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Mediastinum and PleuraJulie Takasugi, Puget Sound VA
Francis Wessbecher, Tacoma Radiology Associates
J. David Godwin, UW Medical Center
Case 1. Left paratracheal mass pushing trachea to the right
What next?CT with IV contrastCT without IV contrastEsophagramIodine-131 study
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Case 1. Next study should be CT without IV contrast.DX: Thyroid goiter
DDX for CXR: Thyroid tumor, lymphoma, metastasis, duplication cyst
CT should be without IV contrast. For a thyroid mass, radioiodine might be given.If the mass is not in thyroid, IV contrast can be given.Goiter enhances heterogeneously, some areas intensely;
prolonged enhancement (longer than muscle) reflects iodine trapping.There may be cystic, solid, or calcified components. Goiters have clear surrounding fat planes.
Case 2. Bronchogenic cyst, typical subcarinal location. Attenuation is higher than water because of protein or blood. MRI may show high signal intensity
on T1 images.
Case 2. Bronchogenic cyst, typical subcarinal location. Attenuation is higher than water because of protein or blood. MRI may show high signal intensity
on T1 images.
Different patient
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Case 3. Atypical chest pain
Case 3a. Right cardiophrenic angle massDDX: Pericardial cyst, Morgagni hernia, lymphadenopathy (various causes),
mediastinal fat pad, fibrous tumor of pleura.
Water attenuation
DX: Pericardial cyst
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Case 3b. Morgagni hernia containing colon
Case 3c. Right cardiophrenic angle (CPA) lymphadenopathy
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Case 3c. Right CPAlymphadenopathy
Lymphoma
Tumors that involve CPA (aka diaphragmatic) nodes include lymphoma and tumors of the breast and upper abdomen.
Neurofibroma
Case 4a. Paraspinal mass: neurofibroma.
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Case 4b. Paraspinal mass(es)Extramedullary hematopoiesis in thalassemia
Case 4b. Paraspinal mass(es)Extramedullary hematopoiesis in thalassemia
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Case 4b. Paraspinal mass(es)Extramedullary hematopoiesis in thalassemia
Case 5a. Azygoesophageal recess (AER) massTraumatic aortic pseudoaneurysm
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Case 5a. Azygoesophageal recess (AER) massTraumatic aortic pseudoaneurysm
Case 5b. Low azygoesophageal mass (with fluid levels)Paraesophageal hiatal hernia with gastric volvulus
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Cases 5c. Other low azygoesophageal masses
Varices Pancreatic pseudocysts
Case 6a. Breast cancer follow-up
Baseline
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Case 6b. Hoarseness
Case 6b. AP window mass. DDX: lymphadenopathy, ductus aneurysm,traumatic aortic pseudoaneurysm, foregut duplication cyst
Ductusaneurysm
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Case 6c. Cough
Baseline
Note: portion of ascending aortic interface is still visible (green arrow)
Case 6c. Mass in AP window and left hilum, obscured descending aorta and left pulmonary artery; DDX: Lung cancer, lymphadenopathy, aneurysm
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Case 6c. Mass fills AP window and obscures top of left PA
Ascending AO interface is preserved
DX: lung cancer
Case 7. Right paratracheal mass in 31-year-old woman DDX: lymphadenopathy, foregut duplication cyst, lymphangioma;
less common location for thymoma, bronchogenic cyst
Bronchogenic Cyst
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Infiltrating mass lacks sharp borders. attenuation = 8-14 HU (near water)
Infiltrating mass lacks sharp borders. attenuation = 8-14 HU (near water)
DX: Lymphangioma; DDX: pericardial cyst
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Obtuse angle, mediastinal origin
This anterior interface isLost when mass appears
Baseline
Case 8. New mass
Case 8. Mature teratoma
Obtuse angle, mediastinal origin
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Posterior aortic arch visible
Anterior junction linedisplaced to right
Anterior masses displace trachea posteriorly
Case 9. Anterior mass(es)
Case 9. Anterior mass(es). DX: Hodgkin’s lymphomaMultiplicity of masses fits best with lymphoma.
