CLASE 5

IMAGENOLOGÍA
Tórax Parte II

Introducción
al estudio del
mediastino en Rx
Dra. Liliana Hernández Marín
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Imagenología Diagnóstica y Terapéutica
Radiografía Tórax MEDIASTINO Diagnostic Imaging Chest

(Left) Graphic shows a cross section of the mediastinum. The mediastinum is the space between the pleural surfac
bound anteriorly by the sternum and posteriorly by the spine. It contains tissues, structures, and organs that may
affected by various disease processes. Mediastinal divisions are arbitrary and not based on existing tissue planes.
iDESIGN
by(Right)
HiSlide.io Graphic shows a sagittal view of the mediastinum, which extends from the thoracic inlet superiorly to the
diaphragm inferiorly.
Divisiones del mediastino:
Anatómica de Gray

SUPERIOR

• Aorta
• Grandes vasos
• Tráquea
• Tercio superior del esófago
• Timo superior
• Ganglios linfáticos (GL)

ANTERIOR MEDIO POSTERIOR

• Grasa • Pericardio y • Esófago

mediastinal contenido • Aorta torácica
• Timo • Carina descendente
• GLiDESIGN • GL • Vena ácigos
• Conducto
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torácico

Radiology: Vol. 272: No. 1—July 2014

 Divisiones del mediastino:
Radiológica de Felson

ANTERIOR MEDIO POSTERIOR

• Grasa • Tráquea • Vértebras
• Timo • Bronquios • Nervios
T
• Corazón • Esófago espinales
• Aorta • Aorta
ascendente descendente

Ganglios linfáticos

ANTERIOR MEDIO POST

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 Important causes of a widened mediastinum:

Hallazgos
• aortic dilatation (aortic aneurysm or dissection)
• lymph node enlargement

Patología mediastinal = • dilatation of the oesophagus

• thyroid enlargement

en Rx:
• thymic tumours.

ENSANCHAMIENTO
C

Mediastino NL
Figure 100 A normal chest radiograph showing the
mediastinum marked in orange.

The level of the widening (upper, central, lower) can help determine the cause.
• Upper mediastinal widening:
– more likely to be paratracheal lymphadenopathy, thyroid or thymus in origin.
• Central or lower mediastinal widening:
– more likely to be hilar enlargement, aortic widening, lymphadenopathy, dilatation of the oesophagus
or a thymic tumour.

Radiological signs to look for

• If you suspect widening of the aorta:
– follow its outline. You may see a continuous edge that widens to form the edge of the enlarged

FOCAL
mediastinum
– look for calcification in the wall of the aorta and if you can see a line of calcium, follow it
• if the calcified aortic wall bulges, there is likely to be an aortic aneurysm
• if the line of calcium separates from the edge of the aortic shadow then this would be in keeping
with an aortic dissection.

DIFUSO Note: The aorta may become tortuous in the elderly and this may mimic a widened aorta.

Hemorragias, infecciones
• If you suspect an enlarged thyroid:
– look at the position of the trachea. An enlarged thyroid will displace or narrow the trachea.
MASAS que pueden

Presentar
signo de la
silueta
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Invadir (visible
en TAC o RM)

Desplazar Comprimir
Interpretación
Note: Always check to ensurebásica:
the film is notRx deA rotated
rotated. Tórax film can make the mediastinum look
MASAS MEDIASTINALES
widened.

Important causes of a widened mediastinum:

•Alaortic
observar una
dilatation posible
(aortic masa
aneurysm or dissection)
• lymph node enlargement
presente en el mediastino:
• dilatation of the oesophagus
• thyroid enlargement
•1.thymic
¿Origen
tumours.mediastinal o
pulmonar? Diagnostic Imaging Chest

2. ¿Compartimiento anterior, Anterior mediastinal, spherical/ovoid, unilateral soft tissue mass, smooth or lobular bord
No lymphadenopathy

medio, posterior?
Invasive thymoma: Local invasion, pleural nodules
MR
T1WI: Low to intermediate signal intensity

