Mediastinal mass differential diagnosis

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Mediastinal mass Microchapters

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Overview

Anatomy of Mediastinum

Causes

Differentiating Mediastinal Mass from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2]

Overview

The mediastinum is a non-delineated group of structures in the thorax (chest), surrounded by loose connective tissue. It is the central compartment of the thoracic cavity. It contains the heart, the great vessels of the heart, esophagus, trachea, thymus, and lymph nodes of the central chest. A wide variety of diseases involving mediastinal structures may present as a mediastinal mass or widening of the mediastinum on imaging studies. Mediastinal widening is diagnosed by the mediastinum measuring greater than 8 cm in width on PA chest x-ray. The mediastinal mass may present with symptoms or even without any symptoms. Mediastinal mass may cause a variety of symptoms by the mass pressing against surrounding mediastinal structures, collectively known as mediastinal syndrome. Mediastinal may can be differentiated depending on their location in mediastinal cavity into: Anterior mediastinal mass, middle mediastinal mass, or posterior mediastinal mass. Mediastinal mass may also be differentiated according to the content of the mass such as: cystic, fatty or solid (tumor).

Mediastinal Mass Differential Diagnosis

Wide variety of medical conditions can present as a mediastinal mass on radiological imaging.

ABBREVIATIONS: N/A: Not available, SOB: Shortness of breath, M/C: Most common, RI: Respiratory insufficiency, NM: Neuromuscular system, SVCS: Superior vena cava syndrome, SLE: Systemic lupus erythematosus disease, T3: Triiodothyronine, T4: Thyroxine, TSH: Thyroid stimulating hormone, TFT: Thyroid function test, MRI: Magnetic resonance imaging, CNS: Central nervous system, CSF: Cerebrospinal fluid, FNA: Fine needle aspiration, CBC: Complete blood count, COPD: Chronic obstructive pulmonary disease, AIDS: Acquired immune deficiency syndrome, HIV: Human immunodeficiency virus, Hep C: Hepatitis C virus, HTLV-1: human T-lymphotropic virus, EBV: Epstein Barr virus, HHV-8: Human herpes virus-8
Disease Causes/risk factors Clinical presentation Paraclinical findings
General symptoms Mediastinal syndrome
Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Anterior mediastinal mass
Tumors
Thymoma

[1][2][3]

+ + + Biopsy:
CT scan showing presence of voluminous expansive lesion of 6 cm in the upper anterior mediastinum without infiltration of surrounding tissues signs with modest enhancement. Case courtesy of Dr. Domenico Nicoletti (Picture courtesy: Radiopedia)
Associated condition
Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Fatty mass

[4][5]

- - - MRI:
  • Well-defined encapsulated mass
  • Extensive fat content
  • Small amounts of solid areas
  • Fibrous septa
Limited images of an MRI of the chest demonstrate the mass to be of fat density. Case courtesy of A.Prof Frank Gaillard (Picture courtesy: Radiopedia)
Fatty mass can be:
Non-Hodgkin lymphoma

[6][7][8]

+/- +/- +/- Excisional lymph node biopsy with immunohistochemical study
CT scan showing large anterior mediastinal mass. This is most likely lymphoma. Moderate pericardial effusion. Case courtesy of A. Prof Frank Gaillard (Picture courtesy: Radiopedia)
Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Hodgkin's lymphoma

[9][10][11][12][13]

Epstein-Barr virus

Family history

  • First-degree relatives
  • Siblings of the same sex

HIV infection

Autoimmune diseases

Immunodeficiency

Tobacco smoking

Systemic B symptoms:

Other

Mass effect

+ + +/- Lymph node biopsy with immunohistochemistry
CT scan showing A large soft tissue attenuation mass occupying the anterior mediastinal displaying homogeneous attenuation with low-density areas of cystic changes inside. It extends to the middle mediastinum to occupy the pretracheal space and involve the right hilum. Inferiorly it is inseparable from the anterior pericardium. Compression upon the SVC and encasement of the aorta and great vessels are noted. There is also mild right costal pleural thickening and enhancement suggesting infiltration with mild pleural effusion and abdominal retrocaval lymph nodes. Case courtesy of Dr. Ahmed Abdrabou (Picture courtesy: Radiopedia)
Positron emission tomography (PET)
  • Detect small deposits
  • Monitor the response to treatment
  • Detect recurrences
  • Measure the size of lymph nodes with precision
  • Assess for bone marrow involvement
Mediastinal germ cell tumor

(Non-teratomatous)

[14]

  • Exclusively in males
  • 20s - 40s age
+ - - Biopsy may help differentiate histopathological subtypes including:
CT scan showing A large heterogeneous anterior mediastinal mass, pathologically shown to be a germ cell tumor. Case courtesy of Radswiki (Picture courtesy: Radiopedia)
CT scan:

