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
is
the region in the
the region in the
chest between the
chest between the
pleural cavities that
pleural cavities that
contain the
contain the
heart
heart
and other thoracic
and other thoracic
viscera except the
viscera except the
lungs
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 drawn by the sternum and posteriorly by a line drawn
from the anterior aspect of the trachea and from the anterior aspect of the trachea and
along the posterior heart 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 border is mediastinal, anterior border is

defined by a line that is 1 cm posterior defined by a line that is 1 cm posterior
to the anterior edge of the vertebral to the anterior edge of the vertebral
bodies 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

Neoplasma Neoplasma

Pneumomediastinum
Pneumomediastinum

ir in the mediastinum is a common complication of ir in the mediastinum is a common complication of

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

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

!esults from stretching of the mediastinal tissues !esults from stretching of the mediastinal tissues

"ubsternal and aggravated by breathing and changing "ubsternal and aggravated by breathing and changing
position position

Dyspnea, dysphagia, subcutaneous crepitation Dyspnea, dysphagia, subcutaneous crepitation

Mediastinitis
Mediastinitis

cute inflammation of the mediastinum cute inflammation of the mediastinum

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

#hronic mediastinitis #hronic mediastinitis

Neoplasma
Neoplasma
#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 symptoms More than half are malignant if with symptoms
#linical Presentation
#linical Presentation

)ffects on #ompression or invasion of ad*acent tissues )ffects 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 effusion, invasion or irritation of pleural space Pleural effusion, 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 outflow obstruction and cor pulmonale !ight ventricular outflow obstruction and cor pulmonale
#linical Presentation
#linical Presentation

"uperior vena cava "uperior vena cava

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

"uperior vena cava syndrome "uperior vena cava syndrome

!esults from the increase venous pressure in the upper !esults from the increase venous pressure in the upper
thora+ , head and nec. thora+ , head and nec.

characteri/ed by dilation of the collateral veins in the upper characteri/ed by dilation of the collateral veins in the upper
portion of the head and thora+ and edema and phlethora of the portion of the head and thora+ and edema and phlethora of the
face, nec. and upper torso, suffusion and edema of the face, nec. and upper torso, suffusion and edema of the
con*unctiva and cerebral symptoms such as headache, con*unctiva and cerebral symptoms such as headache,
disturbance of consciousness and visual distortion disturbance of consciousness and visual distortion

0ronchogenic carcinoma and lymphoma are the most 0ronchogenic carcinoma and lymphoma are the most
common etiologies common etiologies
#linical Presentation
#linical Presentation

,oarseness, invading or compressing the

,oarseness, invading or compressing the
nerves
nerves

,orners syndrome, involvement of the

,orners syndrome, involvement of the
sympathetic ganglia 1dropping eyelid, decreased
sympathetic ganglia 1dropping eyelid, decreased
pupil si/e,decreased sweating on the ipsilateral
pupil si/e,decreased sweating on the ipsilateral
face2
face2

Dyspnea, from phrenic nerve involvement

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

Tachycardia, secondary to vagus nerve

Tachycardia, secondary to vagus nerve
involvement
involvement

#linical manifestations of spinal cord

#linical manifestations of spinal cord
compression
compression
#linical Presentation
#linical Presentation

"ystemic symptoms and syndromes "ystemic symptoms and syndromes

Fever, anore+ia, weight loss and other non specific Fever, anore+ia, weight loss and other non specific
symptoms of malignancy and granulomatous symptoms of malignancy and granulomatous
inflammation inflammation
Techni3ues for visuali/ing the
Techni3ues for visuali/ing the
mediastinum and its content
mediastinum and its content
!adiographic techni3ue !adiographic techni3ue

#hest +4ray5 "tandard postero antero and lateral #hest +4ray5 "tandard postero antero and lateral
views 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 fluid #an identify normal anatomic variations and fluid
filled cyst filled cyst

"ite of the origin of the mass can be better identified "ite of the origin of the mass can be better identified

1&&' specificity for the #T appearance of teratomas, 1&&' specificity for the #T appearance of teratomas,
thymolipoma, omental fat herniation thymolipoma, omental fat herniation

