ITMIG Definitions and Policies

A Modern Definition of Mediastinal Compartments
Brett W. Carter, MD,* Noriyuki Tomiyama, MD, † Faiz Y. Bhora, MD,‡
Melissa L. Rosado de Christenson, MD,§ Jun Nakajima, MD,║ Phillip M. Boiselle, MD,¶
Frank C. Detterbeck, MD,# and Edith M. Marom, MD*

Abstract: Division of the mediastinum into compartments is used to chest radiograph. The lack of a computed tomography (CT)-
help narrow the differential diagnosis of newly detected mediastinal centric scheme is problematic as the diagnosis, work-up (includ-
masses, to assist in planning biopsy and surgical procedures, and to ing biopsy approach), and formulation of treatment strategies are
facilitate communication among clinicians of multiple disciplines. now determined by CT findings and not by chest radiography.
Several traditional mediastinal division schemes exist based upon The International Thymic Malignancy Interest Group
arbitrary landmarks on the lateral chest radiograph. We describe a (ITMIG) has an established process to develop international
modern, computed tomography-based mediastinal division scheme, standards in the realm of mediastinal disease; this method was
which has been accepted by the International Thymic Malignancy applied to create a practical CT-based division of the medias-
Interest Group as a new standard. This clinical classification defines a tinum. First, ITMIG analyzed the existing literature regarding
prevascular (anterior), a visceral (middle), and a paravertebral (poste- mediastinal compartments. Particular attention was paid to a
rior) compartment, with anatomic boundaries defined clearly by com- mediastinal classification system based on transverse CT images
puted tomography. It is our intention that this definition be used in the recently proposed by the Japanese Association for Research of
reporting of clinical cases and the design of prospective clinical trials. the Thymus (JART) in order to facilitate differential diagnosis of
mediastinal lesions.1 This model, which was derived from a ret-
Key Words: Mediastinum, Compartments, CT. rospective analysis of 445 nonconsecutive pathologically proven
(J Thorac Oncol. 2014;9: S97–S101) mediastinal lesions, divides the mediastinum into four compart-
ments. Based on discussions with experts in the field, ITMIG
has modified the JART model; following the ITMIG process for
standards, this proposed modification was extensively reviewed
T he mediastinum is an intricate segment of the thorax that
contains vital intrathoracic structures such as the heart and
great vessels, trachea and main bronchi, esophagus, thymus,
and subsequently adopted by ITMIG members. In this article,
we describe this new, anatomically based mediastinal compart-
ment system that can be used to accurately localize mediastinal
venous and lymphatic structures, and nerve tissue. As dividing lesions and formulate focused differential diagnoses.
the mediastinum into specific compartments aids in the genera-
tion of differential diagnoses at initial presentation and facilitates METHODS
surgical treatment plans, several different classification systems The process used in the development of this document
have been developed in the past by anatomists, clinicians, and was designed to represent a consensus within the community
radiologists. However, these existing schemes represent arbitrary of clinicians and researchers interested in the divisions of the
nonanatomical divisions of the thorax based largely on the lateral mediastinum and mediastinal diseases. A multidisciplinary
group of 45 experts in thoracic surgery, oncology, diagnostic
*Department of Diagnostic Radiology, The University of Texas MD Anderson radiology, and pathology was surveyed regarding their prefer-
Cancer Center, Houston, TX; †Department of Radiology, Osaka University ence for a 3-compartment or a 4-compartment model. A core
Graduate School of Medicine, Osaka, Japan; ‡Department of Thoracic workgroup (E.M.M., B.W.C., and F.C.D.) analyzed this data,
Surgery, St. Luke’s-Roosevelt Hospital Center, Columbia University reviewed the existing literature regarding mediastinal classi-
College of Physicians and Surgeons, Division of Thoracic Surgery,
Continuum Cancer Centers of New York, New York, NY; §Department of fication schemes, and drafted a proposed CT-based compart-
Radiology, The University of Missouri-Kansas City, Saint Luke’s Hospital ment model. This proposal was then refined by an extended
of Kansas City, Kansas City, MO; ║Department of Thoracic Surgery, workgroup (N.T., F.Y.B., M.L.R., J.N., and P.M.B.). The docu-
Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, ment was distributed to all members of ITMIG for comments
Japan; ¶Department of Radiology, Beth Israel Deaconess Medical Center,
Boston, MA; and #Division of Thoracic Surgery, Department of Surgery,
and revised again. The final document was approved and
Yale University School of Medicine, New Haven, CT. adopted as an ITMIG standard by ITMIG members.
Disclosure: The authors declare no conflict of interest.
Address for correspondence: Brett W. Carter, MD, Department of Diagnostic MEDIASTINAL COMPARTMENTS:
Radiology, The University of Texas MD Anderson Cancer Center, 1515 A MODERN SYSTEM
Holcombe Blvd., Unit 1478, Houston, TX 77030. E-mail: bcarter2@
mdanderson.org Background
Copyright © 2014 by the International Association for the Study of Lung
Cancer Numerous methods for classifying the mediastinal
ISSN: 1556-0864/14/0909-0S97 compartments have been published, the most common of