Laboratory finding:

Teratoma

[14][15][16][17]

Benign

Malignant

+/- +/- +/- Chest CT scan:
CT scan showing A large teratoma in anterior mediastinum. Case courtesy of Dr. Gagandeep Singh (Picture courtesy: Radiopedia)
  • N/A
Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Cystic mass
Thymic cyst

[14]

Congenital
  • Unilocular

Acquired

- - + Biopsy with histopathology and cytology
CT scan showing A thymic mass corresponds to a cystic lesion. Case courtesy of Dr. Stefan Ludwig (Picture courtesy: Radiopedia)
CT scan:
  • Oval shape
  • Smooth contour
  • Midline location
  • Calcified
  • Septate cyst
  • Fluid attenuation
Thyroid gland disease
Mediastinal goiter

[14][18][19]

+ + - Radioactive iodine scan:
CT scan showing A goitrous left lobe 9 cm in its greatest dimension (craniocaudal) extending posterior to the great vessels, 3.4cm below the top of the manubrium. The tracheal axis is shifted to the right and about 2cm below the cricoid cartilage, the trachea is compresssed for a length of 5cm, causing approx. 40% tracheal lumen cross sectional narrowing. Case courtesy of Dr Varun Babu Picture courtesy: Radiopedia)
Hyperactive gland (hyperthyroid):

Hypoactive gland (hypothyroid):

Normal functioning gland (euthyroid):

Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Middle mediastinal mass
Cardiovascular Disease
Pericardial effusion

[14][20][21][22]

+ +/- - Echocardiography guided pericardiocentesis:
CT scan showing pericardial effusion is evident (increased fluid-density around the heart) and this is the cause of the enlarged cardiac silhouette on chest x-ray. Numerous axillary and mediastinal lymph nodes. Case courtesy of A.Prof Frank Gaillard (Picture courtesy: Radiopedia)
Physical findings:

EKG:

Echocardiography:

Aortic dissection

[14][23][24][25][26]

+ +/- + MRI:
CT scan showing dilatation of aortic root, ascending aorta, aortic arch and descending aorta. An intimal flap is seen extending from the aortic root proximally to below the origin of the renal arteries distally dividing the aortic lumen into true and false lumens . Case courtesy of Dr Prashant Mudgal (Picture courtesy: Radiopedia)
TEE:

CTA:

Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Superior vena cava obstruction

[14][27][28][29]

Compression of SVC from: + + ++ Contrast-enhanced CT scan:
CT scan showing a large right upper lobe mass abuts the right brachiocephalic vein and SVC. Case courtesy of Dr Henry Knipe (Picture courtesy: Radiopedia)
Invasive contrast venography:
Partial anomalous pulmonary venous connection

[14][30][31][32]

+ - - MRI with contrast:
CT scan showing the anomalous origin of the right subclavian artery. traversing behind esophagus as it crosses midline from left to right. Case courtesy of Dr Piyush P Siwach (Picture courtesy: Radiopedia)
Associated with

Cardiac catheter:

PFT:

  • Normal despite of severe SOB
Gastrointestinal tract disease
Esophageal achalasia

[33][34][35][36]

+ + - High resolution manometry (HRM):
  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis
  • High intra-esophageal pressure (due to stasis of food)
CT scan showing uniform dilatation of the esophagus with air-fluid level. Patchy consolidation in the upper segment of the right lower lobe likely due to aspiration. Case courtesy of Dr Hani Salam (Picture courtesy: Radiopedia)
X ray:
  • "Bird's beak image" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level due to absent peristalsis
  • Absence of gastric air bubble
  • In advanced achalasia - sigmoid appearance

CT scan:

Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Esophageal cancer

[37][38][39][40][41]

- + - Endoscopy with biopsy:
CT scan showing irregular circumferential thickening of the mid oesophagus with oesophageal dilatation of the proximal segment, invasion of the adjacent right pleura, periosteal reaction without definite invasion of the right 2nd and 3rd ribs, subcarinal lymph node and multiple bilateral metastatic pulmonary nodules Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: Radiopedia)
Barium swallow:
  • Tapering stricture known as a "rat's tail"
  • Irregular stricture
  • Pre-stricture dilatation
  • Shouldering

CT scan:

Esophageal rupture

[42][43][44][45][46][47][48]

Mackler's triad:

Other:

