ONCOLOGY REPORTS 31: 565-572, 2014

Proposal for a new mediastinal compartment classification
of transverse plane images according to the Japanese
Association for Research on the Thymus (JART)
General Rules for the Study of Mediastinal Tumors

Department of Radiology, Kurume University School of Medicine, and Center for Diagnostic Imaging,
Kurume University Hospital, Kurume, Fukuoka 830-0011; 2Department of Radiology, Nagoya City West Medical Center,
Kita-ku, Nagoya 462-8508; 3Department of Radiology, Osaka University Graduate School of Medicine, Suita,
Osaka 565-0871; 4Department of Diagnostic Radiology, National Cancer Center Hospital, Chuo-ku, Tokyo 104-0045;
Department of Diagnostic Radiology, Saitama International Medical Center, Saitama Medical University,
Hidaka, Saitama 350-1298; 6Department of Oncology Immunology and Surgery, Nagoya City University
Graduate School of Medical Sciences, Nagoya 467-8601, Japan

Received October 17, 2013; Accepted November 8, 2013

DOI: 10.3892/or.2013.2904

Abstract. There is no existing worldwide published method for sified as being in the anterior mediastinum compartment. The
mediastinum compartment classification based on transverse majority of intrathoracic goiters (82%, 14/17) were categorized
section images for the differential diagnosis of mediastinal as being in the superior portion of the mediastinum compart-
tumors. Herein, we describe a new method for anatomic ment. Approximately two-thirds of mass lesions in the middle
mediastinal compartment classification using transverse mediastinum were cysts, including foregut and pericardial
section computed tomography (CT) images and the use of cysts. Approximately 80% of 37 mass lesions in the poste-
this method to classify mediastinal lesions, and thus evaluate rior mediastinum were neurogenic tumors. Correspondingly,
whether the method is sufficiently user-friendly and useful. 29 of the 49 neurogenic tumors (60%) were categorized as
In a publication of the Japanese Association for Research on being in the posterior mediastinum, while 10 (20%) were in
the Thymus (JART), we proposed the following four medias- the superior portion of the mediastinum, 4 (8%) in the ante-
tinal compartments based on transverse CT images: superior rior mediastinum, and 6 (12%) in the middle mediastinum.
portion of mediastinum, anterior mediastinum (prevascular Our findings showed that the newly proposed mediastinal
zone), middle mediastinum (peri-tracheoesophageal zone), compartment classification using transverse images appears to
and posterior mediastinum (paravertebral zone). In the be user-friendly enough for practical clinical application and
present study, we retrospectively analyzed 445 pathologically may be helpful in differential diagnoses.
proven mediastinal mass lesions, and categorized them into
the proposed four compartments by consensus reading. Mass Introduction
lesions were classified into compartments based on the loca-
tion of the lesion centroid, and each lesion was satisfactorily The mediastinum constitutes a compartmentalized septum
categorized into a compartment. Almost all thymic epithelial or partition that vertically divides the thorax  (1). It is
tumors (99%, 244/246), all 24 thymic malignant lymphomas anatomically bound on the lateral side by the parietal pleural
and a majority of germ cell neoplasms (93%, 54/58) were clas- reflections along the medial aspects of both lungs, superiorly
by the thoracic inlet, inferiorly by the diaphragm, anteriorly
by the sternum, and posteriorly by the anterior surfaces of
the thoracic vertebral bodies (1-3). When mediastinal mass
lesions are diagnosed using imaging techniques, image
Correspondence to: Dr Kiminori Fujimoto, Department of
interpretation requires accurate assessment of the lesion
Radiology, Kurume University School of Medicine and Center for
Diagnostic Imaging, Kurume University Hospital, 67 Asahi-machi,
origin, area of existence and extension, and inner structures.
Kurume, Fukuoka 830-0011, Japan Therefore, it is clinically important to have a standardized
E-mail: kimichan@med.kurume-u.ac.jp method for classifying the mediastinum into several compart-
ments for the purpose of tumor description and categorization
Key words: mediastinum, compartment, mediastinal mass, mediastinal in differential diagnosis.
neoplasm, computed tomography, differential diagnosis Published methods for classifying mediastinal compart-
ments include the traditional method, Fraser and Paré method,

