Radiology Examination of Mediastinum

Arlavinda A. Lubis
Radiology Department,Ulin Hospital / Faculty of Medicine, Lambung Mangkurat University

Introduction
The mediastinum is the

region in the chest between the pleural cavities that contain the heart and other thoracic viscera except the lungs

Mediastinal anatomy
Boundaries Lateral - parietal pleura Anterior - sternum Posterior - vertebral column and paravertebral gutters Superior - thoracic inlet Inferior - diaphragm

Mediastinal compartment by Felson

FelsonRadiologists

Anterior mediastinal, is bounded anteriorly by

the sternum and posteriorly by a line drawn from the anterior aspect of the trachea and along the posterior heart border

Middle mediastinal compartment lies between the anterior and posterior mediastinum

Posterior mediastinal, anterior border is defined by a line that is 1 cm posterior to the anterior edge of the vertebral bodies

(Meschan, 1981; resited by Lange & Walsh, 2007)

Diseases of the Mediastinum

Pneumomediastinum
Mediastinitis Neoplasma

 Pneumomediastinum
Air in the mediastinum is a common complication of

mechanical ventilation is also commonly encountered in some conditions Pain is the most common symptom
Results from stretching of the mediastinal tissues Substernal and aggravated by breathing and changing position

Dyspnea, dysphagia, subcutaneous crepitation

 Mediastinitis
Acute inflammation of the mediastinum
Substernal chest pain, chills, high fever, prostration

Chronic mediastinitis

Neoplasma

Clinical Presentation
Asymptomatic mass
Incidental discovery most common 50% of all mediastinal mass are asymptomatic 80% of such mass are benign More than half are malignant if with symptoms

Clinical Presentation
Effects on Compression or invasion of adjacent tissues Chest pain, from traction on mediastinal mass, tissue invasion,

or bone erosion is common

Cough, because of extrinsic compression of the trachea or

bronchi, or erosion into the airway it self

Hemoptysis, hoarseness or stridor Pleural effusion, invasion or irritation of pleural space Dysphagia, invasion or direct invasion of the esophagus Pericarditis or pericardial tamponade Right ventricular outflow obstruction and cor pulmonale

Clinical Presentation
Superior vena cava
Vulnerable to extrinsic compression and obstruction because it is thin

walled and its intravascular pressure is low, and relatively confined by lymph nodes and other rigid structures

Superior vena cava syndrome

Results from the increase venous pressure in the upper thorax , head

and neck characterized by dilation of the collateral veins in the upper portion of the head and thorax and edema and phlethora of the face, neck and upper torso, suffusion and edema of the conjunctiva and cerebral symptoms such as headache, disturbance of consciousness and visual distortion Bronchogenic carcinoma and lymphoma are the most

common etiologies

Clinical Presentation
Hoarseness, invading or compressing the nerves
Horners syndrome, involvement of the sympathetic

ganglia [dropping eyelid, decreased pupil size,decreased sweating on the ipsilateral face]
Dyspnea, from phrenic nerve involvement causing

diaphragmatic paralysis
Tachycardia, secondary to vagus nerve involvement Clinical manifestations of spinal cord compression

Clinical Presentation
Systemic symptoms and syndromes
Fever, anorexia, weight loss and other non specific

symptoms of malignancy and granulomatous inflammation

Techniques for visualizing the mediastinum and its content

Radiographic technique
Chest x-ray: Standard postero antero and lateral views
Most mediastinal tumors are discovered

Fluoroscopy and tomography

Computed tomography
Can identify normal anatomic variations and fluid filled

cyst
Site of the origin of the mass can be better identified

100% specificity for the CT appearance of teratomas,

thymolipoma, omental fat herniation

Overall accuracy for predicting mediastinal mass is only

48%

Computed tomography
Limitation
Horizontal oriented structures and boundaries are difficult to

evaluate Abnormalities in the aortopulmonary window area and the subcarinal area
CT has become the initial imaging procedure of choice for

evaluation of mediastinum in patients with primary mediastinal mass or with lung cancer

Magnetic Resonance Imaging

Assesses tissue by measuring the radiofrequency

induced nuclear resonance instead of measuring the attenuation of transmitted ionizing radiation structures and boundaries are better evaluated medistinum, chest wall and diaphragm

Coronal and sagittal planes are better viewed, vertical Superior sulcus tumors, lesions invading the

