MARQUEZ, JANELLE BUENA

MIGUEL, JAKE ALBERT

MUNDA CRUZ, REIDEN
MEDIASTINUM
Mediastinum is defined as the space within the thoracic cavity that is bounded:
anteriorly by the sternum,
posteriorly by the vertebral bodies,
superiorly by the thoracic inlet,
inferiorly by the diaphragm, and
laterally by the parietal pleura.
Anatomically, the mediastinum is divided into compartments by drawing a line from the
sternal angle to the fourth thoracic intervertebral space.
Computed tomography (CT)
-proved to be the most efficacious study to evaluate a mediastinal abnormality observed on
plain films. --provides excellent contrast discrimination between fat, air, calcification, and
soft-tissue structures and eliminates the problem of superimposition of structures seen with
the chest radiograph
-with the use of intravenous contrast agents, CT can further define vascular structures and
better determine the relative vascularity of structures other than vessels.
Magnetic resonance imaging (MRI)
-limited role compared with CT
-decreased spatial resolution, prolonged scanning times, and relatively high cost.
ANTERIOR MEDIASTINUM
1. Lymphoma- malignant neoplasms of lymphocytes and histiocytes mixed with nonneoplastic inflammatory cells. They are commonly classified into two types:
Hodgkins (HL) and non-Hodgkins (NHL).
HL comprises approximately 20% to 40% of all lymphomas. It is differentiated histologically
from NHL by the Reed-Sternberg cell.

-Typically, multiple lymph node groups in the thorax are

affected; this can produce a lobulated appearance on
chest radiographs (Fig. 32-1A,B). This lymph node involvement is characteristically bilateral,
with contiguous progression from one lymph node group to the next. Adenopathy of the
internal mammary chains can occur, but involvement of these nodes in the absence of
lymphadenopathy elsewhere in the chest has not been described.
-Localized disease is usually treated with radiation therapy, whereas diffuse disease is
treated with chemotherapy.

2. Lesions of the Thymus

-normal thymus- retrosternal location behind the manubrium, anterior to the proximal
ascending aorta and distal superior vena cava.
-In the newborn it usually is larger than the heart; in older children it may often extend
inferiorly to occupy the space anterior to the heart. The size of the normal thymus is largest
between 12 and 19 years of age. The shape of a normal thymus is variable and has been
described as resembling an arrowhead in 62% of patients, bilobar in 32%, and consisting of
only one lobe in 6% of patients. It typically has an approximately symmetrical shape, with
the left lobe usually larger than the right lobe. These lobes commonly connect in the
midline, each lobe being surrounded by a fibrous capsule.
Thymic hyperplasia
-most common anterior mediastinal mass in the pediatric age group up to puberty

-often seen in association with hyperthyroidism, myasthenia gravis, acromegaly, or

Addisons disease
-no specific MRI signal pattern for thymic hyperplasia
Thymomas- most common primary neoplasms of the anterior mediastinum
-arise from both the epithelial and the lymphocytic components of the thymus gland.
-four types: encapsulated thymoma (intact fibrous capsule), locally invasive thymoma,
metastasizing thymoma (benign cytologic appearance with pleural and pulmonary
parenchymal seeding), and thymic carcinoma (frankly malignant histology and worse
prognosis than other thymomas).
-Approximately 30% to 35% of thymomas are malignant, as defined by invasion into
adjacent mediastinal fat and fascia.
-patients older than 40 years of age, with 70% occurring in the fifth or sixth decade.
-unusual before the age of 20 years and are equally common in male and female patients.
-Thymomas are classically asymptomatic
-Radiographically, thymomas are usually found in the anterior mediastinum anterior to the
ascending aorta above the right ventricular outflow tract and main pulmonary artery (Fig.
32-4A, B). On CT, benign thymomas are typically well-demarcated masses with homogenous
density and uniform contrast enhancement (Fig. 32-4C).

Thyroid
Masses
Intrathoracic Multinodular (Substernal) Goiter-represents approximately 10% of all
mediastinal masses
-approximately 75% to 80% of cases, these masses are found in the anterior mediastinum;
the remainder are found in the posterior mediastinum
-usually asymptomatic, but symptoms related to tracheal, esophageal, and recurrent
laryngeal nerve compression can occur

-Radiographically, intrathoracic multinodular goiters may have a well-defined, lobulated

appearance. These masses commonly displace and/or narrow the trachea. They may be
located anterior or lateral to the trachea and at times are found posterior to the trachea,
often separating the trachea and esophagus ( Fig. 32-5A, B). At CT, calcification with a
nodular, curvilinear, or circumferential configuration may be seen ( Fig. 32-5C through E).

MIDDLE MEDIASTINUM
1. Bronchogenic cysts (bronchial cysts)- most common type of intrathoracic foregut cyst.
-result from anomalous budding or branching of the tracheobronchial tree during
development.
-For these cysts to be classified as bronchogenic in origin, they must be lined by a columnar
respiratory epithelium and contain seromucous glands.
-usually in the region of the carina. Much less commonly, they are located in the lung
parenchyma and may have a systemic arterial supply, in which case they may represent a
form of pulmonary sequestration.
-In children, these cysts occasionally compress or displace the trachea, bronchi, or
esophagus, resulting in symptoms such as stridor, wheezing, or dysphagia. In adult patients
they usually are asymptomatic.
On plain chest radiographs, bronchogenic cysts are well-defined, smooth, round masses
located in the middle mediastinum near the carina, more commonly on the right (Fig. 32-6A,
B). On CT, a cystic structure that molds to the surrounding bronchovascular structures
usually is demonstrated. These cysts should have a smooth or lobulated thin wall and may
be unilocular or multilocular (see Fig. 32-6C).