1%) were classified sification using transaxial section images acquired by CT. gists checked the medical records retrospectively and collected We found that this method has several strong features. 343/445) were classified as being located in the the new method for anatomic mediastinal compartment clas. and most germ cell neoplasms Materials and methods (93%.5%) in the middle mediastinum. The fundamental basis of this meth. 55 were excluded for technical posterior mediastinum. distinguish between certain situations.3%) in the posterior mediastinum. All research in the middle mediastinum. Using this system. 24 thymic malig- structures (8-12). Finally. while 10 (20%) were in the superior portion (paravertebral zone) (13). Most The purpose of this study was two-fold: firstly. of the mediastinum. and as being located in the superior portion of the mediastinum. it was possible to using the transverse plane image in a recent set of Japanese satisfactorily classify each mediastinal mass lesion into one General Rules for the Study of Mediastinal Tumors (13). 17 intrathoracic goiters and Our group of diagnostic radiologists from the Japanese 51 cystic lesions (34 bronchogenic cysts. 31 malignant germ cell tumors.1%. The majority of intrathoracic goiters The Ethics Committee of Kurume University approved this (82%. ment includes an original organ or structure from which the defined as the geometric center (centroid) in the transverse mediastinal lesion arose. foregut and peri­cardial cysts. For cation. neurogenic tumors. 14/17) were categorized as being located in the superior retrospective study (research no. and assigned each lesion to one different authors use different terms and methods for the of the proposed four compartments in individual institution. Accordingly. a new method for classifying the mediastinal compartment Based on the location of the centroid. we were able to section showing the greatest size of the lesion. 54/58) were classified as being in the anterior medi- astinum compartment. and whether this method was however. insufficient image resolution and X-ray computed tomography (CT) is currently the main motion artifact. same thing. one was located in the anterior and one was located retrospective review of their records and images. Heitzman method. They included 246 thymic epithelial tumors existence. reasons. 38 lesions (8. which are easy to identify during CT image interpretation In the present study. However. 1 and 2 show the details of the classification method. We also investigated the use From the end of December 2007. 27 mature to be classified based on the transverse plane image. of this method in terms of its usefulness and user-friendliness. a respectively 100 consecutive cases with a mediastinal mass lesion's compartment is defined as the compartment in which that was proven surgically and/or pathologically in respective the lesion centroid is found. which cannot helpful in differential diagnosis. Approximately into the following four compartments that are visible on 80% of the 37 mass lesions in the posterior mediastinum were transverse CT images: superior portion of mediastinum. middle mediastinum tumors (60%) were categorized as being located in the poste- (peri-tracheoesophageal zone). to be subjects. large number of mediastinal lesions. For example. the mediastinum compartment needs nant lymphomas. Of the remaining ment to obtain patient approval or informed consent for the two goiters. odology is that a mass lesion is classified into one of the four and 6 (12%) were in the middle mediastinum. 49 neurogenic tumors. portion of the mediastinum compartment. This method is practical and user-friendly. such as small size. anterior mediastinum. each compartment is clearly bound by drawing each case. all 24 thymic malignant lymphomas. 12002) and waived the require. what is confusing is the fact that lesion based on the CT image. to assess whether the proposed method was user. including Helsinki (version 2008) of the World Medical Association. to present tumors (77. and 37 lesions friendly and applicable by using it to retrospectively classify a (8. Almost all thymic epithelial tumors (99%. compartments of which the arising organ or tissue of a medi- astinal mass lesion exists and there is a potential space which a Discussion lesion easily extends. and posterior mediastinum rior mediastinum. teratomas. and the middle compart- ment can include some masses that are both in the middle and Of the 500 selected cases.566 FUJIMOTO et al: JART MEDIASTINAL COMPARTMENT CLASSIFICATION FOR CT Felson method. proposed the division of the mediastinum (particularly in the right cardiophrenic sinus). two-thirds We. were set as the index of the boundary. 244/246). On the other hand. the ante- rior compartment can include some masses that are in both the Results anterior and middle mediastinum. seen on transverse plane images. we described a new method for classifying and operation. leaving little room for misclassifi- five institutions. it utilizes a lateral chest radiograph. and Whitten Each independent radiologist evaluated each mediastinal method  (1-7). The anatomical structure and the virtual line. each radiologist selected at least one representative anatomical boundary reference lines. Second. and extension of a lesion in complicated mediastinal (193 thymomas and 53 thymic carcinomas). compartment without any inconsistencies (Table II). First. 29 of the 49 neurogenic anterior mediastinum (prevascular zone). while 27 lesions (6. satisfactorily classify each of 455 mass lesions into one of the . five radiologists of the Diagnostic Imaging Committee of pericardial cysts were located in the anterior mediastinum of the JART. secondly. each compart- CT image that included the center of a mediastinal lesion. Table I the location of mediastinal lesions according to compartments and Figs. Thus. The remaining 445 cases were considered practical clinical examination used for assessing the origin. without any contradictions. 4 (8%) were in the anterior mediastinum. each of the five radiolo. thus 500 cases were collected in total. Among these methods the classification of the We further discussed whether each mediastinal lesion could mediastinum into three compartments by Felson (4) is strictly be satisfactorily categorized into one of the four compartments based on radiology. Approximately two-thirds of was in compliance with the principles of the Declaration of mass lesions in the middle mediastinum were cysts. 15 pericardial cysts Association for Research on the Thymus (JART) described and 2 esophageal duplication cysts). Zylak method.

