Clinical Radiology 76 (2021) 477e487

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Clinical Radiology
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Pictorial Review

The paediatric thymus: recognising normal and

ectopic thymic tissue
T. Wee a, *, A.F. Lee b, c, H. Nadel d, H. Bray a, e
a
Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
b
Department of Pathology, BC Children’s Hospital, Vancouver, British Columbia, Canada
c
Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
d
Department of Radiology and Division of Nuclear Medicine, Lucile Packard Children’s Hospital at Stanford
University, Stanford, CA, USA
e
Department of Radiology, BC Children’s Hospital, Vancouver, British Columbia, Canada

art icl e i nformat ion

The appearance of the paediatric thymus changes as the normal process of thymic involution
Article history: occurs. Thymic tissue may be orthotopic within the anterior mediastinum or ectopically
Received 1 October 2020 located along the course of its embryological development. The variable appearance of
Accepted 11 February 2021 orthotopic and ectopic thymic tissue in children on imaging studies may lead to misinter-
pretation of the normal thymus as pathology. Recognition of normal thymic tissue can mitigate
unnecessary further diagnostic testing and patient anxiety.
In this review, we discuss the embryological development and anatomical variants of normal
thymus, and demonstrate the multimodality imaging features of the normal thymus in chil-
dren, including positron-emission tomography, and diffusion-weighted imaging and in- and
opposed-phase imaging on magnetic resonance imaging. We demonstrate the normal thymus
mimicking pathological processes and discuss features that distinguish normal thymus,
including thymic rebound hyperplasia, from pathology.
Ó 2021 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction
The thymus is an important lymphatic organ playing a
major role in the development of the adaptive immune
system. It arises during the 6th week of gestation primarily
from the third pharyngeal pouch with minimal contribution
from the fourth pharyngeal pouch bilaterally.1 The thymic
primordia form thymopharyngeal ducts at the 7th week of
gestation, which then descend caudally and medially to the
anterior mediastinum bilaterally (Fig 1).2 The lobes of the
thymus fuse at the 8th week of gestation and rest on the
anterosuperior aspect of the heart and the great vessels,
while the thymopharyngeal ducts involute.1 It is only at the
10th week of gestation that lymphoid cells migrate to the
thymus from the liver and bone marrow for T cell lym-
phopoeisis.1 As it has the greatest activity during childhood,
the thymus continues to grow in size during the neonatal
and post-natal period, reaching its greatest volume at pu-
berty.1 Subsequently, the thymic tissue involutes leading to
a reduction in its size and replacement of thymic soft tissue

* Guarantor and correspondent: T. Wee. Gordon and Leslie Health Care Centre, 11141-2775, Laurel St., Vancouver, BC, V5Z 1M9, Canada.
E-mail address: t.wee@alumni.ubc.ca (T. Wee).

https://doi.org/10.1016/j.crad.2021.02.017
0009-9260/Ó 2021 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
478 T. Wee et al. / Clinical Radiology 76 (2021) 477e487

Figure 1 (a) Thymus development at 6 weeks gestational age. The bilateral third pharyngeal pouches (pink appendages) form the thymic
primordia, which become the thymopharyngeal ducts. The ducts descend caudally and medially (purple arrows) to fuse at the anterior
mediastinum. (b) Normal variant locations of ectopic thymus (green structures) can be anywhere along the pathway of descent of the thy-
mopharyngeal duct, including submandibular and intrathyroidal locations. The normal thymus can also extend above the manubrium as a
cervical thymus, abutting the thyroid gland.

