---t" medical imaging

Current Use of Imaging in the Evaluation of Primary

Mediastinal Masses·
Kathleen Brown, M.D., F.C.C.R; Denise R. Aberle, M.D.;
Poonam Batra, M.D., F.C.C.R; and Richard] Steckel, M.D.

A wide variety of lesions occur in the mediastinum in normal structures in the region, localization of lesions to
patients of every age. Twenty 6ve to 50 percent of these compartments of the mediastinum may assist in diagnosis.
primary mediastinal masses may be malignant, making This article reviews imaging techniques for lesions origi-
early diagnosis and therapy crucial. Since most arise from nating in the mediastinum. (Chat 1990; 98:466-73)

Plesions
rimary mediastinal masses are a diverse group of
which present a diagnostic and therapeutic
thoracic vertebral bodies separates the middle and
posterior mediastinum. All methods of division are
challenge to clinicians, as well as radiologists. In a arbitrary but are intended to facilitate understanding
combined series of 1,000 patients with mediastinal of the complex anatomy of the mediastinum. For the
tumors and cysts, the relative incidence was as follows: purposes of this review, the traditional method of
neurogenic tumors, 24 percent; cysts, 21 percent; dividing the mediastinum is used.
germ cell tumors, 17 percent; thymomas, 12 percent; Nonvascular lesions that tend to occur in each of
lymphomas, 13 percent; and others, 13 percent. 1 A the compartments of the mediastinum are listed in
thorough understanding of mediastinal anatomy is Table 1. Thymomas, primary mediastinal germ cell
essential for the evaluation ofa mediastinal mass, since tumors, lymphomas, mesenchymal tumors, and sub-
specific lesions have a predilection for certain sites. In sternal extensions of the thyroid are major considera-
order to formulate reasonable differential diagnoses in tions in the differential diagnosis of primary anterior
the evaluation of mediastinal abnormalities, several mediastinal masses. Middle mediastinal masses in-
methods have been suggested to divide the mediasti- clude lymph node enlargement from a variety of
num into compartments.v' With the classic (tradi- causes, pericardial cysts, and bronchogenic cysts.
tional) anatomic method," the anterior mediastinum Posterior mediastinal masses are usually neurogenic
has been defined as being bounded anteriorly by the in origin, but they may also arise from the esophagus
sternum and posteriorly by the pericardium, aorta or represent gastroenteric cysts. Nodal enlargement
and brachiocephalic vessels; the middle mediastinum from metastatic disease, including extrathoracic as
contains the pericardium and heart, the ascending well as bronchogenic primaries, may occur in any
and transverse portions of the aorta, the vena cavae, mediastinal compartment.
the phrenic and vagus nerves, the trachea, mainstem
GENERAL IMAGING CONSIDERATIONS
bronchi and contiguous lymph nodes, and the central
pulmonary arteries and veins. The posterior mediasti- High kilovoltage posteroanterior and lateral radio-
num is bordered anteriorly by the pericardium and
posteriorly by the spine.! With the radiologic method Table I-NonfXJlJCU1ar LaionB Occurring in Mediaatinum
ofclassification, the mediastinum is divided into three Anterior Middle Posterior
compartments based on the lateral chest radiograph.
A line drawn from the diaphragm to the thoracic inlet Thymic tumors Lymphoma Neurogenic tumors
Germ cell tumors Pericardial cyst Neurenteric cyst
along the back of the heart and anterior to the trachea Intrathoracic goiter Bronchogenic cyst Gastroenteric cyst
divides the anterior and middle mediastinum, and a Lymphoma Meningocele
line drawn 1 cm behind the anterior margin of the Parathyroid adenoma Esophageal lesions
Mesenchymal tumors
Lipoma .
