COMPUTED TOMOGRAPHIC EVALUATION OF MEDIASTINAL LESIONS by

Dr. K.R. PRASAD

Dissertation submitted to RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, in partial fulfillment of university regulations for the award of

M.D. DEGREE IN RADIO-DIAGNOSIS

Under the guidance of

Prof H. SATISHCHANDRA

DEPARTMENT OF RADIO-DIAGNOSIS BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE BANGALORE 2008

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

DECLARATION BY THE CANDIDATE

I here by declare that this dissertation titled COMPUTED TOMOGRAPHIC

EVALUATION OF MEDIASTINAL LESIONS is a bonafide and genuine research work carried out by me under the guidance of Dr H. SATISHCHANDRA , Professor and Head, Department of Radio-Diagnosis, Bangalore Medical College and Research Institute , Bangalore.

Date: Place: Bangalore

Dr. K R PRASAD Post Graduate in Radio-Diagnosis Bangalore Medical College and Research Institute, Bangalore.

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

CERTIFICATE
This is to certify that this dissertation titled COMPUTED TOMOGRAPHIC EVALUATION OF MEDIASTINAL LESIONS is a bonafide work done by Dr. K R PRASAD, in partial fulfillment of the requirement for the award of M.D. Degree in Radio-Diagnosis.

Date: Place: Bangalore

Dr H. SATISHCHANDRA
MDRD, FICR Professor and Head Department of Radio-Diagnosis Bangalore Medical College and Research Institute, Bangalore. .

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

CERTIFICATE BY THE CO-GUIDE

This is to certify that this dissertation titled COMPUTED TOMOGRAPHIC EVALUATION OF MEDIASTINAL LESIONS is a bonafide work done by Dr. K R PRASAD, in partial fulfillment of the requirement for the award of M.D. Degree in Radio-Diagnosis.

Date:
Place: Bangalore

DR D C PRABHU
Professor of Pathology Bangalore Medical College and Research Institute, Bangalore.

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled COMPUTED TOMOGRAPHIC EVALUATION OF MEDIASTINAL LESIONS is a bonafide research work done by Dr. K R PRASAD, under the guidance of Dr H. SATISHCHANDRA , Professor and Head, Department of Radio-Diagnosis, Bangalore Medical College and Research Institute , Bangalore.

DR. H. SATISHCHANDRA
PROFESSOR AND HEAD

DR. G .T. SUBHASH

DIRECTOR CUM DEAN

DEPARTMENT OF RADIO-DIAGNOSIS BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE BANGALORE

BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE BANGALORE

Date: Place: Bangalore

Date: Place: Bangalore

COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore, shall have the rights to preserve, use and disseminate this dissertation entitled

COMPUTED TOMOGRAPHIC EVALUATION OF MEDIASTINAL LESIONS

in print or electronic format for academic / research purpose.

Date: Place: Bangalore

Dr. K R PRASAD Post Graduate in Radio-Diagnosis Bangalore Medical College and Research Institute, Bangalore.

 Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENTS
I express my deep sense of gratitude to Dr. H.SATISHCHANDRA, Professor and Head, Department of Radio-Diagnosis, Bangalore Medical College, Bangalore, for his valuable guidance and constant encouragement in bringing out this dissertation. I am extremely grateful to Dr. G.GURUSHANKAR, Professor of Radio-Diagnosis, Victoria Hospital, for his continuous encouragement and help in preparing this dissertation. I also express my sincere thanks to Dr. B.R.NAGARAJ, Professor of Radio-Diagnosis, Victoria Hospital, for his valuable suggestions in preparing this dissertation. I thank Dr. R.K.SAROJA, Professor, Dept of Nuclear Medicine, Victoria Hospital, Bangalore, for the kind co-operation.

My sincere thanks to all the Professors and Teaching faculty of Medicine, and concerned postgraduates, for having permitted me to study the cases under their care. I thank my father Mr. .K C Ramaiah and mother Mrs .B C Vedavathi and for their care and support for me in my life and for my studies. I also thank my postgraduate colleagues, who helped me in preparation of this dissertation

Lastly, my sincere thanks to all the patients, who with their excellent cooperation became the backbone of this dissertation.

Date: Place: Bangalore

Dr. K R PRASAD Post Graduate in Radio-Diagnosis Bangalore Medical College and Research Institute Bangalore.

LIST OF ABBREVIATIONS USED

AM MM PM HO HT ST V - Anterior Mediastinum Middle Mediastinum

- Posterior Mediastinum - Homogeneous - Heterogeneous - Soft Tissue Vascular

WD IL RT LT CA NECT CT CXR HPR N LN UL LL ML CL CN PE -

- Well Defined - Ill Defined - Right Left

- Carcinoma - Non Enhanced Computed Tomography - Computed Tomography Chest X-ray - Histopathology Report - Normal Lymph Node

- Upper Lobe Lower Lobe Middle Lobe Collapse Consolidation Pleural Effusion

ABSTRACT
BACKGROUND AND OBJECTIVES: Objective of our study were characterize the Mediastinal lesions /masses in plane and contrast enhanced Computed Tomography. To study the distribution of mediastinal masses. To study the involvement of neighboring structures by mediastinal masses and To compare Computed Tomography finding with Pathological Diagnosis where ever possible.

MATERIALS AND METHODS: This study was performed from September 2005 to August 2007 in the Department of Radio-diagnosis in hospitals attached to Bangalore medical college namely Victoria hospital, Bowring and Lady Curzon Hospitals and Vani vilas Hospital, Bangalore. Referred patients from Medicine, Surgery and Paediatrics were evaluated through detailed history, necessary physical examination and computed tomography is carried out using Multislice CT scan - Siemens 6 slice scanner. Scans obtained with both Plain and Contrast study RESULTS: This study included 50 cases of mediastinal lesions between age groups 6-76 years. We classified our mediastinal lesions in to three categories as anterior, middle and posterior mediastinal masses. Characterize the nature of the lesion, enhancement pattern of lesion, presence of calcifications and presence of mass effect INTERPRETATION AND CONCLUSION: Computed Tomography plays a significant role in the assessment of various mediastinal pathology which are initially detected on the chest radiographs. The maximum number or cases occurred in 4th to 6th decade. In our study of 50 cases of mediastinal masses, the anterior mediastinum was the most common compartment to be involved with 52% involvement followed by posterior mediastinum (30%) and then middle mediastinum (18%). So we conclude that computed tomography definitely has a major role to play in the evaluation of a mediastinal mass regarding the distribution pattern, CT diagnosis and mass effect upon adjacent structures.

Key words: - Computed tomography, Mediastinum.

CONTENTS
PAGE NO 1. 2 3

INTRODUCTION AIMS AND OBJECTIVES REVIEW OF LITERATURE HISTORICAL REVIEW

01 02

03

EMBRYOLOGY & ANATOMY CT ANATOMY IMAGING OF MEDIASTINUM CT GUIDED BIOPSY

4. 5. 6. 7. 8. 9.

06 11 13 60 62 66 87 92 93 101

MATERIALS AND METHODS OBSERVATION AND RESULTS DISCUSSION SUMMARY AND CONCLUSION BIBLIOGRAPHY ANNEXURE

LIST OF TABLES AND CHARTS

SI. No

TABLES AND CHARTS

PAGE No.

1.

DISTRIBUTION OF CASES ACCORDING TO VARIOUS AGE AND SEX GROUP

66

2.

DISTRIBUTION OF CLINICAL SYMPTOMS COMPARTMENTAL DISTRIBUTION OF MEDIASTINAL LESIONS

67

3.

68

4.

DISTRIBUTION OF ANTERIOR MEDIASTINAL MASSES

69

5.

DISTRIBUTION OF MIDDLE MEDIASTINAL MASSES

70

6.

DISTRIBUTION OF POSTERIOR MEDIASTINAL MASSES

71

7.

DISTRIBUTION OF THYMIC MASSES

72

8.

DISTRIBUTION OF NEURAL TUMORS

73

9.

DISTRIBUTION OF LYMPH NODAL LESIONS

73

10.

CORRELATION BETWEEN CT AND HISTOPATHOLOGY

73

11

CT DIAGNOSIS

77

12

FINAL DIAGNOSIS

78

LIST OF FIGURES

Sl No.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

CONTENTS
ANEURYSM OF ARCH OF AORTA HODGKINS LYMPHOMA THYMOMA THYMOLIPOMA CARCINOMA OF LUNG WITH MEDIASTINAL LYMPHADENOPATHY NEUROGENIC TUMOUR METASTATIC LYMPHADENOPATHY WITH SVC OBSTRUCTION THYMIC CYST BRONCHOGENIC CYST TUBERCULAR LYMPHADENOPATHY TUBERCULAR SPINE WITH PARAVERTEBRAL ABSCESS CARCINOMA OF ESOPHAGUS DISSECTION OF AORTA PATHOLOGY SLIDE - THYMOMA PATHOLOGY SLIDE -HODGKINS LYMPHOMA

PAGE No.
79 80 80 81 81 82 82 83 83 84

11.

84

12. 13. 14. 15.

85 85 86 86

INTRODUCTION
Computed tomography is a new method of forming images from x-rays. It was developed and introduced into clinical use by the British physicist Godfrey Hounsfield in 1972. It had a tremendous impact in the field of diagnostic radiology. The mediastinum is an extremely complex and interesting area of the body. The multitude of diseases affecting the mediastinum vary considerably, ranging from

tumours (benign to extremely malignant) cysts, vascular anomalies, lymph node masses , mediastinitis, mediastinal fibrosis and pneumo- mediastinum. Hence every possible effort has to be made to arrive at a specific diagnosis at the earliest. Computed Tomography has hence revolutionized the diagnosis of mediastinal lesions. It is one of finest non-invasive imaging modalities available for imaging of the thorax. It is capable of defining the precise anatomical details and characterizing the nature, site and extent. While both CT and MR provides cross sectional depiction. CT has better spatial resolution and shorter imaging time, besides being less expensive and being more widely available. Coexisting lung abnormalities and calcification within the lesions are better appreciated on CT. The additional role of CT in performing CT guided biopsies of lesions cannot be over emphasized. Since the advent of CT, a decline in the use of other diagnostic chest procedures like chest fluoroscopy, tomography, mediastinoscopy, arteriography and thoracotomy has occurred. The skepticism and controversy that greeted the introduction of this expensive modality has gradually faded away. This study was conducted to evaluate the data obtained from thoracic Computed tomography of mediastinal lesions 1

AIMS AND OBJECTIVES

1) To study the computed tomographic characteristics of Mediastinal lesions / masses in Plain and Contrast enhanced scans. 2) To study the distribution of mediastinal masses 3) To study the involvement of neighboring structures by mediastinal masses 4) To compare the CT findings with pathological diagnosis wherever possible