with fat.1,3 The process of involution continues to adult-
hood, with complete fatty replacement found in 50% of
adults >40 years of age.4 Although these age-related
changes to the thymus are well-described, the appearance
of the normal thymus in children can be quite variable and
can cause diagnostic confusion. This is further complicated
by individual anatomical variants, which include the pres-
ence of ectopic thymic tissue within the neck and thyroid. In
children, prior to thymic involution, these anatomical var-
iants can be mistaken for pathological masses leading to
extensive diagnostic work-up.
Although the reference standard for diagnosis of cervical
and mediastinal masses in children is biopsy with patho-
logical confirmation, radiological advances have made it
possible to differentiate normal thymic tissue from patho-
logical processes. Therefore, a thorough understanding of
the appearance of the thymus in children on various im-
aging modalities can mitigate the need for unnecessary
procedures and patient anxiety.5e9 This review will discuss
normal anatomical variants of the thymus and the normal
multimodality imaging features of the thymus in children.
Distinguishing features that aid in the correct identification
of normal thymic tissue will be discussed. Institutional
ethics review board approval to supplement the literature
review with anonymised local patient images was obtained.
Normal anatomical variants of the thymus in
children
Although thymic tissue is primarily found in the anterior
mediastinum, it can be found anywhere along the course of
the embryonic thymopharyngeal ducts from the angle of
the mandible to the anterior mediastinum (Fig 1b). Ectopic
thymus is the term used to describe thymic tissue lying
outside of the anterior mediastinum. Common locations of
ectopic thymus include the submandibular region
anteromedial to the sternocleidomastoid muscle, some-
times within the carotid sheath adhering to the carotid ar-
tery, jugular vein, vagus nerve, and recurrent laryngeal
nerves, within the thyroid gland and rarely in the retro-
pharyngeal region.5,10e17 Cervical extension of thymus is
extension of the orthotopic anterior mediastinal thymus
above the manubrium, often extending to the inferior pole
of the thyroid. Submandibular ectopic thymic tissue may
present as an asymptomatic palpable mass. Intrathyroidal
thymic tissue and cervical extensions of the thymus are
usually detected incidentally on imaging studies. Intra-
thyroidal thymus is most commonly found in the middle or
inferior portion of the thyroid, occasionally with tissue
connecting it to the orthotopic thymus, aiding in its iden-
tification. Foci of ectopic thymus are attributed to the failure
of remnants of the thymopharyngeal ducts to descend or to
involute during development. Sequestration of thymic tis-
sue during its descent may lead to complete absence of the
orthotopic thymus.18
The reported prevalence of ectopic thymus is highly
variable, ranging from 0.4e66.5%.5,6,12,13,15,16,19e21 The
largest population study to date investigating the preva-
lence of intrathyroidal thymus arose from the Fukushima
Health Survey, which included 360,000 children <18 years
of age who resided in the Fukushima prefecture during the
nuclear reactor accident on 11 March 2011.21 With 37,812
screening neck ultrasounds conducted from October 2011 to
March 2012, the study found a prevalence of 0.99% (375/
360,000).21 Furthermore, similar to other studies, they
found its prevalence to decrease with increasing
age.12,13,21,22 Most studies have found a left-sided predom-
inance, regardless of location.5,6,15,22,23 Reports of bilateral
ectopic thymus have been described.5,17,19,21 Although most
patients with ectopic thymus are asymptomatic, there are
reported cases of ectopic thymus causing dyspnoea, stridor,
hoarseness, and dysphagia.10,11,24e26 The recommended
management of ectopic thymic tissue is “watchful waiting”
 T. Wee et al. / Clinical Radiology 76 (2021) 477e487
anticipating thymic involution unless the patient is symp-
tomatic with dysphagia and/or severe respiratory symp-
toms; however, due to diagnostic difficulty, most reports of
ectopic thymus in the literature were confirmed
postoperatively.7,24,27e30
Thymic rebound hyperplasia
The thymus can undergo acute involution with reduction
of thymic volume in response to stressful biological condi-
tions, which include chemotherapy, systemic corticosteroid
treatment, and malnutrition.1 Choyke et al. observed this
phenomenon in patients with various types of malignancy
who were undergoing chemotherapy, which was followed
by thymic rebound hypertrophy after cessation of chemo-
therapy.31 Thymic rebound has been defined as an
enlargement of thymic tissue by >50% of its size prior to
initiation of treatment. In addition to malignancy, it has
been observed to occur with treatment of rheumatoid
arthritis, pneumonia, and Cushing’s syndrome.32e34 Both