6verall accuracy for predicting mediastinal mass is 6verall accuracy for predicting mediastinal mass is
only 7(' only 7('
#omputed tomography
#omputed tomography

8imitation 8imitation

,ori/ontal oriented structures and boundaries are ,ori/ontal oriented structures and boundaries are
difficult to evaluate difficult to evaluate

bnormalities in the aortopulmonary window area and bnormalities in the aortopulmonary window area and
the subcarinal area the subcarinal area

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

ssesses tissue by measuring the

ssesses tissue by measuring the
radiofre3uency induced nuclear resonance
radiofre3uency induced nuclear resonance
instead of measuring the attenuation of
instead of measuring the attenuation of
transmitted ioni/ing radiation
transmitted ioni/ing 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

8imitations 8imitations

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

#annot distinguish between a benign and a malignant #annot distinguish between a benign and a malignant
causes for lymph node enlargement causes for lymph node enlargement
9ltrasonography
9ltrasonography

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

9seful in guiding endoscopic biopsy techni3ue 9seful in guiding endoscopic biopsy techni3ue
!adionuclide imaging
!adionuclide imaging

!ely on the locali/ation of mar.ers based on !ely on the locali/ation of mar.ers based on
specific metabolic or immunologic properties of the specific metabolic or immunologic properties of the
target tissue target tissue

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

Planar imaging with gallium :; and thallium4<&1 Planar imaging with gallium :; and thallium4<&1
P6"IT!6N )MI""I6N
P6"IT!6N )MI""I6N
T6M6=!P,>
T6M6=!P,>

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

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

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

%ccumulation of the isotope can then be identified using a &'T %ccumulation of the isotope can then be identified using a &'T
camera 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
P6"IT!6N )MI""I6N
P6"IT!6N )MI""I6N
T6M6=!P,>
T6M6=!P,>

The techni3ue is not infallible because certain

The techni3ue is not infallible because certain
non4neoplastic processes, including
non4neoplastic processes, including
granulomatous and other inflammatory
granulomatous and other inflammatory
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 lower
are also an issue, with the lower
limit of resolution of the study being
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 upta.e of the isotope in abnormal
intensity of upta.e of the isotope in abnormal
cells
cells

6ne should not rely on a negative P)T finding

6ne should not rely on a negative P)T finding
for lesions less than 1 cm on #T scan
for lesions less than 1 cm on #T scan
Dealing with mediastinal mass
Dealing with mediastinal mass
#onventional radiographic signs
#onventional radiographic signs

The ?silhouette sign@ The ?silhouette sign@

The hilar overlay sign The hilar overlay sign

The hilar convergence sign The hilar convergence sign

The cervicothoracic sign The cervicothoracic sign

Foto thora.s normal
Foto thora.s normal
The ?silhouette sign@
The ?silhouette sign@

Ahen a mass abuts a normal Ahen 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 structure margin of the normal structure
can be used to locali/e a can be used to locali/e a
mediastinal mass to the same mediastinal mass to the same
compartment as the normal compartment as the normal
structure structure
The hilar overlay sign
The hilar overlay sign

especially useful in especially useful in

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

If the bifurcation of the If the bifurcation of the

main pulmonary artery is main pulmonary artery is
B1 cm medial to the lateral B1 cm medial to the lateral
border of the cardiac border of the cardiac
silhouette, it is strongly silhouette, it is strongly
suggestive of a 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 sign
The hilar convergence sign

is used to distinguish between a prominent hilum is used to distinguish between a prominent hilum
and an enlarged pulmonary artery and an enlarged pulmonary artery

If the pulmonary arteries converge into the lateral If the pulmonary arteries converge into the lateral
border of a hilar mass, the mass represents an border of a hilar mass, the mass represents an
enlarged pulmonary artery 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 not enlarged pulmonary artery, but the vessels will not
arise from the marginC instead they will seem to pass arise from the marginC instead they will seem to pass
through the margins as they converge on the true through the margins as they converge on the true
artery artery
an enlarged
pulmonary arery
Hillar mass
The cervicothoracic sign
The cervicothoracic sign

