mediastinum fkunlam

7/22/2019 Mediastinum FKUnLam

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Radiology Examination ofRadiology Examination ofMediastinumMediastinum

Arlavinda A. LubisArlavinda A. Lubis

Radiology Department,Ulin Hospital /Radiology Department,Ulin Hospital /Faculty of Medicine, Lambung Mangurat UniversityFaculty of Medicine, Lambung Mangurat University


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IntroductionIntroduction

TheThe mediastinummediastinum isisthe region in thethe region in the

chest between thechest between thepleural cavities thatpleural cavities thatcontain thecontain the heartheartand other thoracicand other thoracicviscera except theviscera except thelungslungs


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Mediastinal anatomyMediastinal anatomy

BoundariesBoundaries

LateralLateral - parietal pleura- parietal pleura

AnteriorAnterior - sternum- sternum PosteriorPosterior - vertebral column and- vertebral column andparavertebral guttersparavertebral gutters

SuperiorSuperior - thoracic inlet - thoracic inlet

nferiornferior - diaphragm- diaphragm


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!elson!elson"Radiologists""Radiologists" Anterior mediastinal#Anterior mediastinal# is bounded anteriorlyis bounded anteriorly

by the sternum and posteriorly by a line drawnby the sternum and posteriorly by a line drawn

from the anterior aspect of the trachea andfrom the anterior aspect of the trachea andalong the posterior heartalong the posterior heart borderborder

MiddleMiddle mediastinal compartment liesmediastinal compartment lies

between the anterior and posteriorbetween the anterior and posterior

mediastinummediastinum

PosteriorPosterior mediastinal, anterior border ismediastinal, anterior border isdefined by a line that is 1 cm posteriordefined by a line that is 1 cm posterior

to the anterior edge of the vertebralto the anterior edge of the vertebral

bodiesbodies

Mediastinal compartmentMediastinal compartment

by Felsonby Felson


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(Meschan, 1981;

resited by Lange & Walsh, 2007)


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Diseases of theDiseases of the

MediastinumMediastinum

PneumomediastinumPneumomediastinum

MediastinitisMediastinitis

NeoplasmaNeoplasma


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

mechanical ventilation is also commonly encounteredmechanical ventilation is also commonly encounteredin some conditionsin some conditions

Pain is the most common symptomPain 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

positionposition Dyspnea, dysphagia, subcutaneous crepitationDyspnea, dysphagia, subcutaneous crepitation


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MediastinitisMediastinitis cute inflammation of the mediastinumcute inflammation of the mediastinum

"ubsternal chest pain, chills, high fever, prostration"ubsternal chest pain, chills, high fever, prostration #hronic mediastinitis#hronic mediastinitis


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NeoplasmaNeoplasma


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#linical Presentation#linical Presentation

symptomatic masssymptomatic mass

Incidental discovery $ most commonIncidental 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 symptomsMore than half are malignant if with symptoms


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)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, tissueinvasion, or bone erosion is commoninvasion, or bone erosion is common

#ough#ough, because of e+trinsic compression of the trachea, because of e+trinsic compression of the tracheaor bronchi, or erosion into the airway it selfor bronchi, or erosion into the airway it self

emoptysis, hoarseness or stridoremoptysis, hoarseness or stridor

Pleural effusion, invasion or irritation of pleural spacePleural effusion, invasion or irritation of pleural space

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

Pericarditis or pericardial tamponadePericarditis or pericardial tamponade

!ight ventricular outflow obstruction and cor pulmonale!ight ventricular outflow obstruction and cor pulmonale


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"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, andis thin walled and its intravascular pressure is low, andrelatively confined by lymph nodes and other rigid structuresrelatively 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 uppercharacteri/ed by dilation of the collateral veins in the upper

portion of the head and thora+ and edema and phlethora of theportion of the head and thora+ and edema and phlethora of theface, nec. and upper torso, suffusion and edema of theface, nec. and upper torso, suffusion and edema of thecon*unctiva and cerebral symptoms such as headache,con*unctiva and cerebral symptoms such as headache,

disturbance of consciousness and visual distortiondisturbance of consciousness and visual distortion 0ronchogenic carcinoma and lymphoma are the most0ronchogenic carcinoma and lymphoma are the most

common etiologiescommon etiologies


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oarseness, invading or compressing theoarseness, invading or compressing thenervesnerves

orners syndrome, involvement of theorners syndrome, involvement of thesympathetic ganglia dropping eyelid, decreasedsympathetic ganglia dropping eyelid, decreasedpupil si/e,decreased sweating on the ipsilateralpupil si/e,decreased sweating on the ipsilateralface2face2

