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Chest
Mediastinal Masses
Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management
Mediastinum
1-Anterior Mediastinal Masses
2-Middle Mediastinal Masses
3-Posterior Mediastinal Masses
Mediastinal lines or stripes are interfaces between the soft tissue of
mediastinal structures and the lung, the aortopulmonary window is
the interface below the aorta and above the pulmonary trunk and is
concave or straight laterally
Anterior junction line results from the anterior apposition of the lungs, which lies behind the upper two-
thirds of the sternum, the line consists of four layers of pleura and a variable amount of
intervening fat, it appears as a thin oblique line projecting over the superior two-thirds of the
sternum and runs from the upper right to the lower left, it does not extend above the level of
clavicles, posterior junction line results from the apposition of the lungs posterior to the
esophagus and anterior to the 3rd to 5th thoracic vertebrae, similarly to anterior junction line, it is
formed by four layers of pleura, it appears as a thin straight line projecting through the trachea,
unlike anterior junction line, it can be seen above the clavicles
Mediastinal signs, frontal chest film (a) shows the hilum (arrow), which indicates
that the mass is either anterior or posterior to the hilum, this is the hilum
overlay sign in patient with lymphoma, frontal chest film (b) shows
enlargement of the right superior mediastinum, above the level of the
clavicles, the margins of the mass are sharp (arrow) due to the interface
with adjacent lung, indicating that the mass is located in the posterior
mediastinum
1-Anterior Mediastinal Masses (5Ts)
a) Thymus Abnormalities
b) Thyroid Masses
c) Terrible Mediastinal Lymphoma
d) Germ Cell Tumors
e) Thoracic Aortic Aneurysm
f) Pericardial Cyst
g) Morgagni Hernia
h) Sternal Tumors
i) Pericardial Fat Pad
-The anterior mediastinum is that portion
of the mediastinum anterior to the
pericardium and below the level of
the clavicles
-It includes the thymus , lymph nodes and
may contain the portions of a retrosternal
thyroid
Diagnostic Imaging of Mediastinal Masses
a) Thymus Abnormalities :
1-Thymoma
2-Thymolipoma
3-Benign Thymic Hyperplasia
4-Thymic Cyst
-On frontal chest radiographs in
infants and young children , the
thymus is strikingly large but
difficult to discriminate from the
cardiac silhouette
-The thymus usually has smooth
borders and remains visible on
radiographs through the age of 3
years
-The thymic wave sign , a scalloped
or wavy contour of the organ is
created by the impression of the
anterior reflection of the ribs
-The thymic sail sign , a triangular
slightly convex right lobe of the
thymus with a sharply demarcated
base caused by the minor fissure
-Typically , the thymus is
visible at CT and fills the
perivascular space
throughout the first 2
decades of life
-In children younger than 5
years , it typically appears
quadrilateral with convex
borders
-As children grow , the
thymus gradually
becomes triangular with
straight or concave
border
1-Thymoma :
a) Incidence
b) Associations
c) Pathology
d) Radiographic Features
a) Incidence :
-Thymoma is the most common anterior
mediastinal tumor in the adult (very rare in
children)
b) Associations :
1-Myasthenia Gravis (35% of thymoma
patients have myasthenia gravis)
2-Aplastic Anemia (50% have thymoma)
3-Hypogammaglobulinemia
4-Red cell Aplasia
c) Pathology :
1-Benign Thymoma, 75% :
-Common in patients with myasthenia
2-Malignant Thymoma , 25% :
-Local spread into pleura but no
hematogenous metastases
-More common in patients without
myasthenia
d) Radiographic Features :
1-Plain Radiography
2-CT
1-Plain Radiography :
-Presents as an anterior mediastinal mass
-Seen as a well defined lobulated soft tissue
density slightly towards one side of the
mediastinum
-Can demonstrate associated calcification
(commonly amorphous / flocculent)
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
2-CT :
-Anterior mediastinal soft tissue mass :
1-Asymmetrical location on one side
2-Homogeneous density and signal intensity
3-Some have cystic components (40% of the cases and
are mostly focal)
4-Contrast medium enhancement
5-Invasive thymomas show growth through capsule into
adjacent tissue , drop metastases into pleural space are
common
6-Calcification , 20 %
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
CT shows anterior mediastinal masses with coarse calcifications (A) and a
circular peripheral calcification (B)
Cystic thymoma , CT+C shows a low attenuation lesion (arrow) in the anterior
mediastinum
Invasive thymoma with pleural metastases
Axial contrast-enhanced CT images showing a left anterior mediastinal
mass (arrows in a) associated with a left parietal pleural nodule
(arrow in b) and left diaphragmatic pleural nodules (arrows in c),
apperances are those of invasive thymoma with pleural «drop
metastases»
Thymoma with no signs of mediastinal fat invasion (A, arrows) , one year after
surgery , pleural metastasis was found (B, arrow)
2-Thymolipoma :
a) Incidence
b) Associations
c) Pathology
d) Radiographic Features
a) Incidence :
-Is a rare benign anterior mediastinal
mass of thymic origin
-Comprises 2-9% of all thymic neoplasms
-Mean age of 22 years
-Tumors usually grow to large sizes (75%
are >500 g) with few or no symptoms
b) Associations :
1-Myasthenia Gravis (in 3 % of thymolipoma)
2-Aplastic Anemia
3-Hypogammaglobulinemia
4-Grave’s Disease
c) Pathology :
-Thymolipomas are composed of a mixture mature
adipose tissue with islands of thiymic tissue
d) Radiographic Features :
1-Plain Radiography
2-CT
1-Plain Radiography :
-Typically these tumors appear as
large anterior mediastinal masses
-The larger tumors tend to hang down one
or either side of the pericardium and being
soft , they mold themselves to the
adjacent mediastinum and diaphragm and
often mimic cardiomegaly
Diagnostic Imaging of Mediastinal Masses
Thymolipoma : a) Chest radiograph showing a widening of the cardiac
silhouette , b) CT confirms the presence of a heterogeneous mass
with fatty components growing in caudal direction
Diagnostic Imaging of Mediastinal Masses
2-CT :
-On CT thymolipomas typically appears
almost entirely fatty with some areas of
inhomogeneous soft tissue density that
represent thymic tissue
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
CT show a large and well defined mass (arrows) that has extensive fat content
and contains small amounts of thin fibrous septa
Diagnostic Imaging of Mediastinal Masses
3-Benign Thymic Hyperplasia :
a) Pathology
b) Causes
c) Radiographic Features
a) Pathology :
-It can be subdivided into two forms :
1-True Thymic Hyperplasia
2-Lymphoid Hyperplasia
b) Causes :
1-True Thymic Hyperplasia :
a) Rebound hyperplasia to chemotherapy ,
thymic rebound hyperplasia (3 to 10
months after the start of chemotherapy)
b) Radiation Therapy
c) Burns
d) Other Severe Systemic Stresses (e.g.
pneumonia)
2-Lymphoid Hyperplasia :
a) Myaesthenia Gravis
b) SLE
c) Rheumatoid Arthritis
d) Scleroderma
e) Graves Disease
c) Radiographic Features :
-Diffuse symmetric enlargement of the gland is
the key morphologic feature of hyperplasia
(neoplasm tends to manifest as a focal mass)
-Size and morphology of normal thymus :
>20 years of age : <13 mm
>30 years of age : Convex margins are abnormal
-No increase in size over time
Thymic rebound hyperplasia in an 18 month old girl recovering from pneumonia
(a) Frontal chest radiograph shows air trapping and bilateral perihilar peribronchial infiltrates (arrows) ,
findings consistent with viral pneumonia
(b) Follow-up radiograph shows thymic rebound hyperplasia (arrowheads) and resolution of the
pneumonic infiltrates (arrows)
Thymic rebound hyperplasia in an 11 year old girl with Hodgkin lymphoma
(a) CTC shows right sided mediastinal adenopathy (arrow) , Arrowhead = thymus
(b) CT scan obtained after completion of chemotherapy shows regression of the
adenopathy (arrow) , there is early thymic rebound hyperplasia (arrowhead)
(c) CT scan obtained 1 month after chemotherapy shows that the nodal mass has almost
resolved (arrow) and the thymic rebound hyperplasia is nearly complete (arrowhead)
Dramatic thymic rebound hyperplasia in a 14 year old boy who
completed chemotherapy for primary mediastinal T-cell lymphoma 6
months earlier
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
4-Thymic Cyst :
a) Causes
b) Radiographic Features
a) Causes :
1-Congenital :
-Contains thymic tissue in wall : often unilocular
2-Acquired : often multilocular
a) Secondary to thoracotomy
b) Following chemotherapy or radiotherapy for
mediastinal malignancy
c) Inflammatory
b) Radiographic Features :
1-Plain Radiography
2-CT
1-Plain Radiography :
-Thymic cysts usually appear as
homogeneous circumscribed masses that
may have calcified rims
Diagnostic Imaging of Mediastinal Masses
2-CT :
-Thin walls and no solid component and
show no contrast enhancement
CT+C shows inhomogenous unilocular low attenuation mass (arrows)
in the anterior mediastinum
A well marginated mass with a homogeneous attenuation usually in the
range of water attenuation (0–20 HU) and without an enhancement
of the wall or infiltrative appearance
Cystic changes of the thymus and lymph nodes at diagnosis in a 19
year old man with Hodgkin lymphoma , CT+C shows a solid (arrow
in a) and cystic (arrows in b) thymic mass , by the time the patient
completed chemotherapy , the cystic nodes had resolved but the
cystic areas in the thymus remained unchanged
Cystic change of the thymus in a 28 year old man with Hodgkin
lymphoma treated 3 years earlier , CT+C shows a thymic cyst
(arrow) and thymic rebound hyperplasia (arrowhead)
b) Thyroid Masses :
1-Incidence
2-Radiographic Features
1-Incidence :
-Thyroid masses that extend into the
mediastinum : goiter > adenoma ,
carcinoma , lymphoma
2-Radiographic Features :
a) Plain Radiography
b) CT
a) Plain Radiography :
-Tracheal displacement is the most common
finding by CXR
Diagnostic Imaging of Mediastinal Masses
CXR of a partial substernal goiter compressing the trachea from the right side
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
b) CT :
-Mass is contiguous with cervical thyroid and is
well defined
-Heterogeneous density by CT : calcium , iodine
(70 to 120 HU) , colloid cysts
-Marked and prolonged contrast enhancement
-They don’t usually project below the arch of the
aorta (differentiating them from thymomas and
teratoma)
-Nuclear scan with either 99mTc or 123I confirms
the diagnosis
Frontal (a) view of the chest radiograph shows an opacity on the right side of
the trachea (arrow), which appears shifted contralaterally and reduced in
caliber, unenhanced CT scans (b-d) demostrate a heterogenous mass
which goes down into the anterior mediastinum referred to a goiter
Substernal Thyroid Goiter , CT+C of the chest shows a large contrast
enhancing mass in the anterior mediastinal containing calcifications
and areas of necrosis
CT of a partial substernal goiter compressing the trachea from the left side
c) Mediastinal Lymphoma :
1-Incidence
2-Pathology
3-Radiographic Features
1-Incidence :
-Lymphomas are responsible for 45%
of anterior mediastinal masses in children
-Only 10% of lymphomas which involve the
mediastinum are primary (i.e.
