots$
lymph nodes$ parasympathetic chain$ thoracic
duct$ descending thoracic aorta$ small vessels and
the vertebrae+

4ost masses in the posterior mediastinum are

neurogenic in nature+
These can arise from the sympathetic ganglia -eg
neuroblastoma. or from the nerve roots -eg
schwannoma or neuro'broma.+
Cervicothoracic sign
On he le# he MR o# he same paien.
- urned ou o +e a sch!annoma.
AanglioneuromaH During evaluation for unrelated problem, chest AanglioneuromaH During evaluation for unrelated problem, chest
radiography in a @:7year7old woman revealed an asymptomatic radiography in a @:7year7old woman revealed an asymptomatic
posterior mediastinal massH /istologic showed ganglioneuroma posterior mediastinal massH /istologic showed ganglioneuroma
L L"tlas of diagnostic oncology, "rthur #$ Skarin,%&&' "tlas of diagnostic oncology, "rthur #$ Skarin,%&&'M M
%las o# diagnosic oncology, %rhur ,. S.arin, /''0