Dyspnea, from phrenic nerve involvementDyspnea, from phrenic nerve involvementcausing diaphragmatic paralysiscausing diaphragmatic paralysis

Tachycardia, secondary to vagus nerveTachycardia, secondary to vagus nerve

involvementinvolvement


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"ystemic symptoms and syndromes"ystemic symptoms and syndromes

Fever, anore+ia, weight loss and other non specificFever, anore+ia, weight loss and other non specific

symptoms of malignancy and granulomatoussymptoms of malignancy and granulomatousinflammationinflammation


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Techni3ues for visuali/ing theTechni3ues for visuali/ing the

mediastinum and its contentmediastinum and its content

!adiographic techni3ue!adiographic techni3ue

#hest +4ray5 "tandard postero antero and lateral#hest +4ray5 "tandard postero antero and lateral

viewsviews Most mediastinal tumors are discoveredMost mediastinal tumors are discovered

Fluoroscopy and tomographyFluoroscopy and tomography


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#omputed tomography#omputed tomography

#an identify normal anatomic variations and fluid#an identify normal anatomic variations and fluidfilled cystfilled 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 herniationthymolipoma, omental fat herniation

6verall accuracy for predicting mediastinal mass is6verall accuracy for predicting mediastinal mass isonly 7('only 7('


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#omputed tomography#omputed tomography

8imitation8imitation

ori/ontal oriented structures and boundaries areori/ontal oriented structures and boundaries are

difficult to evaluatedifficult to evaluate

bnormalities in the aortopulmonary window area andbnormalities in the aortopulmonary window area and

the subcarinal areathe 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 withchoice for evaluation of mediastinum in patients withprimary mediastinal mass or with lung cancerprimary mediastinal mass or with lung cancer


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Magnetic !esonanceMagnetic !esonance

ImagingImaging

ssesses tissue by measuring thessesses tissue by measuring theradiofre3uency induced nuclear resonanceradiofre3uency induced nuclear resonanceinstead of measuring the attenuation ofinstead of measuring the attenuation of

transmitted ioni/ing radiationtransmitted ioni/ing radiation#oronal and sagittal planes are better viewed,#oronal and sagittal planes are better viewed,

vertical structures and boundaries are bettervertical structures and boundaries are betterevaluatedevaluated

"uperior sulcus tumors, lesions invading the"uperior sulcus tumors, lesions invading themedistinum, chest wall and diaphragmmedistinum, chest wall and diaphragm

nd possible invasion of the brachial ple+us,nd possible invasion of the brachial ple+us,and for evaluating vertebral invasionand for evaluating vertebral invasion


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Magnetic !esonanceMagnetic !esonance

ImagingImaging

8imitations8imitations

Distinguish poorly between hilar mass and ad*acentDistinguish poorly between hilar mass and ad*acent

collapsed or consolidated lungcollapsed or consolidated lung

#annot distinguish between a benign and a malignant#annot distinguish between a benign and a malignant

causes for lymph node enlargementcauses for lymph node enlargement


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9ltrasonography9ltrasonography

For cystic nature of mediatinal massFor cystic nature of mediatinal mass

9seful in guiding endoscopic biopsy techni3ue9seful in guiding endoscopic biopsy techni3ue


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!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 thespecific metabolic or immunologic properties of the

target tissuetarget tissue

Potential ability to diagnose and stage a malignancyPotential ability to diagnose and stage a malignancy

and identify distant metastasisand identify distant metastasis

Planar imaging with gallium :; and thallium4


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P6"IT!6N )MI""I6NP6"IT!6N )MI""I6N

T6M6=!P>T6M6=!P> The single most notable addition to the stagingThe single most notable addition to the staging

armamentarium for the evaluation of lung cancerarmamentarium for the evaluation of lung cancer

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

PET is a metabolic imaging technique based on the function ofPET is a metabolic imaging technique based on the function of

a tissue rather than its anatomya tissue rather than its anatomy Lung cancer cells demonstrate increased cellular uptake ofLung cancer cells demonstrate increased cellular uptake of

glucose and a higher rate of glycolysis when compared toglucose and a higher rate of glycolysis when compared tonormal cellsnormal 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# butglucose undergoes the same cellular uptake as glucose# butafter phosphorylation is not further metaboli$ed and becomesafter phosphorylation is not further metaboli$ed and becomestrapped in cellstrapped in cells

