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Mediastinal Masses

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What Radiology Residents Need to Know: Chest Radiology

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Abstract

Mediastinal masses are conveniently divided into those that occur in the anterior compartment (thymic lesion, teratoma, thyroid mass, lymphoma), medial compartment (lymphadenopathy, enlarged pulmonary artery, bronchogenic cyst), and posterior compartment (arising in relation to the esophagus or neural tissue or extramedullary hematopoiesis). This chapter describes their imaging findings as well as other masses arising in the mediastinum.

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References

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Authors and Affiliations

  1. Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Ronald L. Eisenberg MD, JD

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  1. Ronald L. Eisenberg MD, JD
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Electronic Supplementary Material

Fig. e16.1

Thymoma. (a) Large lobulated mass (arrows) extending to both sides of the mediastinum (arrows) (TIF 726 kb)

Fig. e16.1

Thymoma. (b) The mass fills the anterior precardiac space and causes posterior displacement of the left side of the heart. [3] (TIF 728 kb)

Fig. e16.2

Thymoma. Enormous soft-tissue mass in the anterior mediastinum with posterior displacement of other mediastinal structures. No difference in attenuation can be seen between the mass and the heart behind it [3] (TIF 677 kb)

Fig. e16.3

Thymomas of varying composition. (a) Soft-tissue attenuation (arrow). [1] (TIF 1812 kb)

Fig. e16.3

Thymomas of varying composition. (b) Large fatty mass (thymolipoma) that wraps around the heart [3] (TIF 1570 kb)

Fig. e16.4

Thymic carcinoma. The anterior mediastinal mass is closely attached to the pericardium. Loss of the fat plane (arrows) between the two entities suggests pericardial involvement. There also is a pericardial effusion [3] (TIF 822 kb)

Fig. e16.5

Thymic malignancy. (a) Low-grade soft-tissue mass in the anterior mediastinum that is partly calcified (closed arrow). The mass has irregular margins (open arrows) and insinuates into the mediastinal fat, but without pleural involvement. (b) Advanced-stage malignancy has heterogeneous attenuation that reflects the presence of coarse calcifications and necrosis (arrowhead). Mediastinal deviation with unilateral pleural thickening (open arrows) and atelectasis (closed arrow) suggests left pleural and parenchymal involvement. Note the centrally necrotic subcarinal lymphadenopathy (asterisk) [4] (TIF 1412 kb)

Fig. e16.6

Thymic hyperplasia. (a) Axial, (b) coronal, and (c) sagittal CT images demonstrate the homogeneous appearance of the hyperplasic thymus in this young patient who had been treated for lymphoma [5] (TIF 1252 kb)

Fig. e16.7

Thymic cyst. (a) Axial CT (TIF 692 kb)

Fig. e16.7

Thymic cyst. (b) T1-weighted (TIF 691 kb)

Fig. e16.7

Thymic cyst. (c) T2-weighted MR images demonstrate the fluid-filled structure (arrow) [4] (TIF 691 kb)

Fig. e16.8

Calcified thymic cyst. (a) Large, calcified anterior mediastinal mass (arrow) (TIF 1344 kb)

Fig. e16.8

Calcified thymic cyst. (b) Large, calcified anterior mediastinal mass (arrow) (TIF 1663 kb)

Fig. e16.8

Calcified thymic cyst. (c) Large, calcified anterior mediastinal mass (arrow) (TIF 650 kb)

Fig. e16.9

Teratoma. Anterior mediastinal mass with heterogeneous attenuation that indicates the presence of an encapsulated fatty component (solid arrows) associated with focal toothlike calcification (open arrow) [4] (TIF 1353 kb)

Fig. e16.10

Teratoma. Anterior mediastinal mass of primarily soft-tissue attenuation with areas of reduced attenuation consistent with fat (arrows). The mass compresses and displaces mediastinal veins [4] (TIF 2223 kb)

Fig. e16.11

Teratoma. (A, B) Round lesion of the anterior mediastinum with extensive hypoattenuating central area (consistent with fat), surrounded by thick soft-tissue attenuation and small foci of calcification (arrow). Note the small amount of collapsed lung parenchyma adjacent to the mediastinal mass (arrow, B) [5] (TIF 946 kb)

Fig. e16.12

Teratoma. (a) Scout view from a CT examination demonstrates a large mass (arrow) involving the lower half of the right lung (TIF 682 kb)

Fig. e16.12

Teratoma. (b) The large anterior mediastinal mass (arrow) is composed of multiple tissue elements, including fluid, fat, and calcification. At pathology, the mass contained teeth and hair (TIF 699 kb)

Fig. e16.12

Teratoma. (c) The large anterior mediastinal mass (arrow) is composed of multiple tissue elements, including fluid, fat, and calcification. At pathology, the mass contained teeth and hair (TIF 2342 kb)

