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
FelsonRadiologists
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
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
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,
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
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
Computed tomography
Can identify normal anatomic variations and fluid filled
cyst
Site of the origin of the mass can be better identified
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
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
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
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
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
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
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
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
Hillar mass
upper chest
The uppermost border of the anterior mediastinum ends at 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
thymus, lymph nodes, ascending aorta, pulmonary artery, phrenic nerves and thyroid.
masses::
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
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
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
Thymoma
Thymomas are neoplastic but most are benign
Invasive tumors have a poorer prognosis 5 year
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
advocated
Teratoma and teratocarcinoma Seminoma Embryonal cell carcinoma Choriocarcinoma They are believed to arise from remnant multipotent germ
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,
Teratomas
Young adults
materials can occur Can rupture in the pleural space and can cause ARDS or enter the
Teratomas
On CXR, Teratomas are smooth, rounded and well
circumscribed if they are cystic and more lobulated and asymmetric if they are solid
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
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
Seminoma
They may secrete HCG, but not AFP
Poor prognosis
Age >35 y/o SVC syndrome Supraclavicular, clavicular or hilar adenopathy Presentation with fever
Lymphomas
Common cause in both adults and children
10-20% of cases Hodgkins disease occurs bimodally in adolescents and
Non-Hodgkins occurs in older adults 50-60% of HD have mediastinal lymph node 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
the superior mediastinum. On the lateral chest film the retrosternal clear space is obliterated.
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
Thyroid lesions
Common in women
Middle or older age Asymptomatic Hoarseness. Cough, swelling of the face Recognized by radioactive iodine screning
sternotomy approach
Parathyroid lesions
Mediastinal parathyroid tissue accounts for as many as
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
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.
Developmental cyst
Comprise 10-20% of all mediatinal mass in both adults and
children
Pericardial, bronchogenic and enteric cyst on the basis of
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
generally appears on the left side, presumably because the liver prevents formation on the right
They are usually incidental finding but can cause
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
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)