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

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

the medial and posterior mediastinum e+tends above the the medial and posterior mediastinum e+tends above the
claviclesD mediastinal mass that pro*ects superior to the claviclesD mediastinal mass that pro*ects superior to the
level of the clavicles must therefore be located either level of the clavicles must therefore be located either
within the middle or posterior mediastinumD within the middle or posterior mediastinumD

the more cephalad the mass e+tends, the more posterior the more cephalad the mass e+tends, the more posterior
the location 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
.) Terrible Lymphoma
Sanjeev Bhalla, Marieke Hazewinkel and Roin Smithuis
/ardiothoracic 0maging 1ection of the 2allinckrodt 0nstitute of 3adiology# 1t) Louis# 41% and the
3adiology department the 2edical /entre %lkmaar and the 3i5nland 6ospital# Leiderdorp# the
7etherlands
8esions typically in the
8esions typically in the
nterior Mediastinum
nterior Mediastinum

Thymic neoplasm
Thymic neoplasm

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

!ecogni/ed more often recently because of increase !ecogni/ed more often recently because of increase
aggresiveness in evaluating patients with myasthenia aggresiveness in evaluating patients with myasthenia
gravis gravis

#omposed of lymphocytes and epithelial cells #omposed of lymphocytes and epithelial cells
Thymoma
Thymoma

Pea. incidence is 7&4:& yEo Pea. incidence is 7&4:& yEo

)3ual gender predilection )3ual gender predilection

!are in children !are in children

<EF assymptomatic at the time of diagnosis <EF assymptomatic at the time of diagnosis

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

#hest pain, cough, dyspnea #hest pain, cough, dyspnea

7&4;&' of patients can have systemic syndromes 7&4;&' of patients can have systemic syndromes
Thymoma
Thymoma

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

6ccurs in 1&4%&' of patients 6ccurs in 1&4%&' of patients

,ow thymoma produced myasthenia is un.nown but ,ow thymoma produced myasthenia is un.nown but
autoantibodies to the post synaptic acetylcholine autoantibodies to the post synaptic acetylcholine
receptor appears to e+plain the dysfunction of the receptor appears to e+plain the dysfunction of the
neuromuscular *unction neuromuscular *unction
Thymoma
Thymoma

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

!ound or oval, smooth or lobulated as compared !ound or oval, smooth or lobulated as compared
with thymic hyperplasia which is symmetrical with thymic hyperplasia which is symmetrical

9sually distorts the gland normal shaped 9sually distorts the gland normal shaped
Thymoma
Thymoma

Thymomas are neoplastic but most are benign

Thymomas are neoplastic but most are benign

Invasive tumors have a poorer prognosis

Invasive tumors have a poorer prognosis

% year
% year
G %&4;;' survival rate
G %&4;;' survival rate

1& year G F&4%%' survival rate

1& year G F&4%%' survival rate

!ecurrence after resection occurs in 1EF of

!ecurrence after resection occurs in 1EF of
patients
patients

Presence of thymoma4associated systemic

Presence of thymoma4associated 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 -T" approach or -T"

d*unctive treatment with post operative d*unctive treatment with post operative
radiotherapy radiotherapy

ddition of perioperative radiotherapy is provided ddition of perioperative radiotherapy is provided

thymoma
thymoma
6ther thymic mass
6ther thymic mass

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

Thymic carcinoma is a malignant process that Thymic carcinoma is a malignant process that
invades locally and fre3uently metastasi/ed invades locally and fre3uently metastasi/ed

Prognosis is poor Prognosis is poor

!esection followed by ad*uvant chemoradiotherapy !esection followed by ad*uvant chemoradiotherapy

is advocated is advocated
=erm cell tumors
=erm cell tumors

1&41< ' of primary mediastinal tumors are derived 1&41< ' of primary mediastinal tumors are derived
from germinal tissues both in adults and in children from germinal tissues both in adults 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 multipotent They are believed to arise from remnant multipotent
germ cells that have migrated abnormally during germ cells that have migrated abnormally during
embryonic development embryonic development
Teratomas
Teratomas