%ccumulation of the isotope can then be identified using a &'T%ccumulation of the isotope can then be identified using a &'Tcameracamera

Specific criteria for an abnormal PET scan are either a standard

uptake value ofgreater than 2.5 or uptakein the lesion that is greaterthan the background activity of the mediastinum

It has proved useful in differentiating neoplasticfrom normal tissues


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P6"IT!6N )MI""I6NP6"IT!6N )MI""I6N

T6M6=!P>T6M6=!P>

The techni3ue is not infallible because certainThe techni3ue is not infallible because certainnon4neoplastic processes, includingnon4neoplastic processes, including

granulomatous and other inflammatorygranulomatous and other inflammatory

diseases as well as infectionsdiseases as well as infections,,may alsomay alsodemonstrate positive P)T imagingdemonstrate positive P)T imaging

Size limitationsSize limitationsare also an issue, with the lowerare also an issue, with the lowerlimit of resolution of the study beinglimit of resolution of the study being

appro+imatelyappro+imately 7 to 8 mm7 to 8 mmdepending on thedepending on theintensity of upta.e of the isotope in abnormalintensity of upta.e of the isotope in abnormalcellscells

6ne should not rely on a negative P)T finding6ne should not rely on a negative P)T findingfor lesions less than 1 cm on #T scanfor lesions less than 1 cm on #T scan


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Dealing with mediastinal massDealing with mediastinal mass


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#onventional radiographic signs#onventional radiographic signs

The ?silhouette sign@The ?silhouette sign@

The hilar overlay signThe hilar overlay sign

The hilar convergence signThe hilar convergence sign

The cervicothoracic signThe cervicothoracic sign


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Foto thora.s normalFoto thora.s normal


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The ?silhouette sign@The ?silhouette sign@

Ahen a mass abuts a normalAhen a mass abuts a normal

mediastinal structure ofmediastinal structure of

similar radiodensity, thesimilar radiodensity, the

margins of the < structuresmargins of the < structureswill be obliteratedwill be obliterated

This apparent loss of theThis apparent loss of the

margin of the normal structuremargin of the normal structure

can be used to locali/e acan be used to locali/e amediastinal mass to the samemediastinal mass to the same

compartment as the normalcompartment as the normal

structurestructure


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The hilar overlay signThe hilar overlay sign

especially useful inespecially useful indistinguishing an anteriordistinguishing an anteriormediastinal mass from amediastinal mass from a

prominent cardiacprominent cardiacsilhouettesilhouette

If the bifurcation of theIf the bifurcation of themain pulmonary artery ismain pulmonary artery is

B1 cm medial to the lateralB1 cm medial to the lateralborder of the cardiacborder of the cardiacsilhouette, it is stronglysilhouette, it is stronglysuggestive of asuggestive of amediastinal massmediastinal mass

Imaging of the mediastinum in oncology

Michele Lesslie, DO; Marvin H. Chasen, MD, MSEE; Reginald F. Munden, MD,

DMD


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The hilar convergence signThe hilar convergence sign

is used to distinguish between a prominent hilumis used to distinguish between a prominent hilum

and an enlarged pulmonary arteryand an enlarged pulmonary artery

If the pulmonary arteries converge into the lateralIf the pulmonary arteries converge into the lateralborder of a hilar mass, the mass represents anborder of a hilar mass, the mass represents an

enlarged pulmonary arteryenlarged 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 notenlarged pulmonary artery, but the vessels will not

arise from the marginC instead they will seem to passarise from the marginC instead they will seem to pass

through the margins as they converge on the truethrough the margins as they converge on the true

arteryartery


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an enlarged

pulmonary arery

Hillar mass


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The cervicothoracic signThe cervicothoracic sign

is used to determine the location of a mediastinal lesionis used to determine the location of a mediastinal lesionin the upper chestin the upper chest

The uppermost border of the anterior mediastinum endsThe uppermost border of the anterior mediastinum endsat the level of the claviclesat the level of the clavicles

the medial and posterior mediastinum e+tends above thethe medial and posterior mediastinum e+tends above theclavicles mediastinal mass that pro*ects superior to theclavicles mediastinal mass that pro*ects superior to thelevel of the clavicles must therefore be located eitherlevel of the clavicles must therefore be located either

within the middle or posterior mediastinumwithin the middle or posterior mediastinum

the more cephalad the mass e+tends, the more posteriorthe more cephalad the mass e+tends, the more posteriorthe locationthe location


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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 mediastinalmasses((