superior vena cava. ascending aorta. (H) pulmonary trunk. (B) upper rim of clavicle. (I) left atrium. LSPV. esophagus. (J) tricuspid valve. RA. (D) left bra- chiocephalic vein across TML. E. left pulmonary artery. LIPV. RSPV. LCCA. bronchus. middle-posterior boundary line (see Materials and methods). second rib. 2014 567 Figure 1. left common carotid artery. PA. Br. sternum. right atrium. right brachiocephalic artery. pulmonary artery. (E) aortic arch. clavicle. RBCA. left atrium. Ster. AA. ONCOLOGY REPORTS 31: 565-572. SCA. subclavian vein. right inferior pulmonary vein. right brachicephalic vein. Abbreviations: CL. TML. trachea. first rib. left inferior pulmonary vein. subclavian artery. AsA. LPA. (A) Thoracic inlet. left superior pulmonary vein. (C) sterno-clavicular joint. (F) tracheal carina. aortic arch. Tr. SCV. ITV. tracheal mid-line. M-PBL. SVC. right superior pulmonary vein. internal thoracic vessels. LA. RBCV. . RIPV. (G) right main pulmonary artery. LSCA. Schematic diagram represents the new proposal for mediastinal compartment classification according to the General Rules for Study of Mediastinal Tumors of the Japan Association for Research on the Thymus (JART). LBCV. left subclavian artery. 1R. left brachicephalic vein. 2R.

(G) right main pulmonary artery. Abbreviations: TML. (H) pulmonary trunk. . (B) upper rim of clavicle. (L) middle of 12th thoracic vertebral body. M-PBL. (E) aortic arch. (I) left atrium. (A) Thoracic inlet. middle-posterior boundaryline (see Materials and methods). (K) hepatic dome of diaphragm. tracheal mid-line. (C) sterno-clavicular joint. (F) tracheal carina.568 FUJIMOTO et al: JART MEDIASTINAL COMPARTMENT CLASSIFICATION FOR CT Figure 2. Contrast-enhanced CT images represent new proposal of mediastinal compartment classification according to the General Rules for Study of Mediastinal Tumors of the JART. (D) left brachiocephalic vein across TML. (J) tricuspid valve.