mediastinum involvement not part of
systemic disease) and the majority are
Hodgkin lymphomas (50-70%)
2-Pathology :
a) Hodgkin Lymphoma :
1-Lymphocyte Predominant (LP) , <5 %
2-Nodular Sclerosing (NS) , 70%
3-Mixed Cellularity (MC) , 25%
4-Lymphocyte Depleted (LD) , <5%
b) B-Cell Neoplasms
c) T-Cell Neoplasms
-Primary mediastinal lymphomas are most
frequently of 3 histologic varieties :
1-Nodular Sclerosing Hodgkin lymphoma
2-Primary mediastinal large B-cell
lymphoma
3-Lymphoblastic Lymphoma (T-cell)
3-Radiographic Features :
a) Plain Radiography
b) CT
a) Plain Radiography :
-A soft tissue mass may be clearly visible or more
frequently the mediastinum is widened and
the retrosternal airspace is obscured
-The hilum overlay sign refers to an appearance on
frontal chest radiographs of patients with a mass
projected at the level of the hilum which is in fact either
anterior or posterior to the hilum , when a mass arises
from the hilum, the pulmonary vessels are in contact with
the mass and as such their silhouette is obliterated , the
ability to see the edges of the vessels through the mass
implies that the mass is not contacting the hilum and is
therefore either anterior or posterior to it , most of these
masses are found to be in the anterior mediastinum
Normal Obliteration of the retrosternal space in mediastinal lymphoma
Hilum Overlay Sign
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
b) CT :
-Soft tissue attenuating mass with smooth or
lobulated margins which conforms to
surrounding structures (prevascular ,
paratracheal) involvement
-Other features include :
1-Parenchymal invasion , uncommon
2-Pleural effusion
3-Pericardial effusion
4-Chest wall invasion
-Calcification is usually seen following
therapy and can have varying morphology
including irregular , diffuse or even egg
shell
-Lymphomas have areas of necrosis but
they usually do not have cystic areas ,
thymic cysts can occur after irradiation of
mediastinal lymphomas or chemotherapy
Large soft tissue mass in the anterior mediastinum which
arises in the thymus , there is associated paratracheal
adenopathy (arrow)
Diagnostic Imaging of Mediastinal Masses
Anterior mediastinal mass with bilateral pleural effusion
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
28 year old woman with Hodgkin disease , chest radiograph shows an
anterior mediastinal mass (A, arrow) which on axial CT is irregular
and shows areas of necrosis (B, arrows)
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
d) Germ Cell Tumors :
1-Incidence
2-Pathology
3-Radiographic Features
4-Differential Diagnosis
1-Incidence :
-Germ cell tumors are the most common
cause of a fat containing lesions in the
anterior mediastinum and the second
most common cause of an anterior
mediastinal mass in children
2-Pathology :
-Tumors arise from rests of primitive cells and are
of variable malignant potential (SECTE)
a) Seminoma
b) Embryonal cell carcinoma
c) Choriocarcinoma
d) Teratoma (70% of germ cell tumors) ,
teratocarcinoma
e) Endodermal sinus tumors (yolk sac tumors)
3-Radiographic Features :
a) Plain Radiography
b) CT
a) Plain Radiography :
-Anterior mediastinal mass +/- areas of
calcifications
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Teratoma in a 39 year old man , PA chest film shows an anterior
mediastinal mass (A, arrows) , CT shows a large area of fat within
the mass (B, arrow)
Diagnostic Imaging of Mediastinal Masses
b) CT :
-Benign teratoma (90%) is a well defined thick wall
cystic mass containing a variable mixture of :
Calcification , 30%
Fat , fat-fluid levels
Cystic areas
Soft tissue
-Mature teratoma can be very large and still be
benign
-Malignant teratoma (10%) tends to have irregular
or nodular walls and a predominance of soft
tissue components , may show pulmonary or
liver metastases and chest wall invasion
Extensive mediastinal involvement (A,B, white arrows) , cystic upper
mediastinal mass (A,B red arrows) , immature tooth (B, yellow arrow)
42 year old man with a teratoma , note the coarse calcifications (A,B,
white arrows) and areas of fat attenuation measuring -103 HU (A,B,
red arrows)
CT+C shows large septated anterior mediastinal mass
containing fat and bony elements
CT+C shows an anterior mediastinal mass containing calcification (black arrow)
, fat (white arrow) and soft tissue components (dotted white arrow)
Benign Teratoma
Benign Teratoma
Malignant Teratoma
Diagnostic Imaging of Mediastinal Masses
4-Differential Diagnosis :
-From Mediastinal Masses Containing Fat
a) Teratodermoid
b) Diaphragmatic Hernia
c) Lipoma
d) Liposarcoma
e) Thymolipoma
f) Mediastinal Lipomatosis
g) Hamartoma
h) Chylolymphatic Cyst
e) Thoracic Aortic Aneurysm :
1-Incidence
2-Pathology
3-Radiographic Features
1-Incidence :
-Are relatively uncommon compared to
abdominal aortic aneurysm
2-Pathology :
-Thoracic aortic aneurysms can be divided
pathologically according to their relationship to
the aortic wall :
a) True Aneurysm :
1-Atherosclerotic aneurysms (most common)
2-Inflammatory / Aortitis :
-R.A. , Ankylosing Spondylitis , Giant cell Arteritis
& Syphilis
3-Structural : Cystic media necrosis
-Marfan disease
-Ehlers-Danlos syndrome
b) False Aneurysm :
-Trauma
-Mycotic aneurysm
3-Radiographic Features :
a) Plain Radiography
b) CT
a) Plain Radiography :
-The thoracic aorta can usually be seen on
both frontal and lateral chest radiographs
and aneurysms are often obvious
-Mural calcification is seen both in
atherosclerotic disease as well as various
causes of aortitis
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
b) CT :
-CTA is the work horse of aneurysm assessment
-Typically aneurysms appear as dilatations of the
lumen , the walls may be thin or thickened by
presence of mural thrombus (circumferential or
more frequently eccentric)
-Calcified atherosclerotic disease is often identified
not only in the wall of the aneurysm but in
adjacent arteries
-If rupture or leak has occurred hematoma / fluid
may be seen adjacent to the aorta , in the left
pleural cavity or in the pericardium
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Dissecting Aoritc Aneurysm
f) Pericardial Cyst :
1-Incidence
2-Location
3-Radiographic Features
4-Differential Diagnosis
1-Incidence :
-Uncommon benign congenital anomaly of
the anterior mediastinum
-Incidental findings in asymptomatic patients
, usually after age 30
2-Location :
-Found in the right anterior cardiophrenic
angle but can be found almost anywhere
adjacent to the heart
3-Radiographic Features :
a) Plain Radiography
b) CT
a) Plain Radiography :
-Well defined round or oval masses located
in the normally clear cardiophrenic angle
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
b) CT :
-Usually appears as a well defined non-
enhancing low (water) attenuating
rounded mass next to the pericardium
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Typical benign pericardial cyst with serous content in a 46-year-old
woman, (a) Coronal T1 shows a round low-signal-intensity cyst with
a regular thin wall, (b) T2 shows a homogeneous high-signal-
intensity cyst without septation or a mural nodule
4-Differential Diagnosis : From cystic mediastinal mass :
1-Congenital :
a) Bronchogenic cyst , usually subcarinal or right
paratracheal site
b) Enteric cyst , paraoesophageal site
c) Neuroenteric cyst , associated anomaly of spine
2-Pericardial cyst , usually cardiophrenic angle
3-Thymic cyst , can develop following radiotherapy for
Hodgkin’s disease
4-Cystic tumors :
a) Lymphangioma
b) Teratoma
c) Teratodermoid
5-Pancreatic pseudocyst , can track up into mediastinum
6-Meningocele , 75% association with NF
7-Chronic abscess
8-Old hematoma
g) Morgagni Hernia :
-See Congenital Pulmonary Lesions
Morgagni hernia in a 2 year old child , lateral chest radiograph shows
herniation of a bowel loop (arrows) in a classic location through an
anteromedial defect
Diagnostic Imaging of Mediastinal Masses
h) Sternal Tumors :
-Metastases are the most common (breast ,
bronchus , kidney & thyroid)
-Malignant primary tumors (chondrosarcoma
, myeloma , reticulum cell sarcoma and
lymphoma) are more common than benign
(chondroma , Aneurysmal bone cyst and
Giant cell tumor)
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
i) Pericardial Fat Pad :
-Especially in obese people
-A triangular opacity in the cardiophrenic
angle on the PA view
-It appears less dense than expected
because of the fat content
Epicardial fat pad , (a) PA chest radiograph shows loss of the cardiac
silhouette at the border of the right side of the heart and an
epicardial fat pad with relatively low density (arrow) , (b) CT scan
shows the fat pad (arrow) as an area of homogeneous fat
attenuation adjacent to the right border of the heart
-Differential Diagnosis : Cardiophrenic angle
lesions
1-Pericardial fat pad
2-Pericardial cyst
3-Pericardial fat necrosis
4-Morgagni’s hernia
5-Lymphadenopathy : metastases , lymphoma
6-Pericardial lipomatosis
2-Middle Mediastinal Masses : (A+B)
1-Adenopathy
2-Aortic Aneurysm
3-Bronchogenic Cyst
4-Carcinoma of the Bronchus
1-Adenopathy :
-The paratracheal , bronchopulmonary and / or
subcarinal nodes may be enlarged
-This may be due to :
a) Neoplasm (Lymphoma , Leukemia & Mets)
b) Infection (most commonly T.B. , Histoplasmosis
or coccidiodomycosis)
c) Sarcoidosis
d) Hyperplasia (Castleman’s disease)
a) Neoplasm (Lymphoma , Leukemia & Mets) :
-See Lung neoplasms
b) Infection (most commonly T.B. ,
Histoplasmosis or coccidiodomycosis) :
-See Pulmonary Infections
c) Sarcoidosis :
-See Diffuse Lung Lesions
Diagnostic Imaging of Mediastinal Masses
PA chest radiograph shows the right paratracheal stripe (arrow) , the azygos vein is seen at the
inferior margin of the stripe at the tracheobronchial angle (arrowhead) , (b) CT shows the right
wall of the trachea with medial and lateral air soft tissue interfaces caused by air within the
tracheal lumen and right lung (arrow) , these interfaces create the right paratracheal stripe , note
the position of the SVC (arrowhead) which explains why the paratracheal stripe is seen projecting
through the SVC at radiography , (c) CT obtained at the level of the azygos arch shows that the
azygos vein (arrow) disrupts the lung tracheal wall interface at the tracheobronchial angle
Lymphadenopathy , (a) PA chest radiograph , the right paratracheal stripe is not
seen having been obliterated by a right paratracheal mass (arrowheads) ,
(b) CT shows right paratracheal lymphadenopathy (arrow) which obliterates
the air soft tissue interface between the right lung and the tracheal wall , this
finding explains the obliteration of the right paratracheal stripe in a
PA chest radiograph , the AP window reflection (arrowhead) extends from the aortic knob
to the left pulmonary artery and has a normal concave appearance , the aortic
pulmonary reflection (arrow) is a more anterior line and extends from the aortic arch
to the level of the left main bronchus
AP window lymphadenopathy , (a) Chest radiograph shows the AP
window with an abnormal convex border (arrow) , (b) CT shows
lymphadenopathy (arrow) which accounts for the distortion of the AP
window in a
Paratracheal lymph node enlargement in metastatic carcinoma
Frontal Chest X-ray (a,b) shows a slightly convex border of the aortopulmonary
window (arrow) suspicious for the presence of a mass in the middle
mediastinum, CT scan shows enlarged lymphnodes in the aortopulmonary
window (arrow), causing the abnormality seen on chest radiography, it was
a lymphoma in a 11-year-old-girl
Paratracheal and aortopulmonary window lymph node
enlargement
Subcarinal lymph node enlargement in CLL
Frontal (a) and lateral (b) chest X-ray show a bilateral hilar enlargement, more
evident on the right, CT+C (c,d) showing bilateral hilar lymph nodes in
patient with sarcoidosis
d) Giant Benign Lymph Node Hyperplasia
(Castleman’s disease) :
1-Incidence
2-Pathology
3-Radiographic Features
1-Incidence :
-Rare
-Age < 30 years
-Large benign mediastinal lymph node
masses
-Etiology is unknown (nodal hyperplasia vs
benign tumor)
2-Pathology :
-Two histologic types :
a) Hyaline vascular , 90%
b) Plasma cell , 10%
3-Radiographic Features :
-Bulky mediastinal mass lesion (3 to 12 cm) :
anterior > middle > posterior mediastinum
-Dense homogeneous contrast enhancement is
the key feature (vascular lesions)
-On CT, 5% to 10% of Castleman disease showed
intralesional calcifications, typically being
discrete in morphology
-Dynamic CT demonstrates early rapid
enhancement with washout in the delayed phase
PA chest Radiograph shows
widening of upper
mediastinum ,
aortopulmonary and
azygos adenopathy and
enlargement of hila
(arrows) with extension of
lesion below right hilum
Diagnostic Imaging of Mediastinal Masses
Unenhanced CT using bone window setting reveals posterior
mediastinal mass (arrow) with typical arborizing pattern of
intralesional calcifications
CT+C shows matted lymphadenopathy (arrows) formed by confluence
of inhomogeneously enhancing enlarged lymph nodes confined to
anterior mediastinum
Diagnostic Imaging of Mediastinal Masses
2-Aortic Aneurysm :
-See before
Aneurysm of the aortic arch. (a) PA chest radiograph shows the AP window with a convex
border (arrow) , (b) CT reveals an aneurysm (arrow) arising laterally from the aortic
arch , a finding that accounts for the abnormality seen in a
Diagnostic Imaging of Mediastinal Masses
3-Bronchogenic Cyst :
-See Congenital Pulmonary lesions
(a) PA chest radiograph demonstrates a subcarinal abnormality with increased
opacity (*) , splaying of the carina and abnormal convexity of the upper and
middle thirds of the azygoesophageal line (arrowheads) , (b) Corresponding
CT scan helps confirm a subcarinal mass (arrow) which proved to be a
bronchogenic cyst
Diagnostic Imaging of Mediastinal Masses
CT+C : well circumscribed unilocular water attenuation cyst in the
middle mediastinum , the cyst has smooth imperceptible walls with
no enhancement
Bronchogenic cyst , CT shows a subcarinal mass with fluid density
CT Scanogram (a) shows an oval, huge, mass (arrows) that cause a widening
and distortion of azygoesophageal recess, coronal (b) and sagittal (c) MPR
reconstruction demonstrate a cyst with uniform water attenuation and with
an imperceptible wall, this was a bronchogenic cyst
Bronchogenic cyst in a 49-year-old man with a 2-week history of fever and
cough, (a) Chest radiograph shows a round mass (arrow) that displaces the
right primary bronchus superiorly, as well as pneumonia of the middle lobe
and pleural effusion, (b) Contrast material-enhanced CT scan shows a cyst
with uniform water attenuation and with an imperceptible wall.