orthotopic thymus and ectopic thymus can undergo
rebound hyperplasia.35,36 Its onset varies; rebound has been
observed to occur 2 months or earlier from initiation of
treatment to as late as 15 months after completing
treatment.31,34,36e39 The rate of regression of thymic
rebound is also variable.32,39,40 Although the characteristics
of thymus rebound would be expected to be similar to
normal thymus, Tian et al. showed that most of the anterior
mediastinal rebound thymus slightly displaces blood ves-
sels.39 Despite the extensive description of this phenome-
non in the literature, especially post-chemotherapy, it often
causes diagnostic confusion due to concerns of disease
recurrence. The use of advanced imaging techniques has
greatly aided the process of distinguishing thymic rebound
hyperplasia from other disease processes in adults. These
techniques have been less applicable to paediatric thymus
imaging as the paediatric thymus is composed of soft tissue
as opposed to the largely fatty thymus in adults; however,
the use of multimodal imaging features can clarify the
diagnosis.
Imaging features of the normal paediatric
thymus
Radiography
The paediatric thymus may be prominent and mistaken
for a mediastinal mass on chest radiographs. As thymic
tissue is soft and pliable, it readily conforms to the shape of
its surrounding structures. Orthotopic anterior mediastinal
thymus appears as a homogeneous soft-tissue structure
with smooth undulating margins at the reflection of the
anterior ribs, producing the “wave sign”, and sharply
demarcated by the minor fissure of the right lung, produc-
ing the “sail sign” (Fig 2a). The prominent thymus can
juxtapose the heart thereby mimicking cardiomegaly;
however, the presence of a “notch sign” indicates the infe-
rior extent of the thymus adjacent to the heart (Fig 2b).
479
Normal orthotopic thymus can also be elevated by air in the
mediastinum, mimicking pathological lung or mediastinal
opacity on both frontal and lateral chest radiographs, in
what is known as the “spinnaker sign” (Fig 2c and d).
Normal thymic tissue usually has no mass effect on adjacent
tissues. If anterior mediastinal soft tissue exerts mass effect
on other mediastinal structures, or is not homogeneous in
attenuation, an anterior mediastinal mass such as germ cell
tumour, lymphoma, Langerhans cell histiocytosis, or thy-
moma should be considered (Fig 3); however, there have
been cases where normal thymic tissue has compressed the
oesophagus or the airway, prompting further evalua-
tion.10,11,26 In contrast, the adult thymus should be involuted
and inconspicuous on chest radiographs.
Ultrasonography
Ultrasound is the imaging method of choice in the
investigation of neck masses in children as it does not
require exposure to ionising radiation, is readily available in
most institutions and can be performed without sedation in
young children. Recognition of ectopic normal thymic tissue
on sonography can exclude malignant processes and reas-
sure patients. On sonography, thymic tissue is homoge-
neous and hypoechoic with multiple diffuse linear or
branching hyperechoic foci that produce a “starry sky” or
“dot and dash” appearance (Fig 4a).41 This is a consistent
finding regardless of location of thymic tissue. Although
ectopic intrathyroid thymus may mimic malignant thyroid
nodules with microcalcifications, a distinguishing feature is
the lack of associated acoustic shadowing from the hyper-
echoic foci in ectopic thymic tissue (Fig. 4bed). Further-
more, when it has an intrathyroid location, ectopic thymus
has well-defined margins and a fusiform shape (Fig 4c).6 On
Doppler sonography, thymic tissue can either be hypo-
vascular or similar in vascularity to the surrounding thyroid
gland.16 Due to its malleability, its shape changes with
respirations or cardiac contractions particularly for the
orthotopic thymus.41 Ectopic cervical or intrathyroid
thymus can occasionally have tissue connecting it to the
mediastinal thymus, aiding in its identification, while so-
nography readily identifies the cervical extension of
orthotopic thymus (Fig. 4cee).
CT
Computed tomography (CT) may be used for investiga-
tion of neck and mediastinal masses due to ease of acqui-
sition. Contour of the orthotopic anterior mediastinal
thymus on cross-sectional imaging varies with patient age.
At its maximal volume during childhood, the thymus has a
quadrilateral shape with convex borders (Fig 5a). As it be-
gins to involute and reduce in volume, it forms a triangular
shape with convex or straight borders (Fig 5b). By adoles-
cence, the thymus appears as a thin band of tissue anterior
to mediastinal vascular structures. Similar to observations
on other imaging modalities, the thymus typically moulds
to the contours of the mediastinum and other surrounding
structures without deforming or compressing them.42
480 T. Wee et al. / Clinical Radiology 76 (2021) 477e487