superior vena cava. the anterior rim of the descending aorta and a vertical line connecting a point on each thoracic vertebral body at 1 cm behind its anterior margin [middle-posterior boundary line (M-PBL). The area is also anatomically bound anteriorly by the sternum. and posterolaterally by a vertical line against the posterior rim of the chest wall at the lateral rim of the thoracic vertebral transverse process (orange lines in figures). This compartment includes mainly the trachea. the boundary of the superior portion of the mediastinum. the sternum. the diaphragm. 1 and 2]. ascending aorta. the diaphragm. anterior. anterior. the diaphragm. 2014 569 Table I. Middle mediastinum (Peritracheoesophageal zone) The anatomical boundaries of this compartment (area highlighted yellow in Figs. 1 and 2). This lower border is the same as the anatomical definition of the right upper paratracheal (#2R) lymph nodes. and the lateral rim of the aortic arch. Posterior mediastinum (Paravertebral zone) This compartment (area highlighted blue in Figs. laterally by the parietal (mediastinal) pleural reflections. posteriorly by the anterior rim of the thoracic vertebral body. crossing in front of the trachea at the midline). and the heart. the boundary of the superior portion of the mediastinum. ONCOLOGY REPORTS 31: 565-572. a vertical line against the posterior rim of the chest wall at the lateral rim of the lateral process of the thoracic spine (orange lines in Figs. and posterior. superior vena cava. inferior. and posterior. 1 and 2) are as follows: superior. the pericardium (including a horizontal line at the posterior rim of the heart). anterior rims of the left brachiocephalic vein. Anterior mediastinum (Prevascular zone) The anatomical boundaries of this compartment (area highlighted red in Figs. lateral. bilateral main bronchi and esophagus. 1 and 2) is defined as the space between the superior border of the mediastinum (i. bilateral main pulmonary arteries. . black line in Figs. the boundary of the middle mediastinum (M-PBL). 1 and 2. 1 and 2) is anatomically bounded as follows: superior. 1 and 2) is anatomically bounded as follows: superior. ascending aorta. anterior.. the inferior boundary of the superior portion of the mediastinum (a horizontal line at the upper rim of the brachiocephalic vein where it ascends to the left. and superior and inferior pulmonary veins). inferior. Definition of the JART mediastinum compartments Mediastinal compartment Definition Superior portion of the mediastinum This compartment (area highlighted green in Figs. superior and inferior pulmonary veins. based on the lymph node map of the International Association for Study of Lung Cancer (IASLC) (14). 1D and 2C]. the thoracic inlet) and a horizontal plane at the intersection of the caudate margin of the brachiocephalic vein with the trachea [tracheal midline line (TML). and posterio-lateral.e. red lines in Figs. the parietal (mediastinal) pleural reflections (including the lateral rims of the bilateral internal thoracic arteries and veins. inferior. All descriptions of areas and lines in highlighted colors are illustrated in Figs. the posterior rim of the left brachiocephalic vein.

The great vessels (including the left brachiocephalic compartments vein. medias. We decided that since the esophagus. the pulmonary outflow tract. represent the anterior boundary of the middle mediastinal astinum on a lateral chest radiograph. middle mediastinum. the anterior mediastinum (under the superior portion of the and bronchi share an embryological origin (foregut. P. we did not include the vessels. However. boundary line between the anterior and middle mediastinum is Some previously described methods of mediastinal drawn along the tracheal anterior edge and the cardiac poste. and the pericardium. Namely. At the center of the human body (i. of Mediastinal Tumors (13). ascending aorta and the lateral rim of the aortic arch) Mediastinal masses S A M P Total may be pushed backward and downward by expanding Intrathoracic goiter 14 1 2 - 17 neoplasms of thymic origin (e. anterior mediastinum.12). in that many intratho- proposed a way to guess the location of a mass based on its racic goiters would be categorized as being in the anterior or location relative to two drawn lines. but would impact differential diagnosis. and these tumors were the main tion method and Felson's method (using a lateral chest type existing in this zone. In Sone et al (15) assessed potential spaces of mediastinal the present study.. mediastinum) in our presently described classification system these should all be classified into the same compartment (the corresponds