3. ¿Es posible caracterizar si la T2WI: Hyperintense

Top Differential Diagnoses
Thymic malignancy
lesión tiene calcio, grasa, líquido Lymphoma
Thymic carcinoma & carcinoid

o componentes vasculares?
Malignant germ cell neoplasm
Clinical Issues
70% present in 5th & 6th decades, M = F

(Difícil en Rx)
Symptoms
Asymptomatic, incidental diagnosis
Compression/invasion of adjacent structures
Paraneoplastic syndromes

76 What to look for in C – Circulation

Mediastino normal
Treatment
Stage I & II: Complete surgical excision
Stage III & IVa: Neoadjuvant chemotherapy & complete excision
Example 3 Stage IVb: Palliative chemotherapy

Figure 100 A normal chest radiograph showing the

iDESIGN mediastinum marked in orange.
by HiSlide.io

The level of the widening (upper, central, lower) can help determine the cause.
• Upper mediastinal widening:
– more likely to be paratracheal lymphadenopathy, thyroid or thymus in origin.
• Central or lower mediastinal widening:
– more likely to be hilar enlargement, aortic widening, lymphadenopathy, dilatation of the oesophagus
Interpretación básica: ¿Mediastino o pulmón?
Mediastino (y no pulmonar):
• No contiene broncograma
aéreo
• Márgenes con el pulmón son
OBTUSOS.
• +/- Anomalías vertebrales,
costales o esternales
• Desplazamiento o
ensanchamiento de líneas y
bandas mediastinales Pulmonar
Pulmonar

Pulmón Mediastino
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Mediastinal
Interpretación básica: Signo de la silueta (SS)

Estructuras con SIMILAR

DENSIDAD:
• CONTIGUAS pierden sus
límites (SS +)

• NO CONTIGUAS (por
interposición aire alveolar)
se distinguen sus límites (SS -)

SS
+ : corazón SS
- : aorta - : corazón
= Masa mediastino +: aórtico (+ discreto con
vértebras derechas)
anterior
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= Masa mediastino
medio a posterior

Valorar SS vs corazón,
aorta, diafragma, pared
torácica
 Anatomía
Images radiológica:
for this section:
Líneas y bandas del tórax
Divisiones del mediastino:
Bandas paratraqueales
Anatómica (Gray) y Radiológica
Línea de(Felson)
unión posterior

Receso Línea de unión anterior

acigoesofágico

Líneas paraespinales

Línea paraesofágica
Masas mediastinales: Lesiones por compartimiento

MASAS MALIGNAS (%) TUMOR MAS COMÚN

Anterosuperior 59% Anterosuperior Timoma
Medio 29% Medio Linfoma
Posterior 16% Posterior Tumores neurogénicos

MASAS MÁS COMÚNES

Las “5 T” del mediastino anterior
• Timoma
• Tumor neurogénico (TN) • Tiroides (ectópica o bocio)
En general • Quistes benignos • Timo
• Linfoadenopatía (LAD): infecciosa, • Teratoma (tipo de TCG)
granulomatosa, etc
• Aorta torácica (ascendente)
• TN • Terrible linfoma
Pediátricos • Tumor de céls. germinales (TCG)
• Quistes de duplicación
iDESIGN
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• LAD
Adultos • Timoma
• Masas tiroideas
Interpretación básica: Hallazgos en radiografías
SUPERIOR:
LAD, tiroides, timo, TCG

MEDIAL
Crecimiento hiliar, dilatación vascular (aorta,
pulmonar), LAD

INFERIOR:
Esófago (hernias, anomalías de la motilidad,
quistes de duplicación), pericardio

Tiroides
LAD/Linfoma
Timo
Ganglioneuroma

Q duplicación
iDESIGN TCG bronquial
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Q duplicación
entérica

Q pericárdico
oracic
thoracic
aortaaorta
with with
lymphlymph
nodenode
enlargement.
enlargement.
You can
You tell
canittell
is the
it isaorta
the aorta
as the
asoutline
the outline
continues
continues
inferiorly
inferiorly
downdown
the the
gth
length
of the
ofthorax.
the thorax.

