OSCE Chest

THEN, Look at the key!

A well-defined, metallic density, sharp edge,
triangular shaped, 0.5 x 0.3 cm in size at right
main bronchus
Decreased right lung volume compared with
the left

Diagnosis : a tooth in right main bronchus

causing partial right lung collapse

Cervicothoracic sign

Which compartment do you think this mass is

in?

See sharp
margin
above clavicle

Click for lateral view

This
should
help!

Click for answer

Cervicothoracic sign
Answer: mass is in posterior mediastinum.
We know because it remains sharply outlined
in apex of thorax, indicating that it is
surrounded by lung.
This particular example is a ganglioneuroma

Cervicothoracic sign

Which compartment do you think this mass is

in?

Mass
disappears
at clavicle

Click for answer

Cervicothoracic sign
Answer: mass lies in anterior mediastinum.
We know this because it disappears at the
level of the clavicle where it extends into the
neck.
This particular example is Non-Hodgkins
lymphoma

Thoracoabdominal sign
A sharply marginated mediastinal mass seen through
the diaphragm must lie entirely within the chest.
The posterior costophrenic sulcus extends far more
caudally than the anterior aspect of the lung
Therefore
Any mass that extends below the dome of the diaphragm
and remains sharply outlined must be in the posterior
compartments and surrounded by lung, and Any mass
that terminates at dome of diaphragm must be anterior

Can you
see the
outline of the
mass below
the diaphragm?

Click for answer

Thoracoabdominal sign
Answer: margin of mass is apparent and
below diaphragm, therefore this must be in
the middle or posterior compartments where
it is surrounded by lung
This example is a lipoma

Hilum overlay and convergence signs

Principle of hilum overlay
the proximal segments of the
R and L main pulmonary
arteries lie lateral to the
cardiac silhouette on PA film

With pericardial effusion or

cardiac enlargement, this
relationship is unchanged
Conversely, an anterior
mediastinal mass will
overlap the main
pulmonary arteries,
therefore they will be seen
within the margins of the
mass

Hilum convergence
To distinguish between
enlarged pulmonary artery
and mediastinal mass

If branches of the
pulmonary artery converge
toward a central mass
enlarged PA
If branches of PA converge
toward the heart rather
than the central mass
mediastinal tumor

Hilum can
be seen
through
mass

Click for answer

Hilum overlay sign

Answer: this must be an anterior mediastinal
mass because it overlaps rather than pushes
out the main pulmonary arteries
This particular example is a thymoma

Yes!!

Click for more info

Hilum overlay sign

Heart is enlarged, but hilar vessels still visible
lateral to the cardiac silhouette
This case is pericardial effusion

Effect on adjacent structures

Trachea
May see deviation or narrowing of trachea with
anterior compartment masses (see next slide for example)

Ribs/ vertebrae
May see bony destruction with posterior
compartment masses

Lesions

Fluid

Fat

Vascular

Anterior

Thymic
Lymphoma
Germ cell
Goiter

Thymic C
Thymoma
Pericardial C
Germ cell
Lymphoma

Germ cell b
Thymolipoma
Fat pad

Thyroid
Cardiac
Coronary

Middle

Lymph nodes
Duplication C
Arch anomaly

Duplication C

Lipoma
Esophageal FV
polyp

Arch anomaly
Azygous vein
Vascular nodes

Posterior

Neurogenic
Bone and
marrow

Neuroenteric C
Schwannoma
Meningocele

Extramedullary
hematopoiesis

Desc aorta

> 1 comp

Infection
Hemorrhage
Lung cancer

Lymphangioma
Mediastinitis

Liposarcoma

Hemangioma

Necrotic nodes
Pericard recess

Imaging Findings

Bilateral paraspinal masses with round, lobulated margins

Medullary expansion of the bony structures with widening of the ribs
being the most pronounced bony finding
Resorption of trabeculae produces coarsened appearance to bones
Splenomegaly (or absent spleen)
Masses do not calcify and do not usually cause bone erosion
The lesions are usually of low-attenuation on non-contrast CT and
may mildly enhance after contrast