Most common germ cell tumors Most common germ cell tumors

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

)ctodermal derivatives predominate )ctodermal derivatives predominate

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

>oung adults >oung adults

0ut reported in all age groups 0ut reported in all age groups

Men and women affected e3ually Men and women affected e3ually

(&' are benign (&' are benign

1EF are asymptomatic 1EF are asymptomatic

Pain, cough, dyspnea Pain, cough, dyspnea

,emoptysis if tumor erodes into a bronchus ,emoptysis if tumor erodes into a bronchus

)+pectoration of differentiated tissue such as hair HtrichoptysisI or )+pectoration of differentiated tissue such as hair HtrichoptysisI or
sebaceous materials can occur sebaceous materials can occur

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

6n #J!, Teratomas are smooth, rounded and

6n #J!, Teratomas are smooth, rounded and
well circumscribed if they are cystic and
well circumscribed if they are cystic and
more lobulated and asymmetric if they are
more lobulated and asymmetric if they are
solid
solid

"oft tissue, fat and calcification Hoccasionally

"oft tissue, fat and calcification Hoccasionally
fully formed teeth and boneI can be seen on
fully formed teeth and boneI can be seen on
#T images
#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
=erm cell tumor
=erm 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 HdysgerminomaI "eminoma HdysgerminomaI

6ccurs almost e+clusively in men 6ccurs almost e+clusively in men

9sually in the F 9sually in the F

rd rd
decade of life decade of life

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

"-# syndrome can occur "-# syndrome can occur

They are aggressive malignant tumors that e+tend They are aggressive malignant tumors that e+tend
locally and metastasi/ed distantly, usually to the locally and metastasi/ed distantly, usually to the
s.eletal bones s.eletal bones
"eminoma
"eminoma

They may secrete ,#=, but not FP They may secrete ,#=, but not FP

Poor prognosis Poor prognosis

ge BF% yEo ge BF% yEo

"-# syndrome "-# 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 cases of dramatically with chemotherapy even in cases of
dissemination dissemination

#isplatin based regimen is used #isplatin based regimen is used

8ong term survival is (&' 8ong term survival is (&'

8ymphomas
8ymphomas

#ommon cause in both adults and children #ommon cause in both adults and children

1&4<&' of cases 1&4<&' of cases

,odg.inKs disease occurs bimodally in adolescents ,odg.inKs disease occurs bimodally in adolescents
and young adults and in those over %& and young adults and in those over %&

Non4,odg.inKs occurs in older adults Non4,odg.inKs occurs in older adults

%&4:&' of ,D have mediastinal lymph node %&4:&' of ,D have mediastinal lymph node
involvement at the time of diagnosis involvement at the time of diagnosis

6nly <&' of N,8 have mediastinal involvement 6nly <&' of N,8 have mediastinal involvement
8ymphoma
8ymphoma

Incidental discovery of a mass on #J! is a common Incidental discovery of a mass on #J! is a common
presentation of lymphoma presentation of lymphoma

"ystemic and locali/ed symptoms "ystemic and locali/ed symptoms

Tracheal compromise and "-# are common Tracheal compromise and "-# are common

Pericardial and pleural involvement Pericardial and pleural involvement

!esection is not a necessary part of therapy, but !esection is not a necessary part of therapy, but
anterior thoracotomy or mediastinoscopy is re3uired anterior thoracotomy or mediastinoscopy is re3uired
to confirm the diagnosis if adenopathyis not evident to confirm the 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 anterior #ervical goiter e+tends susternally into the anterior
mediastinum mediastinum

Primary intrathoracic goiter, originating from the Primary intrathoracic goiter, originating from the
heterotropic thyroid tissue is rare heterotropic thyroid tissue is rare

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

#ommon in women #ommon in women

Middle or older age Middle or older age

symptomatic symptomatic

,oarsenessD #ough, swelling of the face ,oarsenessD #ough, swelling of the face

!ecogni/ed by radioactive iodine screning !ecogni/ed by radioactive iodine screning

!esected by transcervical approach wihout the use !esected by transcervical approach wihout the use
of sternotomy approach of sternotomy approach
Parathyroid lesions
Parathyroid lesions

Mediastinal parathyroid tissue accounts for as many Mediastinal parathyroid tissue accounts for as many
as 1&' of cases of hyperparathyroidism as 1&' of cases of hyperparathyroidism

