Mediastinal Masses Imaging and Localization

MEDIASTINAL MASSES
BY: joseph soquea, MD
MEDIASTINAL MASSES
Statistically > 60% Thymomas Neurogenic Tumors Benign Cysts Lymphadenopathy (LAD) Children Neurogenic tumors Germ cell tumors Foregut cysts
MEDIASTINAL MASSES
In adults the most common are: Lymphomas LAD Thymomas Thyroid masses
MEDIASTINAL MASSES
Localizing:
mediastinal mass will not contain air bronchograms. The margins with the lung will be obtuse. Mediastinal lines (azygoesophageal recess, anterior and posterior junction lines) will be disrupted.
MEDIASTINAL MASSES
Localizing: There can be associated spinal, costal or sternal abnormalities. A lung mass abutts the mediastinal surface and creates acute angles with the lung, while a mediastinal mass will sit under the surface creating obtuse angles with the lung
MEDIASTINAL MASSES
LEFT: A lung mass abutts the mediastinal surface and creates acute angles with the lung. RIGHT: A mediastinal mass will sit under the surface of the mediastinum, creating obtuse angles with the lung.
MEDIASTINAL MASSES
A. Pancoast tumor.
B. Thymoma
ANATOMY
ANATOMY
Anatomic divisions: 1. anterior (prevascular) 2. middle (cardiovascular) 3. posterior (postvascular)
Anterior compartment
Boundaries: Ant sternum Post pericardium, aorta, & brachiocephalic vessels merges superiorly with the anterior aspect of the thoracic inlet and extends down to the level of the diaphragm
Contents
thymus, lymph nodes, ascending aorta, pulmonary artery, phrenic nerves and thyroid. Masses: most common will be of thymic or lymphnode in origin.
The four T's make up the mnemonic for anterior mediastinal masses::
1. 2. 3. 4. Thymus Teratoma (germ cell) Thyroid Terrible Lymphoma
Anterior compartment:
Appearance on conventional radiograph: displaced anterior junction line obliterated cardiophrenic angles obliterated retrosternal space hilum overlay sign effacement/ dense ascending aorta
WIDENING OF THE SUPERIOR MEDIASTINUM AND OBLITERATED RETROSTERNAL SPACE
Hilum Overlay Sign: hilar vessels are seen through a mediastinal mass
Thymoma
most common primary neoplasm to occur in the anterior mediastinum arise from thymic epithelial cells affects man and women equally uncommon in children and is diagnosed between ages 40 - 60 may have cystic component and sometimes comprise most of the tumor
Thymoma
noninvasive (encapsulated) and invasive symptoms are cause by pressure of the enlarged thymus on the trachea and blood vessels associated conditions: a. pure red cell aplasia b. myasthenia gravis (most common paraneoplastic disease asso.) c. hypogammaglobulinemia
Thymoma
Thymoma in a 55-year-old woman with recurrent lung cancer. A homogenous mass with convex margin is demonstrated within the thymus. Left lung nodule (white arrow) represents lung cancer recurrence.
Thymoma
Invasive thymoma. Homogeneous, anterior mediastinal mass extends to the left. Irregular interface suggests extracapsular invasion; lung and pericardial invasion were found at surgery.
Thymoma
Invasive thymomas. (A) Irregular interface with lung (arrow) suggests pulmonary invasion (surgically proven). (B) Encasement of the aorta and mass protruding into the lung, suggesting invasion.
Thymoma
Thymoma tends to spread along the pleural surfaces and may extend into the abdomen via the retrocrural space. (A) Small discrete pleural implant (black arrow), visualized to advantage on lung window. (B) Left retrocrural spread (white arrow). (C) Retroperitoneal implant (black short arrow).
Thymoma
A small thymoma anterior to the heart (marked with the red line)
Thymoma
WHO Histologic classification:
A - a tumor composed of a population of neoplastic thymic epithelial cells having a spindle/oval shape, lacking nuclear atypia and accompanied by few or no nonneoplastic lymphocytes - tumor in which foci having the features of type A thymoma are admixed with foci rich in nonneoplastic lymphocytes - tumor resembles the normal functional thymus because it contains large numbers of cells that have an appearance almost indistinguishable from normal thymic cortex with areas resembling thymic medulla
