Chapter 12 Recognizing Diseases of the Chest

TABLE 12-1 CHEST ABNORMALITIES DISCUSSED ELSEWHERE IN THIS TEXT
Topic | Appears in |
---|---|
Atelectasis | Chapter 5 |
Pleural effusion | Chapter 6 |
Pneumonia | Chapter 7 |
Pneumothorax, pneumomediastinum, and pneumopericardium | Chapter 8 |
Cardiac and thoracic aortic abnormalities | Chapter 9 |
Chest trauma | Chapter 17 |
Mediastinal Masses



The mediastinum can be arbitrarily subdivided into three compartments: anterior, middle, and posterior, with each containing its favorite set of diseases. The anterior mediastinum is the compartment that extends from the back of the sternum to the anterior border of the heart and great vessels (dotted black outline). The middle mediastinum is the compartment that extends from the anterior border of the heart and aorta to the posterior border of the heart and origins of the great vessels (solid white outline). The posterior mediastinum is the compartment that extends from the posterior border of the heart to the anterior border of the vertebral column (solid black outline). For practical purposes, however, it is considered to extend into the paravertebral gutters.
Pitfall: Since these compartments have no true anatomic boundaries, diseases from one compartment may extend into another compartment. When a mediastinal abnormality becomes extensive or a mediastinal mass becomes quite large, it is often impossible to determine which compartment was its site of origin.

Anterior Mediastinum

TABLE 12-2 ANTERIOR MEDIASTINAL MASSES (“3 Ts and an L”)
Mass | What to Look For |
---|---|
Thyroid goiter | The only anterior mediastinal mass that routinely deviates the trachea |
Lymphoma (lymphadenopathy) | Lobulated, polycyclic mass, frequently asymmetrical, that may occur in any compartment of the mediastinum |
Thymoma | Look for a well-marginated mass that may be associated with myasthenia gravis |
Teratoma | Well-marginated mass that may contain fat and calcium on CT scans |
Thyroid Masses




Figure 12-2 Substernal thyroid mass.
The lower pole of the thyroid may enlarge but project downward into the upper thorax (white oval) rather than anteriorly into the neck. Classically, substernal thyroid goiters produce mediastinal masses that do not extend below the top of the aortic arch (solid white arrow). Substernal goiters characteristically displace the trachea (solid black arrow) either to the left or right above the aortic knob, a tendency the other anterior mediastinal masses do not typically demonstrate. Therefore, you should think of an enlarged substernal thyroid goiter whenever you see an anterior mediastinal mass that displaces the trachea.
Therefore, you should think of an enlarged substernal thyroid whenever you see an anterior mediastinal mass that displaces the trachea.



Figure 12-3 CT of a substernal thyroid goiter without and with contrast enhancement.
These are two images at the same level in a patient who was scanned both before (A) and then after intravenous contrast administration (B). A, On CT scans, substernal thyroid masses (solid white arrow) are contiguous with the thyroid gland, frequently contain calcification (dotted white arrow) and (B) avidly take up intravenous contrast but with a mottled, inhomogeneous appearance (solid white arrow). This mass is displacing the trachea (T) slightly to the left.
Lymphoma




On chest radiographs, this finding may help differentiate lymphadenopathy from other mediastinal masses.






Figure 12-4 Mediastinal adenopathy from Hodgkin disease.
Lymphadenopathy frequently presents with a lobulated or polycyclic border due to the conglomeration of enlarged nodes that produce the mass (solid white arrows). This finding may help differentiate lymphadenopathy from other mediastinal masses. Mediastinal lymphadenopathy in Hodgkin disease is usually bilateral (dotted white arrows) and frequently asymmetric.

Figure 12-5 CT of anterior mediastinal adenopathy in Hodgkin disease.
On CT, lymphomas will produce multiple, lobulated soft-tissue masses or a large soft-tissue mass from lymph node aggregation (solid white arrows). The mass is usually homogeneous in density, as in this case, but may be heterogeneous when the nodes achieve a sufficient size to undergo necrosis (areas of low attenuation, i.e., blacker) or hemorrhage (areas of high attenuation, i.e., whiter). The superior vena cava (SVC) is compressed by the nodes while the ascending (A) and descending aorta (Ao) are typically less so.
TABLE 12-3 SARCOIDOSIS VS. LYMPHOMA
Sarcoid | Lymphoma |
---|---|
Bilateral hilar and right paratracheal adenopathy classic combination | More often mediastinal adenopathy, associated with asymmetrical hilar enlargement |
Bronchopulmonary nodes more peripheral | Hilar nodes more central |
Pleural effusion in about 5% | Pleural effusion more common—in 30% |
Anterior mediastinal adenopathy is uncommon | Anterior mediastinal adenopathy is common |
Thymic Masses


Thymomas are associated with myasthenia gravis about 35% of the time they are present. Conversely, about 15% of patients with clinical myasthenia gravis will be found to have a thymoma. The importance of identifying a thymoma in patients with myasthenia gravis lies in the favorable prognosis for patients with myasthenia after thymectomy.



Figure 12-6 Thymoma, chest radiograph, and CT scan.
Thymomas are neoplasms of thymic epithelium and lymphocytes that occur most often in middle-aged adults, generally at an older age than those with teratomas. A, The chest radiograph shows a smoothly marginated anterior mediastinal mass (solid black arrow). B, Contrast-enhanced CT scan confirms the anterior mediastinal location and homogeneous density of the mass (solid white arrow). The patient had myasthenia gravis and improved following resection of the thymoma. (A = ascending aorta; Ao = descending aorta; PA = main pulmonary artery; SVC = superior vena cava.)
Teratoma



Figure 12-7 Mediastinal teratoma.
Teratomas are germinal tumors that typically contain all three germ layers. They tend to be discovered at a younger age than thymomas. The most common variety of teratoma is cystic, as in this case (solid white arrows). As shown here, they usually produce a well-marginated mass near the origin of the great vessels. On CT, they characteristically contain fat (solid black arrow), cartilage, and sometimes bone (dotted white arrow).
Middle Mediastinum



Figure 12-8 Middle mediastinal lymphadenopathy.
While lymphoma is the most likely cause of adenopathy in the middle mediastinum, other malignancies, such as small cell lung carcinoma and metastatic disease, as well as several benign diseases, can produce these findings. This patient has a mediastinal mass demonstrated on both the frontal (A) (solid white arrows) and lateral (B) views (solid black arrow). The mass is pushing the trachea forward (dotted white arrow) on the lateral view. The biopsied lymph nodes in this patient demonstrated small cell carcinoma of the lung.
Posterior Mediastinum


Neurogenic Tumors






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