*From the Department of Radiological Sciences, and the Jonsson
Comprehensive Cancer Center, UCLA School of Medicine, Los Lymphangioma
Angeles. Fibroma
Reprint requests: Dr. Brown, UCLA School of Medicine/Radiology, Hemangioma
10833 Le Conte Avenue, Los Angeles 90024

466 Imaging in Evaluation of Primary Mediastinal Masses (Brown et aI)

graphs of the chest continue to be the most valuable
technique for the initial evaluation of mediastinal
masses. Contour distortions of the normal interfaces
between the lung and the mediastinum may occur
even with small mediastinal masses which, with en-
largement, may project into the adjacent hemithorax.
Oblique views may also be useful in the evaluation of
patients with an equivocal chest radiograph. Careful
fluoroscopy may allow optimal determination of obliq-
uity to visualize a lesion better and may assist by
demonstrating intrinsic or transmitted pulsations with
masses. Occasionally, calcifications within lesions are
also identified initially in this way
Although conventional tomography has been used
in the past to evaluate the mediastinum, computed
tomography (CT) has now largely replaced conven-
tional tomography in most institutions as the most
useful imaging modality following routine radiogra-
phy" In fact, CT has been shown to be more useful in
evaluating the mediastinum than any other region in
the thorax. Mediastinal pathology may easily be de-
tected by CT even in the presence of a normal chest
radiograph. Superior contrast resolution permits dif-
ferentiation of normal mediastinal structures from
mediastinal masses, allows accurate delineation of the
densities of tissues within a mass, and with intravenous
contrast, may distinguish between vascular and non-
vascular lesions. The transaxial imaging plane of CT
allows clear definition of normal structures in the
mediastinum, most of which course perpendicular to
the imaging plane (eg, major vessels and airways).
Computed tomography can also assist in determining
the best approach for the biopsy of mediastinal lesions.
More recently, magnetic resonance imaging (MRI)
has been used to evaluate the mediastinum. The lack
of ionizing radiation, the availability of direct cross-
sectional images in multiple imaging planes, and the
ability to distinguish vascular structures without using
intravenous contrast has made MRI a potentially
valuable alternative to CT scanning. Multiple studies
have now shown MRI to be equivalent to CT for
detecting mediastinal lymph nodes and masses. 5-7
Although initially it was hoped that differences in
signal intensity would allow differentiation between
benign and malignant masses, MRI has been unable
to discriminate between enlarged benign and malig-
nant nodes. However, there is evidence to suggest that
in the future, MRI may prove to be useful in the
differentiation of residual tumor from fibrosis." Inva-
sion or encasement of major cardiovascular structures
by tumor may be demonstrated better on MRI than
CT. The direct sagittal and coronal images afforded
by MRI may also allow better evaluation of lesions in
the thoracic apex and the diaphragmatic areas than
CT. However, because of diminished spatial resolution,
inability to detect small calcifications, long scan time,
and the current difficulty in imaging the lung paren-
chyma, the overall utility of MRI for evaluating the
thorax remains limited at this time. 7
A brief discussion follows of diagnostic imaging
applications for the major masses which occur in the
mediastinum.
THYMOMA
Thymoma is the most frequent tumor occurring in
the anterior mediastinum. Although it may occur at
any age, it is most common in patients over the age of
40. Thymomas arise from both the epithelial and the
thymocytic elements of the gland and can be classified
into the following four subtypes based on the predom-
inant cell: (1) lymphocytic; (2) epithelial; (3) mixed
lymphoepithelial; and (4) spindle cell. Histologic ex-
amination alone does not allow the differentiation of
benign from malignant lesions, and the presence at
surgery of complete encapsulation or local invasion is
used to estimate malignancy and prognosis.
The association between thymic neoplasms and
myasthenia gravis is well known. Thymic tumors occur
in approximately 8 to 15 percent of patients with
myasthenia gravis, and approximately 25 to 50 percent
of patients with thymic tumors have been shown to
have myasthenia. Other associated conditions that
have been reported include red blood cell hypoplasia,
hypogammaglobulinemia, and/or Cushing's syndrome.
