RADIO-IMAGING DIAGNOSIS OF

MEDIASTINUM

Prof.dr.Mircea Buruian
 LEARNING OBJECTIVES
1. Anatomy and imaging
2. Methods of examination
3. Tipical pattern & topography of mediastinal
diseases
4. Main mediastinal diseases
5. Clinical cases
6. Conclusions
1.Anatomy and imaging
MEDIASTINAL
LINES
2. METHODS OF EXAMINATION

 Conventional methods

 Imaging methods
 Conventional methods

 Plain chest radiography

 Angio-pneumo-cardiography

 Barium study

 Bronhoscopy
 Imaging methods
 SCINTIGRAPHY

 ULTRASOUND

 MRI

 CT

 FNPB UNDER CT GUIDANCE

 PET/CT

 PET/MRI
3.TYPICAL PATTERN OF MEDIASTINAL
LESIONS
 Typical pattern of mediastinal lesions

1) hemispheric opacity ; 2) ovoidal opacity (dermoid cyst ) ; 3)

marginal calcification (cyst, aneurism)
 Typical pattern of mediastinal lesions

4) policiclic opacity (malignant lymphogranulomatosis) ; 5) bosel

opacity (teratoma) 6) round opacity with diffuse margins
 Typical pattern of mediastinal lesions

7)fusiform opacity (mediastinal effusion) ; 8) trapezoidal opacity

(lymphosarcoma) ; 9) paramedian opacity without precise contour
(mediastinitis)
Typical pattern of mediastinal lesions

10) Mixed opacity ( after Bariety-

Coury)
Topography of main mediastinal
lesions
ANTERIOR MEDIASTINUM (III)
1-thyroid retrosternal goiter
2- timoma, hemangioma ;
3-teratoma ;

MIDDLE MEDIASTINUM (II)

4-primary lymphoma
5-bronchogenic cyst, carcinoma

POSTERIOR MEDIASTINUM (I)

6-neurogenic tumor
7-esophageal tumor
Topography of main mediastinal
lesions
8 – goiter cyst ;
9 - timic cyst ;
10 –cystic teratoma;
11- mezotelioma ;
12 –bronchogenic cyst ;
13 – meningocel ;
14 –neuroenteric cyst;
15 – lymphangioma
Topography of main mediastinal
lesions
16 –timic lipoma
17 – dermoid cyst ;
18 – lipoma ;
19 – liposarcoma.
(after Fraser-Pare :
modificated by
Twinning-Zuppinger)
 4.MEDIASTINAL MASS

 anterior mediastinal mass - superior level

- middle level
- inferior level

 middle mediastinal mass

 posterior mediastinal mass - superior level

- middle level
- inferior level
Anterior Mediastinal Mass (Superior)
• Presenting Signs and Symptoms

 Asymptomatic and incidental finding on plain chest

radiograph

 Displacement, deviation, or compression of the

trachea (upper thoracic portion)

 Myasthenia gravis (in up to 30–50% of patients with

thymoma)
Anterior Mediastinal Mass (Superior)

• Common Causes
– Substernal thyroid
– Lymph node enlargement
– Parathyroid mass
– Other causes of anterior, middle or posterior
mediastinal masses
Anterior Mediastinal Mass (Superior)

• Common Causes
– Thymoma
– Teratoma
– Lymphoma
– Parathyroid tumor (ectopic)
– Aortic aneurysm (ascending portion)
– Morgagni hernia
Anterior Mediastinal Mass (Superior)
• Approach to Diagnostic Imaging

– Plain chest radiograph

• Detects a mass displacing, deviating, or compressing the
trachea but
otherwise does little to characterize the mass
• Detects and determines precise compartment of a
mediastinal mass but otherwise does little to characterize
the mass (can demonstrate erosion ofthe sternum in
Hodgkin's disease and gas within a Morgagni hernia)

– Radionuclide thyroid scan

• Most accurate method for diagnosing the presence of
abnormal thyroid tissue in the neck or superior
mediastinum
Anterior Mediastinal Mass (Superior)
• Approach to Diagnostic Imaging

– Computed tomography
• Definitive imaging study for defining the origin and extent of
the mass andfor determining its underlying characteristics
• With contrast enhancement, highly accurate in differentiating
among fatty,cystic, and soft-tissue masses and aneurysms

– Magnetic resonance imaging

• Equivalent to CT in confirming the presence and location of a
mediastinal mass
• Less effective than CT for assessing tracheal involvement and
for demonstrating calcification
• Superior to CT for distinguishing tumor from fibrosis and in
patients in whom the use of iodinated contrast material is
contraindicated
 Thyroid
pathology
Thymoma
Cystic dermoid
tumour
Lymphoma
Mediastinal teratoma
Retrosternal
goiter
Retrosternal
goiter
Cervico-thoracic goiter
Thymus hypertrophy
Thymoma
 Thymoma : MRI