HISTORICAL REVIEW
1656 Blalock removed an anterior mediastinal tumour from a patient with severe myasthenia gravis. 1696 Richard Wrieman first described the causes for the aneurysm 1757 William Hunter - used the terms true or false aneurysm in the modern sense. He described the pressure effects due to the aortic aneurysms and reported a patient with an aneurysmal sac pointing through the chest wall which oozed blood for some weeks before death. 1760 Donald Monro - first referred to syphilis as the cause aneurysm. 1844 John Erichson - wrote a detailed historical review on aortic aneurysm 1859 Mayer reported first case of bronchogenic cyst in mediastinum 1893 Bastianelli performed the earliest successful removal of derm cyst from the anterior mediastinum after resecting manubrium 1895 Wilhelm Conrad Roentgen - discovered the X-rays. 1939 Robb and Steinberg - first described the techniques of angiocardiography by venous injection 1945 The basic phenomenon of Nuclear Magnetic Resonance discovered. Successful medical application of ultrasound be shortly after the World War-II, in the late 1940's and early 1950's. 1970 Reed Sternberg and Long scope described the histological features of characteristic giant cell of Hodgkins disease 1971 Mayo clinic review Wychulis et al [1] of 1064 cases identified over 40 years period, 60% constituted neurogenic neoplasms, thymomas and benign cysts;

and majorities were adults.80% were younger than 15 years of age at diagnosis. 1972 Benjamin et al [2] in their CT study of 214 cases found neural tumors as the commonest mediastinal mass constituting 22.9% of the total. 1972 The first two dimensional nuclear magnetic resonance image using proton density and spin lattice relaxation time techniques were performed by Lauterbaur. 1972 At the annual congress of the British Institute of Radiology in April of 1972, Godfrey Hounsfield, announced the invention of a revolutionary new imaging technique which he called "Computerized axial transverse scanning". 1978 McLoud et al [3] in their CT study showed hilar mediastinal lymphadenopathy in 2-3% of cases were secondary to extra thoracic malignancy. 1981 Baron, Richard L [4] showed that CT scanning can differentiate vascular from avascular causes of mediastinal widening. 1982 Baron, Richard L [5] showed that CT is the method of choice when suspected thymic abnormality requires further evaluation; CT differentiates benign thymic cysts from solid tumors 1987 Webb WR [6] showed that CT allows the differentiation of mediastinal mass from normal mediastinal structures, characterization of its density, its localization and discrimination of vascular and avascular lesions. 1987 Davis et al [8] in their study of 400 consecutive patients with mediastinal masses found thymic tumors as the commonest mediastinal mass comprising 17% 1988 Chen et al [9] in their study on 34 patients with CT diagnosis of Thymic

masses. Thymoma constituted 91%, thymic cyst 2.9%. 1991 Cohen et al [10] in their study of 230 cases reported 16.9% were neural tumors, 24.3% were thymic tumor 20% benign cysts. 1993 Im et al [11] in their study on Tuberculosis lymphadenopathy, 52% of the TB lymphadenopathy showed rim enhancement with central areas of low attenuation. Right Para tracheal lymph nodes were commonly involved in 87%. 1993 Morgenthaler et al [12] in their study showed that thymoma constitutes 15% of primary mediastinal masses. 1997 Strollo et al [13] showed the middle and posterior mediastinal masses constituted nearly 50% of primary mediastinal masses. 2003 Kim JH et al [14] showed that mesenchymal neoplasms account for about 55% of mediastinal tumours and the radiological pattern of these masses are quite characteristic. 2003 Lee K.H et al [15] in their retrospective study of 46 patients showed 54% were purely cystic masses and 46% were cystic tumours with solid portion in the anterior mediastinum compartment

EMBRYOLOGY AND ANATOMY

Embryology [16]:
The mediastinum is embyrologically complex, anatomically diverse and yet remarkably compact. Therefore, it is subjected to development of various pathological lesions. The septum transversum is a thick plate of mesodermal tissue occupying the space between the thoracic cavity and the stalk of the yolk sac. This septum does not separate the thoracic and abdominal cavities completely leaving large openings, the pericardioperitoneal canals on each side of the foregut. With the rapid growth and expansion of the lung buds the mesoderm of the body wall is split into two components as:1) Definitive wall of the thorax 2) Pleuropericardial membranes which with the descent of the heart and positional changes of the sinus venous result in the formation of the pericardial cavity and two pleural cavities. The brachial arches and primitive foregut forms the lungs, heart, great vessels and esophagus. Additionally the thymus, thyroid and parathyroid glands migrate to their respective positions. The complexity of these changes in the foetus facilitates frequent errors in development.

Anatomy of the Mediastinum:

A. Boundaries: Mediastinum is the extra pleural space within the thorax between the two pleural spaces. It extends from the sternum anteriorly to the vertebral column posteriorly. The upper limit is formed by the thoracic inlet and the lower limit by the diaphragm. B. Mediastinal Compartment: An imaginary plane extends from the sternal angle to the lower border of the fourth dorsal vertebra dividing the mediastinum into superior and inferior divisions. The inferior mediastinum is subdivided by the heart into anterior, middle and posterior mediastinum (Shanks and Kerley) [17]

Anatomical classification of mediastinum According to Felson [18], mediastinal compartments are ascertained from the lateral roentgenogram as follows: An imaginary line is drawn upward from the diaphragm along the back of the heart and front of the trachea to the neck. This divides anterior from middle mediastinum. A second imaginary vertical line connects a point on each of the thoracic vertebra 1cm behind its anterior margin. This divides middle from posterior mediastinum.

Felson classification of mediastinum [18]

Fraser modified classification of mediastinum [19] Fraser and Pare [19] divided mediastinum into three compartments, Anterior, middle and posterior. The anterior mediastinal compartment is bounded anteriorly by the sternum posteriorly by the pericardium, aorta, and brachiocephalic vessels. It is narrowest anteriorly where the pleura of the right and left upper lobe converges to form the anterior junctional line. The posterior mediastinal compartment is bounded anteriorly by the pericardium and the vertical part of the diaphragm, laterally by the mediastinal pleura, and posteriorly by the bodies of the thoracic vertebrae (although for practical purpose, the Para vertebral gutters are included).The middle mediastinum lies in between the anterior and posterior mediastinal compartment According to the Heitzmann [20] the normal mediastinum is divided into six anatomic regions:

1. Thoracic inlet , 2. Anterior mediastinum 3. Supra azygos 4. Supra aortic 5. Infra azygos 6. Infra aortic C. Contents of mediastinum (based on anatomical division): 1. Superior Mediastinum: Vessels: Innominate veins, SVC, aortic arch, great vessels, thoracic duct, azygos vein and upper hemiazygos vein. Nerves: Vagi nerves, left recurrent laryngeal nerve and both phrenic nerves Thymic and lymph nodes Trachea and upper thoracic oesophagus. 2. Anterior mediastinum: Vessels: Ascending aorta, Internal mammary arteries, lower part of thymus and Lymph nodes. 3. Middle mediastinum: Vessels: Aortic root, IVC lower of SVC terminal part of azygos vein, Pulmonary arteries and veins. Nerves: Phrenic nerve Cardia with pericardium, hila of lungs, tracheal bifurcation and tracheo bronchial lymph nodes 4. Posterior mediastinum: Vessels: Descending thoracic aorta, intercostals vessels, peribronchial and oesophageal vessels, thoracic duct, azygos vein and hemiazygos vein. Lower thoracic oesophagus, Para vertebral lymph nodes.

Nerves: Autonomic nerves (vagus and splanchnic nerves).

Normal Mediastinal Contents

Anterior Compartment Thymus gland Substernal extensions of thyroid and parathyroid glands Lymphatic vessels and lymph nodes Connective tissue Middle Compartment Heart Pericardium Aortic arch and great vessels Innominate veins and superior vena cava Trachea and main bronchi Hila Lymph nodes Phrenic and upper vagus nerves Connective tissue Posterior Compartment Esophagus Descending aorta Azygos and hemiazygos veins Thoracic duct Lymph nodes Vagus nerves (lower portions) Sympathetic chains, Connective tissue

NORMAL CT ANATOMY

The cross sectional anatomy of the mediastinum is easily separated into a set of basic slices or levels, which can be conveniently described based on the major structures at each level. CT of normal mediastinum. Five 1-cm thick sections have been selected to show the important anatomical features (AE). The level of each section is illustrated in the diagram. A.Ao = ascending aorta, AV = azygos vein, D.Ao = descending aorta, IA = innominate artery, LCA = left carotid artery, LIV = left innominate vein, LPA = left pulmonary artery, LSA = left subclavian artery, MPA = main pulmonary artery, Oes = oesophagus, RIV = right innominate vein, RPA = right pulmonary artery, SVC = superior vena cava, T = trachea, RA = right atrium, LA = left atrium, RVO = right ventricular outflow tract.

Axial CT scans of thorax showing normal mediastinum at various levels at illustrated in the diagram.

IMAGING OF MEDIASTINUM
Radiographic evaluation of the mediastinum has been widely used for investigating the location and the extent of the mediastinal masses within the thorax. Clinically, a plain chest radiograph taken in two planes (PA and lateral) provides basic information on the location of a mediastinal mass. Computed tomography or MRI (or both) will routinely complement the chest radiograph. Other imaging techniques may incorporate specific biologic features of the mass. A. CHEST AND LATERAL RADIOGRAPH: The mediastinum contains all soft tissue thoracic organs with the exception of the two lungs. The thoracic inlet forms the superior limit. The diaphragm provides the inferior border of the mediastinum. MEDIASTINAL LINES [18]: These lines represent pleural reflections delineated by air in the adjacent lungs. The chest film must be well penetrated and the pleural lines optimally oriented for their demonstration. The right paraspinal line: Runs from the thoracic inlet to the diaphragm, a millimeter or two from the right border of the thoracic spine. It is produced by the normal soft tissues covering the bone. It is displaced laterally by osteophytes; an expanding lesion of the vertebrae, a para vertebral mass such as a neurogenic tumor, abscess or lymphoma, azygos vein enlargement and hematoma. The left paraspinal line: Lies medial to the lateral border of the descending aorta and is seldom seen above the aortic knob. This is displaced by similar conditions as the right paraspinal line.

The right paraesophageal line: Is concave to the right in the upper thorax. It extends from the pulmonary apex down to about the level of the right main stem bronchus. The upper segment of this line is visible through the trachea in about 10% of adults and 50% of children. In peptic esophagitis, cardiospasm and esophageal varices, it may increase to 20mm in width. Enlargement of the heart, especially of the left atrium, may displace the right paraesophageal line. The left paraesophageal line: Less often seen as the adjacent descending aorta obliterates it. The left para aortic lines: Lies parallel to the left paraspinal line along side the lateral border of the aorta. The lower end of the right para aortic line may sometimes be seen just above the diaphragm on a well penetrated film. The posterior junction line: Between the two lungs behind the esophagus, it is difficult or impossible to distinguish from the paraesophageal lines without barium. The anterior junction line: Between the lungs usually lie near the midline and is near visible above the sternal notch. It is seen in about 20% of chest as a 'V' shaped structure only 2 to 3 inches in length extending downward from the level of the angle of Louis. This line is seldom apparent in infants because of the thymus. The right Para tracheal line: Is visible in 63% of normal chest films. Carcinoma of the tracheal. Wall, lymph node enlargement and other mediastinal masses and nearby lung lesion may efface its border. Left pericardial line: Is sometimes demonstrated as it obliquely crosses the aortic knob and is continues with the left heart border.