Patients with cervical perforations can present with

+ + - Esophagogram:
CT scan showing extensive pneumomediastinum and fluid in the mediastinum. Proximal oesophagus is air-filled and distended to the level of T7 and after this it is largely collapsed. Moderate sized bilateral pleural effusions and a small right apical pneumothorax. Severe centrilobular emphysema. Case courtesy of RMH Core Conditions (Picture courtesy: Radiopedia)
CT scan:
Hiatus hernia

[49][50]

  • 50 or older age
- + - High resolution manometry with esophageal pressure topography (EPT):
CT scan shows herniation of stomach into the thorax through the hiatus with displacement of gastro-oesophageal junction. Case courtesy of DrDrsmail Kabakus (Picture courtesy: Radiopedia)
Ultrasound:

Ultrasound in pediatric population:

CT scan:

Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Pulmonary disease
Hilar lymphadenopathy

[51][52][53][54]

Lymphadenopathy: Constituitional symptoms like: + - - Lymph node biopsy and histopathology
CT scan shows bi-hilar lymphadenopathy and reticulonodular infiltrates. Case courtesy of Dr Ruslan Asadov (Picture courtesy: Radiopedia)
CT scan
Pneumomediastinum

[55][56][57][58][59][60][61]

+ - - CT scan:

Pediatric pneumomediastinum:

  • Thymic wing sign: Elevated thymus
  • Haystack sign (the heart appears like a haystack in a Monet painting)
CT scan shows extensipneumomediastiumium is demonstrated throughout the chest with no pneumothorax. Case courtesy of A.Prof Frank Gaillard Picture courtesy: Radiopedia)
Physical exam:
Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Sarcoidosis

[62][63][64][65]

Genetic factors

Immune system

  • Higher expression of serum amyloid A
  • Immune system exhaustion and failure of effective antigen clearence

Drug side effect

Cutaneous sarcoidosis

Ocular sarcoidosis

Upper respiratory tract

Cardiac sarcoidosis

Neurosarcoidosis

Reticuloendothelial system

Musculocutaneous

Lofgren syndrome

Exocrine glands

Renal & electrolyte

+ - - Endoscopy with biopsy and histopathology
CT scan shows extensive calcified lymph nodiiniin mediastinum, extensive architectural distortion of lung tissue, associated with marked fibrosis. Multiple pulmonary nodules are present in both lungs. Case courtesy of Prof Oliver Hennessy (Picture courtesy: Radiopedia)
Laboratory findings:
  • Serum ACE levels greater than two times the upper limit of normal

CT scan:

  • Honeycombing
  • Parenchymal nodules and opacities along bronchovascular bundles as well as in subpleural locations
Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Infectious disease
Mediastinitis

[66][67][68][69]

Infection:

Risk factors:

+ - - Culture and sensitivity of mediastinal tissue collected by biopsy/aspiration
CT scan shows airway narrowing of the right lower lobe bronchus. There is thickening of the right pleura and right interlobular septae. There are partially calcified right hilar and mediastinal lymph nodes. Case courtesy of Dr Darel E Heitkamp (Picture courtesy: Radiopedia)
Physical exam

CBC

CT scan

Anthrax

[70][71]

B. anthracis

People at higher risk include

  • Veterinarians
  • Laboratory professionals dealing the bacteria
  • Health care workers
  • Livestock producers
  • People who handle animal products
  • Mail handlers, military personnel, and response workers, in case of bioterrorism
  • People who make or play animal hide drums
  • Travelers, particularly to the follow areas:
    • Central and South America
    • Sub-Saharan Africa
    • Central and southwestern Asia
    • Southern and eastern Europe
    • The Caribbean

Inhalation or pulmonary anthrax

+ - - Culture and sensitivity:
CT scan shows showing bilateral pulmonary consolidation (yellow arrows) and pleural effusions (blue arrows). Case courtesy and picture courtesy: Centers for Disease Control and Prevention
CT scan

PCR

Tuberculosis

[72][73]

M. tuberculosis

Traveling or living in endemic regions (Sub-saharan African, Russia, India, Pakistan, China)

Immunosuppression:

The risk of contracting TB increases in:

+ - - Culture and sensitivity
CT scan shows the cavity (arrows) and extensive endobronchial spread particularly within the left upper lobe (Circle). In places there is a tree-in-bud appearance. Case courtesy of DDrNatalie Yang (Picture courtesy: Radiopedia)
Chest X-ray

Primary tuberculosis

Secondary Tuberculosis

  • Consolidation involves more than one lobe
Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Cystic mass
Bronchogenic cyst

[14]

+ - - CT scan
CT scan shows a large fluid density cystic structure abutting the right side of the superior mediastinum without evidence of invasion into either the mediastinum or the lung. It is well circumscribed and has appearances most consistent with a bronchogenic cyst. Case courtesy of Dr Gagandeep Choudhary (Picture courtesy: Radiopedia)
CT scan:
Esophageal duplication cysts