Journal of Thoracic Oncology  ®  •  Volume 9, Number 9, Supplement 2, September 2014 S97

less complicated aspect of the pericardium as it wraps around in a curvilinear design. clinical. teriorly. compartments. the major contents of the prevascular com- superior and anterior mediastinal compartments may not partment include the thymus. and posterior) compartments is com. In the JART study. these locations. extremely valuable in guiding the work-up and treatment of a patient with a mediastinal mass. be readily identified on CT (Fig. However. Furthermore. (3) anteriorly—the sternum. differences in terminology and methods roid goiters from other anterior mediastinal tumors. For example. Zylak. as compartment decreases. the greatest size of the lesion) localizes the abnormality to a middle. a very large the CT-based classification system proposed by JART. Because establishing a presumptive clinical diagnosis is late relevant differential diagnoses. having a reliable way to iden- Number of Compartments tify the origin of a lesion is important. and posterior divisions. the center of a mediastinal lesion (defined as whether a superior mediastinal compartment is distinguished the center point of the lesion on the axial CT image showing or not. we rec- This nonanatomic boundary makes implementation and dis. and tumors may freely spread to both sections ment boundaries and the anatomic structures they contain can without being restricted by fascial planes. the general used to localize mediastinal abnormalities on CT scans. terior neurogenic tumors do not respect this arbitrary division. (4) laterally—the the similarity to the published anatomic. other included optimal distinction of disease entities in 67%. whereas the 3-compartment specific compartment. perception that most clinicians and radiologists do not use the existing 4-compartment schemes. as mediastinal compart- tory processes. Felson. There are two the number of specific compartments to include in the sys. pos. Additionally. parietal mediastinal pleura. ommend the following boundaries of the prevascular compart- semination of any 4-compartment model difficult. other compartments. and Whitten models3–8 used in radiologic rate superior compartment arises primarily by separating thy- practice. The first is the “center method. and (5) posteriorly—the anterior logic 3-compartment models currently used. and the fact that specific compartmental boundaries fashion (thus any vessels contained within the pericardium are established along true anatomic planes. are located in the middle mediastinum) (Table 1). and the anterior mediastinal mass may displace organs of the middle fact that the majority of thyroid goiters are typically located mediastinal compartment such as the trachea or the heart pos- within the superior mediastinum. and 5% did not have a prefer- accurate localization of the origin of the lesion and the extent ence. the division between the superior and We propose a 3-compartment model of the mediastinum inferior (anterior. ferred the 4-compartment model. Journal of Thoracic Oncology  ®  •  Volume 9. some mediastinal abnormali. Disadvantages of a 4-com. tools that are helpful in deciphering the compartment from tem. 72% preferred the 3-compartment model. and posterior divisions. because it is more ments has been proposed. particularly relevant because a growing number of mediasti. 23% pre- cross-sectional imaging techniques. lymph nodes. because traditional models are based can usually be reliably identified on CT. However. Thus. ing a standardized method for dividing the mediastinum into specific compartments based on CT imaging is necessary in Localization of Mediastinal Abnormalities order to appropriately describe mediastinal lesions and formu. as infectious and inflamma. visceral (middle). and the left S98 Copyright © 2014 by the International Association for the Study of Lung Cancer .” Very large mediastinal masses can displace organs from similarity to established anatomic and radiologic 4-compart. ITMIG recommends that both of these methods be partment CT system include increased complexity. in classification of all 445 mediastinal masses to specific com- Both models have strengths and weaknesses.1 A universally adopted scheme is anatomic in 53% and because it is easier to use in 48%.Carter et al. (2) inferiorly—the Advantages of a 3-compartment CT model include diaphragm. similarity to what they currently use in 63%. anterior. Reasons why the participants chose one model over the of disease are crucial. the advantage of having a separate superior mediastinal ties cannot be reliably localized to a specific compartment. a 3-com- nal abnormalities are detected by CT studies performed for partment model was selected as the backbone for the CT-based screening and other purposes. middle. vertebral (posterior) compartments. depending on In this method. ment: (1) superiorly—the thoracic inlet. Fraser and Pare. September 2014 which include the Shields’ classification scheme2 used in result in adequate separation of entities that occur in each of clinical practice and the traditional. partments. Number 9. classification scheme proposed by ITMIG. Classification schemes have traditionally divided the which the tumor originated. Based on this feedback given by this group. and para- pletely artificial and nonanatomic. this method resulted models describe only anterior. 1 and 2). Sometimes very large In constructing a CT-based definition of mediastinal mediastinal lesions extend from one compartment to another. fat. Most 4-compartment models include superior. The primary dis. the efficacy of such a system as demonstrated by from which the tumor originated. sification scheme for division of the mediastinal compart. consensus regard. Among the surveyed multidisciplinary group of 45 As mediastinal lesions are optimally evaluated with experts. For example.1 In actual between these schemes have resulted in confusion among practice. including prevascular (anterior).1 The second tool is the “structure displacement Advantages of a 4-compartment CT model include the tool. in the era of on the lateral chest radiograph.” mediastinum into three or four compartments. usually those that abut the compartment ment models. It is only recently that a CT-based clas. this is rarely a clinical dilemma since a thyroid goiter physicians. Based on advantage of the 3-compartment model is that merging the these landmarks. CT. Supplement 2. the benefit of distinguishing a sepa- Heitzman. and radio. one of the most important decisions involved making it hard to identify the site of origin.10 and several nonanatomic ITMIG Definition of Mediastinal Compartments features. In the proposed CT-based classification system.9 Therefore. middle. principally CT and MRI. considerable overlap exists.