Thymoma : CT
Pathological processes of the upper floor of the
anterior mediastinum

Thyroid
Adenoma
Pathological processes of the upper floor of the
anterior mediastinum

Intrathoracic goiter
Pathological processes of the upper floor of the
anterior mediastinum
Gyant bronhial cyst
Bronchial cyst
Pericardial cyst
 Pleuro – pericardial
cyst
MORGAGNI HERNIA
HODGKIN disease
HODGKIN disease-
terapeuthic test
Mediastinal
lymphosarcoma
Gangliobronchial tuberculosis
Pulmonary sarcoidosis/
Besnier-Boeck-
Schaumann disease
Giant right Neurofibroma
Dorsal Schwanoma
Dorsal
schwanoma
Schwanoma
Apical left ganglioneuroma
Dorsal Ganglioneurinoma
POTT
disease
Esophageal cancer
CLINICAL CASES
Aneurism of aortic cross+ calcifications
Pericardial Cyst
Morgagni Hernia
Mediastinal Lipomatosis
Mediastinal
Liposarcoma
Anterior mediastinal mass
Pneumomediastinum
Tymoma
Aortic dissection
67 year old woman with chest pain. Rule out aortic
dissection
What is your diagnosis: 1. Infected cyst ?
2. Esophageal perforation ?
3. Aortic aneurysm ?
4. Other?
Final Diagnosis: esophageal diverticulum
Achalasia
65 y.o. male with pain in left hemithorax

Diagnosis:
1. Lung cyst
2. Mediastinal cyst
3. Hiatus hernia
4. Congenital malformation
Diagnosis: hiatus hernia with stomach volvulus
27-7-02

29-7-02
KEY POINTS :

Always rule out a digestive origin in middle

mediastinal masses.
 24 y.o. male, asymptomatic

Diagnosis: 1. Thymic tumor

2. Intrathoracic goiter
3. Teratoma
4. Other
Diagnosis:
Aneurysm of ascending aorta
( Marfan’s syndrome)
63 y.o. male with fever and malaise
What is your diagnosis:
1. Hiatus hernia ?
2. Esophageal tumor ?
3. Neurogenic tumor ?
4. Other ?
 Final diagnosis:
mycotic aneurism
 KEY POINTS :

1. Ninety percent of the mediastinum are vessels.

2. Always think of a vascular abnormality as a

. cause of a mediastinal mass
Diagnosis: idiopathic dilatation of pulmonary artery
Diagnosis: idiopathic dilatation of pulmonary artery
64 y.o. Male with ascitis
What is your diagnosis:
1. Enlarged lymph nodes
2. Esophageal
leiomiomatosis
3. Liposarcoma
4. Other
Diagnosis: para esophageal varices in cirrhosis
 Para esophageal varices in hepatic
cirrhosis

 Present as masses of the lower

middle mediastinum, usually right-
sided or bilateral

 When present, seen in about 10%

chest radiographs

Diagnosis: enhanced CT
 KEY POINTS:

1. Aside from arteries, considere as well

venous structures as a cause of mediastinal
masses.
Azygos continuation of inferior vena cava
54 y.o. male, asymptomatic

What is your diagnosis:

1. Thymoma ?
2. Mediastinal fat ?
3. Aneurism of ascending aorta ?
4. Endothoracic goiter
Post-op Pre-op
Diagnosis: displaced
mediastinal fat after internal
mammary artery by-pass
 Post-op

Pre-op
 15-9-03 31-10-03

52 y.o. lady with two episodes of acute

chest pain
What is your diagnosis:
1. Lingular pneumonia ?
2. Pulmonary infarction ?
3. Epicardial fat ?
4. Pericardial cyst ?
Diagnosis:
1. Lingular
pneumonia
2. Pulmonary
infarction
3. Epicardial fat
4. Pericardial cyst
 Epipericardial fat necrosis

 Nineteen published cases ( 3 with CT )

 Acute chest pain
 Paracardiac opacity in chest radiograph
 CT: encapsulated epipericardial fat
 Diagnosis: follow-up

Pineda, Cáceres , Vilar. Epipericardial fat necrosis..AJR Nov ‘05

31-10-03 16-12-03
Acute left chest pain Three days later
Final diagnosis : post-operative diagnosis: epipericardial fat necrosis.
Mejores fotos
Mujer de 41 años, asintomática
 KEY POINTS:

 Mediastinal fat is ubiquitary.

 May simulate mediastinal masses

because its density its similar to that of
soft tissues in conventional radiography.
THANK YOU FOR YOUR
ATTENTION !