Interpretación Rx: LAD mediastinales 76 76

WhatWhat
to look
to for
lookinfor
C –inCirculation
C – Circulation

xample
Example
2 2 Example
Example
3 3

What to look for in C – Circulation 75

gure
Figure
102 102
Two identical
Two identical
chestchest
radiographs
radiographs
showing
showing
hilar hilar
and paratracheal
and paratracheal
lymph
lymph
nodenode
enlargement.
enlargement.
The central
The central
and and
perupper
mediastinum
ar hilar
lymph
mediastinum
lymph
lookslooks
nodesnodes
marked
widened
marked
widened
with with
in orange.
a smooth
in orange.
a smooth
lobular
lobular
appearance.
appearance.
The right
The right
radiograph
radiograph
showsshows CC
the paratracheal
the paratracheal
and and

Example 1 FigureFigure
103 Two 103 identical
Two identical
chest chest
radiographs
radiographs
showing
showing
right paratracheal
right paratracheal
lymphlymph
node node
enlargement.
enlargement.
The upper
The upper
mediastinum
mediastinum
looks looks
widened
widened
with awith
smooth
a smooth
lobular
lobular
appearance.
appearance.
The trachea
The trachea
is actually
is actually
deviated
deviated
to thetoleft
the– left
being
– being
pushedpushed
over byoverthebyenlarged
the enlarged
lymphlymph
node.node.
The right
The radiograph
right radiograph
showsshows
the paratracheal
the paratracheal
lymphlymph
node node
marked marked
in orange.
in oraI
this case
this the
caselikely
the likely
causecause
of unilateral
of unilateral
lymphlymph
node node
enlargement
enlargement
could could
be TBbe
or TBa primary
or a primary
lymphoma.
lymphoma.

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Mediastino NL
Interpretación Rx: Masas hiliares

Hilios NL

LAD HILIAR:
• Inflamatoria
• Neoplásica
(primario y METS)
• Infecciosa
LAD
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Hipertensión
pulmonar

NOTA: Los hilios son extramediastinales

Interpretación Rx: Timoma

Rx Lat NL

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Interpretación Rx: TCG - Teratoma

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An anterior mediastinal mass. Capelle S, et al. EURORAD

de ESR. Caso 9148. 17.03.2011
Interpretación Rx: Linfoma

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Interpretación Rx: Hernia hiatal

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Interpretación Rx: Schwannoma nervio espinal

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Interpretación Rx: Timo normal del Recién Nacido

Ensanchamiento Ensanchamiento
mediastinal DIFUSO mediastinal FOCAL

Timo normal Timo normal

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“Signo de las olas” “Signo de la vela”

 ITMIG: International Thymic Malignancy Interest Group

Mediastino: TAC

TAC (y RM): Estudios de elección

para el estudio de patologías
mediastinales

Sistema de división de ITMIG

Primordialmente para TAC

Prevascular (anterior)
Visceral (medio)
Paravertebral (posterior)

Teratoma (Med. Ant): Quiste neuroentérico Schwannoma

Líquido, grasa y calcio (Med. Med): Líquido (Med. Post): Líquido y calcio

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 FACMED 2020

Gracias
radestudiantes@gmail.com

Referencias principales:
• Pediatric Thoracic Imaging. Lee EY, et al. Wolters Kluwer - 2019
• Felson: Principios de Radiología Torácica: Un Texto Programado. Goodman L. McGraw-Hill/
Interamericana de España, 3a Ed - 2009
• Chest X-rays For Medical Students, Christopher Clarke-Anthony Dux - Wiley-blackwell - 2011
• Diagnostic Imaging: Chest, Rosado L. - Amirsys - 2012
• Introduction to Radiology (Tutorials) - University of Virginia - med-ed.virginia.edu/courses/rad/
cxr/Index.html
• Radiology Assistant: radiologyassistant.nl
• Radiopaedia: radiopaedia.org