Radiographically, these lesions appear as round,
oval or lobulated masses in the anterior mediastinum,
usually just anterior to the junction of the heart and
the great vessels (Fig 1). Nearly one-quarter of thy-
momas may not be detected initially on routine
posteroanterior chest radiographs, but diagnostic ac-
curacy is increased to 94 percent when both postero-
anterior and lateral views are considered." Calcifica-
tion has been reported both throughout the lesion and
in the periphery of a thymoma, in benign as well as
malignant types. While thymomas usually appear as
circumscribed soft tissue masses in the mediastinum
on CT, this modality cannot reliably differentiate
benign from malignant lesions. Thymomas may exhibit
fibrous adherence to the mediastinum in the absence
of tumor infiltration, causing partial obliteration of the
interfaces between tumor and mediastinal fat without
tumor invasion." Thymomas typically spread by local
invasion and by direct extension to the pleura, major
blood vessels and lungs with distant metastases un-
common. Computed tomography remains superior to
MRI for imaging the thymus in patients with myasthe-
nia gravis because of better spatial resolution and
thymic definition in a shorter scan time. 10
Thymolipoma is an uncommon benign lesion in the
thymus, representing approximately 2 to 9 percent of
thymic tumors." This tumor may occur at any age and
has no sex predilection. Because the tumor is quite
CHEST I 98 I 2 I AUGUS'T. 1990 487
 FIGURE lA (left) and 18 (right). PA and lateral chest radiographs demonstrate a lobulated anterior
mediastinal mass (arrows) . Surgically proven thymoma.
soft in consistency and slowly growing, patients are
usually asymptomatic and the tumor can attain a large
size. It is usually discovered on routine chest radiog-
raphy. Large thymolipomas may sag toward the dia-
phragm and adapt themselves to the diaphragmatic
contours. There is no known association between
thymolipoma and myasthenia gravis or any other
syndrome. On plain chest radiographs, a clear differ-
ence between the fatty mass and the adjacent water
density structures may often be noted.
GERM CELL TUMORS
The anterior mediastinum is the most frequent site
for primary extragonadal germ cell tumors. This
category of tumor includes teratoma (benign or malig-
nant), seminoma or dysgerminoma, embryonal cell
carcinoma, choriocarcinoma, endodermal sinus (yolk
sac) tumors, and benign dermoid cysts. Incomplete
migration or persistence of primitive germinal cells
during embryogenesis is theorized to account for the
presence of these lesions in the mediastinum. The
germ cell tumors usually become manifest during
adolescence or early adulthood. Eighty percent of
primary germ cell tumors in the mediastinum are
benign teratomas. Benign lesions occur more often in
women and malignant lesions more frequently in men.
Teratomas are the most common primary medias-
tinal germ cell tumor. These anterior mediastinal
lesions are comprised of all three embryonic layers
and may be either cystic or solid. They are malignant
468
in approximately 30 percent ofcases. Radiographically,
the solid lesions often appear lobulated and the cystic
lesions more smooth and circumscribed. Peripheral
calcification may occur and rarely ossification, with
skeletal parts or teeth, allowing a definitive diagnosis.
Malignant teratomas are less likely to demonstrate
well differentiated structures. Computed tomography
is particularly useful in evaluating these lesions, since
the sensitivity to contrast differences allows for the
identification of fat and calcifications.12
Primary mediastinal seminomas or dysgerminomas
are much more frequent in young men and appear
roentgenographically as lobulated anterior mediastinal
masses. These lesions are radiosensitive and poten -
tially radiocurable, as compared to the nonsemino-
matous mahgnancies." Primary embryonal cell carci-
nomas, choriocarcinomas, and endodermal sinus
tumors are highly malignant lesions and also occur in
young men. There are no radiographic features that
allow their differentiation from other mediastinal
masses on chest radiography. On cr scanning, these
lesions appear as lobulated anterior mediastinal
masses. While obliteration of normal mediastinal fat
planes may suggest malignancy, this finding may also
occur with fibrous adherence of benign masses to
vessels," Because of differences in prognosis and
therapy, differentiation between seminomas and non-
seminomatous tumors is crucial, and biopsy is essential
for diagnosis.