and (4) posterolaterally—a vertical line along the visceral–paravertebral compartment boundary line. lymphoma. prevascular compartment.. brachiocephalic vein. Therefore. and at the level of the left atrium (C) demonstrate the proposed classification scheme. the most common masses assign these mediastinal abnormalities to the prevascular in the prevascular compartment include thymic abnormali. paravertebral compartment. lesions of the heart. visceral compartment. blue line. and esopha- gus. (2) compartment. superior vena cava. metastatic lymphadenopathy. the proximal aspect of the ascending aorta and lateral rim aries of the compartment by these lesions may be used to of the aortic arch. cardium (which envelops the distal aspect of the superior vena placement of the vessels described as the posterior bound. enhanced CT demonstrates the proposed classification scheme. yellow. cava. in contrast. aortic arch. aortic aneurysm) may FIGURE 2.e. 3B). green. and descending thoracic aorta. 3C).  Coned-down contrast-enhanced axial CT images slightly below the aortic arch (A).. tracheal lesions. green. It is important to note that the prevascular compart.g. September 2014ModernDefinitionofMediastinalCompartments FIGURE 1. intrapericardial pulmonary arteries. pericardial cyst). Red. Red. fore- gut duplication cysts. The paravertebral compartment is defined by the fol- ment wraps around the heart and pericardium in the visceral lowing boundaries: (1) superiorly—the thoracic inlet. compartment. and the thoracic duct) and (2) the trachea. and (4) posteriorly—a vertical line connecting a point on the thoracic vertebral bodies 1 cm posterior to the anterior margin of the spine (visceral–paravertebral compartment boundary line) (Table 1). and malignancies such as thymoma. visceral–paravertebral compartment boundary line. paravertebral compartment. yellow.. (3) anteriorly—the anterior aspect of the peri- intrathoracic goiter (Fig. The majority of abnormalities in the visceral compartment include lymph- adenopathy (related to lymphoma or metastatic disease). 3A). ascending thoracic aorta. This vertical line was selected as the posterior boundary of the visceral compartment and the anterior bound- ary of the paravertebral compartment because most neoplasms in the latter compartment are neurogenic tumors that arise from dorsal root ganglia/neurons adjacent to the intervertebral foramina. Posterior and inferior dis.  Sagittal reformatted image from contrast- also be encountered in this compartment (Fig. Additionally. and great vessels (e. (2) inferiorly— neoplasms. which share an embryological origin (the endoderm) as well as lymph nodes. Number 9. germ cell boundaries: (1) superiorly—the thoracic inlet. partment. hyperplasia. The major contents of the visceral compartment fall into two main categories: (1) a vascular category (i. posterior margin of the chest wall at the lateral aspect of the Copyright © 2014 by the International Association for the Study of Lung Cancer S99 . prevascular compartment. (3) anteriorly—the visceral com- compartment. and the intrapericardial pulmonary arteries). we suggest that all structures within the pericardium be included in the visceral compartment. pericardium (e. the middle compartment did not include the heart and great vessels1. and neuroendocrine tumors). blue line. visceral inferiorly—the diaphragm. at the level of the left pulmonary artery (B). We consider struc- tures such as the extrapericardial pulmonary arteries and veins to be pulmonary and not mediastinal structures. and the diaphragm. Supplement 2.g.Journal of Thoracic Oncology  ®  •  Volume 9. and esophageal tumors (Fig. ties (cysts. The visceral compartment is defined by the following thymic carcinoma. carina. heart. In the JART description.