AB
B1
Thymoma WHO Histologic classification:
B2 - the neoplastic epithelial component of this tumor type appears as scattered plump cells with vesicular nuclei and distinct nucleoli among a heavy population of nonneoplastic lymphocytes - is predominantly composed of epithelial cells that have a round or polygonal shape and that exhibit no or mild atypia. The epithelial cells are admixed with a minor component lymphocytes. - a thymic tumor exhibiting clear-cut cytologic atypia and a set of cytoarchitectural features no longer specific to the thymus, but rather analogous to those seen in crcinomas of other organs
B3
Thymoma Pathologic characteristics:
most type A & B are well encapsulated and round or slightly lobulated usually 5 to 15 cm in diameter subdivided into numerous lobules by variably thick fibrous band some may have cystic component
Thymoma
An encapsulated cystic thymoma.
Thymoma
MEDIASTINUM: LOCALLY INVASIVE, CIRCUMSCRIBED THYMOMA (MIXED LYMPHOCYTIC AND EPITHELIAL AND MIXED POLYGONAL AND SPINDLE)
Thymoma Radiologic Manifestations:
most type A & B are situated near the jxn of the heart and great vessels radiographically, they are round or oval, and their margins are usually smooth or lobulated displace the heart and great vessels posteriorly on CT, they are typically located in the region of the thymus anterior to the aortic root and main pulmonary artery & project to one side of the mediastinum
Thymic Carcinoma (type c)
5 15cm in diameter are often found to invade adjacent tissues at the time of diagnosis most will show evidence of extension outside the thymus with focal or diffuse obliteration of the adjacent fat planes. squamous cell CA- most common histologic type
Radiologic presentation large ant mediastinal mass with irregular or poorly defined margins.
.
CT scan presentation: can have a homogenous ST attenuation or heterogenous due to necrosis or hemorrhage calcification is present in 10% of cases Pericardial or pleural involvement and pleural effusion are frequent findings
Other findings: hilar lymph node enlargement diaphragmatic elevation suggesting phrenic nerve palsy lung nodules suggestive of metastases
Thymic SSC. Large heterogenous mass extending along the pericardium, with probable invasion (arrows). Six weeks following a Chamberlain procedure (left anterior thoracotomy) there is new chest wall invasion, compatible with tumor seeding in the surgical wound.
High grade thymic carcinoma with mediastinal lymph node enlargement (black arrow) and pleural involvement, including pleural mass (white arrow head) and loculated pleural effusion (white arrow).
Thymoma. Large mass extending into the right hemithorax, containing punctuate and coarse calcifications. Low attenuation regions suggesting necrosis and/or hemorrhage
Thymic Lymphoma
2nd most common primary anterior mediastinal mass. cancer of the lymphatic system indistinguishable from other solid neoplasm arising w/in the thymus most commonly involves the anterior mediastinal and hilar nodal group enlarged spleen displacing the gastric bubble medially in the upper abd. Portion of the frontal chest film
Thymic Lymphoma CT advantages
to better characterized and localized for staging, prognosis and therapy guidance for trans thoracic or open biopsy to monitor response to therapy detection of relapse
Thymic Lymphoma
A, B) Thymic lymphoma. Thymic mass and enlarged mediastinal and right hilar lymph nodes.
Thymic hyperplasia:
meas: CT thickness = <20 yrs 1.8cm >20 yrs 1.3cm rare in adults inc in size with normal gross architecture histologic appearance. rebound to atrophy 2nd to chemotherapy or by hypercorticolism
CT images of the normal involution of the thymus A. childhood B. early adulthood C. middle age D. late adulthood