Diagrams illustrating the mediastinal boundaries and junction lines. The visualization of the junction lines on a plain chest radiograph is variable, depending on how much fat is present in the mediastinum and on how closely the two lungs approximate to one another. (A) Section just above the level of the aortic arch; (B) section through the aortic arch; (C) section through the heart [21]

GENERAL

RADIOGRAPHIC

FEATURES

AND

SIGNS

OF

MEDIASTINAL MASSES
1. Silhouette sign: An intrathoracic lesion touching a border of the heart, aorta or diaphragm will obliterate the border whereas; an intra thoracic lesion not anatomically contiguous with a border of these structures is distinctly seen separately. Anterior mediastinal masses: Cause obliteration of a part or whole of the heart border and right border of ascending aorta. The opacity of an anterior mediastinal mass will overlap the left border of aortic knob but not obliterate it, since aortic knob lies posteriorly its border are seen through the opacity. Posterior mediastinal masses: Obliterate the left border of the aortic knob. The same opacity will overlap the cardiac border but does not obliterate it. In short an anterior mediastinal mass causes a silhouette of the heart or ascending aorta but a posterior one does not, although it may obliterate the aortic knob. 2. Hilum overlay sign: Used to differentiate opacity of an anterior mediastinal mass from that of an enlarged heart. The proximal segment of the visible left pulmonary artery lies lateral to the cardiac shadow or just within its outer edge in over 98% of normal individuals. In the remainder it lies slightly more than 1 cm within the cardiac silhouette. The opacity of an anterior mediastinal mass may closely resemble that of an enlarged heart or pericardial sac, but the opacity will overlap the main pulmonary artery which

will be well seen within the margins of the mass. If the pulmonary artery is seen lateral to the opacity, enlarged heart or pericardial sac is indicated. Failure of Hilum overlay sign: However, certain types of congenital heart disease, especially among infants, may result in a lateral bulge anterior to the pulmonary trunk, causing the left pulmonary artery to appear well within the left border of the cardiac silhouette. 3. Hilum convergence sign: If the pulmonary artery branches converge towards the mass, rather than toward the heart then it is an enlarged pulmonary artery. The reverse indicates mediastinal mass. 4. Cervicothoracic sign: This sign is based on the fact that if a thoracic lesion is in anatomic contact with the soft tissues of the neck, its contiguous border will be lost. The cephalic border of the anterior mediastinum ends at the level of the clavicles, whereas that of the posterior mediastinum extends much higher. Hence a lesion clearly visible above the clavicle on the frontal view must be posteriorly situated and be entirely within the thorax. If anterior, the cervical soft tissues could have obscured its upper border. 5. Thoraco abdominal sign: Convergence of the lower margin of the mass towards the spine indicates that the lesion is probably entirely intrathoracic whereas divergence indicates an abdominal mass. The thoracoabdominal sign is seen in aneurysm, neoplastic conditions, and azygos continuation of the inferior venacava.

6. Other signs [22]: Interface of a mediastinal mass with adjacent mediastinal structure will usually be an obtuse angle. Whereas a lung lesion against the mediastinum will often be an acute angle. Posterior mediastinum is continuous below the diaphragm with the retrocrural region. Thus masses, that extend with above and below the diaphragm usually lie in the posterior mediastinum. Presence of air bronchogram within the lesion indicates that it lies in the lung rather than in the mediastinum. B. Fluoroscopy: Assists in evaluating the effects of the mediastinal mass on diaphragm movement. For example, To evaluate the phrenic nerve paralysis - "sniff test" may be performed to determine paradoxical elevation of the diaphragm. C. Ultrasound: Used via transthoracic (transcutaneous) or transesophageal routes and can identify masses overlying the heart. It generally tells whether the mass is solid or cystic. D .MRI [23] It has several advantages over CT in imaging the heart and mediastinum like: Ability to produce orthogonal views Ability to image vessels and moving blood as flow voids. Thus obviate iodinated contrast material. Ability to image masses adjacent to the heart and paraspinal region. Ability to distinguish mass and fibrous tissue in a patient with treated lymphoma or carcinoma in whom tumor recurrence may be present.

IMAGING APPROACH TO MEDIASTINAL MASSES Clinical suspicion of mediastinal mass

Abnormal or suspicious chest radiograph

Normal chest radiograph

Penetrated view Oblique view Digital technique ( optional )

Suspected metastasis Lymphoma evaluation Suspected thymoma in myasthenia Hyperparathyroidism

Probable thyroid mass

Dysphagia

All Others

Thyroid scan

Barium swallow Computed Tomography Location Density Other characteristics

Clinical correlation Differential diagnosis

USG, Arteriography, Venography, MRI

Final Diagnosis

Biopsy

INDICATIONS FOR THE CT EVALUATION OF THE MEDIASTINUM [7, 19, 25]

1.

To define and characterize a mediastinal abnormality suspected or diagnosed on

plain radiographs, Mass differentiation: cystic, fatty or solid in nature and also localization to other mediastinal structure. Mediastinal widening: assessment of the cause - pathological or anatomical variation. Hilum: differentiate an enlarged pulmonary artery from a mass. Paraspinal widening: distinguish between lymph node enlargement, tumor, infection or vascular cause 2. To evaluate the mediastinum in patients who have normal chest radiographs yet a clinical reason to suspect mediastinal disease. Eg: - search for Thymoma or Ectopic parathyroid adenoma in a Myasthenia gravis or surgically resistant Hyperparathyroidism patients respectively. 3. 4. Radiation treatment planning and follow up Aid biopsy or drainage procedures.

APPROACH TO THE DIAGNOSIS OF MEDIASTINAL MASS ON COMPUTED TOMOGRAPHY

The differential diagnosis of a mediastinal mass on CT is usually based on several findings, including its location, identification of the structure from which it is arising, whether it is single, multifocal or diffuse, its size and shape, its attenuation, the presence of calcification and its character and amounts, and its opacification following contrast administration. The mediastinum is divided anatomically into superior, anterior, middle and

posterior compartments, and localizing a mediastinal mass to one of these divisions can facilitate their differential diagnosis on conventional radiographs (Table A) [24]. On CT, however, it is more appropriate to base the differential diagnosis of a mediastinal mass on a direct observation of the tissue or structure from which the mass is arising (e.g., lymph nodes, veins, arteries, thymus, thyroid) rather than its location. If this is not possible, then localize the mass to specific regions of the mediastinum (e.g." prevascular space, pretracheal space, subcarinal, aorticopulmonary window) (Table B) [23]. However it is also important to keep in mind, that although many pathologic processes have a typical location or locations. Most can be seen in any part of the mediastinum. Based on CT attenuation masses can be categorized as (a) fat attenuation, (b) Low attenuation, having density greater than fat but less than muscle (c) high attenuation, with density greater than that of muscle, (d) enhancing, showing significant increase in attenuation following contrast administration (Table C) Following determination of density and location. other CT characteristics of mediastinal masses are considered in improving specificity of the differential diagnosis such as shape, edge, sharpness, contour, relation to normal structures, effect on adjacent structures (especially displacement) and the presence of other abnormalities including those visible in the lung and abdomen as well as those remote from the mass in the mediastinum. Clinical information including age and sex of the patient is often as useful as any imaging parameter in achieving a logical and useful differential diagnosis list.

CLASSIFICATION OF MEDIASTINAL MASSES

Table A: Based on Location [24]

Common lesions Tortuous brachiocephalic vein Lymph node enlargement Retrosternal goiter Fat deposition Thymic tumour Germ cell Epicardiac fat pad tumours Diaphragmatic hump Pleuropericardial cyst

Rare lesions Aneurysm of brachiocephalic artery Lymphangioma Parathyroid adenoma Sternal mass Lipoma Haemangioma Morgagni hernia

Anterior mediastinum

Middle mediastinum

Lymph node enlargement Aneurysm arch aorta Enlarged pulmonary artery Dilated superior vena cava Bronchogenic cyst

Tracheal lesions Cardiac tumours

Posterior mediastinum

Neurogenic tumours Hiatus hernia Aneurysm of descending artery Oesophageal masses Dilatation of azygos vein Para vertebral mass

Neurenteric cyst Pseudocyst of pancreas Sequestration lung Thoracic duct cyst Bochdalek hernia Extramedullary hemopoiesis Thoracic duct cyst

Thoracic aorta passes through all the divisions of mediastinum. Hydatid cyst can occur most commonly in the middle and posterior mediastinum. Masses situated in all mediastinal compartments are lymphoma and sclerosing mediastinitis

DIFFERENTIAL DIAGNOSIS OF MEDIASTINAL MASSES BASED ON COMMON SITES OF ORIGIN [23] Prevascular space Aorticopulmonary window Thymic masses Lymph node masses Hyperplasia Lung carcinoma Thymoma Sarcoidosis Thymic carcinoma Lymphoma Thymic carcinoid tumour Metastases Thymolipoma Mesenchymal masses (e.g., Thymic cyst lipomatosis, lipoma) Thymic lymphoma Vascular abnormalities (aorta Metastases or Pulmonary artery) Foregut cyst Germ cell tumour Subcarinal space, azygoesophageal Teratoma recess Seminoma Lymph node masses Non semiomatous germ cell tumours Lung carcinoma Sarcoidosis Thyroid abnormalities Lymphoma Parathyroid tumour Metastases Lymph node masses (particularly Hodgkin lymphoma) Foregut cyst Vascular abnormalities (aorta and great vessels) Mesenchymal abnormalities (e.g., lipomatosis, lipoma) Foregut cyst Lymphangioma and hemangioma Cardiophrenic angle Paravertebral region Lymph node masses (particularly Neurogenic tumour lymphoma and metastases) Nerve sheath tumours Pericardial cyst Sympathetic ganglia tumors Morgagni hernia Paraganglioma Thymic masses Foregut cyst Germ cell tumours Meningocoele Pretracheal space Extramedullary hematopoeisis Lymph node masses Pseudocyst Lung carcinoma /Sarcoidosis Thoracic spine abnormalities Lymphoma (particularly Hodgkin disease) Hernias Metastases Esophageal masses Infections (e.g., TB) Mesenchymal masses Foregut cyst, Tracheal tumour (e.g., lipomatosis, lipoma) Mesenchymal masses (e.g., lipomatosis, lipoma) Lymph node masses Thyroid abnormalities, Lymphoma (particularly Non Vascular abnormalities (aorta and great vessels) Hodgkin) Metastases Thymic mass or germ cell tumour Lymphangioma and Hemangioma

COMMON SITES OF ORIGIN

6 1

Suttons method
1. Pretracheal space 2. Prevascular space 3. Cardiophrenic angle 4. Aorticopulmonary window 5. Azygoesophageal