Figure 2 Normal thymus on chest radiographs of neonates. (a) A 2-month-old male patient with a prominent thymus displaying the “sail sign”
(arrow). The “wave sign” (arrowhead) is also seen. (b) Female neonate with the orthotopic thymus over the cardiac silhouette creating the
appearance of cardiomegaly. The presence of the “notch sign” (arrow) delineates the inferior border of the thymus from the heart. Male neonates
with a large pneumomediastinum, elevating the thymus and producing the “spinnaker sign” (arrows) on (c) lateral and (d) frontal radiographs.

Figure 3 Male neonate presenting with grunting and respiratory distress at birth. (a) Frontal and (b) lateral chest radiographs demonstrate
anterior mediastinal soft-tissue mass (white arrows) causing posterior displacement and compression of the trachea (black arrow). (c) Trans-
verse contrast-enhanced CT image demonstrates a heterogeneous multiseptate cystic mass arising from left lobe of thymus (arrow), displacing
mediastinal vascular structures posteriorly and to the right. Normal thymic tissue is present in the right anterior mediastinum (arrowhead).
Histology confirmed mass to be a germ cell tumour.
 T. Wee et al. / Clinical Radiology 76 (2021) 477e487 481

Figure 4 Ultrasound of normal orthotopic and ectopic thymus. (a) Normal anterior mediastinal thymic tissue on echocardiogram in a young
child. The normal orthotopic thymus (arrow) is hypoechoic with linear hyperechoic foci giving the “starry-sky” appearance. The thymus con-
forms to the contour of the underlying aortic arch and brachiocephalic vein (arrowhead) with no mass effect. (b) Screening thyroid ultrasound of
a healthy 4-year-old male patient. Intrathyroidal thymic tissue (arrow) is seen on transverse neck ultrasound with the characteristic appearance
of normal thymic tissue. (c) Sagittal view demonstrates intrathyroidal thymic tissue within the midpolar region of left lobe of thyroid (arrow),
and cervical thymus (arrowhead) extending to the inferior thyroid pole. Fine-needle aspiration biopsy of the intrathyroid lesion confirmed the
presence of normal lymphoid tissue, and its appearance remained stable over 4 years of ultrasound follow-up. A 4.5-year-old male patient
undergoing neck ultrasound for palpable cervical nymph nodes with incidentally detected intrathyroid (arrow) and cervical thymus (arrow-
heads) abutting the lower pole of the thyroid gland on (d,e) sagittal neck ultrasound images.

When mass effect is present, other pathological anterior
mediastinal masses must be considered (Fig 6).
On unenhanced CT, the attenuation of the normal thymic
tissue decreases with age.43 The study by Sklair-Levy et al.
found the thymus at <1 year of age to have a mean attenu-
ation value of 80.8
5.7 HU and to be hyperdense compared
to the chest wall and the myocardium.43 As age increases, the
mean thymus attenuation decreases, becoming isodense to
the chest wall and the myocardium.43 The thymus has ho-
mogeneous attenuation in children <10 years of age, but
becomes heterogeneous after puberty due to the inter-
spersed fat in the thymus soft tissue as involution pro-
gresses.4 Following contrast medium administration, thymic
tissue exhibits mild enhancement regardless of its
location.8,42
Thymic rebound hyperplasia has similar imaging fea-
tures to the normal orthotopic thymus with similar CT
attenuation and contrast-enhancement characteristics.36,40
Thymic rebound hyperplasia displays diffuse enlargement
without a lobular appearance, differentiating it from
aggressive pathologies, such as lymphoma.39,40,44
MRI
Thymic tissue in children has homogeneous signal in-
tensity on magnetic resonance imaging (MRI), slightly
482 T. Wee et al. / Clinical Radiology 76 (2021) 477e487

Figure 5 Normal orthotopic thymus on chest CT. (a) Contrast-enhanced transverse CT image of a 6-month-old female patient with a prominent
biconvex normal thymus (arrows). (b) Transverse image from contrast-enhanced CT in an 11-year-old male patient shows partially involuted
orthotopic thymus with straight borders (arrows).