Thymic hyperplasia:
Thymic hyperplasia in a 29-year-old female. A. Mild diffuse thymic enlargement with biconvex margins. B. CT scan 3 years later demonstrates residual normal thymic tissue.
GERM CELL TUMORS 1. TERATOMA
most common GCT consist of one or more types of tissue, usually derived from more than one germ layer majority are cystic and benign if solid most likely malignant
GERM CELL TUMORS TERATOMA
subdivided into a. mature most common form - 8 to 10cm in diameter, often multicystic - ectodermal elements (epidermis & skin) b. immature - same as mature but contain a foci of primitive less well organized tissue resembling seen in fetus c. teratoma with malignant transformation - mature tiss + immature tiss and neoplastic tisssue
GERM CELL TUMORS TERATOMA Symptoms:
shortness of breath cough sensation of pressure or pain in the retrosternal area malignant forms may obstruct the SVC mediastinitis, empyema, fistula formation, due to rupture of cystic form
Rad features: localized mass in the anterior compartment close to the origin of the great vessels in the heart calcification is present in 20% on CT mature teratoma can have smooth or lobulated margins and may contain one or more cystic areas
Complication:
atelectasis and obstructive pneumonitis (airway compression) pneumonitis (rupture into the lung) effusion (rupture into the pleural space or pericardium)
GERM CELL TUMORS 2. SEMINOMA
second most common mediastinal germ cell tumor majority are solid, but can have multilocular cystic component occurs almost exclusively in men average age of occurrence is 20-30 y/o
GERM CELL TUMORS SEMINOMA
Radiographic appearance:
invasion of adjacent structures is uncommon large masses that project to one or both sides of the mediastinum homogenous attenuation on CT & only enhances slightly with contrast
Contrast-enhanced axial CT scan shows an ill-defined anterior mediastinal mass with irregular borders that is infiltrating the mediastinal fat. CT-guided needle biopsy revealed a mediastinal seminoma.
GERM CELL TUMORS THYROID TUMORS
Multinodular Goiter - most frequent thyroid tumor - commonly in women in their forties 80% of the tumors arise from a lower pole or the isthmus & extends into the ant or mid mediastinum 20% arise from the post. aspect of thyroid and extend to the post aspect of the mediastinum
THYROID TUMORS
Radiographic appearance:
sharply defined, smooth or lobulated mass that causes displacement and narrowing of the trachea ant & mid mediastinal mass, displaces the trachea post & lat post mediastinal mass pushes the trachea ant the thyroid enhance intensely on CT w/ contrast focal non enhancing areas of low attenuation as a result of hemorrhage or cyst
LIPOMA:
CT scan is usually diagnostic has lower attenuattion than most mediastinal masses does not cause symptoms may have an hourglass appearance, with homogenous fat attenuation surgical excision is curative
LIPOMATOSIS:
non-neoplastic excessive accumulation of fat asso with hypercortisolism,(Cushings synd, ectopic adrenocorticotrophic hormone syndrome, long term corticosteroid therapy) Rad features - smooth, symmetrical widening of the mediastinum - widening usually extends from the thoracic inlet to the hila bilaterally - CT is diagnostic
DEVELOPMENTAL ANOMALIES:
1. HEMANGIOMA can isolated or part of a multifocal hemangiomatous malformation most are located in the upper portion of the anterior mediastinum 2. Lymphangioma Types a. cystic hygroma extends from the neck into the mediastinum, usually occurs in infants
Lympangioma b. found in adults and located in the lower anterior mediastinum sharply defined, smoothly marginated mediastinal mass that displaces adjacent midiastinal structures on CT smoothly marginated cystic mass with homogenous water density, that can either displace or surround adjacent vessels
3. Mesothelial (pericarial) cyst