to that in Felson's method. the retrosternal vessels. the sagittal section plane shows the anterior medias. portion of the mediastinum. This is one reason Mature teratoma 2 24 - 1 27 why these structures are the anatomic posterior boundary of the anterior mediastinum. Among zone’ described by Sone et al (15).7. the majority of intrathoracic goiters and compartments using a CT pneumomediastinography and one-fifth of neurogenic tumors were located in the superior described discrepancies between the anatomical classifica. mediastinum. the middle mediastinum. However. Except for this portion. while Felson's method. and main bronchi are located in the middle space). triangular gland that occupies the thyropericardiac surrounding the thoracic descending aorta is classified as part space of the anterior mediastinum. Felson (4) and Sone  et al (15) stated that there is no need to classify the Neurogenic tumors 10 4 6 29 49 superior mediastinum due to the continuity of the inferior mediastinal zone. and lymphadenopathy. classifying the superior portion Total 27 343 38 37 445 of the mediastinum has the advantage of making it easy to S. The majority of the lesions these.e. and is similar to the ‘central tinal fatty tissue and anterior mediastinal lymph nodes. differentiate an intrathoracic goiter or neurogenic tumor of M. endoderm). trachea. Our definition of this proximal ascending aorta. at the left side of the cardiovascular system in the JART General Rules for Study mediastinum. These vascular structures are Thymic carcinoma - 52 1 - 53 also barriers to prevent an anterior mediastinal tumor from Thymic malignant lymphoma - 24 - - 24 extending into the posterior or inferior area. while the esophagus is located in the posterior tinal zone to be ahead of the anterior tracheal wall. Not classifying this compartment radiograph) (4). thymic epithelial tumors and thymic malignant lymphomas) and germ cell tumors in Thymoma - 192 1 - 193 the anterior mediastinal zone. superior vena cava. and the boundary is only the M-PBL (the transverse plane at 1 cm . and it extends caudally sometimes down to masses into the JART mediastinal compartment model. This boundary is familiar to thoracic radiologists. The anterior rims of great vessels. are tumors of thymic origin (8-11). the posterior boundary of the anterior medias. the great mediastinum (3. and the compartment characteristics were upper paratracheal) and #4R (right lower paratracheal) medi- considered to be useful in differential diagnoses. the thymus is the most important organ in the anterior found in the middle mediastinum included foregut cysts. A. posterior mediastinum.. the thoracic inlet from other mediastinal tumors. physicians and surgeons. and pericardium and heart are considered to be the posterior this anatomical complexity produces inconsistency with the boundary of the anterior mediastinal compartment.g. Malignant germ cell tumors - 30 1 - 31 Traditional anatomical method divides the mediastinum Pericardial cyst - 10 5 - 15 into two major compartments (the superior and inferior medi- Bronchogenic cyst 1 6 20 7 34 astinum) by an imaginary line extending from the sternal Esophageal duplication cyst - - 2 - 2 angle to the fourth intervertebral (Th4/5) disc. After birth. it is located anterior to the of the middle or posterior mediastinum. astinal lymph nodes on the IASLC lymph node map (14). In contrast. pericardium and heart some masses possibly in both the anterior and middle medi. superior portion of the mediastinum. In Felson's method. the thymus is It has not been clearly stated whether the paraaortic area a bi-lobed. compartment. the level of the diaphragm (8). mediastinum since a majority of anterior mediastinal masses tracheal and esophageal tumors. middle mediastinum). trachea. Result of the classification of the 445 mediastinal superior vena cava. the anterior compartment includes the posterior rims of the great vessels. This anatomical zone surrounds the The anterior mediastinum contains the thymus. compartmentalization have stated that the heart and great rior edge. as it corresponds to an imaginary boundary of #2R (right four compartments. We defined the boundary at the caudate rim of the brachiocephalic vein with the trachea (tracheal midline). superior and inferior pulmonary -------------------------------------- veins. tracheobronchoesophageal zone. tinum spreads deeply along the aortic arch and left hilum.570 FUJIMOTO et al: JART MEDIASTINAL COMPARTMENT CLASSIFICATION FOR CT Table II. Our proposed anterior medias- tinum compartment corresponds to the normal location of the Mediastinal thymus. Felson did not classify the mediastinum.