1) Thymus

") Teratoma +germ cell,

-) Thyroid

.) Terrible Lymphoma


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Sanjeev Bhalla, Marieke Hazewinkel and Roin Smithuis

/ardiothoracic 0maging ection of the 2allinckrodt 0nstitute of 3adiology# t) Louis# 4% and the

3adiology department the 2edical /entre %lkmaar and the 3i5nland 6ospital# Leiderdorp# the

7etherlands


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8esions typically in the8esions typically in the

nterior Mediastinumnterior Mediastinum

Thymic neoplasmThymic neoplasm Thymoma is the most common neoplasm occuring inThymoma is the most common neoplasm occuring in

the anterior mediastinumthe anterior mediastinum !ecogni/ed more often recently because of increase!ecogni/ed more often recently because of increase

aggresiveness in evaluating patients with myastheniaaggresiveness in evaluating patients with myasthenia

gravisgravis

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


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ThymomaThymoma

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

)3ual gender predilection)3ual gender predilection

!are in children!are in children


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ThymomaThymoma

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

6ccurs in 1&4%&' of patients6ccurs in 1&4%&' of patients

ow thymoma produced myasthenia is un.nown butow thymoma produced myasthenia is un.nown but

autoantibodies to the post synaptic acetylcholineautoantibodies to the post synaptic acetylcholine

receptor appears to e+plain the dysfunction of thereceptor appears to e+plain the dysfunction of the

neuromuscular *unctionneuromuscular *unction


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ThymomaThymoma

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

vesselsvessels

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

9sually distorts the gland normal shaped9sually distorts the gland normal shaped


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ThymomaThymoma

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

Invasive tumors have a poorer prognosisInvasive tumors have a poorer prognosis

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

1& year G &4%%' survival rate1& year G &4%%' survival rate

!ecurrence after resection occurs in 1E of!ecurrence after resection occurs in 1E of

patientspatientsPresence of thymoma4associated systemicPresence of thymoma4associated systemic

syndrome is a poor prognostic signsyndrome is a poor prognostic sign


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ThymomaThymoma

May respond to hormonal therapyMay respond to hormonal therapy

Manage by resection via median sternotomyManage by resection via median sternotomy

approach or -T"approach or -T"

d*unctive treatment with post operatived*unctive treatment with post operative

radiotherapyradiotherapy

ddition of perioperative radiotherapy is providedddition of perioperative radiotherapy is provided


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thymomathymoma


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6ther thymic mass6ther thymic mass

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

Thymic carcinoma is a malignant process thatThymic carcinoma is a malignant process that

invades locally and fre3uently metastasi/edinvades locally and fre3uently metastasi/ed

Prognosis is poorPrognosis is poor

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

is advocatedis advocated


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=erm cell tumors=erm cell tumors

1&41< ' of primary mediastinal tumors are derived1&41< ' of primary mediastinal tumors are derivedfrom germinal tissues both in adults and in childrenfrom germinal tissues both in adults and in children

Teratoma and teratocarcinomaTeratoma and teratocarcinoma

"eminoma"eminoma

)mbryonal cell carcinoma)mbryonal cell carcinoma

#horiocarcinoma#horiocarcinoma

They are believed to arise from remnant multipotentThey are believed to arise from remnant multipotentgerm cells that have migrated abnormally duringgerm cells that have migrated abnormally duringembryonic developmentembryonic development


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TeratomasTeratomas

Most common germ cell tumorsMost common germ cell tumors

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

occuroccur

)ctodermal derivatives predominate)ctodermal derivatives predominate

Ahen only the epidermis and its derivatives areAhen only the epidermis and its derivatives are

present, the term dermoid cystpresent, the term dermoid cyst


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TeratomasTeratomas

>oung adults>oung adults

0ut reported in all age groups0ut reported in all age groups

Men and women affected e3uallyMen and women affected e3ually

(&' are benign(&' are benign

1E are asymptomatic1E are asymptomatic

Pain, cough, dyspneaPain, cough, dyspnea

emoptysis if tumor erodes into a bronchusemoptysis if tumor erodes into a bronchus

)+pectoration of differentiated tissue such as hair Htrichoptysis or)+pectoration of differentiated tissue such as hair Htrichoptysis orsebaceous materials can occursebaceous 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 Tamponadethe pericardium causing Pericardial Tamponade