hyperintense to muscle and hypointense to fat on T1-
weighted imaging (T1WI; Fig 7a), and slightly hyperin-
tense to muscle and isointense to fat on T2-weighted im-
aging (T2WI).27,28,44,45 It also demonstrates mild contrast
enhancement with gadolinium.9 On both T1WI and T2WI
sequences, normal thymic signal intensity increases with
age and increasing fat content associated with thymic
involution46; however, fat-saturated T1WI and T2WI se-
quences are not sufficiently sensitive to microscopic fat to
cause signal suppression in normally involuting thymus,
with thymic tissue remaining hyperintense to muscle and
liver on fat saturated T1WI and T2WI (Fig 7b).37
Additional MRI sequences that detect the presence of
microscopic fat can confirm the presence of normal invo-
luted thymus to differentiate it from malignancy. In- and
opposed-phase T1WI better detects microscopic fat in the
normal involuting thymus, with loss of signal intensity on
opposed-phase images; however, there is no observed
signal intensity loss in the normal thymus of patients <10
years of age due to its high cellularity, limiting utility of in-
and opposed-phase T1WI in differentiating the normal
paediatric thymus from malignancy in young children.47
Above the age of 10, there are age-related differences in
signal intensity loss of normal thymus, with a positive
correlation between patient age and thymic signal intensity
loss, as expected due to the normal process of thymic fatty
involution (Fig 8).47
The normal adult thymus has lower cellularity and
higher fat content resulting in unrestricted diffusion and
high apparent diffusion coefficient (ADC) values on
diffusion-weighted MRI (DWI; Fig 7c and d); however,
similar to signal intensity loss, there are age-related differ-
ences in ADC of the normal thymus due to higher thymus
cellularity at a younger age.48 Thus, the normal paediatric
thymus may have restricted diffusion, as previously re-
ported, and as observed in Fig 9.9 These examples highlight

Figure 6 A 15-year old female patient with fatigue and weakness. (a) Frontal and (b) lateral chest radiographs demonstrate a left anterior
mediastinal mass (arrows). (c) Transverse contrast-enhanced CT image demonstrates a heterogeneous soft-tissue mass arising from left lobe of
thymus (arrow) displacing the left pulmonary artery posteriorly and causing atelectasis in the left upper lobe. The right lobe of thymus
(arrowhead) has normal size and contour for age. Histology confirmed mass to be thymoma.
 T. Wee et al. / Clinical Radiology 76 (2021) 477e487 483

Figure 7 Chest MRI of 4.5-year-old male patient to exclude the presence of thymoma. Coronal images of the orthotopic thymus on MRI with
cervical extension representing a cervical thymus. (a) T1WI of the orthotopic thymus shows that it is mildly hyperintense to muscle and
hypointense to fat. (b) T2WI with fat saturation shows the orthotopic thymus is mildly hyperintense to the liver and the muscle, and does not
saturate on fat saturation sequence, as expected of the paediatric thymus. (c) Transverse DWI (b ¼ 800) image of the chest with the (d) cor-
responding ADC map indicates unrestricted diffusion of the normal orthotopic thymus.

the pitfall of using in- and opposed-phase imaging and DWI
in identifying the normal paediatric thymus.
Nuclear medicine/positron-emission tomography
Metabolic activity can be used to discriminate between
malignancy and normal tissue, and is therefore a useful
means for differentiating thymic rebound and malignancy
recurrence. Currently, gallium- and thallium-based imaging
are not frequently used to discriminate between the normal
thymus and malignancy as there have been multiple case
reports of gallium- and thallium-avid thymic rebound
hyperplasia.49e51 On positron-emission tomography (PET),
the thymus is typically mildly physiologically avid on 2-
484 T. Wee et al. / Clinical Radiology 76 (2021) 477e487

Figure 8 A 12-year-old female patient who was being investigated for chronic cough. (a) Frontal chest radiograph shows a widened medias-
tinum (arrowheads), raising concerns for lymphoma. Opposed (b) and in-phase (c) T1WI performed for work-up of the widened mediastinum
(arrow) revealed mild signal intensity loss of the anterior mediastinal tissue on opposed-phase imaging. Biopsy confirmed thymic hyperplasia.