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

Technetium scanning are accurate in diagnosing Technetium scanning are accurate in diagnosing
parathyroid tissue parathyroid tissue

#ured by complete resection #ured by complete resection

Mesenchymal tumors
Mesenchymal tumors

Iipomas, fibroma, mesothelioma,

Iipomas, fibroma, mesothelioma,
lymphangiomas,
lymphangiomas,

They arise from connective tissue, fat, smooth

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

,istologically they differ from their counterpart

,istologically they differ from their counterpart

Presence of symptoms means that the lesion is

Presence of symptoms means that the lesion is
malignant
malignant
8ipoma
8ipoma

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 defined margins "mooth, rounded with sharply defined margins
8ipomatosis
8ipomatosis

More common than lipoma

More common than lipoma

=enerali/ed overabundance of histologically

=enerali/ed overabundance of histologically
normal unencapsulated fat
normal unencapsulated fat

The presence of some fat in the mediastinum is

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

ccumulation of e+cess fat is associated with

ccumulation of e+cess fat is associated with
generali/ed obesity or #ushingLs syndrome or
generali/ed obesity or #ushingLs syndrome or
with the use of e+ogenous steroids or drugs
with the use of e+ogenous 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 ma5ority 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)
8esions typically in the
8esions typically in the
Middle Mediastinum
Middle Mediastinum

)nlargement of the lymph node )nlargement of the lymph node

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

8ymphomas 8ymphomas

Metatastic cancer Metatastic cancer

=ranulomatous inflammation =ranulomatous inflammation

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&4<&' of all mediatinal mass in both #omprise 1&4<&' of all mediatinal mass in both
adults and children adults and children

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

0ronchogenic and enteric cyst are referred to as 0ronchogenic and enteric cyst are referred to as
foregut duplication cyst because of their origin from foregut duplication cyst because of their origin from
aberrant portions of the ventral and dorsal foregut aberrant portions of the ventral and dorsal foregut
Developmental #ysts
Developmental #ysts

Pericardial cyst Pericardial cyst

ccounts for 1EF of cystic masses in adults ccounts for 1EF of cystic masses in adults

8ess common in children 8ess common in children

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

It can enlarge to cause right ventricular outflow tract It can enlarge to cause right ventricular outflow tract
obstruction, or rupture and hemorrhage to cause obstruction, or rupture and hemorrhage to cause
pericardial tamponade or sudden cardiac death pericardial tamponade or sudden cardiac death
Developmental #ysts
Developmental #ysts

0ronchogenic cyst
0ronchogenic cyst

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

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

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

They can communicate with the tracheobronchial They can communicate with the tracheobronchial
tree and can become infected and cause airway tree and can become infected and cause airway
obstruction, pulmonary artery compression and obstruction, pulmonary artery compression and
hemodynamic collapse or rupture with disastrous hemodynamic collapse or rupture with disastrous
conse3uences conse3uences
Developmental #ysts
Developmental #ysts

)nteric or entergenous cyst )nteric or entergenous cyst

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

9ncommon in adults 9ncommon in adults

#ommonly seen in infants and children #ommonly seen in infants and children

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

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

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

0ochdale.Ks hernia, in the posterior mediastinum, 0ochdale.Ks hernia, in the posterior mediastinum,
generally appears on the left side, presumably generally appears on the left side, presumably
because the liver prevents formation on the right because the liver prevents formation on the right

They are usually incidental finding but can cause They are usually incidental finding but can cause
complication in some cases 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)

2ost 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 neurofibroma,)
Cervicothoracic sign
On he le# he MR o# he same paien.
- urned ou o +e a sch!annoma.
=anglioneuromaD During evaluation for unrelated problem, chest radiography in a =anglioneuromaD During evaluation for unrelated problem, chest radiography in a
<74year4old woman revealed an asymptomatic posterior mediastinal massD <74year4old woman revealed an asymptomatic posterior mediastinal massD
,istologic showed ganglioneuroma H ,istologic showed ganglioneuroma H!tlas of diagnostic oncology, !rthur "# !tlas of diagnostic oncology, !rthur "#
Skarin,$%%& Skarin,$%%&I I
%las o# diagnosic oncology, %rhur ,. S.arin, /''0