. Dr Hiroyuki Shiono from neurogenic tumor from an intercostal neurogenic tumor by Nara Hospital Kinki University Faculty of Medicine. we described a method for the mediastinum a JART. Dr  Koichi  Kobayashi and masses occur with a higher incidence than those in other Dr  Masafumi  Kawamura from Keio University School compartments (2. Osaka. this space becomes Medical University.3. Sciences. . Association for Research on the Thymus (JARTa) General astinum is drawn along the line connecting a point on each Rules for Study of Mediastinal Tumors are as follows: thoracic vertebral body at 1 cm behind its anterior margin (4). The posterior mediastinum corre. Osaka. One methodology stated that the Research (C) (no. there is no potential Dr  Masaki  Hara (Section editor) from Nagoya City West space in a normal situation as the paravertebral area is strongly Medical Center. Further study is needed to analyze Medical Center and Cardiovascular Diseases. However. user-friendly for practical clinical use and is potentially useful tion techniques may be necessary due to the present lack of for the differential diagnoses of mediastinal mass lesions. Kasugai. Methodologies that have classified the heart and great Acknowledgements vessels as part of the middle mediastinum. This is one reason for Suita. Nagoya. based on expediency and experience. This study was supported. The worldwide publication and review of this (Section editor). Most neoplasms in of Medicine and Kurume University Hospital. by a Grant-in-Aid for Scientific rior cardiac edge (1. Dr  Ryosuke  Tsuchiya from Cancer Institute intra-observer agreements for classifying masses into the four Hospital of JFCR. Dr Takashi Kondo from Tohoku University. Dr Kazuya Kondo as a majority of the collected cases were anterior mediastinal and Dr  Shoji Sakiyama from University of Tokushima masses. and there may have been a sample bias Graduate School of Medicine. However.7-10). from Tokyo Saiseikai Central Hospital. Hospital. 13) cation method using CT transverse images is sufficiently and the members of the committee are listed in this book. of the paravertebral zone as bilateral vertical lines against from Nagoya City University Graduate School of Medical the posterior rim of the chest wall at the lateral rim of the Sciences. Yokohama. have also defined the front boundary of the posterior mediastinum as the poste. Nagoya 467-8601. Therefore. it Clinic. 2014 571 behind the anterior edge of vertebral body). Our quote the contents of the guideline book of the General Rules for results indicate that the new mediastinal compartment classifi­ Study of Mediastinal Tumors (Kanehara. our proposal of this mediastinal Dr Koji Takami from National Hospital Organization Osaka compartment classification method has not yet been validated National Hospital. Kouriyama. behind the anterior margin of the vertebral body. Ikoma.F. however. it is well known that anterior mediastinal Graduate School. using this boundary. from Hokkaido in other populations. wall (16). Sone et al did from Saitama International Medical Center. Hidaka. Sapporo. On the other hand.6. c/o Division of Oncology Immunology and Surgery. in part. Suita. Dr  Masahiko Kusumoto from surrounded by connective tissue. Niiza. proposal will be important for validating this classification Tokyo. ONCOLOGY REPORTS 31: 565-572. setting the anterior boundary of the paravertebral zone at 1 cm Dr Yuji Matsumura from Ohta Nishinouchi Hospital. of the posterior and lateral boundaries of the paravertebral Tokyo. Felson's method stated that the The members of the Editorial Board of the Japan boundary of the middle mediastinum and posterior medi. in practice. compartment classification based on transverse plane images Nagoya City University Graduate School of Medical Sciences. Tokushima. Japan. from Kasugai Municipal method for use in differential diagnosis of mediastinal masses Hospital. TNM the paravertebral zone are neurogenic tumors that arise from Classification and Therapy: Dr Meinoshin Okumura (Section the dorsal root ganglion/neuron. Saitama not mention this compartment. 2009) (ref. The present study had several limitations. Dr Masahiro Tsuboi from Yokohama City herein we set the bilateral posterolateral boundary lines University Medical Center. Tokyo. Further classifica.). We also evaluated this novel classification Research on the Thymus (JART) has granted permission to method by using it to assess 445 mediastinal mass lesions. Tokyo. Sendai. it was a Sakai. However. K. obtained by CT. and Dr Yoshihiro Matsuno. Nagoya. and of this compartment is useful in diagnosing paravertebral Dr  Kiminori  Fujimoto from Kurume University School neurogenic tumors using tumor location. Dr  Ken  Kodama from Osaka mediastinal compartments.) from the Japan Society for paravertebral region is bounded at the front by the anterior the Promotion of Science (JSPS) and the National Cancer Center surface of the vertebral column and at the back by the chest Research and Development Fund (23-A-25 to M. Tokyo. Dr  Noriyuki  Tomiyama from clearly evident when a mass lesion exists in this zone. Kyoto. Committee Chair: Dr  Yoshitaka  Fujii (Chief editor) from We adopted this method as the anterior boundary for the Nagoya City University Graduate School of Medical posterior mediastinum. Third. Dr Harubumi Kato from Niizashiki Central General zone. Dr Toshiki Hirata and Dr Hiroshi Date from might be somewhat difficult to differentiate a paravertebral Kyoto University Hospital. In conclusion. since air does not pass into National Cancer Center Hospital. Dr  Tomoki  Yano. and reading agreements.7). Dr Jun Nakajima and Dr Tomohiro Murakawa The literature does not include any previous descriptions from University of Tokyo Graduate School of Medicine.K.F. Suita. with the aim of providing a clinically practical Mizuho-machi 1. adjacent to the intervertebral foramen. Second. Dr Fumikazu Sakai this area during CT pneumomediastinography. Inclusion Osaka University Graduate School of Medicine. Nagoya. Dr  Shinichi  Toyooka from Okayama University retrospective study. appropriate methods. Dr Tomoki Utsumi from NHO Kinki Chuo Medical Center. 24591799 to K. Okayama. Dr  Hisashi  Tateyama. Committee Co-chairs: Diagnostic Imaging: sponds to the paravertebral zone. method that can lead to more consistent and exact diagnosis of The Editorial Committee of the Japanese Association for mediastinal masses.and of Medicine. most of which are located editor) from Osaka University Graduate School of Medicine. University Hospital. Dr  Hiromi  Wada from Osaka-Wada thoracic vertebral transverse process. Histopathology: Dr Kiyoshi Mukai outside of Japan. First. we did not analyze inter.

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