Bronchogenic cyst in a 44-year-old woman with a 3-year history of
chest pain, CT scan shows a thin-walled water-attenuation cyst in
the posterior mediastinum (arrow)
4-Carcinoma of the Bronchus :
-See Pulmonary Tumors
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
a) A 55 yr old dyspnoeic
female , chest radiograph
shows widened
mediastinum particularly
on the right with reduced
vascularity of the right
lung
b) CT+C shows central
mediastinal mass
invading the right
pulmonary artery , small
cell carcinoma was
confirmed on
percutaneous biopsy
3-Posterior Mediastinal Masses (ACTH)
1-Posterior Mediastinal Neural Tumors
2-Extrameduallary Hematopoiesis
3-Paraspinal Abscess
4-Descending Aortic Aneurysm
5-Oesophageal Duplication Cyst
6-Neuroenteric Cyst
7-Pancreatic Pseudocyst
8-Bochdalek Hernia
9-Hiatus Hernia
10-Lateral Meningocele
1-Posterior Mediastinal Neural Tumors :
a) Incidence
b) Peripheral Nerve Sheath Tumor
c) Sympathetic Ganglia Tumors
d) Paraganglioma
a) Incidence :
-Neurogenic tumors are the cause of
approximately 90% of posterior mediastinal
masses
-They can be subdivided into three groups by their
location and involvement of peripheral nerves or
sympathetic chain :
1-Peripheral Nerve Sheath Tumors
2-Sympathetic Ganglia Tumors
3-Paraganglioma
-Peripheral nerve sheath tumors and
paragangliomas are far more common in
adults while the sympathetic ganglia tumors
are commoner in children
b) Peripheral Nerve Sheath Tumor :
1-Incidence
2-Schwannoma
3-Neurofibroma
4-Malignant Peripheral Nerve Sheath
Tumors
1-Incidence :
-These tumors manifest as round paravertebral
masses that span one or two vertebral bodies
-They are homogenous soft tissue attenuation
masses at CT and the commonest cause of
posterior mediastinal and paravertebral masses
-They may cause widening of the neural foramen
and thickening of the adjacent posterior rib
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
2-Schwannoma :
a) Incidence
b) Location
c) Radiographic Features
a) Incidence :
-Are benign tumors of schwann cell origin
and are the most common tumor of
peripheral nerves
-Peak presentation is in the 5th-6th decades
-When they occur in patients with
neurofibromatosis type 2 (NF2)
schwannomas usually present by the 3rd
decade
b) Location :
-Arise posteriorly , frequently in neural
foramina
1-Vertebral Body
2-Neural Foramen
3-Articular Pillar
4-Lamina
5-Spinous Process
Diagnostic Imaging of Mediastinal Masses
c) Radiographic Features :
1-Plain Radiography
2-CT
3-MRI
1-Plain Radiography :
-Both benign and malignant tumors may erode ribs
-They may enlarge the neural foramina (dumbbell
shaped lesion)
-Scalloping of posterior vertebral bodies may occur
-They may produce a scoliosis
-Pleural effusion may occur with benign as well
as malignant neural tumor
There is an opacity in the left posterior mediastinum , there is associated
widening of the 4th intercostal space posteriorly with scalloping of the
inferior margin of the 4th rib , there is also some coarse calcification within
the lesion
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Cervical X-Ray (a-b) demonstrate a marginated and round opacity
(white arrows), with disrupting of left paravertebral stripe, CT scan
(c) confirms a left hypodense and homogeneous paravertebral
mass, this mass revealed features consistent with schwannoma
2-CT :
-Isodense round or oval mass , <2 vertebral
bodies long
-Dense contrast enhancement :
Small tumors show homogeneous
enhancement
Larger tumors may show heterogeneous
enhancement
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
CT+C
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
3-MRI :
*T1 : 70% hypointense , 30% isointense
*T2 : Very hyperintense , may show small
internal low signal foci (calcification) and
areas of necrosis
*T1+C : Dense enhancement :
-Homogeneous if small
-Heterogeneous if large
Diagnostic Imaging of Mediastinal Masses
T1
T2
Coronal T2 shows well defined paravertebral mass with peripheral high signal
intensity and relatively low signal intensity centrally , mass has peripheral
low signal intensity rim (arrows) that reflects tumor capsule
Axial T2 shows well defined mass with heterogeneous high signal intensity in
right paravertebral region , mass protrudes toward adjacent right neural
foramen (arrow) and shows “dumbbell” configuration , mass has low signal
intensity rim (arrowhead) in periphery
Axial T1+C shows heterogeneous enhancement that is relatively strong
in center of mass
T1+C
T1
T2
T1+C
A, Coronal T2 shows well-
defined mass in right
paravertebral region ,
mass has very high signal
intensity area (arrow) in
center and low signal
intensity rim (arrowhead)
in periphery
B, Coronal T1+C fat-
suppressed shows no
enhancement of central
area (arrow) which
reflects cystic change in
mass
3-Neurofibroma :
a) Incidence
b) Location
c) Radiographic Features
a) Incidence :
-Are benign peripheral nerve sheath tumors
-Peak presentation is between 20 and 30
years of age
-The majority of neurofibromas are solitary
and sporadic , however there is an
association with NF1
b) Location :
-Arise posteriorly , frequently in neural
foramina
c) Radiographic Features :
1-Plain Radiography
2-CT
3-MRI
1-Plain Radiography :
-Both benign and malignant tumors may erode ribs
-They may enlarge the neural foramina (dumbbell
shaped lesion)
-Scalloping of posterior vertebral bodies may occur
-They may produce a scoliosis
-Pleural effusion may occur with benign as well
as malignant neural tumor
Neurofibroma (red arrow) , multiple subcutaneous neurofibromas (yellow
arrows)
Posterior scalloping of lumbar vertebral bodies in NF
Diagnostic Imaging of Mediastinal Masses
2-CT :
-Well defined hypodense mass
-Minimal or no contrast enhancement
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Rib notching with Dumbbell-shaped Neurofibroma
3-MRI :
*T1 :
-Hypointense
*T2 :
-Hyperintense
-A hyperintense rim and central area of low signal
resulting in a target sign may be seen due to a
dense central area of collagenous stroma
*T1+C :
-Heterogenous enhancement
T1+C , dumbbell shaped neurofibroma with intra and
extraspinal extension , note the displacement of the
adjacent thoracic cord (arrow)
Axial T2 shows well defined mass with homogeneous high signal intensity in left
paravertebral region , mass has thin low signal intensity rim (arrows) in
periphery
Target sign in Neurofibroma
4-Malignant Peripheral Nerve Sheath
Tumors (MPNST) :
-Are malignant forms of neurofibromas and
schwannomas
-Associated with NF1
-Imaging criteria are generally considered
unreliable in differentiating from a more
benign neurofibroma or schwannoma
c) Sympathetic Ganglia Tumors :
1-Incidence
2-Neuroblastoma
3-Ganglioneuroma
4-Ganglioneuroblastoma
1-Incidence :
-These tumors tend to present as elongated
paraspinal masses that span multiple vertebral
levels
-Intratumoural calcification is common
-They are :
a) Neuroblastoma : young children
b) Ganglioneuroma : children and adults
c) Ganglioneuroblastoma : older children
-Neuroblastoma and ganglioneuroblastoma are
most commonly seen in children and in a child
they comprise the commonest neurogenic tumor
2-Neuroblastoma :
a) Incidence
b) Location
c) Radiographic Features
a) Incidence :
-Is a tumor of neuroblastic origin and the most
common extracranial solid childhood
malignancies and the third commonest
childhood tumor after leukemia and brain
malignancies
-The tumors typically occur in infants and very
young children (mean age of presentation being
22 months) with 95% of cases diagnosed before
the age of 10 years
b) Location :
-Neuroblastomas arise from the sympathetic
nervous system
-Posterior mediastinum : 20%
c) Radiographic Features :
1-Plain Radiography
2-CT
3-MRI
1-Plain Radiography :
-Appearances are non-specific , typically
shows an intrathoracic soft tissue mass
-Pressure on adjacent bones may cause
remodeling of ribs , vertebral bodies or
pedicle thinning
-Up to 30% may have evidence of
calcification on the plain film
Homogenous opacity lesion in the right upper and mid zone with broad base towards
mediastinum , the lesion is causing shift of mediastinum and trachea to the
contralateral side and compressing the trachea just above the carina (arrow head) ,
the lesion is extending above the clavicle (cervico-thoracic sign) and erosion of
posterior end of third and fourth ribs (Long arrow)
*N.B. : Cervico-thoracic sign
-A variant of the silhouette sign
-It helps to discern the anterior or posterior location of mass
in the superior mediastinum on frontal chest radiographs
-As the anterior mediastinum ends at the level of
the clavicles and as such the upper border an anterior
mediastinal lesions cannot be visualized extending
above the clavicles
-Any lesions with a discernible upper border above that
level must be located posteriorly in the chest ; i.e. apical
segments of upper lobes , pleura or posterior
mediastinum
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
2-CT :
-The tumor typically is heterogeneous with calcifications
seen in 80 - 90% of cases
-Areas of necrosis are of low attenuation
-The morphology of is often most helpful with the mass
seen insinuating itself beneath the aorta and lifting it off
the vertebral column , it tends to encase vessels and
may lead to compression , adjacent organs are usually
displaced
-Lymph node enlargement is often present
-Calcification in a posterior mediastinal mass points to a
neural tumor in a kid rather than a met from somewhere
else
Heterogeneously enhancing mass lesion in the right posterior
mediastinum extending to middle mediastinum causing compression
of the trachea , the lesion is showing multiple small foci of
calcification (black arrows)
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
3-MRI :
*T1 :
- Heterogeneous and iso to hypointense
*T2 :
-Heterogeneous and hyperintense
-cystic / necrotic areas very high intensity
*T1+C :
-Variable and heterogeneous enhancement
1 month old boy with mediastinal neuroblastoma , coronal T2 shows long
vertically oriented mass with homogeneous high signal intensity and
tapering appearance in left paravertebral region , invasion of vertebrae is
not seen
Axial T2 in a patient with a thoracic neuroblastoma shows a large right posterior
mediastinal mass extending into the spinal canal and displacing the cord laterally to
the left , the mass is hyperintense on T2
T1+C shows inhomogeneous enhancement of the mass which appears
to have a component arising from the neural foramen (white arrow)
3-Ganglioneuroma :
a) Incidence
b) Location
c) Radiographic Features
a) Incidence :
-They tend to occur in the pediatric
population and are often asymptomatic
-Usually , patients are older than 10 years
old , compared to neuroblastoma which
occurs in patient younger than 3 years old
b) Location :
-Can potentially occur anywhere along the
peripheral autonomic ganglion sites , the
posterior mediastinum one of the
commonest locations (40%)
c) Radiographic Features :
1-Plain Radiography
2-CT
3-MRI
1-Plain Radiography :
-All neuroblastic tumors (i.e.
ganglioneuroblastomas , ganglioneuromas
and neuroblastomas) look similar
-See Neuroblastoma
Chest radiograph shows a right paraspinal well-defined density in the
retrocardiac region , the right cardiophrenic angle appears normal
2-CT :
-Typically seen as well circumscribed solid
encapsulated masses
-Tend to be iso to hypoattenuating to muscle
-May demonstrate calcifications (40%)
-Delayed heterogeneous uptake of contrast
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Paraspinal Ganglioneuroma, non-enhanced Axial CT scan reveals a
paraspinal homogeneous low attenuation fusiform mass which after
resection proved to be a ganglioneuroma
3-MRI :
*T1 :
-Homogeneously low or intermediate signal
*T2 :
-Heterogenously intermediate or high signal
*T1+C :
-Ranging from none to heterogenous
enhancement
(a) Chest radiography shows an oblong mass in the right paraspinal region , the lateral
margins of the mass are indistinct & there is RT lower lobe pneumonia , (b) CT+C
shows that the mass is heterogenous and contains calcifications (c) T2 shows that
the mass is of high signal intensity
Coronal T2 shows long vertically oriented mass with heterogeneous
high signal intensity and tapering appearance in left paravertebral
region
, Coronal T1+C shows heterogeneous enhancement in
mass.