congenital and result from aberrations in formation of the coelomic cavities. common in the vicinity of the heart spherical or oval, thin walled, and often translucent most are unilocular
DEVELOPMENTAL ANOMALIES
Messothelial (pericarial) cyst

Rad findings: located in the cardiophrenic angles, most commonly in the right smooth, round and oval 3 8 cm in diameter CT has a water density, smooth, round, or oval cystic lesion abutting the pericardium
Middle compartment
Contents: 1.pericardium and its contents 2.aortic arch & proximal great arteries 3.central pulmonary arteries & veins 4.trachea and main bronchi 5 lymph nodes 6. hila (considered as extension)
Middle compartment
Presentation on conventional radiograph 1. widened paratracheal stripes. 2. AP window mass 3. displaced azygoesophageal recess in the right 4. mass on posterior trachea 5. lateral doughnut
Middle compartment
AP chest radiograph showing widening of the azygoesophageal recess on the right. There is an apparent widening of the paravertebral line on the left. On the lateral film the mass is anterior to the spine and therefore is located in the middle mediastinal.
Middle compartment
CT showing the azygoesophageal recess is displaced to the right due to oesophageal varices (blue arrow) and there is also a new interface on the left. This is a patient with cirrhosis of the liver and varices as a result of portal hypertension.
Middle compartment
PA film showing a lobulated paratracheal stripe on the right.On the lateral radiograph there is a density overlying the ascending aorta and filling the retrosternal space.These findings indicate a mass in the anterior aswell as in the middle mediastinum.
Middle compartment
A lobulated mass surrounding the right bronchus creating a 'doughnut' with the bronchus as the hole in the doughnut.
Middle compartment
Masses 1. Lymph node enlargement
most middle mediastinal lymph node masses are malignant malignant causes: - bronchogenic CA - extra thoracic malignancy - leukemia - lymphoma
Middle compartment
Lymph node enlargement
benign - sarcoidosis - mycobacterial and fungal - angiofolicular lymph node hyperplasia (Castleman disease) - angioimmunoblastic lymphadenopathy
1 (red) = highest mediastinal nodes, 2R and 2L (dark blue) = right and left upper paratracheal nodes 3 (pink) = pre-vascular and retrotracheal nodes 4R and 4L (orange) = right and left lower paratracheal 5 (black) = subaortic nodes 6 (red) = para-aortic nodes. 7 (blue) = subcarinal nodes
8 (grey) = para-oesophageal 9 (brown) = pulmonary ligament nodes 10R and 10L (yellow) = right and left hilar 11R and 11L (green) = right and left interlobar 12R and 12L (pink) = right and left lobar nodes 13R and 13L (pink) = right and left segmental 14R and 14L (pink) = right and left subsegmental Ao = aortic arch, PA = main pulmonary artery,,
Middle compartment
Rad appearance: multiple bilateral mediastinal masses that distorts the lung/mediastinal interface. round or oval soft tissue masses > 1cm in their short axis diameter if solitary, tends to be elongated and lobulated rather spherical calcifications can sometimes be seen
Middle compartment
Rad appearance: CT scan is more sensitive in detecting nodal calcification CT is unable to distinguish between benign inflamatory nodes and those involved by malignancy.
Middle compartment
Mesothelial cysts:
1. Congenital Bronchogenic Cyst result from anomalous budding of the tracheobronchial tree. walls should be lined with respiratory epithelium arise w/in the mediastinum in the vicinity of the tracheal carina
Middle compartment
Congenital Bronchogenic Cyst
frequently seen in the subcarinal or right paratracheal space sometimes maybe seen in hilum, posterior mediastinum, periesophageal region single smooth, round or elliptic mass CT is the method of choice for diagnosis
Middle compartment
Congenital Bronchogenic Cyst
Benign well defined thin walled mass of fluid density that fails to enhance with contrast. - some are lobulated
Middle compartment
(Mesothelial) Pericardial Cyst:
arise from the parietal pericardium most are 3-8cm in diameter commonly in the anterior cardiophrenic angles more common in the right than in the left usually present as a unilocullar cystic mass on CT scan
Posterior compartment
Contents
descending aorta azygous and hemiazygous vein thoracic duct intercostal and autonomic nerves Conventional radiographs Cervicothoracic Sign Widening of the paravertebral stripes
Cervicothoracic sign - the anterior mediastinum stops at the level of the superior clavicle.Therefore, when a mass extends above the superior clavicle, it is located either in the neck or in the posterior mediastinum. When lung tissue comes between the mass and the neck, the mass is probably in the posterior mediastinum.
There is widening of the paravertebral stripes on both the left and the right on the this PA radiograph. On the lateral radiograph there is a severely narrowed disc space.
most are neurogenic in nature - from the sympathetic ganglia (eg neuroblastoma) - from the nerve roots (eg schwannoma or neurofibroma). lymphadenopathy neuroenteric cysts, schwannomas or meningoceles.
1. Neurogenic Tumors. Classification: a. neurofibroma, schwanoma (arising from the intercostal nerves) b. ganglioneuroma, ganglioneuroblastoma, neuroblastoma (sympathetic ganlia) c. chemodectoma, pheochromocytoma (paraganlionic cells) neuroblastoma & ganlioneuroma common in children neurofibroma & schwanoma affects adult more frequently
Neurogenic Tumors.
Rad appearance: intercostal nerve tumors appear as round or oval paravertebral soft tis masses CT smooth or lobulated paraspinal soft tissue mass w/c may erode adjacent vertebra or rib
Enteric/Neuroenteric cyst
fluid filled masses lined by enteric epithelium esophageal cyst arise intramurarly or immediately adjacent to the esop. neuroenteric cyst persistent communication with the spinal canal and asso with congenital defects of the T-spine.
Fluid containing masses