Fig. e16.13

Thyroid goiter. (a) In a woman who presented with dysphagia, there is enlargement of the left and right thyroid lobes (thick arrow), with small calcification on the left (thin arrow) (TIF 1240 kb)

Fig. e16.13

Thyroid goiter(b) At a lower level, the goiter is in a left paratracheal location (thick arrow), displacing supra-aortic branches to the left (thin arrows) (TIF 1527 kb)

Fig. e16.13

Thyroid goiter. (c) Coronal reconstruction shows the complete apical-basilar extension of the goiter (thick arrow) and areas of calcification (thin arrow) [4] (TIF 1460 kb)

Fig. e16.14

Thyroid goiter. (a) Huge anterior mediastinal mass that extends downward well below the level of the carina (arrows). Note that the mass projects over the right hilum (hilum overlay sign), indicating that it is not in the middle mediastinum (TIF 3349 kb)

Fig. e16.14

Thyroid goiter. (b) Huge anterior mediastinal mass that extends downward well below the level of the carina (arrows). Note that the mass projects over the right hilum (hilum overlay sign), indicating that it is not in the middle mediastinum (TIF 2167 kb)

Fig. e16.14

Thyroid goiter. (c) Sagittal CT image clearly demonstrates the connection of this anterior mediastinal mass to the thyroid gland in the neck (arrows) (TIF 1123 kb)

Fig. e16.15

Thyroid goiter. Rounded mass (asterisk) in the anterior mediastinum that has typical high attenuation [4] (TIF 584 kb)

Fig. e16.16

Posterior intrathoracic goiter. The well-defined, homogeneous soft-tissue mass fills the retrotracheal space and displaces the trachea, esophagus, and supra-aortic vessels anteriorly [3] (TIF 560 kb)

Fig. e16.17

Lymphoma. Large mass fills the anterior mediastinum. Note that the lung interfaces with the hilar vessels (arrow) and aorta (arrowhead), which are well preserved. This explains why, on plain radiographs (not available), these middle mediastinal structures were clearly seen through the mass (hilum overlay sign; see Fig. 2.6A), indicating that the lesion was either in the anterior or posterior portion of the mediastinum [1] (TIF 703 kb)

Fig. e16.18

Lymphoma. Lymph nodes with coarse calcification (arrow) that developed after chemotherapy [4] (TIF 1349 kb)

Fig. e16.19

Lymphoma. (A, B) In two different patients, lymph nodes in the anterior mediastinum are enlarged, coalescent, and of heterogeneous attenuation (closed arrows). Note the esophageal stent (open arrow, B) (TIF 1279 kb)

Fig. e16.20

Lymphoma. (a) Bulky mass of heterogeneous attenuation (arrow) in the anterior mediastinum. The growing mass encases and compresses mediastinal veins (TIF 508 kb)

Fig. e16.20

Lymphoma. (b) PET/CT image shows an FDG-avid structure (closed arrow) corresponding to the lymphomatous mass. Signal heterogeneity reflecting necrosis of the lesion is clearly detectable (open arrow) [4] (TIF 1474 kb)

Fig. e16.21

Lipoma. (a) Scout view of a CT examination shows focal bulging of the right paratracheal stripe (arrow). (b) Axial, (c) coronal, and (d) sagittal scans demonstrate that the right paratracheal mass has homogeneous fat attenuation (arrows) [5] (TIF 820 kb)

Fig. e16.22

Mediastinal hemorrhage. (a) Following right lobectomy, there is a large soft-tissue mass (arrow) representing postoperative hemorrhage (TIF 2645 kb)

Fig. e16.22

Mediastinal hemorrhage. (b) CT image demonstrates amorphous areas of contrast in the right middle lobe (arrow), highly suspicious for the site of active bleeding (TIF 610 kb)

Fig. e16.23

Ascending thoracic aortic aneurysm. (a) Right mediastinal enlargement (arrows) and obliteration of the retrosternal space (TIF 791 kb)

Fig. e16.23

Ascending thoracic aortic aneurysm. (b) Right mediastinal enlargement (arrows) and obliteration of the retrosternal space (TIF 773 kb)

Fig. e16.23

Ascending thoracic aortic aneurysm. (c) Enhanced CT images show severe dilatation of the ascending aorta (asterisk). Note the compression and displacement of the superior vena cava (arrow, c) [4] (TIF 744 kb)

Fig. e16.23

Ascending thoracic aortic aneurysm. (d) Enhanced CT images show severe dilatation of the ascending aorta (asterisk). Note the compression and displacement of the superior vena cava (arrow, c) [4] (TIF 1461 kb)