Figure 9 Incidentally detected submandibular mass while investigating facial asymmetry in a 1-month old male. (a) Transverse T1W image of
neck with fat saturation reveals a homogeneous left submandibular lesion (arrow) that does not saturate, while it is mildly hyperintense to
muscle on (b) T2WI. (c) DWI (b ¼ 1000) of the head with (d) the corresponding ADC map shows a left-sided diffusion restricting lesion (arrow).
(e) Neck ultrasound of the left-sided lesion (arrows) localised the mass between the internal carotid artery and internal jugular vein without
displacement of the vessels. The hypoechoic well-circumscribed mass has the typical ultrasound appearance of thymic tissue.
 T. Wee et al. / Clinical Radiology 76 (2021) 477e487 485

Figure 10 18F-FDG PET/CT pre- and post-treatment of a metastatic abdominopelvic germ cell tumour to the anterior mediastinum in a 10-year-
old female patient. At presentation, (a) transverse CT, PET, and fused PET/CT images demonstrate a highly FDG-avid centrally necrotic anterior
mediastinal mass. The patient underwent chemotherapy and complete surgical resection of the residual anterior mediastinal metastasis. (b)
Transverse CT, PET, and fused PET/CT performed 9 months after completion of treatment shows a new mediastinal soft-tissue mass with trace
FDG avidity similar to the orthotopic thymus. Diagnosis of normal thymic rebound was confirmed with endobronchial ultrasound-guided biopsy
of the soft-tissue mass.

[18F]-fluoro-2-deoxy-D-glucose (FDG) imaging. In conjunc-
tion with CT imaging, the anatomical appearance and
attenuation pattern can help identify the normal thymus in
many patients, including thymic rebound hyperplasia
(Fig 10).
There have been reported age-related changes in phys-
iological thymic FDG uptake due to innate changes in the
activity of the organ over time. The mean maximum SUV
(SUVmax) of normal orthotopic thymus in the paediatric
population is < 3, while most adults have undetectable
levels of uptake in the thymus.52e54 Although this
threshold has generally been used to differentiate thymic
rebound hyperplasia from disease recurrence, there seems
to be much greater variability in the SUVmax of thymic
rebound hyperplasia as it ranges from 1.2e4.2, limiting its
discriminatory ability.40,54,55 Some have suggested that the
pattern of uptake may aid in diagnosis of rebound hyper-
plasia, which is generally diffuse, but thymomas and
thymic carcinomas may similarly present with either pat-
chy or diffuse patterns of uptake.56 One of the most
consistent means of identifying normal orthotopic thymus
is by recognising its characteristic bi-lobed appearance in
the anterior mediastinum with mild FDG avidity. Some
studies have used this feature to determine the presence of
thymic rebound hyperplasia, which was supported by
follow-up PET imaging that showed either unchanged or
resolved FDG avidity.32,55
Conclusions
The thymus is largest early in life, but can also be
enlarged following illness. Normal thymus in children, both
orthotopic in the anterior mediastinum and ectopic in the
neck and thyroid, may be mistaken for pathological pro-
cesses. Regardless of its location, radiologists must be
familiar with the normal imaging features of the paediatric
thymus on radiographs, ultrasound, CT, MRI, and PET, to
mitigate unnecessary diagnostic investigation and anxiety
for patients and their families. Lesions suspected to be
486 T. Wee et al. / Clinical Radiology 76 (2021) 477e487
normal thymic tissue can be observed rather than biopsied
or resected.
Ultrasound is the ideal first-line imaging modality in the
investigation of paediatric neck masses, and readily iden-
tifies the normal thymus in ectopic areas within the neck
and thyroid, or the cervical extension of the anterior
mediastinal thymus. Ultrasound remains the most consis-
tent of all modalities in identifying the normal thymus as
thymic tissue has a characteristic sonographic appearance;
however, its utility is limited to the characterisation of neck
masses.
Outside of early childhood when characteristic radio-
graphic features can distinguish the normal thymus from
pathological processes, cross-sectional imaging may be
necessary to characterise mediastinal tissue. The CT charac-
teristics of the thymus are relatively unchanged in adults and
children apart from size and shape of the thymus. Compared
to adults, MRI has less discriminatory value in differentiating
malignancy from the normal thymus due to the greater
cellularity and minimal fat content of the paediatric thymus.
This can lead to greater diffusion restriction and low ADC in
the normal paediatric thymus. There is also limited fat sup-
pression, limiting the use of inversion recovery and in- and
opposed-phase MRI. PET/CT will show variable physiological
FDG uptake, but may be useful in differentiating malignancies
with high metabolic activity from thymic hyperplasia. Further
investigation and development of nomograms of ADC, signal
intensity loss and SUV values in the normal thymus from birth
through adolescence will assist in distinguishing the normal
thymus from malignant tissue at all stages of childhood on
MRI and PET/CT.
Conflict of interest
The authors declare no conflict of interest.
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