And possible invasion of the brachial plexus, and

for evaluating vertebral invasion

Magnetic Resonance Imaging

Limitations
Distinguish poorly between hilar mass and adjacent

collapsed or consolidated lung Cannot distinguish between a benign and a malignant causes for lymph node enlargement

Ultrasonography
For cystic nature of mediatinal mass
Useful in guiding endoscopic biopsy technique

Radionuclide imaging
Rely on the localization of markers based on specific

metabolic or immunologic properties of the target tissue

Potential ability to diagnose and stage a malignancy and

identify distant metastasis

Planar imaging with gallium 67 and thallium-201

POSITRON EMISSION TOMOGRAPHY

The single most notable addition to the staging armamentarium for

the evaluation of lung cancer

Based on the biologic activity of neoplastic cells

rather than its anatomy uptake value of greater than 2.5 or uptake in the lesion that is greater Lung cancer cells demonstrate increased cellular uptake of glucose than the background activity of the mediastinum and a higher rate of glycolysis when compared to normal cells It has proved useful in differentiating neoplastic from normal tissues The radiolabeled glucose analogue [18F] fluoro-2-deoxy-d-glucose undergoes the same cellular uptake as glucose, but after phosphorylation is not further metabolized and becomes trapped in cells
Accumulation of the isotope can then be identified using a PET

Specific criteria for an abnormal PET scan are either a standard PET is a metabolic imaging technique based on the function of a tissue

camera

POSITRON EMISSION TOMOGRAPHY

The technique is not infallible because certain non-

neoplastic processes, including granulomatous and other inflammatory diseases as well as infections, may also demonstrate positive PET imaging
Size limitations are also an issue, with the lower limit

of resolution of the study being approximately 7 to 8 mm depending on the intensity of uptake of the isotope in abnormal cells
One should not rely on a negative PET finding for

lesions less than 1 cm on CT scan

Dealing with mediastinal mass

Conventional radiographic signs

The "silhouette sign

The hilar overlay sign The hilar convergence sign The cervicothoracic sign

Foto thoraks normal

The "silhouette sign

When a mass abuts a normal

mediastinal structure of similar radiodensity, the margins of the 2 structures will be obliterated
This apparent loss of the margin

of the normal structure can be used to localize a mediastinal mass to the same compartment as the normal structure

The hilar overlay sign

especially useful in

distinguishing an anterior mediastinal mass from a prominent cardiac silhouette

If the bifurcation of the main

pulmonary artery is >1 cm medial to the lateral border of the cardiac silhouette, it is strongly suggestive of a mediastinal mass
Imaging of the mediastinum in oncology Michele Lesslie, DO; Marvin H. Chasen, MD, MSEE; Reginald F. Munden, MD, DMD

The hilar convergence sign

is used to distinguish between a prominent hilum and an

enlarged pulmonary artery

If the pulmonary arteries converge into the lateral border

of a hilar mass, the mass represents an enlarged pulmonary artery

A hilar mass may have the appearance of an enlarged

pulmonary artery, but the vessels will not arise from the margin; instead they will seem to pass through the margins as they converge on the true artery

an enlarged pulmonary artery

Hillar mass

The cervicothoracic sign

is used to determine the location of a mediastinal lesion in the

upper chest
The uppermost border of the anterior mediastinum ends at the

level of the clavicles.

the medial and posterior mediastinum extends above the

clavicles. A mediastinal mass that projects superior to the level of the clavicles must therefore be located either within the middle or posterior mediastinum.
the more cephalad the mass extends, the more posterior the

location

 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 mediastinal

masses::

1. Thymus 2. Teratoma (germ cell) 3. Thyroid 4. Terrible Lymphoma

Sanjeev Bhalla, Marieke Hazewinkel and Robin Smithuis Cardiothoracic Imaging Section of the Mallinckrodt Institute of Radiology, St. Louis, USA and the Radiology department the Medical Centre Alkmaar and the Rijnland Hospital, Leiderdorp, the Netherlands

Lesions typically in the Anterior Mediastinum

Thymic neoplasm
Thymoma is the most common neoplasm occuring in the

anterior mediastinum Recognized more often recently because of increase aggresiveness in evaluating patients with myasthenia gravis Composed of lymphocytes and epithelial cells

Thymoma
Peak incidence is 40-60 y/o
Equal gender predilection Rare in children

2/3 assymptomatic at the time of diagnosis

Anterior mediastinal mass may be discovered incidentally Chest pain, cough, dyspnea