6. Paravertebral region

ANTERIOR MEDIASTINAL MASSES

2

Thymus and related masses: Computed tomography should be the imaging method of choice following plain chest radiograph when suspected thymic abnormality require further evaluation. [27]. The size of normal thymus varies dramatically with age. Differentiating between a large normal thymus and thymic mass can therefore be difficult in children and young adults. The normal thymus conforms to the shape of the adjacent vessels on CT and MRI, where as a thymic mass does not tends to. Also, a mass gives rise to focal swelling, usually centered away from the midline, whereas the normal gland is approximately symmetrical. The left lobe is usually slightly larger than the adjacent right lobe. Adjacent fat planes may be obliterated by invasive neoplasm and inflammation [28]. Thymic hyperplasia The most common association is myasthenia gravis, but thymic hyperplasia is also seen in other conditions notably thyrotoxicoisis. The thymus may atrophy due to stress or consequence of steroid or anti neoplastic drug therapy. [29, 30] The gland returns to its original position on recovery or cessation of treatment, or may become larger than its previous normal size, in the phenomenon known as Rebound Thymic Hyperplasia. Thymic hyperplasia is also found in autoimmune diseases like Hashimotos thyroiditis, Addisons disease, Autoimmune Hemolytic Anemia and Behcets disease. [31]

Thymus [32]
2

Normal measurements of the thymus on CT: Mean values AP Diameter in cm (SD) 12.52 (0.82) 12.56 (0.88) Thickness of Limbs in cm (SD) '1.5 (0.46) 1.05 (0.36) Craniocaudal. Width in cm Length in cm (SD) (SD) 3.53 (0.99) 3.13 (0:85) 4.99(1.25) 3.05(1.17)

Age (y) 0-10 '10-20

Of all the measurements i.e. length (measured in the cephalo caudal dimension), width (measured in the transverse dimensional) and thickness (perpendicular to the length), the thickness is most helpful value for thymic size assessment. Under age 20, a thickness of 1.8 cm is considered maximum allowable value whereas 1.3cm being maximum normal value in older subjects [23]. Thymic cyst: Uncommon lesion, mostly asymptomatic and accounts for 3% of all tumors in the anterior mediastinum. They can be congenital or acquired in origin. Congenital are derived from remnants of thymopharyngeal duct and are typically unilocular, contains clear fluid of water density with a thin wall usually less than 6cm in diameter. In contrast acquired thymic cyst result from an inflammatory process and occurs in patients after thoracotomy, radiation therapy for Hodgkin's disease or in association with thymic tumors. These are usually multilocular, wall of variable thickness and range in size from 3 to 17cm in diameter, sometimes septations and calcification of the cyst wall may be seen21. On MRI, hypo intense on T1, hyper intense on T2 [14].

Thymoma:

Most common primary tumor of the anterior mediastinum, it accounts for 15% of primary mediastinal mass [23]. These are neoplasms originating from the thymic epithelium, which are rare before age 20 and are most common during 5th to 6th decade. 30 to 54% patients with thymoma develop myasthenia gravis. Approximately 30% of thymomas are invasive. Characteristically invasive thymomas infiltrate adjacent-structures or result in pleural or pericardial implants. Thymoma rarely metastasizes outside the thorax On CT, thymomas, appear as homogenous soft tissue density masses, which are usually sharply demarcated and oval, round or lobulated in shape, project to one side of the mediastinum, and do not conform to the normal shape of the thymus. Rarely, cystic with discrete nodular components. Except in patients with cystic masses, thymomas usually enhance homogenously and not uncommonly may contain calcium. Pleural implants may be present which are often unilateral and usually unassociated with pleural effusion. Large tumors have areas of hemorrhage, necrosis or cyst formation.

Staging of thymoma:
Stage I: Intact capsule Stage II: Invasion of adjacent fat only Stage III: Invasion into other mediastinal structures, lung and pleura

Differentiation of thymoma and normal thymus (CT criteria) [23];

Thymoma Patient over 30 Mass spherical or lobulated Attenuation > chest wall muscle Lesion surrounded by fat Calcification present Unilateral or midline

Normal Thymus Patient under 20 Mass elongated with length > width Mass diffusely infiltrated with fat Paucity of fat No calcification Bilateral soft tissue prominence seen in usual location of right and left thymic lobes

Thymic Carcinoma: Arises from thymic epithelial cells and accounts for about 20% of thymic epithelial tumors. It is aggressive and more likely to result in distant metastases than invasive thymoma. (I.e. 50% to 65%). Frequent sites of metastases are lungs, liver, brain and bone [33]. Age of incidence is around 50 years. Symptoms are usually attributable to the mediastinal mass and superior venacava syndrome may be present. Paraneoplastic syndromes such as Myasthenia gravis, pure red cell aplasia are uncommon. Thymic carcinoma cannot be distinguished from thymoma on CT unless enlarged lymph nodes are visible in the mediastinum or distant metastases are evident. On CT, seen as homogenous soft tissue mass or heterogeneous with areas of cystic necrosis. Calcification seen in 10-40% cases. Obliteration of fat planes and extension into pericardium and pleura is usually seen [34]. Thymolipoma: It is a rare, benign well encapsulated thymic tumor, consisting primarily of mature adipose tissue and variable amounts of thymic tissue. It can arise within the thymus or be

connected to the thymus by a pedicle. Most commonly seen in children and young adults. no symptoms even when large and usually discovered on a screening radiograph. Because of its fatty content and pliability, it tends to drape over the heart, extending inferiorly into the cardiophrenic angles and can simulate cardiac enlargement. CT shows a fatty mass with varying amounts of intermixed soft tissue representing thymic tissue. Sometimes it is predominantly fatty so that it is impossible to distinguish a thymolipoma from a mediastinal lipoma. On MRI, fatty component shows high signal on T1W with soft tissues having intermediate signal intensity. Germ Cell Tumors: Primary germ cell tumors account for about 10% to 15% of primary mediastinal masses as well as 10% to 15% of all anterior mediastinal masses [35]. Presumably they arise from primitive germ cells that have arrested their embryologic migration in the mediastinum. They are most common in the anterior mediastinum. Only about 5% originate in the posterior mediastinum. Most germ cell tumors present during the second to fourth decades of life (mean age 27 years). Germ cell tumors include benign and malignant teratoma, seminomas, embryonal carcinoma, endodermal sinus (yolk sac) tumor, choriocarcinoma and mixed types. Most malignant germ cell tumors (> 90%) occur in men, whereas benign lesions occur with equal sex incidence. Benign tumors are often asymptomatic and commoner in women whereas malignant tumors are more likely to cause symptoms. Confirmation that these lesions are primary to the mediastinum requires that there be no evidence of a testicular or retroperitoneal tumor.

Teratoma:They contain elements of all germinal layers. Teratomas are classified as mature, immature and malignant [35]. Dermoid cysts are said to contain derivatives of only the ectodermal layer, specifically skin and its appendages, but small rests of endodermal and mesodermal cells are often present; they are benign. Mature teratomas are common accounting for 70% of germ cell tumors in childhood and 60% of mediastinal germ cell tumors in adult . Regardless of their histology, CT often shows combination of fluid filled cysts, fat, soft tissue and areas of calcification. Calcification seen in 20% to 80% of cases, being focal, rim like, or rarely representing teeth or bone. A fat fluid level is particularly diagnostic. Cystic teratoma characteristically has a thick wall, soft tissue septations and in homogenous areas approaching fatty attenuation values, within a predominantly near water density mass; differentiate from other benign cysts [5]. Seminoma: Mean age of presentation is 26 years [36]. They constitute 40% of malignant germ cell tumors. Approximately 10% with pure seminoma have evidence of elevated betahuman chorionic gonadotropin (HCG) levels, but never elevated alpha-fetoprotein (AFP) levels. Typically, primary mediastinal seminomas are large, smooth or lobulated, homogenous soft tissue masses, although small areas of low-attenuation may be seen. Obliteration of fat planes is common and pleural or pericardial effusion may be present Non-seminomatous germ cell tumors: Includes embryonal carcinoma, endodermal sinus tumor,

chariocarcinoma and mixed types up to 80% of affected patients have elevated levels of AFP and 54% have elevated levels of bHCG. Up to 20% of affected patients have Klinefelter's syndrome. There exists an association with hematological malignancies as well. On CT, these tumors usually show heterogeneous opacity, including ill defined areas of low attenuation secondary to necrosis and hemorrhage or cystic areas. They often appear infiltrative, with obliteration of fat planes and may be spiculated calcification may be seen. Thyroid masses: Mediastinal involvement by thyroid masses is most often anterior and is due to down ward extension of either a multi nodular colloid goiter, or occasionally an adenoid or carcinoma. Intrathoracic thyroid masses usually have a well defined outline which may be spherical or lobular. Rounded or irregular, well defined areas of calcification may be seen in benign areas, whereas amorphous cloud like calcification is occasionally seen within carcinomas [28]. CT is at greatest value in defining the

morphologic extent. Marked irregularity of the gland contour, loss of distinct mediastinal fascial planes and / or presence of cervical or mediastinal adenopathy should signal potential malignancy. Although scintigraphy can defect mediastinal goiters, the uptake of technetium or iodine is variable. The CT appearance of a mediastinal goiter is variable, but the goiter can confidently diagnosed when continuity of the mass with the thyroid is visible [28]. Parathyroid Adenoma: Anterior mediastinal parathyroid glands are thought to result from islands of parathyroid tissue that are carried into the anterior mediastinum by the descending

thymus during embryologic development. Primary hyperparathyroidism is seen in 85% cases. They may be searched for by CT. US, angiography. Combined Thallium 201/ 99mTc pertechnate imaging or MRI. When visible on CT, they usually appear homogenous in density. In anterior mediastinum, they may be indistinguishable from small thymic remnants, small thymomas or small lymph nodes and are usually found in the expected location of the thymus. CT correctly identified parathyroid adenomas preoperatively in 81 % of patients [37] .