Fig. e16.24

Pericardial cyst. Non-enhancing homogeneous mass (arrow) of water attenuation located adjacent to the pulmonary artery [6] (TIF 587 kb)

Fig. e16.25

Pericardial cyst. (a) T1-weighted contrast MR image shows a non-enhancing mass (∗) of intermediate signal intensity adjacent to the main pulmonary artery (PA) (TIF 1049 kb)

Fig. e16.25

Pericardial cyst. (b) On a T2-weighted image, the mass (∗) has homogeneous high-signal intensity indicating fluid [6] (TIF 1059 kb)

Fig. e16.26

Morgagni hernia. (a) Barium-filled bowel in a hernia sac that lies anteriorly and to the right [3] (TIF 927 kb)

Fig. e16.26

Morgagni hernia. (b) Barium-filled bowel in a hernia sac that lies anteriorly and to the right [3] (TIF 946 kb)

Fig. e16.27

Morgagni hernia. Retrosternal hernia that contains omentum and colon [3] (TIF 724 kb)

Fig. e16.28

Morgagni hernia. (a) Huge hernia containing omentum and small bowel (TIF 1689 kb)

Fig. e16.28

Morgagni hernia. (b) On this view, the large diaphragmatic hernia contains omentum, mesenteric vessels (arrowheads), and small (closed arrow) and large (open arrow) bowel. The diaphragmatic profile cannot be appreciated in the lower portion of the image. [4] (TIF 1684 kb)

Fig. e16.29

Lymphadenopathy. Enlarged nodes (arrow) obliterate the air-soft-tissue interface between the right lung and the tracheal wall (right paratracheal stripe) [3] (TIF 2195 kb)

Fig. e16.30

Lymphadenopathy. In this patient with lymphoma, enlarged nodes (arrow) obliterate the normal concave border of the interface between the left lung and the mediastinum, which constitutes the aorticopulmonary window [3] (TIF 1502 kb)

Fig. e16.31

Bronchogenic cyst. (a) Smooth-walled, spherical mediastinal mass (arrows) projecting into the left lung and hilum [3] (TIF 833 kb)

Fig. e16.32

Bronchogenic cyst. Subcarinal mass (arrow) produces an abnormal convexity of the azygoesophageal recess [3] (TIF 1415 kb)

Fig. e16.33

Hiatal hernia. Herniation of the stomach and bowel posterior to the heart [3] (TIF 720 kb)

Fig. e16.34

Hiatal hernia. (a) Soft-tissue mass with air-fluid level in the lower mediastinum (arrow) (TIF 2005 kb)

Fig. e16.34

Hiatal hernia. (b) CT images confirm the posterior mediastinal mass, which contains stomach and fat (arrows) (TIF 740 kb)

Fig. e16.34

Hiatal hernia. (c) CT images confirm the posterior mediastinal mass, which contains stomach and fat (arrows) (TIF 798 kb)

Fig. e16.35

Bochdalek hernia. (a) Classic appearance of a fat-containing mass in the posterior portion of the left hemidiaphragm (arrows) (TIF 641 kb)

Fig. e16.35

Bochdalek hernia. (b) Classic appearance of a fat-containing mass in the posterior portion of the left hemidiaphragm (arrows) (TIF 596 kb)

Fig. e16.35

Bochdalek hernia. (c) Classic appearance of a fat-containing mass in the posterior portion of the left hemidiaphragm (arrows) (TIF 817 kb)

Fig. e16.36

Esophageal duplication cyst. Well-circumscribed mass of water attenuation adjacent to the esophagus (arrow). The appearance and location of the mass are typical for an esophageal duplication cyst in this asymptomatic young woman, in whom the lesion was an incidental finding on chest radiography [3] (TIF 584 kb)

Fig. e16.37

Esophageal duplication cyst. Thin-walled, non-enhancing cyst of water attenuation adjacent to the esophagus (arrow) [3] (TIF 1745 kb)

Fig. e16.38

Neurogenic cyst. (a) Large, oval, homogeneous mass in the posterior mediastinum. Note the right hydropneumothorax (arrows) with a long air-fluid level that developed as a complication of diagnostic needle biopsy [3] (TIF 715 kb)

Fig. e16.38

Neurogenic cyst. (b) Large, oval, homogeneous mass in the posterior mediastinum. Note the right hydropneumothorax (arrows) with a long air-fluid level that developed as a complication of diagnostic needle biopsy [3] (TIF 786 kb)

Fig. e16.39

Bronchogenic cyst. (a) Fluid-filled mass (arrow) in the posterior mediastinum (TIF 1639 kb)

Fig. e16.39

Bronchogenic cyst. (b) Non-enhanced scan of the upper abdomen in an asymptomatic patient shows a high-attenuation (55 HU) periesophageal mass (arrow) [3] (TIF 691 kb)