Imaging In Evaluation of Primary Me<iastinal Masses(Brown et aI)
 MEDIASTINAL THYROID
Mediastinal extension of cervical thyroid tissue is a
frequent cause of a mediastinal mass. Intrathoracic
thyroid tissue is usually located in the anterior medi-
astinum, but occasionally it may be middle or poste-
rior mediastinal in location. Mediastinal thyroid tissue
is rarely malignant. Radionuclide scanning with iodine
1311, WI, or llIlmTc is the usual method for identifying
intrathoracic thyroid tissues, and contiguity with cer-
vical thyroid is usually present. False negative radio-
nuclide scans may occur because of nonfunctioning
thyroid within the thorax, and CT scanning may be a
useful adjunct to radionuclide scanning. Characteristic
features that may be identified on CT and aid in a
specific diagnosis include the following: (1) anatomic
continuity with the cervical thyroid; (2) high attenua-
tion on the CT scan; (3) rise in attenuation after bolus
administration ofIV contrast with prolonged enhance-
ment; and (4) focal calcification which may occur in
approximately 25 percent of cases. IS
MESENCHYMAL TUMORS
Primary mesenchymal tumors of the mediastinum
are an unusual and heterogeneous group of tumors
arising from connective tissue, fat, muscle, blood
vessels and/or lymphatics. Lipomas are the most
frequent of these lesions and are usually benign,
originating in the anterior mediastinum. They are
usually asymptomatic. Roentgenographically, they are
FIGURE 2A: (left) and 2B (right). Twenty-seven-year old woman with a historyofHodg\dns disease. PAand
lateral radiographs of the chest show abnormal soft tissue densities in the anterior mediastinum and the
left cardiophrenic angle (arrows). Residuallympbangiogram contrast is identified (arrowhead).
lobulated lesions, and because of the lower radio-
graphic density of fat, may appear less dense than
other mediastinal masses and also less dense than the
adjacent mediastinal soft tissues. Liposarcomas may
lead to symptoms when they invade contiguous struc-
tures, and they occur most often in the posterior
mediastinum. On CT scans, islands of soft tissue
density may be interspersed within fat density in
these mass lesions.
Fibromas may occur anywhere in the mediastinum
but are more frequently found in the anterior medi-
astinum. Fibrosarcomas are more often posterior in
location. Radiographically, they appear as soft tissue
masses without any distinguishing radiographic fea-
tures.
Neoplasms arising from mediastinal blood vessels
are all rare and include hemangiomas, endotheliomas,
hemangiopericytomas, and hemangiosarcomas. He-
mangioma is the most common mediastinal blood
vessel tumor and is located most often in the anterior
mediastinum. When visible radiographically, phlebo-
liths are a useful diagnostic sign. The spinal canal and
vertebral bodies may be involved in posterior lesions,
requiring evaluation with myelography, CT with intra-
thecal contrast, or MRI.
Lymphangiomas may be cystic or cavernous and
occur in an anterior location. Continuity with a neck
mass in children may be evident. With recent advances
in ultrasound technology and performance, intrauter-
ine diagnosis has become possible.
CHEST I 98 I 2 I AUGUST, 1990 488
 LYMPHOMA
Nodal enlargement from lymphomatous involve-
ment is one of the most frequent causes of a medias-
tinal mass. Accurate localization of the extent of tumor
and a tissue diagnosis may both be crucial in deter-
mining therapy. Anterior mediastinal, paratracheal, or
tracheobronchial adenopathy is seen in approximately
90 percent of those with intrathoracic involvement in
Hodgkins disease;" In patients with intrathoracic
involvement in non- Hodgkin's lymphoma, these lymph
node groups are affected in approximately 46 percent.
Posterior mediastinal and pericardial nodal groups, as
well as the lung parenchyma, are more frequently
involved in non-Hodgkins lymphoma.