Primary Mediastinal Lymphoma (PML): It constitutes about 20% of all mediastinal neoplasms in adult and 50% in children [38]. A mediastinal mass is also a frequent manifestation of lymphoma. The most common cause for such primary disease are Hodgkin's disease, large cell lymphoma and lymphoblastic lymphoma; other forms are infrequent. Many of these primary mediastinal tumors appear to originate in the thymus
19

. Hodgkins Lymphoma is a more common

cause and occur in older group (Median age 55years) [23]. The typical presentation consists of an anterior mediastinal mass often associated with enlarged nodes in the middle and posterior mediastinum, and hila. PML often affects extra thoracic sites at time of diagnosis particularly abdomen, head and neck. On CT Hodgkin's lymphoma is characterized by the presence of a discrete anterior superior mediastinal mass with surface lobulation. Surface lobulation of main mass is due to involvement of multiple nodes and coalescence Masses typically exhibit homogenous soft tissue attenuation, while large tumours may exhibit heterogeneity with complex low attenuation representing necrosis, hemorrhage and cystic degeneration. It commonly

involves cervical, mediastinal, hilar and Para aortic nodes [39]. Non Hodgkin's lymphoma comprises of mediastinal large 8-cell lymphoma and lymphoblastic lymphoma and is more common in children than Hodgkin's lymphoma. Large cell lymphomas are typically confined to the mediastinum and contiguous nodal areas initially without showing extrathoracic disease at presentation. It may present with hematogenous spread to kidney, liver, ovary, adrenal gland, GI tract and central nervous system during disease progression or at recurrence. CT demonstrates mediastinal mass without surface lobulation, often associated with vascular involvement and pleural or pericardial effusion. Lymphoblastic lymphoma is characterized by mass without surface lobulation involving vascular structures often associated with pleural or pericardial effusion, by systemic nodal involvement including cervical, axillary, paraaortic mesenteric and inguinal and by hepatomegaly and splenomegaly [40]. Morgagni Hernia: They are mostly asymptomatic, it is due to incomplete attachment of diaphragm anteriorly to the sternum. It may contain omental fat or gut. On X- ray opacity is seen in the right cardiophrenic angle. Barium studies show a portion of gut in the hemi thorax. CT demonstrates the herniated fat or the gut. Epicardial Fat Pad: Deposition of fat in either cardiophrenic angles is not uncommon, particularly in obese patients and can simulate a mass. CT can demonstrate the fatty nature of the mass.

Pleuropericardial cyst: Constitutes 6% of mediastinal mass. They result from aberrations in the formation of coelomic cavities. Pericardial cysts are invariably connected to the pericardium. The majority of them arises in the anterior cardiophrenic angle, more frequently on the right, but can be seen as high as the pericardial recesses at the level of the proximal aorta and pulmonary arteries [41]. CT shows thin walled unilocular water density (O-20HU) cystic structure. Wall may calcify. Lymphangiomas: Are rare, benign congenital malformation, constitutes 0.7% to 4.5% of all mediastinal tumors. Majority are discovered during first 2 years of life. They are most common in the neck and axilla, and about 10% extend into the mediastinum. CT usually shows a smooth, lobulated mass, which may mould to or envelop, rather than displace, the adjacent mediastinal structures. They are either unilocular or multilocular with near water density. Calcification is rare. Thin enhancing septations within the mass may be seen [41].

MIDDLE / POSTERIOR MEDIASTINAL MASSES

Foregut duplication cysts: Includes bronchogenic, neuroenteric and oesophageal duplication cysts. Bronchogenic cyst: Bronchogenic cysts are congenital lesions thought to result from abnormal budding of the embryonic foregut. Most cysts are located in the mediastinum, near the tracheal carina predominantly in the middle mediastinum (79%) less commonly may occur within the lung parenchyma, pleura or diaphragm (15%) according to McAdam's series [42]. On CT, typically shows sharply marginated thin walled mediastinal mass of homogenous soft tissue or water attenuation. Rarely, calcification of the cyst wall is present. When dense, bronchogenic cysts may be difficult to distinguish from solid lesions. An important clue can be their lack of enhancement following contrast administration [43]. Neuroenteric cysts: These rare lesions are connected to the meninges through a midline defect in one or more vertebral bodies and are composed of both neural and gastrointestinal elements. A connection with the esophagus is often present. CT appearance is same as that of other duplication cyst, but the presence of vertebral abnormality points to the diagnosis, vertebral anomalies are present in half of the cases. Oesophageal duplication cysts: They are lined by gastrointestinal tract mucosa and are often connected to the esophagus. 60% are found in the lower posterior mediastinum, adjacent to the

oesophagus, and are sometimes found within its wall. On CT indistinguishable from bronchogenic cyst except for the location.

Lymph node masses: Are described later

Rare middle mediastinal masses include:

Tracheal tumours: These are carcinoma, cylindroma, plasmacytoma, tracheobronchomegaly

(Mounier-Kuhn syndrome) and tracheomalacia. They may cause widening of mediastinum carcinoma spreads through the Para tracheal space and invades lymph nodes. Metastatic bronchial carcinoma also gives similar appearance.

POSTERIOR MEDIASTINAL MASSES

Neurogenic Tumours: They account for about 9% of primary mediastinal masses in adults, although they are more prevalent in children, constituting 29% of mediastinal tumours [44] Tumours are divided as follows: Nerve sheath. tumours: Neurofibroma, Schwannoma, Malignant peripheral nerve sheath tumours, Neurofibrosarcoma. Ganglion cell tumours: Ganglioneuroma, Ganglioneuroblastoma,

Neuroblastoma Paragangliomas: Chemodectomas - Aortic body tumour, Sympathetic chain tumours ,Pheochromocytoma The Schwannoma is the most common intra thoracic nerve sheath tumour. In their classic form, Schwannomas are eccentric and encapsulated and have no nerve fibers. Almost all intra thoracic nerve sheath tumours arise either from the intercostals, or the sympathetic nerves, the rare exception being Neurofibromas or Schwannomas of the phrenic or vagus nerves. Many arise close to the spine and may extend through the neural exit foramina into the spinal canal the so-called "Dumb bell tumour". Nerve sheath tumours are rare in patients below age 20 and virtually non existent in patients who are less than 10 years old except in patients with neurofibromatosis [22]. Malignant nerve sheath tumours are infrequent. They may cause pain and are usually associated with neurofibromatosis. Ganglion cell tumours form a spectrum with Neuroblastoma at the malignant end and Ganglioneuroma at the benign end, Ganglioneuroblastoma being an intermediate

form. Neuroblastoma and Ganglioneuroblastoma may occasionally mature into a more benign form. The mediastinum is the second most common primary site after the adrenal gland. Primary mediastinal neuroblastoma appears to have a better prognosis than those that arise primarily in the abdomen. Neuroblastoma and ganglioneurobiastoma are essentially tumours of childhood, fewer than 10% seen in patients older than 20 years of age. Ganglioneuroma is seen in age range of 1 to 50 years. Urinary vaniyll mandelic acid and homovanillyl mandelic acid levels may be raised in Neuroblastoma and Ganglioneuroblastoma .

Common imaging features of neurogenic tumours: Are well defined mass with a smooth or lobulated outline. Most neurogenic tumors are approximately spherical, but some ganglion cell tumours are elongated. It is possible to distinguish between a ganglion cell tumour and a nerve sheath tumour by observing. a. The shape of the mass, since the base of ganglion cell tumour may show a tapered interface with the adjacent chest wall or mediastinum, whereas nerve sheath tumours tend to show sulfurs at their margins. b. Ganglion cell tumours arise slight more anteriorly with their epicenter against the vertebral body, whereas nerve sheath tumours are centered on the exit foramina, or are plastered against the chest wall. Calcification may be seen in all types of neural tumours. In neuroblastoma the calcification is usually finely stippled, whereas In ganglioneuroblastoma and ganglioneuroma, it is denser and coarser occurring most frequently in the larger benign lesions. Nerve sheath tumours calcify only occasionally. Pressure deformity and

displacement of the adjacent ribs and vertebrae are common and absence of these changes in a larger lesion is a pointer against the diagnosis of neurogenic tumour. Pleural effusion is a sign of a malignant tumour. At CT, many neural tumours have mixed density, including low attenuation region, on non contrast enhanced CT Schwannoma often demonstrate lower attenuation than skeletal muscle because of their high lipid content, interstitial fluid and areas of cystic degeneration. Neurofibromas are often more homogenous and show higher attenuation than schwannomas because they have fewer of these histologic features. These lesions may heterogeneously enhancing following contrast administration. On MRI, these neoplasms characteristically show high signal intensity peripherally and low signal intensity centrally (the target sign) as a result of collagen deposition .This feature, when present, helps distinguish neurofibromas from other mediastinal tumours . Plexiform neurofibromas seen in association with Neurofibromatosis-1, on CT demonstrates low attenuation infiltrative masses along the mediastinal nerves and sympathetic chain. The presence of multiple target signs throughout the lesion on MRI favors the diagnosis of a plexiform neurofibroma rather than a malignant tumour of nerve sheath origin. Mediastinal Paragangliomas: They are rare, forms only 2% approximately [45]. One third of mediastinal pheochromocytomas are non-functioning and asymptomatic, the remainder present with symptoms, signs and laboratory findings of catecholamine overproduction.

Imaging:

Rounded soft tissue masses which are usually extremely vascular and intracardiac

therefore enhance brightly. MRI is particularly advantageous in phaeochromocytomas.

Lateral intrathoracic Meningocele: It is a protrusion of the spinal meninges through an intervertebral foramen. Usually detected in patients between 30 and 60 years of age as an asymptomatic mass on a chest radiograph and occasionally associated with pain or neurological abnormality

Approximately 2/3rd associated with neurofibromatosis. CT shows uniform low attenuation of CSF value. CT myelography confirms the diagnosis, showing contrast entering the meningocoele.

PARAVERTEBRAL LESIONS
Includes traumatic compression of a vertebral body with hematoma formation, pyogenic or tuberculous paraspinal abscess, multiple myeloma, disseminated lymphoma, extra medullary hematopoietic tissue and metastatic carcinoma with paraspinal extension.

Radiological features of paravertebral lesions Inflammatory lesions produce narrowing of disc space as well as bone destruction. Where as neoplastic lesions produce only bone destruction. In metastatic lesions pedicles are usually affected . Tuberculous paravertebral lesions [46, 47]: The vertebral column is the most common site of osseous tuberculous involvement comprising in most series about

50% of cases. The lower dorsal and upper lumbar vertebrae are most frequently affected. The spread of tuberculosis of the spine is usually by hematogenous route by perivertebral arterial or venous plexi, or rarely by extension form a paraspinal infection. The infection typically commences at the superior or inferior anterior body corner adjacent to the discovertebral junction, and spreads then by sub ligamentous extension and penetration of the subchondral plate. Advanced disease may demonstrate abscess tracking along the fascial planes. Plain film evaluation of the tuberculous spondylodiscitis may demonstrate loss of vertebral height or disk interval, erosions, in distinction of the end plates, paravertebral masses and sequestrate. Over 50% of the trabecular bone is lost before a lesion is conspicuous on plain film; this process may take up to 6 months. In the thoracic spine visualization of a paravertebral abscess requires an adequately penetrated view. Scalloping of the anterior vertebral contour (aneurysmal appearance) is more commonly seen with children. Plain film is limited in the evaluation of the posterior arch, particularly in the thoracic spine. CT scan is excellent for visualization of end plate destruction, fragmentation of the vertebrae, and paravertebral calcifications. Inflammatory collections and masses are best seen after the contrast administration. Small necrotic foci are recognized by CT scans and they are difficult to find in the radiographs i.e. foci less than 1.5 cm in diameter are not demonstrable in a conventional radiograph. Extension into the canal of epidural abscesses and bony fragments are well demonstrated on axial CT images. CT is also used for guiding percutaneous biopsy and post drainage follow up.