T1+C of a ganglioneuroma shows homogeneous enhancement of the
lesion , the lesion is extending from the right paraspinal region into
the epidural space through the neural foramina causing cord
compression
T1 of a ganglioneuroma , the sagittal views shows a well-defined solid
mass located slightly anterior to the midthoracic vertebral bodies ,
the mass extends into and widening multiple neural foramina , flow
voids within the lesion represents vascularity
4-Ganglioneuroblastoma :
a) Incidence
b) Location
c) Radiographic Features
a) Incidence :
-Uncommon peripheral neuroblastic tumor
- Most commonly in babies and in young
children
-Ganglioneuroblastoma have intermediate
malignant potential between that of
neuroblastomas and ganglioneuromas
b) Location :
-Can potentially occur anywhere along the
peripheral autonomic ganglion sites , the
posterior mediastinum one of the
commonest locations
c) Radiographic Features :
1-Plain Radiography
2-CT
3-MRI
1-Plain Radiography :
-See Neuroblastoma
Diagnostic Imaging of Mediastinal Masses
2-CT :
-See Ganglioneuroma + areas of bleeding
and necrosis may be as large as 4 cm and
appear to be of lower attenuation
CT without contrast of a ganglioneuroblastoma demonstrates a large
left heterogeneous paraspinal lesion with speckled calcifications that
are predominantly peripheral , the mass is displacing the
mediastinum to the right
Diagnostic Imaging of Mediastinal Masses
3-MRI :
-See Ganglioneuroma + areas of hemorrhage
have a high T1 signal intensity and cystic areas
have a high T2 signal intensity
-Ganglioneuroblastomas , like neuroblastomas and
other malignant tumors have an enhancing
pattern of early enhancement followed by a
partial washout , early enhancement is indicative
of high vascularity
Axial T1 shows high signal intensity areas (arrowheads) that suggest
hemorrhage in center of mass
Axial T1+C shows heterogeneous enhancement in mass ,
enhancement is not seen in center of mass (arrowheads) and tumor
necrosis is suspected
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
MRI scan showing homogenous soft tissue density mass in the posterior
mediastinum
d) Paraganglioma :
1-Incidence
2-Location
3-Radiographic Features
1-Incidence :
-Rare tumors derived from chromaffin cells
(neuroectodermal cells) associated with
sympathetic ganglion of the autonomic
nervous system
-Paraganglioma (= chemodectoma ,
histologically similar to
pheochromocytoma) : functional tumors ,
may secrete catecholamines
2-Location :
-They can arise from two major cluster of
sympathetic ganglion cells :
a) Paraaortic (aorticopulmonary)
b) Paravetebral(aorticosympathetic) location
-Normal anatomy of mediastinal
nervous tissues
-Most peripheral nerve tumors
originate from spinal or
proximal intercostal nerve in
posterior mediastinum
-Thoracic sympathetic trunks and
their associated ganglia are
located on side of vertebral
bodies
-Aortosympathetic paraganglia
are adjacent to sympathetic
chain in posterior mediastinum
whereas aortopulmonary
paraganglia are located along
great vessels
3-Radiographic Features :
a) Plain Radiography
b) CT
c) MRI
a) Plain Radiography :
-Well circumscribed rounded mediastinal
mass
Diagnostic Imaging of Mediastinal Masses
29 year old man with posterior mediastinal paraganglioma ,
chest radiograph shows large lobulated mass in left
paraspinal area (arrow)
b) CT :
-Mediastinal paragangliomas are seen in as a
mass in a characteristic location in the
paraaortic region of the middle mediastinum or
paravetebral region of the posterior mediastinum
corresponding to major cluster of sympathetic
ganglion cells
-Uncomplicated mediastinal paragangliomas
demonstrate intense contrast enhancement
29 year old man with posterior mediastinal paraganglioma , CT+C
shows hyperenhancing mass with cystic change (arrowhead) in left
posterior mediastinum
29 year old man with posterior mediastinal paraganglioma , CT shows
linear and punctate foci of calcification (arrow) within tumor mass
Axial CT+C shows heterogeneous mass between ascending aorta and
pulmonary trunk , there are intratumoral vessels (arrows), which suggest
hypervascularity of tumor , pulmonary trunk is compressed by mass and
invasion is suspected
Diagnostic Imaging of Mediastinal Masses
c) MRI :
-Mediastinal paraganglioma shows
enhancement on T1+C with conspicuity of
the lesion hightlighted by flow avoid in the
adjacent mediastinal vessels on spin-echo
sequences
Axial T2 fat-suppressed shows heterogeneous high signal intensity in
mass and flow voids (arrows) that reflect high flow in intratumoral
vessels
2-Extrameduallary Hematopoiesis :
a) Causes
b) Radiographic Features
a) Causes :
-Is a response to erythropoiesis failure in bone
marrow :
1-Myeloproliferative Disorders :
-CML
-Polycythemia Vera
2-Haemoglobinopathies :
-Sickle cell disease
3-Thalassemia
b) Radiographic Features :
-Posterior mediastinal masses , these are
paraspinal masses that may be unilateral or
bilateral and have smooth sharply delineated
often lobulated margins
-Suspect diagnosis if :
1-Multiple bilateral posterior mediastinal masses
2-Cortical bone changes by CT
3-Clinical history of anemia
4-Marked contrast enhancement
Left : There are large paraspinal masses (white arrows) with smoothly
marginated lobulated contours , all of the ribs (red arrow) are
expanded and the overall bone density is increased
Right : Large paraspinal masses are seen (white arrows)
Large lobulated retrocardiac masses
Frontal chest film (a) and scout view (b) show a bulging of the right
paraspinal line, CT scans (c-f) show bilateral soft-tissue paraspinal
masses, representing extramedullary hematopoiesis, in a young
thalassaemic patient
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
3-Paraspinal Abscess :
a) Causes
b) Radiographic Features
a) Causes :
-Infection of the soft tissues surrounding the
spine due to a suppurative bacterial or
mycobacterial infection with phlegmon
formation
b) Radiographic Features :
-High signal intensity fluid collections on T2
-Peripheral enhancement in areas of
reactive granulation tissue on post
contrast
-May be associated with intervertebral disc
space infection
-Tubercular abscesses may eventually
calcify
PA chest radiograph , the left paraspinal line (arrow) is seen separate
and distinct from the vertebral body (black arrowhead) and the
descending thoracic aorta (white arrowhead)
CT shows the left paraspinal line , the descending aorta holds the
pleural reflection (arrow) away from the vertebral body which allows
the lung soft tissue interface to be more tangential to the x-ray beam
and therefore visualized as a line
PA radiograph shows the right paraspinal line (arrow)
Paraspinal abscess , (a) PA chest radiograph shows a mass (arrow) effacing
the left paraspinal line , the lateral wall of the descending aorta is seen as a
separate entity (arrowhead) , (b) CT shows a paraspinal abscess (arrow)
effacing the paraspinal lines , the air soft tissue interface between the lung
and aorta remains intact (arrowhead) , thereby preserving the normal
radiographic appearance of the lateral aortic wall
4-Descending Aortic Aneurysm :
-See before
Descending aortic aneurysm , (a) PA chest radiograph shows lateral
displacement of the lateral margin of the descending thoracic aorta
due to an aortic aneurysm (arrowheads) , (b) CT also demonstrates
the aneurysm (arrow)
Diagnostic Imaging of Mediastinal Masses
Diagnostic Imaging of Mediastinal Masses
5-Esophageal Duplication Cyst :
-See Congenital Pulmonary Lesions
6-Neuroenteric Cyst :
-See Congenital Pulmonary Lesions
Duplication cyst in a 10-year-old girl with cough, (a) Chest radiograph
shows a round area of increased opacity that deforms the
azygoesophageal recess (arrow), (b) CT+C shows a thin-walled
water-attenuation cyst adjacent to the esophagus (arrow)
Esophageal duplication cyst
Esophageal duplication cyst
Neurenteric cyst in a 30 year old female with flank pain , (a) Chest radiograph shows a
well defined round mass (arrow) in the lower thoracic region , (b- c) Both axial T1 and
coronal T2 show a large mass that is of homogenous high signal intensity in the right
paravertebral region (arrow) , the cyst presumably contains proteinaceous fluid
7-Pancreatic Pseudocyst :
a) Incidence
b) Radiographic Features
a) Incidence :
-This follows extension of a pancreatic
pseudocyst in the posterior mediastinum
-This occurs via the esophageal or aortic
hiatus and therefore lies adjacent to the
esophagus
-Most case are seen in adults with clinical
features of a chronic pancreatitis (it can
also occur in children following trauma)
b) Radiographic Features :
1-Plain Radiography
2-CT
1-Plain Radiography :
-A space occupying mass in the posterior or
middle mediastinum
Initial examination showed an intrathoracic mass overlying the left
margin of the heart (arrowheads) , no interstitial pulmonary edema
was noted ,small pleural effusions are shown
2-CT :
-A thin walled cyst continuous with the
pancreas
-Left sided or bilateral effusions
Pancreatic pseudocyst in a 40 year old male with a 3 week history of
chest and epigastric pain , CT+C shows bilateral pleural effusion
and periaortic fluid collection (arrow) displacing the esophagus
(arrow)
Pancreatic pseudocyst in a 45-year-old woman with a 2-week history of
dysphagia and chest pain, (a) CT+C shows bilateral pleural effusion and a
thin-walled periaortic cystic lesion that displaces the esophagus (arrow)
anteriorly, (b) Axial T1 shows a low-signal-intensity cyst (arrow)
CT+C , a large cystic lesion is compressing the heart ,
predominantly the left ventricle (arrowheads)
8-Bochdalek Hernia :
-See Congenital Pulmonary Lesions
9-Hiatus Hernia :
-See Esophagus
Bochdalek Hernia: Axial CT of the lung bases shows abnormal
herniation of abdominal fat contents into the lower posterior left
hemithorax through the left hemidiaphragm (arrows)
On a frontal chest radiograph (a), the distal third of the
azygoesophageal recess demonstrates an abnormal contour and
bilateral convexity, lateral chest X-ray (b) demonstrates a
retrocardiac hyperlucency mass consistent with hiatal hernia
10-Lateral Meningocele :
a) Incidence
b) Radiographic Features
a) Incidence :
-A rare lesion due to protrusion of the spinal
meninges through an intervertebral
foramen
-Usually asymptomatic
-It is commonly associated with
neurofibromatosis (as neurofibroma)
b) Radiographic Features :
1-Plain Radiography
2-CT
1-Plain Radiography :
-A posterior mediastinal mass (often with
pressure deformity on the adjacent bone)
-It is indistinguishable from neurofibroma
X Ray of the chest showing meningocele as a mass lesion‑
2-CT :
-A fluid filled mass (rather than solid)
-Intrathecal contrast medium shows flow into
the lesion
Lateral thoracic meningocele in a 37-year-old man with
neurofibromatosis, CT scan shows a low-attenuation mass
protruding from the enlarged left intervertebral foramen
Lateral Meningocele in NF
MR demonstrates signal intensity identical to CSF
Diagnostic Imaging of Mediastinal Masses

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Diagnostic Imaging of Mediastinal Masses

  • 2. Mohamed Zaitoun Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals Egypt FINR (Fellowship of Interventional Neuroradiology)-Switzerland zaitoun82@gmail.com
  • 5. Knowing as much as possible about your enemy precedes successful battle and learning about the disease process precedes successful management
  • 6. Mediastinum 1-Anterior Mediastinal Masses 2-Middle Mediastinal Masses 3-Posterior Mediastinal Masses
  • 7. Mediastinal lines or stripes are interfaces between the soft tissue of mediastinal structures and the lung, the aortopulmonary window is the interface below the aorta and above the pulmonary trunk and is concave or straight laterally
  • 8. Anterior junction line results from the anterior apposition of the lungs, which lies behind the upper two- thirds of the sternum, the line consists of four layers of pleura and a variable amount of intervening fat, it appears as a thin oblique line projecting over the superior two-thirds of the sternum and runs from the upper right to the lower left, it does not extend above the level of clavicles, posterior junction line results from the apposition of the lungs posterior to the esophagus and anterior to the 3rd to 5th thoracic vertebrae, similarly to anterior junction line, it is formed by four layers of pleura, it appears as a thin straight line projecting through the trachea, unlike anterior junction line, it can be seen above the clavicles