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TeratomasTeratomas

6n #J!, Teratomas are smooth, rounded and6n #J!, Teratomas are smooth, rounded andwell circumscribed if they are cystic andwell circumscribed if they are cystic andmore lobulated and asymmetric if they aremore lobulated and asymmetric if they are

solidsolid"oft tissue, fat and calcification Hoccasionally"oft tissue, fat and calcification Hoccasionally

fully formed teeth and bone can be seen onfully formed teeth and bone can be seen on#T images#T images

ll teratomas should be resected as to thell teratomas should be resected as to theuncertainty whether it is benign anduncertainty whether it is benign andpossibility of further enlargement andpossibility of further enlargement andimpingement on ad*acent structuresimpingement on ad*acent structures


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=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


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$enign eraoma. % &'"year"old man developed mild ches

discom#or. (Atlas of diagnostic oncology, Arthur T.

Skarin,2009)


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"eminomas"eminomas

"eminoma Hdysgerminoma"eminoma Hdysgerminoma

6ccurs almost e+clusively in men6ccurs almost e+clusively in men

9sually in the 9sually in the rdrddecade of lifedecade of life

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

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

They are aggressive malignant tumors that e+tendThey are aggressive malignant tumors that e+tendlocally and metastasi/ed distantly, usually to thelocally and metastasi/ed distantly, usually to thes.eletal boness.eletal bones


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"eminoma"eminoma

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

Poor prognosisPoor prognosis ge B% yEoge B% yEo

"-# syndrome"-# syndrome "upraclavicular, clavicular or hilar adenopathy"upraclavicular, clavicular or hilar adenopathy Presentation with feverPresentation with fever

)+tremely radiosensitive and may respond)+tremely radiosensitive and may responddramatically with chemotherapy even in cases ofdramatically with chemotherapy even in cases ofdisseminationdissemination

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

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


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8ymphomas8ymphomas

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

1&4


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8ymphoma8ymphoma

Incidental discovery of a mass on #J! is a commonIncidental discovery of a mass on #J! is a commonpresentation of lymphomapresentation of lymphoma

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

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

Pericardial and pleural involvementPericardial and pleural involvement

!esection is not a necessary part of therapy, but!esection is not a necessary part of therapy, butanterior thoracotomy or mediastinoscopy is re3uiredanterior thoracotomy or mediastinoscopy is re3uiredto confirm the diagnosis if adenopathyis not evidentto confirm the diagnosis if adenopathyis not evidentoutside the mediatinumoutside the mediatinum


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Obliterated retrosternal clear space

On the PA film there is a lobulated widening of

the superior mediastinum.On the lateral chest film the retrosternal clearspace is obliterated.

This happened to be a patient with lymphoma.


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Thyroid lesionsThyroid lesions

)ctopic thyrod gland accounts for 1&' of)ctopic thyrod gland accounts for 1&' ofmediastinal massmediastinal mass

#ervical goiter e+tends susternally into the anterior#ervical goiter e+tends susternally into the anteriormediastinummediastinum

Primary intrathoracic goiter, originating from thePrimary intrathoracic goiter, originating from theheterotropic thyroid tissue is rareheterotropic thyroid tissue is rare

Most are in the anterior mediastinum but can occurMost are in the anterior mediastinum but can occurin the middle and posterior mediastinumin the middle and posterior mediastinum


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Thyroid lesionsThyroid lesions

#ommon in women#ommon in women

Middle or older ageMiddle or older age

symptomaticsymptomatic

oarseness #ough, swelling of the faceoarseness #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 approachof sternotomy approach


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Parathyroid lesionsParathyroid lesions

Mediastinal parathyroid tissue accounts for as manyMediastinal parathyroid tissue accounts for as manyas 1&' of cases of hyperparathyroidismas 1&' of cases of hyperparathyroidism

Mediastinum is the most common site for ectopicMediastinum is the most common site for ectopicparathyroid adenomas in surgically resistantparathyroid adenomas in surgically resistanthyperparathyroidismhyperparathyroidism

Technetium scanning are accurate in diagnosingTechnetium scanning are accurate in diagnosing

parathyroid tissueparathyroid tissue

#ured by complete resection#ured by complete resection


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Mesenchymal tumorsMesenchymal tumors

Iipomas, fibroma, mesothelioma,Iipomas, fibroma, mesothelioma,lymphangiomas,lymphangiomas,

They arise from connective tissue, fat, smoothThey arise from connective tissue, fat, smoothmuscle, striated muscle, blood vessels ormuscle, striated muscle, blood vessels orlymphatic channels and can occur in a anylymphatic channels and can occur in a anyregion of the mediastinumregion of the mediastinum

istologically they differ from their counterpartistologically they differ from their counterpart