aortic arch.  ITMIG Definition of Mediastinal Compartments Compartment Boundaries Major Contents Prevascular Superior: Thoracic inlet Thymus Inferior: Diaphragm Fat Anterior: Sternum Lymph nodes Lateral: Parietal (mediastinal) pleural reflections. confirming its anterior location. A left pleural effusion (E) and right pleural nodules (arrows) repre- sent pleural dissemination. lateral margin of the bilateral Left brachiocephalic vein internal thoracic arteries and veins. (A) Coned-down contrast-enhanced axial CT image shows a large het- erogeneous mass (M) in the prevascular compartment consistent with a biopsy-proven thymoma. ascending aorta. esophagus. Endoscopic biopsy revealed esophageal cancer. Posterior: Vertical line connecting a point on each thoracic vertebral body at 1 cm intrapericardial pulmonary arteries. thus the origin of this mass is in the paravertebral compartment. The intracardiac location of this lesion confirms its location in the visceral compartment. (B) Coned-down contrast-enhanced axial CT image shows a low attenuation mass (M) located between the left atrium and the thoracic spine. which lies along the anterior margin of the superior vena cava. The mass displaces organs of the visceral compartment such as the heart anteriorly and the central portion of the lesion is localized to the paraverte- bral region. S100 Copyright © 2014 by the International Association for the Study of Lung Cancer . superior and inferior pulmonary veins Visceral Superior: Thoracic inlet Nonvascular: Trachea. Note the posterior displacement of the heart and great vessels. superior vena cava. Supplement 2. September 2014 TABLE 1. and superior and inferior pulmonary veins Posterior: Anterior aspect of the pericardium.Carter et al. Journal of Thoracic Oncology  ®  •  Volume 9. ascending thoracic aorta. confirming its location in the visceral compartment. (D) Coned- down contrast-enhanced axial CT image shows a large mass (M) with calcifications in the left mediastinum. lymph nodes Inferior: Diaphragm Vascular: Heart. and the lateral rim of the aortic arch. Anterior: Posterior boundaries of the prevascular compartment descending thoracic aorta. CT-guided biopsy demonstrated ganglioneuroma. carina. thoracic duct posterior to its anterior margin Paravertebral Superior: Thoracic inlet Paravertebral soft tissues Inferior: Diaphragm Anterior: Posterior boundaries of the visceral compartment Posterolateral: Vertical line against the posterior margin of the chest wall at the lateral margin of the transverse process of the thoracic spine FIGURE 3. Number 9.  Representative examples of mediastinal masses. (C) Coned-down contrast-enhanced axial CT image shows a low attenuation mass (M) located within the left atrium in this patient with an angiosarcoma.

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