  • 9. Mediastinal signs, frontal chest film (a) shows the hilum (arrow), which indicates that the mass is either anterior or posterior to the hilum, this is the hilum overlay sign in patient with lymphoma, frontal chest film (b) shows enlargement of the right superior mediastinum, above the level of the clavicles, the margins of the mass are sharp (arrow) due to the interface with adjacent lung, indicating that the mass is located in the posterior mediastinum
  • 10. 1-Anterior Mediastinal Masses (5Ts) a) Thymus Abnormalities b) Thyroid Masses c) Terrible Mediastinal Lymphoma d) Germ Cell Tumors e) Thoracic Aortic Aneurysm f) Pericardial Cyst g) Morgagni Hernia h) Sternal Tumors i) Pericardial Fat Pad
  • 11. -The anterior mediastinum is that portion of the mediastinum anterior to the pericardium and below the level of the clavicles -It includes the thymus , lymph nodes and may contain the portions of a retrosternal thyroid
  • 13. a) Thymus Abnormalities : 1-Thymoma 2-Thymolipoma 3-Benign Thymic Hyperplasia 4-Thymic Cyst
  • 14. -On frontal chest radiographs in infants and young children , the thymus is strikingly large but difficult to discriminate from the cardiac silhouette -The thymus usually has smooth borders and remains visible on radiographs through the age of 3 years -The thymic wave sign , a scalloped or wavy contour of the organ is created by the impression of the anterior reflection of the ribs -The thymic sail sign , a triangular slightly convex right lobe of the thymus with a sharply demarcated base caused by the minor fissure
  • 15. -Typically , the thymus is visible at CT and fills the perivascular space throughout the first 2 decades of life -In children younger than 5 years , it typically appears quadrilateral with convex borders -As children grow , the thymus gradually becomes triangular with straight or concave border
  • 16. 1-Thymoma : a) Incidence b) Associations c) Pathology d) Radiographic Features
  • 17. a) Incidence : -Thymoma is the most common anterior mediastinal tumor in the adult (very rare in children)
  • 18. b) Associations : 1-Myasthenia Gravis (35% of thymoma patients have myasthenia gravis) 2-Aplastic Anemia (50% have thymoma) 3-Hypogammaglobulinemia 4-Red cell Aplasia
  • 19. c) Pathology : 1-Benign Thymoma, 75% : -Common in patients with myasthenia 2-Malignant Thymoma , 25% : -Local spread into pleura but no hematogenous metastases -More common in patients without myasthenia
  • 20. d) Radiographic Features : 1-Plain Radiography 2-CT
  • 21. 1-Plain Radiography : -Presents as an anterior mediastinal mass -Seen as a well defined lobulated soft tissue density slightly towards one side of the mediastinum -Can demonstrate associated calcification (commonly amorphous / flocculent)
  • 26. 2-CT : -Anterior mediastinal soft tissue mass : 1-Asymmetrical location on one side 2-Homogeneous density and signal intensity 3-Some have cystic components (40% of the cases and are mostly focal) 4-Contrast medium enhancement 5-Invasive thymomas show growth through capsule into adjacent tissue , drop metastases into pleural space are common 6-Calcification , 20 %
  • 31. CT shows anterior mediastinal masses with coarse calcifications (A) and a circular peripheral calcification (B)
  • 32. Cystic thymoma , CT+C shows a low attenuation lesion (arrow) in the anterior mediastinum
  • 33. Invasive thymoma with pleural metastases
  • 34. Axial contrast-enhanced CT images showing a left anterior mediastinal mass (arrows in a) associated with a left parietal pleural nodule (arrow in b) and left diaphragmatic pleural nodules (arrows in c), apperances are those of invasive thymoma with pleural «drop metastases»
  • 35. Thymoma with no signs of mediastinal fat invasion (A, arrows) , one year after surgery , pleural metastasis was found (B, arrow)
  • 36. 2-Thymolipoma : a) Incidence b) Associations c) Pathology d) Radiographic Features
  • 37. a) Incidence : -Is a rare benign anterior mediastinal mass of thymic origin -Comprises 2-9% of all thymic neoplasms -Mean age of 22 years -Tumors usually grow to large sizes (75% are >500 g) with few or no symptoms
  • 38. b) Associations : 1-Myasthenia Gravis (in 3 % of thymolipoma) 2-Aplastic Anemia 3-Hypogammaglobulinemia 4-Grave’s Disease c) Pathology : -Thymolipomas are composed of a mixture mature adipose tissue with islands of thiymic tissue
  • 39. d) Radiographic Features : 1-Plain Radiography 2-CT
  • 40. 1-Plain Radiography : -Typically these tumors appear as large anterior mediastinal masses -The larger tumors tend to hang down one or either side of the pericardium and being soft , they mold themselves to the adjacent mediastinum and diaphragm and often mimic cardiomegaly
  • 42. Thymolipoma : a) Chest radiograph showing a widening of the cardiac silhouette , b) CT confirms the presence of a heterogeneous mass with fatty components growing in caudal direction
  • 44. 2-CT : -On CT thymolipomas typically appears almost entirely fatty with some areas of inhomogeneous soft tissue density that represent thymic tissue
  • 47. CT show a large and well defined mass (arrows) that has extensive fat content and contains small amounts of thin fibrous septa
  • 49. 3-Benign Thymic Hyperplasia : a) Pathology b) Causes c) Radiographic Features
  • 50. a) Pathology : -It can be subdivided into two forms : 1-True Thymic Hyperplasia 2-Lymphoid Hyperplasia
  • 51. b) Causes : 1-True Thymic Hyperplasia : a) Rebound hyperplasia to chemotherapy , thymic rebound hyperplasia (3 to 10 months after the start of chemotherapy) b) Radiation Therapy c) Burns d) Other Severe Systemic Stresses (e.g. pneumonia)
  • 52. 2-Lymphoid Hyperplasia : a) Myaesthenia Gravis b) SLE c) Rheumatoid Arthritis d) Scleroderma e) Graves Disease
  • 53. c) Radiographic Features : -Diffuse symmetric enlargement of the gland is the key morphologic feature of hyperplasia (neoplasm tends to manifest as a focal mass) -Size and morphology of normal thymus : >20 years of age : <13 mm >30 years of age : Convex margins are abnormal -No increase in size over time
  • 54. Thymic rebound hyperplasia in an 18 month old girl recovering from pneumonia (a) Frontal chest radiograph shows air trapping and bilateral perihilar peribronchial infiltrates (arrows) , findings consistent with viral pneumonia (b) Follow-up radiograph shows thymic rebound hyperplasia (arrowheads) and resolution of the pneumonic infiltrates (arrows)
  • 55. Thymic rebound hyperplasia in an 11 year old girl with Hodgkin lymphoma (a) CTC shows right sided mediastinal adenopathy (arrow) , Arrowhead = thymus (b) CT scan obtained after completion of chemotherapy shows regression of the adenopathy (arrow) , there is early thymic rebound hyperplasia (arrowhead) (c) CT scan obtained 1 month after chemotherapy shows that the nodal mass has almost resolved (arrow) and the thymic rebound hyperplasia is nearly complete (arrowhead)
  • 56. Dramatic thymic rebound hyperplasia in a 14 year old boy who completed chemotherapy for primary mediastinal T-cell lymphoma 6 months earlier
  • 59. 4-Thymic Cyst : a) Causes b) Radiographic Features
  • 60. a) Causes : 1-Congenital : -Contains thymic tissue in wall : often unilocular 2-Acquired : often multilocular a) Secondary to thoracotomy b) Following chemotherapy or radiotherapy for mediastinal malignancy c) Inflammatory
  • 61. b) Radiographic Features : 1-Plain Radiography 2-CT
  • 62. 1-Plain Radiography : -Thymic cysts usually appear as homogeneous circumscribed masses that may have calcified rims
  • 64. 2-CT : -Thin walls and no solid component and show no contrast enhancement
  • 65. CT+C shows inhomogenous unilocular low attenuation mass (arrows) in the anterior mediastinum
  • 66. A well marginated mass with a homogeneous attenuation usually in the range of water attenuation (0–20 HU) and without an enhancement of the wall or infiltrative appearance
  • 67. Cystic changes of the thymus and lymph nodes at diagnosis in a 19 year old man with Hodgkin lymphoma , CT+C shows a solid (arrow in a) and cystic (arrows in b) thymic mass , by the time the patient completed chemotherapy , the cystic nodes had resolved but the cystic areas in the thymus remained unchanged
  • 68. Cystic change of the thymus in a 28 year old man with Hodgkin lymphoma treated 3 years earlier , CT+C shows a thymic cyst (arrow) and thymic rebound hyperplasia (arrowhead)
  • 69. b) Thyroid Masses : 1-Incidence 2-Radiographic Features
  • 70. 1-Incidence : -Thyroid masses that extend into the mediastinum : goiter > adenoma , carcinoma , lymphoma
  • 71. 2-Radiographic Features : a) Plain Radiography b) CT
  • 72. a) Plain Radiography : -Tracheal displacement is the most common finding by CXR
  • 74. CXR of a partial substernal goiter compressing the trachea from the right side
  • 78. b) CT : -Mass is contiguous with cervical thyroid and is well defined -Heterogeneous density by CT : calcium , iodine (70 to 120 HU) , colloid cysts -Marked and prolonged contrast enhancement -They don’t usually project below the arch of the aorta (differentiating them from thymomas and teratoma) -Nuclear scan with either 99mTc or 123I confirms the diagnosis
  • 79. Frontal (a) view of the chest radiograph shows an opacity on the right side of the trachea (arrow), which appears shifted contralaterally and reduced in caliber, unenhanced CT scans (b-d) demostrate a heterogenous mass which goes down into the anterior mediastinum referred to a goiter
  • 80. Substernal Thyroid Goiter , CT+C of the chest shows a large contrast enhancing mass in the anterior mediastinal containing calcifications and areas of necrosis
  • 81. CT of a partial substernal goiter compressing the trachea from the left side
  • 82. c) Mediastinal Lymphoma : 1-Incidence 2-Pathology 3-Radiographic Features
  • 83. 1-Incidence : -Lymphomas are responsible for 45% of anterior mediastinal masses in children -Only 10% of lymphomas which involve the mediastinum are primary (i.e. mediastinum involvement not part of systemic disease) and the majority are Hodgkin lymphomas (50-70%)
  • 84. 2-Pathology : a) Hodgkin Lymphoma : 1-Lymphocyte Predominant (LP) , <5 % 2-Nodular Sclerosing (NS) , 70% 3-Mixed Cellularity (MC) , 25% 4-Lymphocyte Depleted (LD) , <5% b) B-Cell Neoplasms c) T-Cell Neoplasms
  • 85. -Primary mediastinal lymphomas are most frequently of 3 histologic varieties : 1-Nodular Sclerosing Hodgkin lymphoma 2-Primary mediastinal large B-cell lymphoma 3-Lymphoblastic Lymphoma (T-cell)
  • 86. 3-Radiographic Features : a) Plain Radiography b) CT
  • 87. a) Plain Radiography : -A soft tissue mass may be clearly visible or more frequently the mediastinum is widened and the retrosternal airspace is obscured -The hilum overlay sign refers to an appearance on frontal chest radiographs of patients with a mass projected at the level of the hilum which is in fact either anterior or posterior to the hilum , when a mass arises from the hilum, the pulmonary vessels are in contact with the mass and as such their silhouette is obliterated , the ability to see the edges of the vessels through the mass implies that the mass is not contacting the hilum and is therefore either anterior or posterior to it , most of these masses are found to be in the anterior mediastinum
  • 88. Normal Obliteration of the retrosternal space in mediastinal lymphoma
  • 94. b) CT : -Soft tissue attenuating mass with smooth or lobulated margins which conforms to surrounding structures (prevascular , paratracheal) involvement -Other features include : 1-Parenchymal invasion , uncommon 2-Pleural effusion 3-Pericardial effusion 4-Chest wall invasion
  • 95. -Calcification is usually seen following therapy and can have varying morphology including irregular , diffuse or even egg shell -Lymphomas have areas of necrosis but they usually do not have cystic areas , thymic cysts can occur after irradiation of mediastinal lymphomas or chemotherapy