[14][74][75]

- + - Endoscopic ultrasound (EUS)
  • Distinguish between solid and cystic lesions
  • Periesophageal homogeneous-hypoechoic mass
  • Multi-layered wall and well-defined margins
  • Anechoic cyst if considerable central fluid present
CT scan shows in the posterior mediastinum, to the left of the esophagus and below the level of the carina is a low attenuation (20 HU), a non-enhancing mass which abuts and displaces the esophagus to the right side. Appearance and location are suggestive of foregut duplication cyst. Case courtesy of Dr Alexandra Stanislavsky (Picture courtesy: Radiopedia)
Endoscopic ultrasound-guided FNA

Endoscopy

Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Lymphangioma

[14]

+ + - Histopathology and cytology
CT scan shows cystic mass which was located on the posterior to the lower esophagus later diagnosed as thoracic duct lymphangioma. Source:Case courtesy of Jin San Bok et al, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital

MRI:

  • Degree of involvement and extent of lesion
  • MRI can prevent extensive, incomplete surgical resection

CT scan:

Chronic inflammatory disease
Churg-Strauss syndrome

[76][77][78][79][80]

+ +/- - Lung biopsy

4 out of 6 positive :

CT scan shows peripheral consolidation / ground glass opacity and solid centrilobular nodulesnon-cavitateded), except the left part which underwent slight changes with now a moderate pleural effusion. Case courtesy oDrDr Fabien Ho (Picture courtesy: Radiopedia)

High-resolution computerized tomography (HRCT):

Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Posterior mediastinal mass
Cystic mass
Mediastinal neurenteric cyst

[14][81][82]

+ +/- - CT scan:
CT showing a well-defined posterior mediastinal cystic lesion (highlight) is seen with air-fluid levels showing mucosal enhancement. A cystic mass is extending in between and is displacing descending thoracic aorta anteriorly (curved arrow), azygous vein posteriorly (straight arrow). Source: Case courtesy of Taruna Yadav et al
Postnatal chest X-ray:

Ultrasound:

Pancreatic pseudocyst

[14][83]

- - - Histopathology and cytology of cyst and fluid content
CT scan showing a low attenuating thick walled peripherally enhancing cystic lesion, measuring approximately 5.2 x 2.8 cm noted in the lower aspect of posterior mediastinum and appears to arise adjacent to the esophageal hiatus and extending up to the carina. Case courtesy of Dr Prashant Mudgal (Picture courtesy:Radiopedia)
CT scan
  • Thin-walled
  • Fluid-containing cyst within the posterior mediastinum
  • In continuity with the intrapancreatic or peripancreatic fluid collections
Disease Etiology Symptoms Dyspnea/

RI

Dysphagia SVCS Gold standard Image Additional findings
Central nervous system disease
Meningocele

[84][85][86][87][88][89]

Maternal nutritional factors

Environmental factors

Symptoms depend on the severity of the defect

Orthopedic abnormalities:

Difficulties with executive functions including:

- - - Prenatal 2D/3D ultrasound:

Postnatal MRI

CT scan showing Right thoracic CSF cyst with smaller left sided out-pouching. Case courtesy of Dr G Balachandran (Picture courtesy: Radiopedia)
Laboratory tests:

MRI:

Neurilemmoma

(Spinal schwannoma)

[90][91]

- - - Biopsy with histopathology
CT scan showing a soft tissue density lesion within the left posterior mediastinum, in a paravertebral location. The lesion is closely related to the left neural exit foramen, but there is no definite extension into the spinal canal. The lesion does extend into the intercostal space. Case courtesy of Dr Paul Leong (Picture courtesy:Radiopedia)
MRI
  • Tumor outside of a nerve or part of a nerve and if it involves other nearby structures
ABBREVIATIONS: N/A: Not available, SOB: Shortness of breath, M/C: Most common, RI: Respiratory insufficiency, NM: Neuromuscular system, SVCS: Superior vena cava syndrome, SLE: Systemic lupus erythematosus disease, T3: Triiodothyronine, T4: Thyroxine, TSH: Thyroid stimulating hormone, TFT: Thyroid function test, MRI: Magnetic resonance imaging, CNS: Central nervous system, CSF: Cerebrospinal fluid, FNA: Fine needle aspiration, CBC: Complete blood count, COPD: Chronic obstructive pulmonary disease, AIDS: Acquired immune deficiency syndrome, HIV: Human immunodeficiency virus, Hep C: Hepatitis C virus, HTLV-1: human T-lymphotropic virus, EBV: Epstein Barr virus, HHV-8: Human herpes virus-8

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