Multi planar capability and optimal tissue contrast make MR imaging the optimal modality for spondylodiscitis. The entire spine and canal can be visualized. MR imaging has higher sensitivity for early infiltrative disease including end plate changes and marrow infiltration than bone scan and plain film. MR imaging affords excellent definition of epidural, paravertebral and intra osseous abscesses and extent of cord compromise. Extra medullary haemopoietic tissue [48]: One of the thoracic manifestations of extra medullary haemopoiesis is a paravertebral mass. It is a compensatory phenomenon. Most commonly seen in congenital haemolytic anemia (e.g., thalassemia and sickle cell anemia). It has been also found in myelosclerosis, carcinomatosis, chronic nephritis, haemochrornatosis, lead poisoning, acholuric jaundice and chronic infections. Marrow is formed in areas outside the normal haemopoietic system. Histologically, resemble splenic tissue. Differential diagnoses are reticulosis and cold abscess. Biopsy of haemopoietic tissue has a high risk of bleeding. CT features - are well-defined margins and have a soft tissue attenuation. Extramedullary haemopoietic tissues are low density masses due to fat content Diaphragmatic Hernia: Abdominal organs or retroperitoneal fat can herniate through areas of congenital or acquired diaphragmatic weakness or tears and manifest as a mediastinal mass on chest radiographs. Common nontraumatic sites of herniation include the anterior parasternal hiatus, the esophageal hiatus and the posterior pleuroperitoneal hiatus. Hiatus hernia are a

common cause of a mediastinal mass in the lower thorax. The diagnosis is easily made if air or contrast material is seen within the hernia. Herniation through the posterior pleuroperitoneal hiatus (Foramen of Bochdalek) is the most common cause of congenital diaphragmatic hernia in infants. In adults, the lesions are usually small and asymptomatic and occurs more commonly on the left (65%) than on the right (35%). They are particularly common in patients over 70 years of age. They are typically found posteriorly some 4 to 5cm from the posterior attachment of the diaphragm . They contain herniated retroperitoneal fat, sometimes kidney or a portion of Spleen. CT demonstrates the fatty nature of the hernial contents and often shows the accompanying muscle defect in the diaphragm [49].

MEDIASTINAL LYMPH NODES AND LYMPH NODE MASSES

Mediastinal lymph node abnormalities can be seen in any mediastinal compartment, although they most commonly involve middle mediastinal regions [23]. Thoracic lymph nodes are usually grouped into parietal and visceral, depending on their location and drainage. The parietal lymph nodes primarily drain structures of the chest wall and are classified as internal mammary, diaphragmatic or paracardiac and intercostal. Visceral node groups include intrapulmonary, bronchopulmonary, tracheobronchial, paratracheal, Para esophageal and anterior mediastinal. Anterior Lymph Nodes: Internal mammary lymph nodes are located in a retrosternal position, at the anterior ends of the intercostals spaces, near the internal mammary artery and veins, they are considered to be part of the parietal lymph node group. They drain the anterior chest wall, anterior diaphragm, medial breasts, and freely communicate with pre vascular lymph nodes. Most often enlarged as a result of lymphoma or metastatic breast cancer. Prevascular lymph nodes lie anterior to the aorta and in relation to the great vessels. These nodes drain most anterior mediastinal structures including the pericardium, thymus, thyroid, pleura and the anterior hila. They represent visceral nodes. They communicate with the internal mammary chain of nodes anteriorly and paratracheal and aorticopulmonary lymph nodes posteriorly. They may be involved in a variety of diseases, notably lymphoma. and granulomatous diseases, but their involvement in lung cancer is relatively uncommon.

Diagram showing AJCCUICC classification of regional lymph nodes

AJCCUICC classifications of regional lymph nodes [21]

1 Highest mediastinal nodes lie above a horizontal line at the upper rim of the bracheocephalic (left innominate) vein 2 Upper Para tracheal nodes lie above a horizontal line drawn tangential to the upper margin of the aortic arch and below the inferior boundary of No 1. nodes 3 Prevascular and retrotracheal nodes may be designated 3A and 3P: midline nodes are considered to be ipsilateral

4 Lower Para tracheal nodes lie to the right or left of the midline of the trachea between a horizontal line drawn tangential to the upper margin of the aortic arch and a line extending across the right or left main bronchus at the upper margin of the ipsilateral upper lobe bronchus. They are contained within the mediastinal pleural envelope. NB: The left lower paratracheal nodes lie medial to the ligamentum arteriosum. 5 Sub aortic (aorto-pulmonary window) nodes lie lateral to the ligamentum arteriosum or the aorta or left pulmonary artery and proximal to the first branch of the left pulmonary artery and lie within the mediastinal pleural envelope 7 Para-aortic nodes (ascending aorta or phrenic) lie anterior and lateral to the ascending aorta and the aortic arch or the innominate artery, beneath a line tangential to the upper margin of the aortic arch 8 Subcarinal nodes lie caudal to the carina of the trachea, but not associated with the lower lobe bronchi or arteries within the lung 9 Paraesophageal nodes (below carina) lie adjacent to the right or left of the midline, excluding subcarinal nodes 10 Pulmonary ligament nodes lie within the pulmonary ligament, including those against the posterior wall and lower part of the inferior pulmonary vein 11 Hilar nodes lie distal to the mediastinal pleura reflection and the nodes adjacent to the bronchus intermedius on the right 12 Interlobar nodes lie between the lobar bronchi 13 Lobar nodes lie adjacent to the distal lobar bronchi 14 Segmental nodes lie adjacent to the segmental bronchi 15 Subsegmental nodes lie around the sub segmental bronchi NB. Station 1 through 9 nodes lie within the mediastinal pleural envelope, whereas station 10 through 14 nodes lie outside the mediastinal pleura within the visceral pleura

Paracardiac or cardiophrenic angle 'lymph nodes lie anterior to or lateral to the heart and pericardium on the surface of the diaphragm. They communicate with the lower internal mammary chain and drain the lower intercostals spaces, pericardium, diaphragm and liver. Most commonly enlarged in lymphoma and metastatic breast carcinoma. Prepericardiac nodes are located posterior to the xiphoid process and slightly lateral to it. Tracheobronchial Lymph Nodes: Tracheobronchial lymph nodes generally serve to drain the lungs. Lung diseases (e.g., lung cancer, sarcoidosis, tuberculosis, fungal infections) that secondarily involve lymph nodes, typically involve these lymph nodes. Tracheobronchial lymph nodes are subdivided into a number of important node groups, which are all closely related. Paratracheal nodes lie anterior to, and on either side of, the trachea, retro tracheal nodes may also be seen. The most inferior node in this region is the so called "Azygos node" medial to the azygos arch. These nodes form the final pathway for lymphatic drainage from most of both lungs, excepting the left upper lobe. Because of this, they are commonly abnormal regardless of the location of the lung disease. Aorticopulmonary nodes are grouped by Rouviere [23] with prevascular nodes, but because they serve the same function on the left as paratracheal nodes on the right and freely communicate with paratracheal nodes, it is most appropriate to group them together. They lie in the aorticopulmonary window, lateral to the left main bronchus and between the aorta and pulmonary artery. The left upper lobe drains via this node group.

Peri bronchial nodes surround the main bronchi on each side, and lie between the main bronchi in the subcarinal space. These drain the lungs, bronchopulmonary nodes are located distal to the main bronchi and are usually considered to be hilar. Subcarinal nodes represent peribronchial nodes lying between the main bronchi in the subcarinal space. These nodes drain the inferior hila and lower lobes on both the right and left, and communicate in turn with the right paratracheal chain. Posterior Lymph Nodes: Paraesophageal and inferior pulmonary ligament nodes are associated with the esophagus and descending aorta and lie medial to the inferior pulmonary ligament. They represent visceral nodes, and drain the medial lower lobes, esophagus, pericardium and posterior diaphragm. Retrocrural lymph nodes lie posterior to the diaphragmatic crura. They communicate with lumbar nodes and posterior mediastinal lymph nodes, and drain the diaphragm and liver and represent the posterior group of diaphragmatic parietal lymph nodes. Intercostals and paravertebral lymph nodes are found in the posterior intercostals spaces and adjacent to thoracic vertebral bodies. These drain the posterior pleura, chest wall and spine, and communicate with other posterior mediastinal lymph nodes. They are part of parietal group. Normal lymph nodes on CT are generally visible as a. b. c. Discrete and surrounded by mediastinal fat Round, elliptical or triangular in shape Soft tissue attenuation.

The short axis or least diameter of a lymph node is generally used when measuring size .Based on 3 study [51] short axis measurement of 12mm is the upper limits of normal for subcarinal lymph nodes, 10mm for right tracheobronchial and low paratracheal lymph nodes, and 8mm for all other lymph nodal groups. According to Glazer et al [52] study suggests that the optimum size in patients suspected of malignancy should exceed 10mm except in the subcarinal region.

DIAGNOSIS OF LYMPH NODE ABNORMALITIES: Are based on a. b. Lymph node enlargement , Lymph node morphology

c.Lymph node attenuation d.Lymph node enhancement Lymph node enlargement: Lymph nodes having a short axis of 2cm or more often reflect the presence of neoplasm, such as metastatic tumor or lymphoma, sarcoidosis or infection and should always be treated as potentially significant. Whereas in variety of non infectious and non-granulomatous inflammatory diseases they are usually smaller than 2cms [53, 54, 55]. Lymph node morphology: a. Discrete enlarged nodes: This pattern can be seen in association with all causes of mediastinal lymph node enlargement b. Coalescence of enlarged nodes: Most typical of infection, granulomatous disease and neoplasm

c. Diffuse mediastinal involvement: This diagnosis may be difficult to make unless the attenuation of mediastinal soft tissue is compared to the attenuation of subcutaneous fat on the same scan - they should be similar[23]- suggests lymphoma,undifferentiated carcinoma, generalized infection, or granulomatous mediastinitis.

Lymph node attenuation [23]:

Calcified lymph nodes Common: Infectious granulomatous diseases Tuberculosis Fungal infections (Histoplasmosis) Sarcoidosis, Silicosis Hodgkin's disease (following treatment) Rare: Pneumocystis carini pneumonia Metastases(mucinous adenocarcinoma) Amyloidosis ,Scleroderma Castleman's disease LYMPH OMA:

Low density I necrotic lymph nodes Common: Infectious granulomatous diseases Tuberculosis Fungal infections (histoplasmosis) Metastases Lung cancer, Seminoma, Lymphoma Rare: Whipple's disease, Sarcoidosis Lymph node enhancement [23]: Enhancing lymph nodes. Common: Metastases , Castleman's disease Rare: Sarcoidosis ,Angio immunoblastic

Lymphom as are primary neoplasms of the

lymphoreti cular system and are classified into Hodgkins disease (HD) and Non-Hodgkins

lymphoma. Hodgkins disease is more common cause of mediastinal involvement [56] Hodgkins disease: Occurs at all ages, but its peak incidence is in the third and eighth decades. Hodgkin's disease has a thoracic predilection in up to 85%, presenting with mediastinal adenopathy. Most commonly involves prevascular and paratracheal lymph nodes [57]. Nodular Sclerosing histology accounts for 50% to 80% of adult Hodgkin's disease [58]. In a study by Castellino et al [59] findings shown on CT changed treatment in more than 9% of patients. Nodes are of homogenous soft tissue attenuation in majority of cases. Multiple enlarged lymph nodes are often seen and they can be well defined and discrete, matted or associated with diffuse mediastinal infiltration. It is uncommon to show areas of low attenuation or necrosis. Hodgkin's disease also has a predilection for involvement of the thymus in association with mediastinal lymph node enlargement [57]. In patients with mediastinal Hodgkin's disease, scanning should always be extended to include the upper abdomen. Intraabdominal peri aortic adenopathy can be found in 25% of patients with Hodgkin's disease and the spleen and liver are involved in 37% and 8% respectively.