  • 96. Large soft tissue mass in the anterior mediastinum which arises in the thymus , there is associated paratracheal adenopathy (arrow)
  • 98. Anterior mediastinal mass with bilateral pleural effusion
  • 101. 28 year old woman with Hodgkin disease , chest radiograph shows an anterior mediastinal mass (A, arrow) which on axial CT is irregular and shows areas of necrosis (B, arrows)
  • 106. d) Germ Cell Tumors : 1-Incidence 2-Pathology 3-Radiographic Features 4-Differential Diagnosis
  • 107. 1-Incidence : -Germ cell tumors are the most common cause of a fat containing lesions in the anterior mediastinum and the second most common cause of an anterior mediastinal mass in children
  • 108. 2-Pathology : -Tumors arise from rests of primitive cells and are of variable malignant potential (SECTE) a) Seminoma b) Embryonal cell carcinoma c) Choriocarcinoma d) Teratoma (70% of germ cell tumors) , teratocarcinoma e) Endodermal sinus tumors (yolk sac tumors)
  • 109. 3-Radiographic Features : a) Plain Radiography b) CT
  • 110. a) Plain Radiography : -Anterior mediastinal mass +/- areas of calcifications
  • 114. Teratoma in a 39 year old man , PA chest film shows an anterior mediastinal mass (A, arrows) , CT shows a large area of fat within the mass (B, arrow)
  • 116. b) CT : -Benign teratoma (90%) is a well defined thick wall cystic mass containing a variable mixture of : Calcification , 30% Fat , fat-fluid levels Cystic areas Soft tissue -Mature teratoma can be very large and still be benign -Malignant teratoma (10%) tends to have irregular or nodular walls and a predominance of soft tissue components , may show pulmonary or liver metastases and chest wall invasion
  • 117. Extensive mediastinal involvement (A,B, white arrows) , cystic upper mediastinal mass (A,B red arrows) , immature tooth (B, yellow arrow)
  • 118. 42 year old man with a teratoma , note the coarse calcifications (A,B, white arrows) and areas of fat attenuation measuring -103 HU (A,B, red arrows)
  • 119. CT+C shows large septated anterior mediastinal mass containing fat and bony elements
  • 120. CT+C shows an anterior mediastinal mass containing calcification (black arrow) , fat (white arrow) and soft tissue components (dotted white arrow)
  • 125. 4-Differential Diagnosis : -From Mediastinal Masses Containing Fat a) Teratodermoid b) Diaphragmatic Hernia c) Lipoma d) Liposarcoma e) Thymolipoma f) Mediastinal Lipomatosis g) Hamartoma h) Chylolymphatic Cyst
  • 126. e) Thoracic Aortic Aneurysm : 1-Incidence 2-Pathology 3-Radiographic Features
  • 127. 1-Incidence : -Are relatively uncommon compared to abdominal aortic aneurysm
  • 128. 2-Pathology : -Thoracic aortic aneurysms can be divided pathologically according to their relationship to the aortic wall : a) True Aneurysm : 1-Atherosclerotic aneurysms (most common) 2-Inflammatory / Aortitis : -R.A. , Ankylosing Spondylitis , Giant cell Arteritis & Syphilis
  • 129. 3-Structural : Cystic media necrosis -Marfan disease -Ehlers-Danlos syndrome b) False Aneurysm : -Trauma -Mycotic aneurysm
  • 130. 3-Radiographic Features : a) Plain Radiography b) CT
  • 131. a) Plain Radiography : -The thoracic aorta can usually be seen on both frontal and lateral chest radiographs and aneurysms are often obvious -Mural calcification is seen both in atherosclerotic disease as well as various causes of aortitis
  • 135. b) CT : -CTA is the work horse of aneurysm assessment -Typically aneurysms appear as dilatations of the lumen , the walls may be thin or thickened by presence of mural thrombus (circumferential or more frequently eccentric) -Calcified atherosclerotic disease is often identified not only in the wall of the aneurysm but in adjacent arteries -If rupture or leak has occurred hematoma / fluid may be seen adjacent to the aorta , in the left pleural cavity or in the pericardium
  • 139. f) Pericardial Cyst : 1-Incidence 2-Location 3-Radiographic Features 4-Differential Diagnosis
  • 140. 1-Incidence : -Uncommon benign congenital anomaly of the anterior mediastinum -Incidental findings in asymptomatic patients , usually after age 30
  • 141. 2-Location : -Found in the right anterior cardiophrenic angle but can be found almost anywhere adjacent to the heart
  • 142. 3-Radiographic Features : a) Plain Radiography b) CT
  • 143. a) Plain Radiography : -Well defined round or oval masses located in the normally clear cardiophrenic angle
  • 148. b) CT : -Usually appears as a well defined non- enhancing low (water) attenuating rounded mass next to the pericardium
  • 154. Typical benign pericardial cyst with serous content in a 46-year-old woman, (a) Coronal T1 shows a round low-signal-intensity cyst with a regular thin wall, (b) T2 shows a homogeneous high-signal- intensity cyst without septation or a mural nodule
  • 155. 4-Differential Diagnosis : From cystic mediastinal mass : 1-Congenital : a) Bronchogenic cyst , usually subcarinal or right paratracheal site b) Enteric cyst , paraoesophageal site c) Neuroenteric cyst , associated anomaly of spine 2-Pericardial cyst , usually cardiophrenic angle 3-Thymic cyst , can develop following radiotherapy for Hodgkin’s disease 4-Cystic tumors : a) Lymphangioma b) Teratoma c) Teratodermoid 5-Pancreatic pseudocyst , can track up into mediastinum 6-Meningocele , 75% association with NF 7-Chronic abscess 8-Old hematoma
  • 156. g) Morgagni Hernia : -See Congenital Pulmonary Lesions
  • 157. Morgagni hernia in a 2 year old child , lateral chest radiograph shows herniation of a bowel loop (arrows) in a classic location through an anteromedial defect
  • 159. h) Sternal Tumors : -Metastases are the most common (breast , bronchus , kidney & thyroid) -Malignant primary tumors (chondrosarcoma , myeloma , reticulum cell sarcoma and lymphoma) are more common than benign (chondroma , Aneurysmal bone cyst and Giant cell tumor)
  • 162. i) Pericardial Fat Pad : -Especially in obese people -A triangular opacity in the cardiophrenic angle on the PA view -It appears less dense than expected because of the fat content
  • 163. Epicardial fat pad , (a) PA chest radiograph shows loss of the cardiac silhouette at the border of the right side of the heart and an epicardial fat pad with relatively low density (arrow) , (b) CT scan shows the fat pad (arrow) as an area of homogeneous fat attenuation adjacent to the right border of the heart
  • 164. -Differential Diagnosis : Cardiophrenic angle lesions 1-Pericardial fat pad 2-Pericardial cyst 3-Pericardial fat necrosis 4-Morgagni’s hernia 5-Lymphadenopathy : metastases , lymphoma 6-Pericardial lipomatosis
  • 165. 2-Middle Mediastinal Masses : (A+B) 1-Adenopathy 2-Aortic Aneurysm 3-Bronchogenic Cyst 4-Carcinoma of the Bronchus
  • 166. 1-Adenopathy : -The paratracheal , bronchopulmonary and / or subcarinal nodes may be enlarged -This may be due to : a) Neoplasm (Lymphoma , Leukemia & Mets) b) Infection (most commonly T.B. , Histoplasmosis or coccidiodomycosis) c) Sarcoidosis d) Hyperplasia (Castleman’s disease)
  • 167. a) Neoplasm (Lymphoma , Leukemia & Mets) : -See Lung neoplasms b) Infection (most commonly T.B. , Histoplasmosis or coccidiodomycosis) : -See Pulmonary Infections c) Sarcoidosis : -See Diffuse Lung Lesions
  • 169. PA chest radiograph shows the right paratracheal stripe (arrow) , the azygos vein is seen at the inferior margin of the stripe at the tracheobronchial angle (arrowhead) , (b) CT shows the right wall of the trachea with medial and lateral air soft tissue interfaces caused by air within the tracheal lumen and right lung (arrow) , these interfaces create the right paratracheal stripe , note the position of the SVC (arrowhead) which explains why the paratracheal stripe is seen projecting through the SVC at radiography , (c) CT obtained at the level of the azygos arch shows that the azygos vein (arrow) disrupts the lung tracheal wall interface at the tracheobronchial angle
  • 170. Lymphadenopathy , (a) PA chest radiograph , the right paratracheal stripe is not seen having been obliterated by a right paratracheal mass (arrowheads) , (b) CT shows right paratracheal lymphadenopathy (arrow) which obliterates the air soft tissue interface between the right lung and the tracheal wall , this finding explains the obliteration of the right paratracheal stripe in a
  • 171. PA chest radiograph , the AP window reflection (arrowhead) extends from the aortic knob to the left pulmonary artery and has a normal concave appearance , the aortic pulmonary reflection (arrow) is a more anterior line and extends from the aortic arch to the level of the left main bronchus
  • 172. AP window lymphadenopathy , (a) Chest radiograph shows the AP window with an abnormal convex border (arrow) , (b) CT shows lymphadenopathy (arrow) which accounts for the distortion of the AP window in a
  • 173. Paratracheal lymph node enlargement in metastatic carcinoma
  • 174. Frontal Chest X-ray (a,b) shows a slightly convex border of the aortopulmonary window (arrow) suspicious for the presence of a mass in the middle mediastinum, CT scan shows enlarged lymphnodes in the aortopulmonary window (arrow), causing the abnormality seen on chest radiography, it was a lymphoma in a 11-year-old-girl
  • 175. Paratracheal and aortopulmonary window lymph node enlargement
  • 176. Subcarinal lymph node enlargement in CLL
  • 177. Frontal (a) and lateral (b) chest X-ray show a bilateral hilar enlargement, more evident on the right, CT+C (c,d) showing bilateral hilar lymph nodes in patient with sarcoidosis
  • 178. d) Giant Benign Lymph Node Hyperplasia (Castleman’s disease) : 1-Incidence 2-Pathology 3-Radiographic Features
  • 179. 1-Incidence : -Rare -Age < 30 years -Large benign mediastinal lymph node masses -Etiology is unknown (nodal hyperplasia vs benign tumor)
  • 180. 2-Pathology : -Two histologic types : a) Hyaline vascular , 90% b) Plasma cell , 10%
  • 181. 3-Radiographic Features : -Bulky mediastinal mass lesion (3 to 12 cm) : anterior > middle > posterior mediastinum -Dense homogeneous contrast enhancement is the key feature (vascular lesions) -On CT, 5% to 10% of Castleman disease showed intralesional calcifications, typically being discrete in morphology -Dynamic CT demonstrates early rapid enhancement with washout in the delayed phase
  • 182. PA chest Radiograph shows widening of upper mediastinum , aortopulmonary and azygos adenopathy and enlargement of hila (arrows) with extension of lesion below right hilum
  • 184. Unenhanced CT using bone window setting reveals posterior mediastinal mass (arrow) with typical arborizing pattern of intralesional calcifications
  • 185. CT+C shows matted lymphadenopathy (arrows) formed by confluence of inhomogeneously enhancing enlarged lymph nodes confined to anterior mediastinum
  • 188. Aneurysm of the aortic arch. (a) PA chest radiograph shows the AP window with a convex border (arrow) , (b) CT reveals an aneurysm (arrow) arising laterally from the aortic arch , a finding that accounts for the abnormality seen in a
  • 190. 3-Bronchogenic Cyst : -See Congenital Pulmonary lesions
  • 191. (a) PA chest radiograph demonstrates a subcarinal abnormality with increased opacity (*) , splaying of the carina and abnormal convexity of the upper and middle thirds of the azygoesophageal line (arrowheads) , (b) Corresponding CT scan helps confirm a subcarinal mass (arrow) which proved to be a bronchogenic cyst
  • 193. CT+C : well circumscribed unilocular water attenuation cyst in the middle mediastinum , the cyst has smooth imperceptible walls with no enhancement
  • 194. Bronchogenic cyst , CT shows a subcarinal mass with fluid density
  • 195. CT Scanogram (a) shows an oval, huge, mass (arrows) that cause a widening and distortion of azygoesophageal recess, coronal (b) and sagittal (c) MPR reconstruction demonstrate a cyst with uniform water attenuation and with an imperceptible wall, this was a bronchogenic cyst
  • 196. Bronchogenic cyst in a 49-year-old man with a 2-week history of fever and cough, (a) Chest radiograph shows a round mass (arrow) that displaces the right primary bronchus superiorly, as well as pneumonia of the middle lobe and pleural effusion, (b) Contrast material-enhanced CT scan shows a cyst with uniform water attenuation and with an imperceptible wall.