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Case 10a. Thymoma - loss of SVC/RA border indicates anterior position
Case 10b. Thymiccarcinoma
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Case 10b. Thymic carcinoma with pleural metastases
Pitfalls
• Not considering vascular “masses”
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Right aortic arch withaberrant left subclavian artery
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Dilation of main pulmonary artery from congenital pulmonic stenosis and
post-operative pulmonary regurgitation
Pitfalls
• Not considering vascular “masses”
• Not considering anatomic variants (including fat)
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Persistent left SVC
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Feb July
Feb JulyLipomatosis from corticosteroids
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Pitfalls
• Not considering vascular “masses”
• Not considering anatomic variants (including fat)
• Mistaking hilar nodes and hilar vessels
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Sarcoidosis
Pulmonary hypertension Sarcoidosis
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Pulmonary hypertension Sarcoidosis
Pitfalls
• Not considering vascular “masses”
• Not considering anatomic variants (including fat)
• Mistaking hilar nodes and hilar vessels
• Missing AP window lesions
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Case 6a. Breast cancer follow-up
Baseline
Pleura
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Pleural Effusion in Heart Disease
CHF right effusion > left
Post cardiac injuryDressler’s syndrome
Postcardiotomypleuritic pain, fever, rub, pericardial and pleural
effusion, atelectasis
Pericardial disease left effusion > right
Unilateral or Selective Left Pleural Effusion
TB
Tumor
Pulmonary embolism
Pericardial disease
Pancreatitis, subphrenic abscess
Splenic abscess, infarction, hematoma
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Bronchopleural Fistula
Gas is rare in ordinary empyema.
Fluid level in pleural space suggests BPF. NB: rule out iatrogenic cause
Gas enters pleural space via:defect in visceral pleura
infection, tumor, infarction, trauma
leaking bronchial stump after lobectomyor pneumonectomy
Empyema-BPF vsLung Abscess
Lenticular, elongated shape
Enhancing, smooth wall < 5 mm
Compression of adjacent lung with displacement of bronchi and vessels
Obtuse angle with chest wall
Separation of pleural layers
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Pleural Thickening
Pleural plaqueAlmost always caused by asbestos exposure
Discrete, sharply marginated
Diffuse pleural thickeningCaused by infection, inflammation, or
hemothorax
Fading edges, no sharp margins
Asbestos pleural plaque
Symmetricfavors 4th-8th ribs
and diaphragm spares CP angles
and apices
DDX:extrapleural fatdiffuse pleural
thickening
Calcificationdystrophicprogresses with timelinear in profile“maple leaf” en face
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Asbestos Pleural Plaque
ParietalDoes not fuse tovisceral pleura
Asbestospleural plaque with calcification
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Asbestos Pleural Plaque
Most frequent manifestation of asbestos exposure
Not a precursor to mesothelioma
10 - 15 year latency
Parietal, favors diaphragm, mostly posterolateral, rarely visceral--can be in fissure
Benign Asbestos Pleurisy
Incidence up to 7%; may recur
Most common early manifestation of asbestos exposure (< 10 years)
Diagnosis of exclusionExposure history
No other cause
No evidence of malignancy within 3 years
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Asbestos Pleurisy & Diffuse Pleural Thickening
Pleural effusion Subsequent diffuse pleural thickening
Diffuse Pleural Thickening(with or without calcification)
Often follows pleural effusion
Caused by infection, inflammation, or hemothorax
Affects parietal and visceral layers
Lacks sharp margins (vs plaque)
Obliterates costophrenic angle
Associated with lung bands andround atelectasis
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Diffuse pleural thickening with lung bands
Lung transplant
Pleural thickening andeffusion with lung bandsand round atelectasis
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Round atelectasisenhances withIV contrast.
Tuberculouspleural thickeningwith calcification
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Tuberculous pleural thickening with calcification
Pleural Tumors
Margin partly sharp, partly fading
Distinguished fromchest wall masses by lack of ribinvolvement
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Secondary Pleural TumorsHematogenous metastases
breast, lung, unknown primary
Thymoma
Lymphoma
Metastatic Melanoma
c/o Julie Takasugi, VAMC
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Primary Pleural Tumors
Solitary fibrous tumor (SFT)
Mesothelioma
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Solitary Fibrous Tumor
No relationship to asbestos exposureMost benign, but 15-20% malignant3/4 arise from visceral pleura1/2 asymptomatic; others cause:
pain, cough, hypoglycemia, hypertrophic osteoarthropathy
Solitary fibrous tumor (large!)
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Solitary fibrous tumor
SFT withenhancingvessels
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Solitary fibrous tumor
Intrapulmonary SFT
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Benign SFT with enhancingblood vessels andpleural effusion
Benign SFT with calcification and inhomogeneous enhancement
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Recurrent malignant SFT
Mesothelioma
Epithelial, sarcomatous, or mixed
Associated asbestos exposure in 50%, most related to chrysotile
Latency 20 - 40 years
Symptoms--SOB, chest pain, cough, dyspnea, weight loss
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Mesothelioma
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Mesothelioma, also pleural plaque
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Mesothelioma
Effusion and nodular thickeninglikes to extend into fissures, little mediastinal shift
Plaque found in only 58% of mesotheliomas
Local invasion (11% at presentation)
chest wall, mediastinum, diaphragm
(Rare) lymphatic & hematogenous spread
DDX: metastatic adenocarcinoma, benign asbestos pleurisy