40-70% of patients can have systemic syndromes

Thymoma
Myasthenia gravis is the most common syndrome
Occurs in 10-50% of patients How thymoma produced myasthenia is unknown but

autoantibodies to the post synaptic acetylcholine receptor appears to explain the dysfunction of the neuromuscular junction

Thymoma
Found near the junction of the heart and great vessels
Round or oval, smooth or lobulated as compared with

thymic hyperplasia which is symmetrical

Usually distorts the gland normal shaped

Thymoma
Thymomas are neoplastic but most are benign
Invasive tumors have a poorer prognosis 5 year

= 50-77% survival rate

10 year = 30-55% survival rate

Recurrence after resection occurs in 1/3 of patients Presence of thymoma-associated systemic syndrome

is a poor prognostic sign

Thymoma
May respond to hormonal therapy
Manage by resection via median sternotomy approach or

VATS
Adjunctive treatment with post operative radiotherapy
Addition of perioperative radiotherapy is provided

thymoma

Other thymic mass

Thymic hyperplasia, thymic cyst and lipothymoma
Thymic carcinoma is a malignant process that invades

locally and frequently metastasized

Prognosis is poor
Resection followed by adjuvant chemoradiotherapy is

advocated

Germ cell tumors

10-12 % of primary mediastinal tumors are derived from

germinal tissues both in adults and in children

Teratoma and teratocarcinoma Seminoma Embryonal cell carcinoma Choriocarcinoma They are believed to arise from remnant multipotent germ

cells that have migrated abnormally during embryonic development

Teratomas
Most common germ cell tumors
Made up of tissues foreign to the area in which they occur Ectodermal derivatives predominate When only the epidermis and its derivatives are present,

the term dermoid cyst

Teratomas
Young adults

But reported in all age groups

Men and women affected equally 80% are benign

1/3 are asymptomatic

Pain, cough, dyspnea Hemoptysis if tumor erodes into a bronchus

Expectoration of differentiated tissue such as hair (trichoptysis) or sebaceous

materials can occur Can rupture in the pleural space and can cause ARDS or enter the

pericardium causing Pericardial Tamponade

Teratomas
On CXR, Teratomas are smooth, rounded and well

circumscribed if they are cystic and more lobulated and asymmetric if they are solid

Soft tissue, fat and calcification (occasionally fully

formed teeth and bone) can be seen on CT images uncertainty whether it is benign and possibility of further enlargement and impingement on adjacent structures

All teratomas should be resected as to the

Germ cell tumor

Smooth, well-defined anterior mediastinal tumor with heterogeneous attenuation associated with calcific intratumoral nodules suggests a mediastinal teratodermoid

Benign teratoma. A 30-year-old man developed mild chest discomfort. (Atlas of diagnostic oncology, Arthur T. Skarin,2009)

Seminomas
Seminoma (dysgerminoma)
Occurs almost exclusively in men Usually in the 3rd decade of life Chest pain, dyspnea, cough, hoarseness and dysphagia SVC syndrome can occur They are aggressive malignant tumors that extend locally

and metastasized distantly, usually to the skeletal bones

Seminoma
They may secrete HCG, but not AFP
Poor prognosis

Age >35 y/o SVC syndrome Supraclavicular, clavicular or hilar adenopathy Presentation with fever

Extremely radiosensitive and may respond dramatically

with chemotherapy even in cases of dissemination

Cisplatin based regimen is used

Long term survival is 80%

Lymphomas
Common cause in both adults and children
10-20% of cases Hodgkins disease occurs bimodally in adolescents and

young adults and in those over 50

Non-Hodgkins occurs in older adults 50-60% of HD have mediastinal lymph node involvement

at the time of diagnosis

Only 20% of NHL have mediastinal involvement

Lymphoma
Incidental discovery of a mass on CXR is a common

presentation of lymphoma

Systemic and localized symptoms Tracheal compromise and SVC are common Pericardial and pleural involvement Resection is not a necessary part of therapy, but anterior

thoracotomy or mediastinoscopy is required to confirm the diagnosis if adenopathyis not evident outside the mediatinum

 Obliterated retrosternal clear space On the PA film there is a lobulated widening of

the superior mediastinum. On the lateral chest film the retrosternal clear space is obliterated.

This happened to be a patient with lymphoma.