Mediastinal lymph node enlargement can be de-
tected on initial chest radiography in approximately
50 percent of patients with Hodgkin's disease. Calci-
fication is not seen within the enlarged nodes initially,
but it may be demonstrated following radiation therapy
or chemotherapy. Computed tomography can confirm
mediastinal involvement in patients with equivocal
findings on chest radiography and can detect addi-
tional sites of disease not demonstrated on the initial
plain films. In one study, occult disease was demon-
strated by cr in one-third of patients with "normal"
FIGURE 2C (upper) and 2D (lower). CT scan better demonstmtes
the relationship of the soft tissue masses (arTVW8) to adjacent
mediastinal structures. Biopsy of the prevascular mass under CT
guidance yielded the diagnosis of recurrent Hodgkin's disease.
470
chest radiographs." Modifications in treatment were
based on these findings in approximately 9 percent of
the patients, with the most significant changes occur-
ring in those patients undergoing radiation therapy
alone.
Serial cr studies may also be useful in the evalua-
tion of response to therapy and for detection of
recurrent disease (Fig 2). Persistent soft tissue masses
in the mediastinum do not necessarily represent
residual tumor, but may be secondary to one or more
fibrotic, sterilized lymph nodes. Nodal calcifications
may be detected on cr scan following therapy. Thymic
cysts have also been reported following therapy in
patients with Hodgkin's disease." Magnetic resonance
imaging may prove to be useful in the future to
differentiate residual or recurrent tumor from fibrosis
following therapy"
PERICARDIAL CYSTS
Pericardial cysts are relatively uncommon lesions
and are presumed to arise from congenital defects
related to ventral and parietal pericardial recesses. 19
They are lined by a single layer of mesothelial cells
and are most often unilocular. These cysts are usually
asymptomatic, but occasionally patients may present
with chest pain, dyspnea, or cough. Approximately 70
percent of pericardial cysts arise in the right cardio-
phrenic angle, but lesions remote from the cardio-
phrenic angle may occur and may be more difficult to
diagnose .
Typically, pericardial cysts appear on plain radio-
graphs as smooth, round homogeneous soft tissue
masses in the cardiophrenic angle, contiguous with
the anterior chest wall and the hemidiaphragm, Cal-
cification may rarely occur within the wall of the cyst.
Occasionally, a pointed superior contour is identified,
presumably due to drooping of the thin-walled cyst
from its point of origin. Fluoroscopic examination may
show changes in the contour of a cyst with changes in
patient position.
Cardiac ultrasound may allow determination of the
cystic nature of the mass if the lesion is adjacent to
the chest wall. Computed tomography is diagnostic
when the mass is in a classic location, does not enhance
with intravenous contrast, and has an attenuation
coefficient consistent with a cystic lesion." A pointed
contour and variations in shape with changes in
position also point to a cystic lesion.21 When the
clinical and radiographic presentation is consistent
with pericardial cyst, thoracotomy is generally not
required in the asymptomatic patient.
FOREGUT DUPLICATION CYSTS
Foregut duplication cysts are rare congenital anom-
alies, accounting for approximately 10 percent of
mediastinal masses in the adult.P Bronchogenic cysts,
ImagingIn Evaluation 01Primary Mediastinal Masses (Brown et 111)
esophageal duplication cysts, and neurenteric cysts
are part of the spectrum of malformations which are
thought to share a common embryogenesis arising
from the primitive foregut early in fetal development.
Bronchogenic cysts are the most common form of
foregut cysts.1 They result from abnormal budding of
the ventral lung bud or abnormal branching of the
tracheobronchial tree. 22.13 These lesions may occur
either within the mediastinum or the lung paren-
chyma, with the mediastinal cysts resulting from
earlier abnormal branching during embryogenesis.
The cysts are lined by secretory epithelium; depend-
ing on whether a communication remains with the
tracheobronchial tree, they may vary from being
completely Huid-filled to completely air-filled.