Fig. e16.40

Adenocarcinoma of the esophagus. (a) Upper mediastinal CT scan shows a markedly dilated, air-filled esophagus (arrow) (TIF 1401 kb)

Fig. e16.40

Adenocarcinoma of the esophagus. (b) Scan more caudally shows a soft-tissue malignant mass (arrow) that obstructs the lower esophagus and causes proximal dilatation. (Courtesy of Gillian Lieberman, MD, Boston) (TIF 1147 kb)

Fig. e16.41

Esophageal varices. (a) Widening of the inferior third of the azygoesophageal recess (arrows). (b) Enhanced CT scan (venous phase) shows multiple enlarged venous vessels (white arrows) closely juxtaposed to the outer wall of the esophagus (black arrow), consistent with paraesophageal varices (TIF 828 kb)

Fig. e16.42

Schwannoma. (a) Radiograph shows a large, smooth mass (arrow) in the lower paraspinal region (arrows). (Courtesy of Ritu Gill, MD, Boston) (TIF 1451 kb)

Fig. e16.42

Schwannoma. (b) Radiograph shows a large, smooth mass (arrow) in the lower paraspinal region (arrows). (Courtesy of Ritu Gill, MD, Boston) (TIF 1977 kb)

Fig. e16.42

Schwannoma. (c) On CT, the lesion has a cystic quality (arrow). (Courtesy of Ritu Gill, MD, Boston) (TIF 572 kb)

Fig. e16.42

Schwannoma. However, MRI images show a solid mass (arrow) containing cystic degeneration, which appears dark on the T1-weighted contrast image (d). (Courtesy of Ritu Gill, MD, Boston) (TIF 483 kb)

Fig. e16.42

Schwannoma. White on the T2-weighted image (e). (Courtesy of Ritu Gill, MD, Boston) (TIF 582 kb)

Fig. e16.43

Multiple myeloma. Posterior soft-tissue mass (white arrow) that is destroying the vertebral body and compromising the spinal canal. There also are associated osteolytic lesions of the posterior elements and adjacent ribs (black arrow) (TIF 670 kb)

Fig. e16.44

Paraspinal abscess. Soft-tissue mass (arrow) extends bilaterally and has effaced the paraspinal lines (arrows). Arrowhead indicates the descending aorta [3] (TIF 1571 kb)

Fig. e16.45

Tuberculous spondylitis and paraspinal cold abscess. Non-contrast scan shows a paravertebral mass that destroys the vertebral body (arrow) and displaces the trachea anteriorly [3] (TIF 685 kb)

Fig. e16.46

Extramedullary hematopoiesis. (a) Large masses in the paravertebral regions that have fat attenuation (arrows) (TIF 768 kb)

Fig. e16.46

Extramedullary hematopoiesis. (b) Large masses in the paravertebral regions that have fat attenuation (arrows) (TIF 658 kb)

Fig. e16.47

Extramedullary hematopoiesis. (a, b) Extensive bilateral masses in the paraspinal regions of the posterior mediastinum (arrows) in a patient with severe chronic anemia. (c) Coronal CT image demonstrates the two large encapsulated masses above the diaphragm. The lesion on the left contains low-attenuation areas in its upper aspect, consistent with fat (arrow). (d) On a T1-weighted MR image, these areas appear hyperintense (arrow) when compared to the hypointense signal of the hematopoietic tissue [5] (TIF 819 kb)

Fig. e16.48

Dissecting aneurysm. (a, b) An intimal flap (black arrow) in the descending aorta divides the true (t) and false (f ) lumens, with partial thrombosis of the false lumen (white arrow) [6] (TIF 389 kb)

Fig. e16.49

Mediastinal lipomatosis. (a) Image of the upper mediastinum demonstrates unconfined tissue of homogeneous fat attenuation that encases anatomic structures (arrows). (b) At a lower level, there is diffuse mediastinal lipomatosis surrounding the heart (arrows) [5] (TIF 415 kb)

Fig. e16.50

Acute mediastinitis. (a, b) Images at two different levels in a patient with fever and chest pain after sternotomy demonstrate a retrosternal mass with ill-defined borders (arrows) that is consistent with mediastinal inflammatory fat stranding [4] (TIF 723 kb)

Fig. e16.51

Fibrosing mediastinitis. Soft-tissue attenuation mass in the anterior mediastinum. (A, aorta; S, superior vena cava) [3] (TIF 664 kb)

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Eisenberg, R.L. (2020). Mediastinal Masses. In: What Radiology Residents Need to Know: Chest Radiology . Springer, Cham. https://doi.org/10.1007/978-3-030-16826-1_16

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