2. Pericardial cysts
-result of an abnormal outpouching of the parietal pericardium
-can result from a defect in embryogenesis or as a sequela of pericarditis.
-typically discovered in patients aged 30 to 40 years
-usually asymptomatic, one third of patients can have symptoms such as chest pain, cough,
and dyspnea
-Imaging studies frequently demonstrate a well-defined, round or oval mass, most commonly
located in the anterior cardiophrenic angles (75%), with the majority located on the right
Occasionally, pericardial cysts extend into the major interlobar fissure, in which case they
have a teardrop or pear shape on lateral chest radiographs. CT typically demonstrates a
unilocular, cystic mass adjacent to the heart that has contents of almost water density.
Although MRI rarely is needed to make a diagnosis, it will reveal findings characteristic of a
simple cyst.

POSTERIOR MEDIASTINUM
1. Intercostal Nerve Tumors
The two most common neurogenic tumors of the mediastinum are the schwannoma
(neurilemoma) and the neurofibroma, with the former being more common.
-Although most of these tumors arise from the intercostal nerves, these masses can
occasionally originate from the phrenic or vagus nerves. When they arise near the spine,
these neoplasms may extendthrough a neural foramen. Because the tumor is narrowed as it
passes through the foramen, it assumes a dumbbell configuration, hence the term

dumbbell tumor. Although they are frequently discussed, they comprise fewer than 5%
ofcases.
-young adults older than 20 years of age.
-may be solitary or multiple and in the latter case may be associated with neurofibromatosis
type I.
-most of these tumors are benign, malignant degeneration of a schwannoma occurs in 10%
of cases.

2. Sympathetic Ganglia Tumors

-primarily in the adrenal gland, the mediastinum is the second most common location.
-usually attains a large size before symptoms occur.
-Radiographically, these tumors typically appear as elongated, vertically oriented
paravertebral soft-tissue masses with a broad area of contact with the posterior
mediastinum (Fig. 32-9). They have a tapered interface with the adjacent chest wall or
mediastinum, and their epicenter is against the vertebral body. Erosion of adjacent vertebral
bodies and ribs can occur, and the calcification seen in approximately 25% of cases is a
helpful diagnostic feature. This calcification tends to be dense and coarse in
ganglioneuromas and ganglioneuroblastomas and finely stippled in neuroblastomas.

3. Esophageal Carcinoma- represents approximately 4% to 10% of all gastrointestinal

malignancies.

-predisposing factors, including excessive alcohol consumption; tobacco use; ingested

carcinogens (nitrates, smoked opiates); mucosal damage (hot tea, lye ingestion, chronic
achalasia); and gastroesophageal reflux (Barretts esophagus).
-At presentation most subjects complain of progressive dysphagia and weight loss. This
dysphagia usually begins with solids and then gradually progresses to include semisolids
and liquids. Other manifestations include substernal chest pain with fullness, hoarseness,
anemia, and pulmonary complications such as aspiration pneumonia. The esophagus does
not have a serosa, and therefore direct extension of the tumor into the paraesophageal
tissues is common. By the time symptoms develop, the prognosis is dismal.
-Radiographically, plain films may demonstrate a widened mediastinum caused by the tumor
itself or by a dilated esophagus proximal to an obstructing lesion. An airfluid level may be
seen in the latter case ( Fig. 32-10A, B). Other plain-film findings include an abnormal
azygoesophageal line, thickening of the tracheoesophageal stripe, and tracheal compression

and deviation. Traditionally, contrast studies have been used to identify and characterize
neoplasms involving the esophagus. In early esophageal cancer, contrast studies
demonstrate a flat, plaque-like lesion, frequently with central ulceration. As the cancer
progresses, luminal irregularities may develop, indicating mucosal damage. In advanced
stages, the lesion may encircle the lumen completely (annular constriction), resulting in
partial or complete obstruction. CT is the single most accurate method for preoperative
staging of patients with esophageal carcinoma (see Fig. 32-10C). It can demonstrate an
intraluminal mass, thickening of the esophageal wall, loss of fat planes between the
esophagus and adjacent structures, and nodal spread to regional, celiac, and gastrohepatic
ligament nodes.
4. Paraesophageal Varices

Rarely, esophageal varices are apparent on frontal chest radiographs. They may appear as
round, lobulated, or serpiginous structures in a retrocardiac location, or they may cause
displacement of the paraspinal lines ( Fig. 32-11A, B).
The diagnosis should be straightforward in the appropriate clinical setting and with the aid of
endoscopy, contrast studies, CT, or portal venography. In addition, flow-sensitive gradientecho techniques make MRI quite useful in detecting varices.

5. Esophageal duplication cysts comprise approximately 10% to 20% of all alimentary tract
duplications.
-fluid-filled structures that arise within the wall of or immediately adjacent to the esophagus.
-caused by abnormal vacuolization of the esophageal lumen in the fifth to eighth week of
gestation, and in most cases no communication exists between the cyst and the esophageal
lumen.
-Frequently they contain ectopic gastric mucosa, which may cause complications such as
ulceration, bleeding, and perforation into adjacent structures.
-majority arise on the right, in thelower thoracic esophagus near the gastroesophageal
junction (60%) ( Fig. 32-12). Patients typically present in childhood, but initial presentation
has been reported in patients as old as 61 years. Esophageal duplication cysts may be
clinically silent, or patients may have symptoms related to compression of adjacent
structures.