Mediastinal bronchogenic cysts typically are asymp-
tomatic and are usually discovered on routine chest
radiograph}'. Symptoms, when present, frequently
result from compression of neighboring structures and
include chest discomfort or pain, nonproductive
cough, wheezing, or dysphagia.
Radiographically, the mediastinal lesions present as
smooth, homogeneous round or ovoid masses of water
density in close association with the trachea or major
bronchi. While they may be located in the middle,
posterior or superior mediastinum, the most typical
location is subcarinal with extension inferiorly. Medi-
astinal bronchogenic cysts rarely have a patent com-
munication with the tracheobronchial tree and are
usually filled with mucoid material. Calcification
within the wall of the cyst is rare.
Computed tomography is invaluable in character-
izing .these congenital cystic lesions. On CT, these
cysts appear as well-defined, rounded masses without
infiltration of adjacent mediastinal structures. Al-
though they are typically of water density, they may
contain sufficient mucoid material to give a high CT
numberZ4·25 and do not enhance following intravenous
contrast administration.
Ultrasound may also be helpful in evaluating these
congenital lesions because of its ability to establish
the cystic nature of a mass. Lesions contiguous with
the chest wall, in the anterior mediastinum, or in the
subcarinal region may be imaged using standard
cardiac projections. Cysts in the posterior mediasti-
num are not assessible by ultrasound because of the
absence of an acoustic window Diagnostic cyst punc-
ture may be approached percutaneously with CT or
ultrasound guidance or by bronchoscopy
Esophageal duplications are presumed to result
from a diverticulum of the dorsal bud of the primitive
foregut or aberrant recanalization of the gut during
embryogenesis.P While they are usually found adja-
cent to or within the esophageal wall, these duplication
cysts may migrate with the lung bud and develop
remote from the esophagus. Simple enteric cysts have
variable radiographic appearances and are not always
distinguishable from bronchogenic cysts.16 They are
usually located in the posterior mediastinum and tend
to be larger than respiratory cysts. Barium esophagram
may show extrinsic compression of the esophagus by
the cyst. .
Neurenteric cysts originate earlier in embryonic life
and result from incomplete separation of the endo-
derm and notocord, resulting in the development of a
diverticulum of the endoderm.P Normal fusion of
vertebral ossification centers is prevented and associ-
ated vertebral anomalies including hemivertebra, but-
terfly vertebra, and scoliosis may occur. These lesions
also occur typically in the posterior mediastinum.
NEUROGENIC TUMORS
Neurogenic tumors arise most often in the posterior
mediastinum and include benign and malignant neo-
plasms arising from the intercostal nerves or compo-
nents of the autonomic system. They are commonly
divided into the following three groups: (1) those of
peripheral nerve origin (neurilemomas, neurofibro-
mas, malignant schwannomas); (2)those of sympathetic
nervous origin (ganglioneuromas, neuroblastomas,
ganglioneuroblastomas); and (3) those of parasympa-
thetic system origin (pheochromocytomas, paragangli-
omas).
Nerve sheath tumors are the most common and are
usually benign. Neurogenic tumors may occur at any
age, but are most common in younger age groups.
Neurilemoma (schwannoma) is the most common
benign tumor. rt
Radiographically, these lesions are similar in ap-
pearance with a smooth, round or oval mass in a
paravertebral location. Ganglia-related tumors tend to
have an elongated or triangular density with a broad
base towards the mediastinum and tapering superior
and inferior margins, distiilguishing them from the
more oval nerve sheath tumors. rt Erosion, destruction,
or spreading of the ribs may occur, as may vertebral
abnormalities, including enlargement of the neural
foramina, erosion of the pedicles, and scoliosis. Mye-
lography is recommended when neurologic symptoms
or vertebral body changes occur in the presence of a
posterior mediastinal mass. Also, MRI can be used
now to evaluate intraspinal extension of these tumors, 7
and additional imaging planes may better define the
origin of the tumor (Fig 3).18
VASCULAR LESIONS
Vascular lesions may simulate mediastinal neo-
plasms and may occur in any mediastinal compart-
ment. 29•30 Clinical symptoms and physical examination
may not distinguish vascular lesions from other me-
diastinal abnormalities, and an accurate radiographic
diagnosis prior to intervention is crucial to prevent
CHEST I 98 I 2 I AUGUSt 1990 471
 FIGURE 3A (left). PAchest radiograph demonstrates a left apical mass (arrow). FIGURE 3B (right). Axial cr
scan demonstrates the mass (arrow), but the origin of the mass cannot be demonstrated.
inappropriate therapy.