Thymoma Teratoma Pericardial Cyst Foregut Duplication Meningocoele Neuroenteric Cyst Cystic Lymphadenopathy Lymphangioma
Fat containing masses

Thymolipoma Teratoma (Germ cell tumors) Esophageal lipoma Fat deposition Lipoma Lipoblastoma Liposarcoma Extramedullary hematopoiesis
Enhancing masses
Hyperenhancing lymph nodes Thyroid tissue Paragangliomas Hemangiomas Vascular Etiologies
THANK YOU
MEDIASTINAL MASSES
ANATOMY
anterior mediastinum (1) middle mediastinum (2) posterior mediastinum (3)
ANATOMY
Superior Med.
bounded by: sup thoracic aperture (thoracic inlet) inf line from sternal angle ant manubrium post 1st 4 thoracic vert.
ANATOMY
1.Anterior ant body of sternum post fibrous pericardium contents: thymus branches of the internal mammary artery and vein lymphnode inferior sternopericardial ligament fats
ANATOMY
2. Middle
between the anterior and posterior subdivision of the mediastinum contents: the pericardium and its contents ascending & transverse portion of the aorta sup & inf vena cava bifurcation of the trachea and two bronchi pulm artery and veins phrenic nerves and the lymphatic glands
ANATOMY
3. Posterior
ant. By the pericardium, laterally by the mediastinal pleura and posteriorly by thoracic vertebrae Contents: descending thoracic aorta esophagus thoracic duct, azygos, 7hemiazygos veins autonomic nerves, fats &lymohnodes
Mediastinal Masses
ANATOMY
Superior mediastinum: content: aortic arch, brachiocephalic arter, left common carotid and the left subclavian. innominate veins, and left and right brachiocephalic veins vagus nerve, cardiac nerve, phrenic nerve, & left recurrent laryngeal nerve trachea, esophagus, thoracic duct, thymus and some lymph glands
ANATOMY
MEDIASTINAL DIVISION
1. Superior mediastinum 2. Inferior mediastinum a. anterior b. middle c. posterior
ANATOMY
ANATOMY
Inferior mediastinum contents: Ant

Mediastinal Masses Imaging and Localization

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Mediastinal Masses Imaging and Localization

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MEDIASTINAL MASSES

BY: joseph soquea, MD

WIDENING OF THE SUPERIOR MEDIASTINUM AND OBLITERATED RETROSTERNAL SPACE

An encapsulated cystic thymoma.

3. Mesothelial (pericarial) cyst

Messothelial (pericarial) cyst

Fluid containing masses

Fat containing masses

anterior mediastinum (1) middle mediastinum (2) posterior mediastinum (3)

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