Thyroid lesions
Ectopic thyrod gland accounts for 10% of mediastinal mass
Cervical goiter extends susternally into the anterior

mediastinum
Primary intrathoracic goiter, originating from the

heterotropic thyroid tissue is rare

Most are in the anterior mediastinum but can occur in the

middle and posterior mediastinum

Thyroid lesions
Common in women
Middle or older age Asymptomatic Hoarseness. Cough, swelling of the face Recognized by radioactive iodine screning

Resected by transcervical approach wihout the use of

sternotomy approach

Parathyroid lesions
Mediastinal parathyroid tissue accounts for as many as

10% of cases of hyperparathyroidism

Mediastinum is the most common site for ectopic

parathyroid adenomas in surgically resistant hyperparathyroidism

Technetium scanning are accurate in diagnosing

parathyroid tissue
Cured by complete resection

Mesenchymal tumors
Iipomas, fibroma, mesothelioma, lymphangiomas,
They arise from connective tissue, fat, smooth

muscle, striated muscle, blood vessels or lymphatic channels and can occur in a any region of the mediastinum
Histologically they differ from their counterpart Presence of symptoms means that the lesion is

malignant

Lipoma
Is the most common mesenchymal tumor
Most often anterior Encapsulted or unencapsulated Smooth, rounded with sharply defined margins

Lipomatosis
More common than lipoma
Generalized overabundance of histologically normal

unencapsulated fat
The presence of some fat in the mediastinum is

normal, usually in and around the thymus

Accumulation of excess fat is associated with

generalized obesity or Cushings syndrome or with the use of exogenous steroids or drugs

Middle Mediastinum
The middle mediastinum contains the following structures:

lymph nodes, trachea, esophagus, azygos vein, vena cavae, posterior heart and the aortic arch.
The majority of middle mediastinal masses will consist of

foregut duplication cysts (eg oesophageal duplication or bronchogenic cysts) or lymphadenopathy. Aortic arch anomalies can also present as middle mediastinal masses.

Lesions typically in the Middle Mediastinum

Enlargement of the lymph node
Mediatinal lymph node enlargement is most often due to

three categories of disease process

Lymphomas
Metatastic cancer Granulomatous inflammation

On the left a patient with a small cell lung carcinoma.

On the PA film there is a lobulated paratracheal stripe on the right. On the lateral radiograph there is a density overlying the ascending aorta and filling the retrosternal space. These findings indicate a mass in the anterior aswell as in the middle mediastinum. CT scanning confirm of lymphoma.

Developmental cyst
Comprise 10-20% of all mediatinal mass in both adults and

children
Pericardial, bronchogenic and enteric cyst on the basis of

their lining tissue

Bronchogenic and enteric cyst are referred to as foregut

duplication cyst because of their origin from aberrant portions of the ventral and dorsal foregut

Developmental Cysts
Pericardial cyst Accounts for 1/3 of cystic masses in adults Less common in children They typically lie against the pericardium, diaphragm or anterior chest wall on the right cardiophrenic angle It can enlarge to cause right ventricular outflow tract obstruction, or rupture and hemorrhage to cause pericardial tamponade or sudden cardiac death

Developmental Cysts
Bronchogenic cyst Found near the large airways, often posterior to the carina, may attach to the esophagus or even inside the pericardium Cyst wall often contains cartilages and respiratory epithelum Most are discovered incidentally and asymptomatic They can communicate with the tracheobronchial tree and can become infected and cause airway obstruction, pulmonary artery compression and hemodynamic collapse or rupture with disastrous consequences

Developmental Cysts
Enteric or entergenous cyst
Similar in location and appearance with bronchogenic cyst,

but have digestive tract epithelum Uncommon in adults Commonly seen in infants and children Associated with spinal extension and malformation of the vertebral column called neurenteric cyst

Diaphragmatic hernia
The protrusion of omental fat or other abdominal contents

through the diaphragm may occur via several potential routes and medatinal mass lesion in any compartment may occur
A hernia thorough the foramen of Morgagni produces a

cardiphrenic angle mass, usually on the right side

 Bochdaleks hernia, in the posterior mediastinum,

generally appears on the left side, presumably because the liver prevents formation on the right
They are usually incidental finding but can cause

complication in some cases

Posterior 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.
Most 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).

Cervicothoracic sign

On the left the MR of the same patient. It turned out to be a schwannoma.

Ganglioneuroma. During evaluation for unrelated problem, chest radiography in a 24-yearold woman revealed an asymptomatic posterior mediastinal mass. Histologic showed ganglioneuroma (Atlas of diagnostic oncology, Arthur T. Skarin,2009)

Atlas of diagnostic oncology, Arthur T. Skarin, 2009