Kelley et al3D divided mediastinal vascular abnor-
malities into the following four groups depending on
their sites of origin; (1) systemic venous system; (2)
pulmonary arterial system; (3) pulmonary venous
system; and (4) systemic arterial system. Abnormali-
FIGURE 3C (upper) and 3D (lower). Tl weighted coronal (upper)
and sagittal (lower) MRI scans clearly demonstrate the extrapleural
origin of the mass (arrow), presumed to be a benign neurofibroma.
472
ties of the systemic veins including the superior vena
cava and the azygos, hemiazygos, and innominate
veins, usually occur in the middle or superior medi-
astinum. Abnormalities of the pulmonary arterial
system, including abnormalities of the pulmonary
trunk and main pulmonary arteries, present as middle
mediastinal or perihilar masses and include pulmonary
valve stenosis, congenital absence of the pulmonary
valve, pulmonary arterial hypertension of any cause,
anomalous left pulmonary artery, or aneurysm of the
ductus arteriosus. Pulmonary venous system abnor-
malities including partial anomalous pulmonary ve-
nous return and pulmonary vein varix may present as
masses in the middle or superior mediastinum.s?
The most common vascular lesions to be confused
with mediastinal neoplasms are abnormalities of the
thoracic aorta and its branches. These lesions typically
occur in elderly patients with hypertension and arte-
riosclerosis. Aneurysms of the thoracic aorta may occur
from a variety of causes, including arteriosclerosis,
trauma, syphilis, or cystic medial necrosis. The major-
ity are discovered on routine radiographs. Peripheral
calcification of a mass may suggest a vascular etiology,
and fluoroscopy has been used to evaluate intrinsic
pulsations. Contrast-enhanced CT should allow differ-
entiation of vascular lesions and soft tissue masses,
but aneurysms filled with thrombus may fail to show
contrast enhancement. Angiography is performed in
most cases prior to definitive therapy.
Magnetic resonance imaging has been shown to be
an excellent modality for the evaluation of the thoracic
aorta and its major branches. The advantages of MRI
include lack of ionizing radiation, multiplanar imaging
capability, and excellent contrast between vascular
structures and soft tissues without the use of intrave-
nous contrast agents . While differentiation between
Imaging in Evaluation01Primary MedIastinal Masses (Brown lit aI)
slow-Howing blood and mural thrombus may be diffi-
cult, and small calcifications are not detectable, our
experience suggests that MRI may eventually supplant
arteriography for evaluating lesions of the thoracic
aorta. 31
The innominate artery commonly undergoes elon-
gation, tortuosity, and buckling, and may appear
radiographically as a curvilinear density coursing
above the right clavicle. While true aneurysms of this
vessel are less common, they are more likely to be
symptomatic.
An aberrant right subclavian artery originating from
a normal left-sided aortic arch is the most common
congenital anomaly of the aortic arch. The aberrant
vessel arises just distal to the left subclavian artery
and courses posterior to the trachea and esophagus.
While individuals with this abnormality are usually
asymptomatic, dysphagia due to compression of the
esophagus has been described ('dysphagia lusoria"),
A barium esophagram classically will demonstrate
anterior displacement of the posterior wall of the
esophagus at the level of the aortic arch. Aortogram,
cr scan, or MRI are diagnostic. Aneurysms of an
aberrant right subclavian artery have been reported
but are rare. 32
A right aortic arch, cervical aortic arch, coarctation,
or pseudocoarctation may all simulate a mediastinal
neoplasm in isolated individuals.
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