Non Hodgkin's Lymphoma (NHL): In comparison to Hodgkin's disease, Non Hodgkin's lymphoma are less common cause of thoracic disease and occur in an older group (median 55 years) [56]. Non Hodgkin's lymphoma is more common than Hodgkin's disease in children [4]

Enlargement of anterior mediastinal, internal mammary, paratracheal and hilar nodes is much less common with non Hodgkin's lymphoma than with Hodgkin's disease. Nonetheless superior mediastinal node involvement remains the most frequently involved site. Rarely, calcification of node masses seen. Extra nodal involvement like lung, pleura, pericardial space and chest wall is common. The abdomen, pelvis and neck must be scanned in all patients with Non Hodgkin's lymphoma as non contiguous spread is common. On CT, large, lobulated anterior mediastinal masses are seen.CT valuable in determined tumour extent, as radiation is usually used; the presence of pleural effusion predicts a poor outcome. LEUKEMIA: Mediastinal lymph node enlargement occurs in about 50% and 67% of cases respectively with acute and chronic lymphocytic leukemia and 35% and 36% of patients with acute and chronic myelogenous leukemia respectively [23]. CT appearance of lymphadenopathy is indistinguishable from lymphomas; hence Clinical correlation is a must to arrive at the correct diagnosis.

METASTATIC TUMOUR: Metastases to mediastinal lymph nodes from extrathoracic malignancies are uncommon. The extrathoracic tumour most likely to metastasize to the mediastinum

are carcinomas of the head and neck, genitourinary tract, breast and malignant melanoma. Lymph node enlargement involving the posterior mediastinal and paravertebral lymph nodes suggests an abdominal location for the primary tumour and superior mediastinal lymph node involvement suggests a head and neck tumour. Internal mammary lymph node metastases are most likely caused by breast carcinoma. SARCOIDOSIS: Typically, node enlargement involves the hilar as well as mediastinal node groups, and masses appear bilateral and symmetrical in the large majority which allows differentiation from lymphoma. In the order of decreasing frequency, paratracheal, aorticopulmonary, subcarinal and prevascular lymph nodes are commonly involved [60]. Lymph nodes shows dense or stippled or egg shell calcification and rarely enhance or appear necrotic. TUBERCULOSIS: Hilar and mediastinal lymph node enlargement is commonly seen on CT in active tuberculosis cases, more frequently in children than adults [61]. Lymph node enlargement is usually seen on the side of lung disease, but involvement of contra lateral nodes can sometimes be present. Right sided adenopathy usually predominates [61]. On CT, the enlarged lymph nodes usually show central areas of low attenuation on contrast enhanced CT, with peripheral rim enhancement. However these areas of low attenuation are not of water density but range from 40 to 50HU.

CT more accurately defines the presence and extent of lymph node enlargement than does routine chest radiography in patients with tuberculosis. In some cases, CT can serve as a guide for determining the best sites for node biopsy, and can help determine whether mediastinoscopy or parasternal mediastinotomy is most appropriate FIBROSING MEDIASTINITIS In some patients with granulomatous disease involving mediastinal lymph nodes, extension of the disease process to involve surrounding mediastinal tissues results in extensive fibrosis. This is termed fibrosing or granulomatous mediastinitis. Symptomatic encasement and/or compression of a number of mediastinal structures, particularly vessels, and the tracheal or oesophagus can result. The most common causes are histoplasmosis, tuberculosis and sarcoidosis; can also be related to autoimmune disease, drugs, retroperitoneal fibrosis, or may be idiopathic. On CT they are manifested by replacement of low density mediastinal fat by higher density fibrous tissue often associated with calcification. Discrete enlarged lymph manifested by replacement of low density mediastinal fat by higher density fibrous tissue, often associated with calcification. Discrete enlarged lymph nodes cannot be identified. Manifestations on CT include hilar and mediastinal masses, stippled or diffuse calcification, and compression and/or encasement of the trachea, main bronchi or mediastinal vessels [62] Rarely does it affect the posterior mediastinum. MEDIASTINAL LIPOMATOSIS Lipomatosis is a benign condition in which over abundant amounts of histologically normal, unencapsulated fat accumulate in the mediastinum. They may

be associated with Cushing's syndrome, steroid treatment, or obesity. It is unassociated with symptoms. The excess fat deposition is most prominent in the upper mediastinum resulting in smooth mediastinal widening as shown on chest radiographs, and convex or bulging mediastinal pleural surfaces on CT . MEDIASTINAL LIPOMA AND LIPOSARCOMA Mediastinal lipoma is uncommon, constituting approximately 2% of all mediastinal tumours. Most commonly occur in the prevascular space. Lipomas are soft and pliable and do not result in symptomatic compression of adjacent structures unless they are very large. Mediastinal liposarcoma are rare malignant tumour, composed largely of rat. CT findings include a. Inhomogeneous attenuation with evidence of significant amounts of soft tissue with in the fatty mass b. Poor definition of adjacent mediastinal structures. c. Evidence of infiltration or invasion of mediastinal structures. ESOPHAGEAL CARCINOMA Esophageal carcinoma represents approximately 10% of all cancers of the gastrointestinal tract. The CT manifestations include: a. Narrowing of the esophageal lumen or dilatation caused by obstruction. b. Thickening of the oesophageal wall, either symmetric or asymmetric c. Loss of periesophageal fat planes, with or without evidence of invasion of surrounding organs.

d. Periesophageal adenopathy

Moss et aI [63, 64] proposed classification based on CT findings as: Stage 1: Intraluminal lesions or those that cause localized wall thickening of between 3 and 5mm. Stage 2: Stage 3: Wall thickening greater than 10mm, either localized or circumferential. Wall thickening associated with evidence of contiguous spread of tumour into adjacent mediastinal structures. Stage 4: Any locally definable disease associated with distal metastases

CT aids in assessment of resectabiltiy, accurate means for detecting invasion of the carina and main stem bronchi. CT is of proven value in detecting liver and lung metastases as well as direct extension of tumour into the pleura, lung, or adjacent vertebral bodies. MEDIASTINITIS AND MEDIASTINAL ABSCESS Acute mediastinal infections are uncommon and are usually related to surgery, esophageal perforation, or spread of infection from adjacent region. CT findings include diffuse or streaky infiltration of mediastinal fat (greater than 25HU), mediastinal widening, localized fluid collections, pleural or pericardial effusion, lymph node enlargement, and compression of mediastinal structures. Gas bubbles in the mediastinum, with or without associated fluid collections is an important finding. ANEURYSM OF THORACIC AORTA

Aortic aneurysms can result in a mass in the anterior, middle or posterior mediastinum. The classical description of Aortic aneurysm is 'An area of permanent dilatation of the aorta where the dilatation is at least 50% greater than baseline or standardized normal limits [65]. The average diameters are 3.5cms for the ascending aorta, 2.6cm at the proximal descending aorta, 2.5cm at the mid descending aorta and 2.4 at the distal descending aorta with progressive increase with age at approximately 0.1 cm per decade [65]. A true aneurysm involves all three layers of the aortic wall. A pseudoaneurysm represents an area of perforation that is contained by the adventitia or para aortic connective tissue. Aneurysmal dilatation may be focal/saccular or diffuse / fusiform. Saccular aneurysms are often seen in infectious etiologies or post traumatic causes. Fusiform aneurysms are most often associated with Atherosclerosis and Cystic medial degeneration. Segmental, irregular or multiple aortic aneurysms are most often seen with non infectious aortitis such as Takayasu's arteritis, Behcet's syndrome. Non enhanced CT scans are useful for evaluating the mural composition of the aneurysm, such as the morphology, pattern and distribution of wall calcification and thrombus. The classic description is thin, linear mural calcification seen in 40% of luetetic aneurysm [66] and coarse thick and irregular calcification in atherosclerotic aneurysms. Cystic medial degeneration often does not associate with mural calcification. The draped aorta [67] has been described as a CT sign of contained leak of aortic aneurysm in the emergent settings, the hyperdensity of the hematoma

points to the area of acute injury and the hyper attenuating crescent sign has been shown to represent acute or impending rupture [68] With infected aneurysms, Perivascular emphysema and inflammatory tissue are suggestive. Contrast administration helps in the visualization of possible dissection. Displacement or compression of the esophagus superior venacava, airway and lung are seen. Erosion of chest wall noted in long standing aneurysm. DISSECTION OF AORTA: Is classified as Stanford type A: Ascending aorta is involved and this type requires immediate surgery; Stanford type B: Begin distal to the origin of left sub clavian artery and are generally treated conservatively. In dissection there is an intimal tear leading to extra vasation of blood into the media. Ascending aorta dissection is usually related to Cystic medial degeneration including Marfan's syndrome. Other causes include arteriosclerosis with

hypertension pregnancy and coarctation of aorta. Calcification in the aortic knuckle which is separated from the outer margin by more than 1cm is said to be suggestive of dissection CT has a sensitivity of 93.8% (MRI 98.3%) and specificity of 87% (MRI: 97.8%) 28. However the CT has the advantage of showing calcification which may be valuable in detecting intimal displacement. On CT the communicating dissections show a 'double barrelled aorta'

Other vascular abnormalities and anomalies (which mimics a mediastinal mass) [28] 1. Right aortic arch 2. Double aortic arch 3. Coarctation or pseudocoarctation of aorta 4. Azygous Continuation of Inferior venacava 5. Persistent Left Superior venacava 6. Aberrant Right Subclavian artery 7. Superior venacava or Branchiocephalic vein obstruction 8. Left ventricular aneurysm / pseudoaneurysm In all these cases, CT (usually with IV contrast material) or MRI is essential for confirming the diagnosis

CT GUIDED BIOPSY

Transthoracic needle biopsy of the mediastinum is an accurate, safe and cost effective diagnostic tool for the evaluation of mediastinal masses and

lymphadenopathy. The technique is most useful in the staging of carcinoma where it serves as a less expensive and minimally invasive alternative to mediastinoscopy for establishing unresectability. An anterior parasternal approach is preferred for most anterior mediastinal masses, whereas a posterior paravertebral approach is used for posterior mediastinal masses. Midline (substernal) masses can undergo biopsy from a transternal approach. Subcarinal biopsy is occasionally performed using a left parasternal approach by entering the mediastinum via the connective tissue space between the descending aorta and spine [69], whenever possible; a direct mediastinal approach is preferable to a transpulmonary approach, because of the risk of pneumothorax. Pneumothorax is the principal complication of CT guided chest biopsy occurring in 25% to 43% of patients [70, 71]. Most patients with pneumothorax requires no therapy, but 5% to 18%. may require placement of a chest tube, hence equipment for immediate chest tube placement should be available whenever a chest biopsy is performed. Hemoptysis can also occur after CT guided thoracic biopsy (less than 5%) and almost always is self limited. [71] With recent advances in immunohistochemical and core biopsy techniques. Transthoracic needle biopsy has become more accurate for establishing the initial diagnosis for lymphoma and for confirming recurrent disease. Core needle biopsy has improved the accuracy of transthoracic needle biopsy and is particularly useful when fine needle aspiration fails to yield a specific diagnosis, when lymphoma or a non carcinomatous lesion is

suspected.