  • 197. Bronchogenic cyst in a 44-year-old woman with a 3-year history of chest pain, CT scan shows a thin-walled water-attenuation cyst in the posterior mediastinum (arrow)
  • 198. 4-Carcinoma of the Bronchus : -See Pulmonary Tumors
  • 202. a) A 55 yr old dyspnoeic female , chest radiograph shows widened mediastinum particularly on the right with reduced vascularity of the right lung b) CT+C shows central mediastinal mass invading the right pulmonary artery , small cell carcinoma was confirmed on percutaneous biopsy
  • 203. 3-Posterior Mediastinal Masses (ACTH) 1-Posterior Mediastinal Neural Tumors 2-Extrameduallary Hematopoiesis 3-Paraspinal Abscess 4-Descending Aortic Aneurysm 5-Oesophageal Duplication Cyst 6-Neuroenteric Cyst 7-Pancreatic Pseudocyst 8-Bochdalek Hernia 9-Hiatus Hernia 10-Lateral Meningocele
  • 204. 1-Posterior Mediastinal Neural Tumors : a) Incidence b) Peripheral Nerve Sheath Tumor c) Sympathetic Ganglia Tumors d) Paraganglioma
  • 205. a) Incidence : -Neurogenic tumors are the cause of approximately 90% of posterior mediastinal masses -They can be subdivided into three groups by their location and involvement of peripheral nerves or sympathetic chain : 1-Peripheral Nerve Sheath Tumors 2-Sympathetic Ganglia Tumors 3-Paraganglioma -Peripheral nerve sheath tumors and paragangliomas are far more common in adults while the sympathetic ganglia tumors are commoner in children
  • 206. b) Peripheral Nerve Sheath Tumor : 1-Incidence 2-Schwannoma 3-Neurofibroma 4-Malignant Peripheral Nerve Sheath Tumors
  • 207. 1-Incidence : -These tumors manifest as round paravertebral masses that span one or two vertebral bodies -They are homogenous soft tissue attenuation masses at CT and the commonest cause of posterior mediastinal and paravertebral masses -They may cause widening of the neural foramen and thickening of the adjacent posterior rib
  • 210. 2-Schwannoma : a) Incidence b) Location c) Radiographic Features
  • 211. a) Incidence : -Are benign tumors of schwann cell origin and are the most common tumor of peripheral nerves -Peak presentation is in the 5th-6th decades -When they occur in patients with neurofibromatosis type 2 (NF2) schwannomas usually present by the 3rd decade
  • 212. b) Location : -Arise posteriorly , frequently in neural foramina
  • 213. 1-Vertebral Body 2-Neural Foramen 3-Articular Pillar 4-Lamina 5-Spinous Process
  • 215. c) Radiographic Features : 1-Plain Radiography 2-CT 3-MRI
  • 216. 1-Plain Radiography : -Both benign and malignant tumors may erode ribs -They may enlarge the neural foramina (dumbbell shaped lesion) -Scalloping of posterior vertebral bodies may occur -They may produce a scoliosis -Pleural effusion may occur with benign as well as malignant neural tumor
  • 217. There is an opacity in the left posterior mediastinum , there is associated widening of the 4th intercostal space posteriorly with scalloping of the inferior margin of the 4th rib , there is also some coarse calcification within the lesion
  • 221. Cervical X-Ray (a-b) demonstrate a marginated and round opacity (white arrows), with disrupting of left paravertebral stripe, CT scan (c) confirms a left hypodense and homogeneous paravertebral mass, this mass revealed features consistent with schwannoma
  • 222. 2-CT : -Isodense round or oval mass , <2 vertebral bodies long -Dense contrast enhancement : Small tumors show homogeneous enhancement Larger tumors may show heterogeneous enhancement
  • 225. CT+C
  • 228. 3-MRI : *T1 : 70% hypointense , 30% isointense *T2 : Very hyperintense , may show small internal low signal foci (calcification) and areas of necrosis *T1+C : Dense enhancement : -Homogeneous if small -Heterogeneous if large
  • 230. T1
  • 231. T2
  • 232. Coronal T2 shows well defined paravertebral mass with peripheral high signal intensity and relatively low signal intensity centrally , mass has peripheral low signal intensity rim (arrows) that reflects tumor capsule
  • 233. Axial T2 shows well defined mass with heterogeneous high signal intensity in right paravertebral region , mass protrudes toward adjacent right neural foramen (arrow) and shows “dumbbell” configuration , mass has low signal intensity rim (arrowhead) in periphery
  • 234. Axial T1+C shows heterogeneous enhancement that is relatively strong in center of mass
  • 235. T1+C
  • 236. T1
  • 237. T2
  • 238. T1+C
  • 239. A, Coronal T2 shows well- defined mass in right paravertebral region , mass has very high signal intensity area (arrow) in center and low signal intensity rim (arrowhead) in periphery B, Coronal T1+C fat- suppressed shows no enhancement of central area (arrow) which reflects cystic change in mass
  • 240. 3-Neurofibroma : a) Incidence b) Location c) Radiographic Features
  • 241. a) Incidence : -Are benign peripheral nerve sheath tumors -Peak presentation is between 20 and 30 years of age -The majority of neurofibromas are solitary and sporadic , however there is an association with NF1
  • 242. b) Location : -Arise posteriorly , frequently in neural foramina
  • 243. c) Radiographic Features : 1-Plain Radiography 2-CT 3-MRI
  • 244. 1-Plain Radiography : -Both benign and malignant tumors may erode ribs -They may enlarge the neural foramina (dumbbell shaped lesion) -Scalloping of posterior vertebral bodies may occur -They may produce a scoliosis -Pleural effusion may occur with benign as well as malignant neural tumor
  • 245. Neurofibroma (red arrow) , multiple subcutaneous neurofibromas (yellow arrows)
  • 246. Posterior scalloping of lumbar vertebral bodies in NF
  • 248. 2-CT : -Well defined hypodense mass -Minimal or no contrast enhancement
  • 251. Rib notching with Dumbbell-shaped Neurofibroma
  • 252. 3-MRI : *T1 : -Hypointense *T2 : -Hyperintense -A hyperintense rim and central area of low signal resulting in a target sign may be seen due to a dense central area of collagenous stroma *T1+C : -Heterogenous enhancement
  • 253. T1+C , dumbbell shaped neurofibroma with intra and extraspinal extension , note the displacement of the adjacent thoracic cord (arrow)
  • 254. Axial T2 shows well defined mass with homogeneous high signal intensity in left paravertebral region , mass has thin low signal intensity rim (arrows) in periphery
  • 255. Target sign in Neurofibroma
  • 256. 4-Malignant Peripheral Nerve Sheath Tumors (MPNST) : -Are malignant forms of neurofibromas and schwannomas -Associated with NF1 -Imaging criteria are generally considered unreliable in differentiating from a more benign neurofibroma or schwannoma
  • 257. c) Sympathetic Ganglia Tumors : 1-Incidence 2-Neuroblastoma 3-Ganglioneuroma 4-Ganglioneuroblastoma
  • 258. 1-Incidence : -These tumors tend to present as elongated paraspinal masses that span multiple vertebral levels -Intratumoural calcification is common -They are : a) Neuroblastoma : young children b) Ganglioneuroma : children and adults c) Ganglioneuroblastoma : older children -Neuroblastoma and ganglioneuroblastoma are most commonly seen in children and in a child they comprise the commonest neurogenic tumor
  • 259. 2-Neuroblastoma : a) Incidence b) Location c) Radiographic Features
  • 260. a) Incidence : -Is a tumor of neuroblastic origin and the most common extracranial solid childhood malignancies and the third commonest childhood tumor after leukemia and brain malignancies -The tumors typically occur in infants and very young children (mean age of presentation being 22 months) with 95% of cases diagnosed before the age of 10 years
  • 261. b) Location : -Neuroblastomas arise from the sympathetic nervous system -Posterior mediastinum : 20%
  • 262. c) Radiographic Features : 1-Plain Radiography 2-CT 3-MRI
  • 263. 1-Plain Radiography : -Appearances are non-specific , typically shows an intrathoracic soft tissue mass -Pressure on adjacent bones may cause remodeling of ribs , vertebral bodies or pedicle thinning -Up to 30% may have evidence of calcification on the plain film
  • 264. Homogenous opacity lesion in the right upper and mid zone with broad base towards mediastinum , the lesion is causing shift of mediastinum and trachea to the contralateral side and compressing the trachea just above the carina (arrow head) , the lesion is extending above the clavicle (cervico-thoracic sign) and erosion of posterior end of third and fourth ribs (Long arrow)
  • 265. *N.B. : Cervico-thoracic sign -A variant of the silhouette sign -It helps to discern the anterior or posterior location of mass in the superior mediastinum on frontal chest radiographs -As the anterior mediastinum ends at the level of the clavicles and as such the upper border an anterior mediastinal lesions cannot be visualized extending above the clavicles -Any lesions with a discernible upper border above that level must be located posteriorly in the chest ; i.e. apical segments of upper lobes , pleura or posterior mediastinum
  • 268. 2-CT : -The tumor typically is heterogeneous with calcifications seen in 80 - 90% of cases -Areas of necrosis are of low attenuation -The morphology of is often most helpful with the mass seen insinuating itself beneath the aorta and lifting it off the vertebral column , it tends to encase vessels and may lead to compression , adjacent organs are usually displaced -Lymph node enlargement is often present -Calcification in a posterior mediastinal mass points to a neural tumor in a kid rather than a met from somewhere else
  • 269. Heterogeneously enhancing mass lesion in the right posterior mediastinum extending to middle mediastinum causing compression of the trachea , the lesion is showing multiple small foci of calcification (black arrows)
  • 273. 3-MRI : *T1 : - Heterogeneous and iso to hypointense *T2 : -Heterogeneous and hyperintense -cystic / necrotic areas very high intensity *T1+C : -Variable and heterogeneous enhancement
  • 274. 1 month old boy with mediastinal neuroblastoma , coronal T2 shows long vertically oriented mass with homogeneous high signal intensity and tapering appearance in left paravertebral region , invasion of vertebrae is not seen
  • 275. Axial T2 in a patient with a thoracic neuroblastoma shows a large right posterior mediastinal mass extending into the spinal canal and displacing the cord laterally to the left , the mass is hyperintense on T2
  • 276. T1+C shows inhomogeneous enhancement of the mass which appears to have a component arising from the neural foramen (white arrow)
  • 277. 3-Ganglioneuroma : a) Incidence b) Location c) Radiographic Features
  • 278. a) Incidence : -They tend to occur in the pediatric population and are often asymptomatic -Usually , patients are older than 10 years old , compared to neuroblastoma which occurs in patient younger than 3 years old
  • 279. b) Location : -Can potentially occur anywhere along the peripheral autonomic ganglion sites , the posterior mediastinum one of the commonest locations (40%)
  • 280. c) Radiographic Features : 1-Plain Radiography 2-CT 3-MRI
  • 281. 1-Plain Radiography : -All neuroblastic tumors (i.e. ganglioneuroblastomas , ganglioneuromas and neuroblastomas) look similar -See Neuroblastoma
  • 282. Chest radiograph shows a right paraspinal well-defined density in the retrocardiac region , the right cardiophrenic angle appears normal
  • 283. 2-CT : -Typically seen as well circumscribed solid encapsulated masses -Tend to be iso to hypoattenuating to muscle -May demonstrate calcifications (40%) -Delayed heterogeneous uptake of contrast
  • 287. Paraspinal Ganglioneuroma, non-enhanced Axial CT scan reveals a paraspinal homogeneous low attenuation fusiform mass which after resection proved to be a ganglioneuroma
  • 288. 3-MRI : *T1 : -Homogeneously low or intermediate signal *T2 : -Heterogenously intermediate or high signal *T1+C : -Ranging from none to heterogenous enhancement
  • 289. (a) Chest radiography shows an oblong mass in the right paraspinal region , the lateral margins of the mass are indistinct & there is RT lower lobe pneumonia , (b) CT+C shows that the mass is heterogenous and contains calcifications (c) T2 shows that the mass is of high signal intensity
  • 290. Coronal T2 shows long vertically oriented mass with heterogeneous high signal intensity and tapering appearance in left paravertebral region
  • 291. , Coronal T1+C shows heterogeneous enhancement in mass.