Presence of symptoms means that the lesion isPresence of symptoms means that the lesion ismalignantmalignant


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8ipoma8ipoma

Is the most common mesenchymal tumorIs the most common mesenchymal tumor

Most often anteriorMost often anterior

)ncapsulted or unencapsulated)ncapsulted or unencapsulated

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


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8ipomatosis8ipomatosis

More common than lipomaMore common than lipoma

=enerali/ed overabundance of histologically=enerali/ed overabundance of histologically

normal unencapsulated fatnormal unencapsulated fat The presence of some fat in the mediastinum isThe presence of some fat in the mediastinum is

normal, usually in and around the thymusnormal, usually in and around the thymus

ccumulation of e+cess fat is associated withccumulation of e+cess fat is associated withgenerali/ed obesity or #ushingLs syndrome orgenerali/ed obesity or #ushingLs syndrome orwith the use of e+ogenous steroids or drugswith the use of e+ogenous steroids or drugs

Middle Mediastinum


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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)

8 i t i ll i th8esions typically in the


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8esions typically in the8esions typically in the

Middle MediastinumMiddle Mediastinum

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

Mediatinal lymph node enlargement is most oftenMediatinal lymph node enlargement is most often

due to three categories of disease processdue to three categories of disease process 8ymphomas8ymphomas

Metatastic cancerMetatastic cancer

=ranulomatous inflammation=ranulomatous inflammation


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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.


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Developmental cystDevelopmental cyst

#omprise 1&4


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Developmental #ystsDevelopmental #ysts

Pericardial cystPericardial cyst ccounts for 1E of cystic masses in adultsccounts for 1E of cystic masses in adults

8ess common in children8ess common in children

They typically lie against the pericardium, diaphragmThey typically lie against the pericardium, diaphragmor anterior chest wall on the right cardiophrenic angleor anterior chest wall on the right cardiophrenic angle

It can enlarge to cause right ventricular outflow tractIt can enlarge to cause right ventricular outflow tractobstruction, or rupture and hemorrhage to causeobstruction, or rupture and hemorrhage to causepericardial tamponade or sudden cardiac deathpericardial tamponade or sudden cardiac death


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0ronchogenic cyst0ronchogenic cyst Found near the large airways, often posterior toFound near the large airways, often posterior to

the carina, may attach to the esophagus or eventhe carina, may attach to the esophagus or even

inside the pericardiuminside the pericardium #yst wall often contains cartilages and respiratory#yst wall often contains cartilages and respiratory

epithelumepithelumMost are discovered incidentally andMost are discovered incidentally and

asymptomaticasymptomatic

They can communicate with the tracheobronchialThey can communicate with the tracheobronchialtree and can become infected and cause airwaytree and can become infected and cause airwayobstruction, pulmonary artery compression andobstruction, pulmonary artery compression andhemodynamic collapse or rupture with disastroushemodynamic collapse or rupture with disastrousconse3uencesconse3uences


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)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 epithelumcyst, but have digestive tract epithelum

9ncommon in adults9ncommon in adults

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

ssociated with spinal e+tension and malformation ofssociated with spinal e+tension and malformation of

the vertebral column called neurenteric cystthe vertebral column called neurenteric cyst


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Diaphragmatic herniaDiaphragmatic hernia

The protrusion of omental fat or other abdominalThe protrusion of omental fat or other abdominal

contents through the diaphragm may occur viacontents through the diaphragm may occur via

several potential routes and medatinal mass lesionseveral potential routes and medatinal mass lesion

in any compartment may occurin any compartment may occur

hernia thorough the foramen of Morgagni hernia thorough the foramen of Morgagni

produces a cardiphrenic angle mass, usually on theproduces a cardiphrenic angle mass, usually on the

right sideright side


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0ochdale.Ks hernia, in the posterior mediastinum,0ochdale.Ks hernia, in the posterior mediastinum,

generally appears on the left side, presumablygenerally appears on the left side, presumably

because the liver prevents formation on the rightbecause the liver prevents formation on the right

They are usually incidental finding but can causeThey are usually incidental finding but can cause

complication in some casescomplication in some cases


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Posterior MediastinumPosterior 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,)


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Cervicothoracic sign


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On he le# he MR o# he same paien.

- urned ou o +e a sch!annoma.


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=anglioneuroma During evaluation for unrelated problem, chest radiography in a=anglioneuroma During evaluation for unrelated problem, chest radiography in a


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mediastinum fkunlam

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