  • 292. T1+C of a ganglioneuroma shows homogeneous enhancement of the lesion , the lesion is extending from the right paraspinal region into the epidural space through the neural foramina causing cord compression
  • 293. T1 of a ganglioneuroma , the sagittal views shows a well-defined solid mass located slightly anterior to the midthoracic vertebral bodies , the mass extends into and widening multiple neural foramina , flow voids within the lesion represents vascularity
  • 294. 4-Ganglioneuroblastoma : a) Incidence b) Location c) Radiographic Features
  • 295. a) Incidence : -Uncommon peripheral neuroblastic tumor - Most commonly in babies and in young children -Ganglioneuroblastoma have intermediate malignant potential between that of neuroblastomas and ganglioneuromas
  • 296. b) Location : -Can potentially occur anywhere along the peripheral autonomic ganglion sites , the posterior mediastinum one of the commonest locations
  • 297. c) Radiographic Features : 1-Plain Radiography 2-CT 3-MRI
  • 298. 1-Plain Radiography : -See Neuroblastoma
  • 300. 2-CT : -See Ganglioneuroma + areas of bleeding and necrosis may be as large as 4 cm and appear to be of lower attenuation
  • 301. CT without contrast of a ganglioneuroblastoma demonstrates a large left heterogeneous paraspinal lesion with speckled calcifications that are predominantly peripheral , the mass is displacing the mediastinum to the right
  • 303. 3-MRI : -See Ganglioneuroma + areas of hemorrhage have a high T1 signal intensity and cystic areas have a high T2 signal intensity -Ganglioneuroblastomas , like neuroblastomas and other malignant tumors have an enhancing pattern of early enhancement followed by a partial washout , early enhancement is indicative of high vascularity
  • 304. Axial T1 shows high signal intensity areas (arrowheads) that suggest hemorrhage in center of mass
  • 305. Axial T1+C shows heterogeneous enhancement in mass , enhancement is not seen in center of mass (arrowheads) and tumor necrosis is suspected
  • 308. MRI scan showing homogenous soft tissue density mass in the posterior mediastinum
  • 310. 1-Incidence : -Rare tumors derived from chromaffin cells (neuroectodermal cells) associated with sympathetic ganglion of the autonomic nervous system -Paraganglioma (= chemodectoma , histologically similar to pheochromocytoma) : functional tumors , may secrete catecholamines
  • 311. 2-Location : -They can arise from two major cluster of sympathetic ganglion cells : a) Paraaortic (aorticopulmonary) b) Paravetebral(aorticosympathetic) location
  • 312. -Normal anatomy of mediastinal nervous tissues -Most peripheral nerve tumors originate from spinal or proximal intercostal nerve in posterior mediastinum -Thoracic sympathetic trunks and their associated ganglia are located on side of vertebral bodies -Aortosympathetic paraganglia are adjacent to sympathetic chain in posterior mediastinum whereas aortopulmonary paraganglia are located along great vessels
  • 313. 3-Radiographic Features : a) Plain Radiography b) CT c) MRI
  • 314. a) Plain Radiography : -Well circumscribed rounded mediastinal mass
  • 316. 29 year old man with posterior mediastinal paraganglioma , chest radiograph shows large lobulated mass in left paraspinal area (arrow)
  • 317. b) CT : -Mediastinal paragangliomas are seen in as a mass in a characteristic location in the paraaortic region of the middle mediastinum or paravetebral region of the posterior mediastinum corresponding to major cluster of sympathetic ganglion cells -Uncomplicated mediastinal paragangliomas demonstrate intense contrast enhancement
  • 318. 29 year old man with posterior mediastinal paraganglioma , CT+C shows hyperenhancing mass with cystic change (arrowhead) in left posterior mediastinum
  • 319. 29 year old man with posterior mediastinal paraganglioma , CT shows linear and punctate foci of calcification (arrow) within tumor mass
  • 320. Axial CT+C shows heterogeneous mass between ascending aorta and pulmonary trunk , there are intratumoral vessels (arrows), which suggest hypervascularity of tumor , pulmonary trunk is compressed by mass and invasion is suspected
  • 322. c) MRI : -Mediastinal paraganglioma shows enhancement on T1+C with conspicuity of the lesion hightlighted by flow avoid in the adjacent mediastinal vessels on spin-echo sequences
  • 323. Axial T2 fat-suppressed shows heterogeneous high signal intensity in mass and flow voids (arrows) that reflect high flow in intratumoral vessels
  • 324. 2-Extrameduallary Hematopoiesis : a) Causes b) Radiographic Features
  • 325. a) Causes : -Is a response to erythropoiesis failure in bone marrow : 1-Myeloproliferative Disorders : -CML -Polycythemia Vera 2-Haemoglobinopathies : -Sickle cell disease 3-Thalassemia
  • 326. b) Radiographic Features : -Posterior mediastinal masses , these are paraspinal masses that may be unilateral or bilateral and have smooth sharply delineated often lobulated margins -Suspect diagnosis if : 1-Multiple bilateral posterior mediastinal masses 2-Cortical bone changes by CT 3-Clinical history of anemia 4-Marked contrast enhancement
  • 327. Left : There are large paraspinal masses (white arrows) with smoothly marginated lobulated contours , all of the ribs (red arrow) are expanded and the overall bone density is increased Right : Large paraspinal masses are seen (white arrows)
  • 329. Frontal chest film (a) and scout view (b) show a bulging of the right paraspinal line, CT scans (c-f) show bilateral soft-tissue paraspinal masses, representing extramedullary hematopoiesis, in a young thalassaemic patient
  • 335. 3-Paraspinal Abscess : a) Causes b) Radiographic Features
  • 336. a) Causes : -Infection of the soft tissues surrounding the spine due to a suppurative bacterial or mycobacterial infection with phlegmon formation
  • 337. b) Radiographic Features : -High signal intensity fluid collections on T2 -Peripheral enhancement in areas of reactive granulation tissue on post contrast -May be associated with intervertebral disc space infection -Tubercular abscesses may eventually calcify
  • 338. PA chest radiograph , the left paraspinal line (arrow) is seen separate and distinct from the vertebral body (black arrowhead) and the descending thoracic aorta (white arrowhead)
  • 339. CT shows the left paraspinal line , the descending aorta holds the pleural reflection (arrow) away from the vertebral body which allows the lung soft tissue interface to be more tangential to the x-ray beam and therefore visualized as a line
  • 340. PA radiograph shows the right paraspinal line (arrow)
  • 341. Paraspinal abscess , (a) PA chest radiograph shows a mass (arrow) effacing the left paraspinal line , the lateral wall of the descending aorta is seen as a separate entity (arrowhead) , (b) CT shows a paraspinal abscess (arrow) effacing the paraspinal lines , the air soft tissue interface between the lung and aorta remains intact (arrowhead) , thereby preserving the normal radiographic appearance of the lateral aortic wall
  • 343. Descending aortic aneurysm , (a) PA chest radiograph shows lateral displacement of the lateral margin of the descending thoracic aorta due to an aortic aneurysm (arrowheads) , (b) CT also demonstrates the aneurysm (arrow)
  • 346. 5-Esophageal Duplication Cyst : -See Congenital Pulmonary Lesions 6-Neuroenteric Cyst : -See Congenital Pulmonary Lesions
  • 347. Duplication cyst in a 10-year-old girl with cough, (a) Chest radiograph shows a round area of increased opacity that deforms the azygoesophageal recess (arrow), (b) CT+C shows a thin-walled water-attenuation cyst adjacent to the esophagus (arrow)
  • 350. Neurenteric cyst in a 30 year old female with flank pain , (a) Chest radiograph shows a well defined round mass (arrow) in the lower thoracic region , (b- c) Both axial T1 and coronal T2 show a large mass that is of homogenous high signal intensity in the right paravertebral region (arrow) , the cyst presumably contains proteinaceous fluid
  • 351. 7-Pancreatic Pseudocyst : a) Incidence b) Radiographic Features
  • 352. a) Incidence : -This follows extension of a pancreatic pseudocyst in the posterior mediastinum -This occurs via the esophageal or aortic hiatus and therefore lies adjacent to the esophagus -Most case are seen in adults with clinical features of a chronic pancreatitis (it can also occur in children following trauma)
  • 353. b) Radiographic Features : 1-Plain Radiography 2-CT
  • 354. 1-Plain Radiography : -A space occupying mass in the posterior or middle mediastinum
  • 355. Initial examination showed an intrathoracic mass overlying the left margin of the heart (arrowheads) , no interstitial pulmonary edema was noted ,small pleural effusions are shown
  • 356. 2-CT : -A thin walled cyst continuous with the pancreas -Left sided or bilateral effusions
  • 357. Pancreatic pseudocyst in a 40 year old male with a 3 week history of chest and epigastric pain , CT+C shows bilateral pleural effusion and periaortic fluid collection (arrow) displacing the esophagus (arrow)
  • 358. Pancreatic pseudocyst in a 45-year-old woman with a 2-week history of dysphagia and chest pain, (a) CT+C shows bilateral pleural effusion and a thin-walled periaortic cystic lesion that displaces the esophagus (arrow) anteriorly, (b) Axial T1 shows a low-signal-intensity cyst (arrow)
  • 359. CT+C , a large cystic lesion is compressing the heart , predominantly the left ventricle (arrowheads)
  • 360. 8-Bochdalek Hernia : -See Congenital Pulmonary Lesions 9-Hiatus Hernia : -See Esophagus
  • 361. Bochdalek Hernia: Axial CT of the lung bases shows abnormal herniation of abdominal fat contents into the lower posterior left hemithorax through the left hemidiaphragm (arrows)
  • 362. On a frontal chest radiograph (a), the distal third of the azygoesophageal recess demonstrates an abnormal contour and bilateral convexity, lateral chest X-ray (b) demonstrates a retrocardiac hyperlucency mass consistent with hiatal hernia
  • 363. 10-Lateral Meningocele : a) Incidence b) Radiographic Features
  • 364. a) Incidence : -A rare lesion due to protrusion of the spinal meninges through an intervertebral foramen -Usually asymptomatic -It is commonly associated with neurofibromatosis (as neurofibroma)
  • 365. b) Radiographic Features : 1-Plain Radiography 2-CT
  • 366. 1-Plain Radiography : -A posterior mediastinal mass (often with pressure deformity on the adjacent bone) -It is indistinguishable from neurofibroma
  • 367. X Ray of the chest showing meningocele as a mass lesion‑
  • 368. 2-CT : -A fluid filled mass (rather than solid) -Intrathecal contrast medium shows flow into the lesion
  • 369. Lateral thoracic meningocele in a 37-year-old man with neurofibromatosis, CT scan shows a low-attenuation mass protruding from the enlarged left intervertebral foramen
  • 371. MR demonstrates signal intensity identical to CSF