MATERIALS AND METHODS

This study of evaluating the efficacy of computed tomography in the diagnosis of mediastinal lesions was performed on 50 cases. Source of Data: All patients referred to Department of Radio-Diagnosis with clinically suspected mediastinal space occupying lesions or who had a chest radiogram with a suspicious mediastinal abnormality are taken up for study The study was conducted in the Department of Radio diagnosis, Bowring and Lady Curzon Hospital between September 2005 to August 2007 Thorough clinical history and clinical examination was done before CT examination. All the cases taken up for the CT were evaluated for the distribution, CT features of the mediastinal mass and also the involvement of adjoining structures. Inclusion criteria: Computed tomography study of the mediastinum was conducted in: . . lesion. Exclusion criteria: a. b. Traumatic causes Cardiac causes Clinically suspected cases of mediastinal mass Patients where the chest radiographs showed the evidence of mediastinal mass

THE COMPUTED TOMOGRAPHY (CT) MACHINE

All the cases were studied on a SEIMENS SOMATOM 6 slice computed tomography system which is a modified third generation machine. Factors of 120 kV and 30 mA were a constant feature for all cases. Preparation of patient: Patients were kept nil orally 4 hrs prior to the CT scan to avoid complications while administrating contrast medium. Risks of contrast administration were explained to the patient and consent was obtained prior to the contrast study. Technique: Routine anteroposterior topogram of the thorax was initially taken in all patients in the supine position with the breath held. An axial section of 10mm thickness was taken from the level of thoracic inlet to the level of suprarenal. In all cases plain scan was followed by contrast scan, intermittent were obtained in intermittent suspended inspiration. For contrast enhancement initially 80-100ml of dynamic injection of Diatrizoate meglumine and Diatrizoate sodium (Trazograf 76%; Urograffin 76%, 60%) OR in a dose of 300mg of Iodine / Kg body weight (in children) was given and axial section were taken from thoracic inlet to the level of suprarenals. Sagittal and coronal reconstructions were made wherever necessary. The magnification mode was commonly employed, and the scans were reviewed on a direct display console at multiple window settings (i.e. soft tissue (mediastinal) window at 320/40; Lung window 1400/-600; Bone window of 2400/200 to examine the wide variation of tissue density and also to look for osseous involvement.

The pre and post contrast attenuation values , the size ,location of the mass , presence of calcification , mass effect on adjoining structures and others associated findings were studied by panel of radiologist

STANDARD IMAGING PROTOCOL [26]

Routine chest scanning protocol: Scout image: Landmark: Slice plane: Anteroposterior Sternal notch Axial or spiral

Intravenous contrast: 80-120ml Rate 1.5-2ml/sec for 15 sec Followed by 1 ml/sec, Oral Contrast: Breath hold: Slice thickness: Slice interval: Start location: None Suspended Respiration 5mm sections from apices to base of lung continuous Strenal notch

Because lung cancer may metastasize to the adrenal glands, scanning is often continued through to the adrenals in patients with a history of cancer. End location: Through lung bases Reconstruction Algorithm: Filming: Standard or detail Soft tissue (mediastinal) window 320/20 Lung window: 1400/-600

SOMOTOM EMOTION SIX SLICE CT SCANNER DEPARTMENT OF RADIO DIAGNOSIS BOWRING AND LADY CURZON HOSPITAL, BANGALORE

In the study all the cases with mediastinal abnormality on radiographs or with secondary involvement of the mediastinum was subjected to CT evaluation for better characterization, extent, probable tissue of origin and effect on adjoining structures. Plain and contrast studies were performed. Our study comprised of 50 patients

Table 1: Age and sex distribution

AGE IN YEARS 0-15 MALE No of Percentage cases 8 57.2 FEMALE No of Percentage cases 6 42.8 TOTAL No of Percentage cases 14 28

16-30

37.5

62.5

16

31-45

57.2

42.8

14

46-60

11

73.3

26.7

15

30

> 61

4 30

66.7 60

2 20

33.3 40

6 50

12

In the study out of 50 cases, 30 cases (60%) were males and 20 cases (40) were females. Of 52 cases, 14 cases (28%) were children. Among them 8 were males (i.e 57.2%) and 6 were females (i.e. 48.2%).

The most common age group to present with the mediastinal mass was between 4660yrs comprising of 15 cases constituting 30% of the total in which males (11 in number = 73.3%) outnumbered the females (4 in number = 26.7%) .

Table 2: Clinical symptoms Distribution No of cases

Cough 22

Percentage
44

Dyspnoea

18

38

Fever

10

20

Chest Pain

10

20

Others

16

32

Graph showing clinical symptoms distribution

60 50

44 36 32

Percentages

40 30

20
20 10 0

20

Cough Dyspnoea Fever Symptoms

chest pain

Others

In our study of 50 cases, Cough was the most common clinical symptom constituting 44 % followed by Dyspnoea 38%, fever 20% and chest pain 20%. In the study out of 50 cases, 3 cases had no symptoms pertaining to the chest and CT showed incidental involvement of the mediastinum. Therefore in the study 94% were symptomatic subjects.

Table 3: Compartmental distribution of mediastinum masses

Compartment Anterior Mediastinum No of Cases 26 Percentage 52

Middle Mediastinum

18

Posterior Mediastinum

15

30

Compartmental distribution of mediastinal masses

Anterior Mediastinum Middle Mediastinum Posterior Mediastinum

In the study the anterior mediastinal masses formed the majority with 52% (N=26) of the total masses. Out of 50 cases, Some of them showed separate mass involving different compartments hence the total number of mass amounts to 55. In this 3 cases (6 %) showed separate mass involving anterior and middle mediastinum (Case no: 1, 401, 412) and they were predominantly the lymph nodal mass due to carcinoma lung or Tuberculosis. 2 cases (4 %) showed masses in both posterior and middle mediastinum and were predominantly due to Tuberculous involvement.

Table 4: Anterior Mediastinal Lesions distribution

NO of CASES Thymic masses Metastatic lymph Node TB Lymph Node Aortic Mass Lymphoma Thyroid Mass Germ cell Tumour 7 5 4 4 3 2 1 26

Percentage
26.9 19.2 15.4 15.4 11.6 7.7 3.8 100

In the study among the anterior mediastinal masses, thymic masses formed the majority constituting 26.9% (n=7) followed by Metastatic Lymph Node 19.2% (n=5) of the total.

Graph showing Distribution of Anterior Mediastinal Lesions

30 25 20 15 10 5 0
Th ym M et ic as m ta as t ic se ly s m ph N TB od Ly e m ph N od A e or t ic M as s Ly m ph om Th a yr oi d G er M as m s ce ll Tu m ou r

Table 5: Middle mediastinal Lesions distribution No of cases

Metastatic Lymph Node TB Lymph Node Neuroenteric cyst Esophageal Duplication Cyst Bronchogenic cyst 4 2 1 1 1 9

Percentage
44.5 22.2 11.1 11.1 11.1 100

Graph showing Distribution of middle mediastinal Lesions

50 45 40 35 30 25 20 15 10 5 0 1 Neuroenteric cyst Esophageal Duplication Cyst Bronchogenic cyst Metastatic Lymph Node TB Lymph Node

Middle mediastinal masses comprised of 18 %( n=9) of the total mediastinal masses. Among them the metastatic lymph node involvement formed the majority i.e. 44.5% (n=4) followed by TB Lymph Node enlargement; 22.2% (n=2).

Table 6: Posterior mediastinal masses distribution

No of masses Neural tumors Para vertebral abscess TB Lymph Node Oesophageal mass Hydatid cyst Para vertebral hematoma Lymphangioma 5 3 2 2 1 1 1 15 Percentage 33.3 20 13.3 13.3 6.7 6.7 6.7 100

In the study, Posterior mediastinal masses comprised 30 % (n=15) of the total mediastinal masses, the majority was contributed by neural tumors constituting 33.3% (n=5) followed by Para vertebral abscess constituting 20% (n=3) each respectively. These masses were predominantly seen among the adults constituting 60% and children constituted 30%.

Graph showing Distribution of Posterior mediastinal Lesions

Neural tumors Para vertebral abscess TB Lymph Node Oesophageal mass Hydatid cyst Para vertebral hematoma 1 Lymphangioma

35 30 25 20 15 10 5 0

Table 7: Thymic masses distribution

No of Masses
Thymoma Thymic hyperplasia Thymolipoma Thymic cyst 3 2 1 1

Percentage
42.8 28.6 14.3 14.3

Among the thymic masses, Thymoma constituted 42.8% (n=3) and is seen predominantly in age group of 46-60 yrs and males outnumbered females 2:1. Thymic

hyperplasia comprised 28.6% (n=2) and was seen in age group of 0-15 yrs.

Table 8: Neural tumors distribution

No of masses Neurogenic Tumor Neuroblastoma 4 1 Percentage 80 20

In the study out of 5 cases, 4 (80%) were neurogenic tumor which again comprised of 50% (n=2) schwannoma, 25%Ganglioneuroblastoma (n=1) and 25% neurofibroma (n=1).

Table 9: Lymph nodal masses distribution

No of masses Metastatic LN TB Lymphadenopathy Lymphoma 9 8 3 Percentage 45 40 15

In the study Lymph nodal masses constituted 40 (N=20) of the total mediastinal masses. Among these the metastatic lymph node involvement is the predominant constitutes 45 % followed by TB lymph node enlargement 40%. TABLE 10: Correlation between CT and Histopathology

Mediastinal Masses

Total

Histological findings

Non verifying

1. 2. 3.

Anterior mediastinum Middle mediastinum Posterior mediastinum

26 9 15

21 9 13

5 0 2

In the study all 43 cases are histologically verified and 4 cases of vascular origin aortic disorder are confirmed with conventional angiography. Remaining 3 cases i.e.Thymic Hyperplasia, Lymphangioma and Hydatid cyst are managed conservatively.

CT CHARACTERISTICS a. CT enhancement pattern of mediastinal masses

No. of cases Heterogeneous enhancement Homogenous enhancement Non enhancing Rim enhancement Intense enhancement 22 14 6 5 3 Percentage 44 28 12 10 6

In the study majority showed heterogeneous enhancement i.e. 44 % (n=22) followed by homogenous enhancement; 28 % (n=14) non enhancing masses constituted 12 (n=6); 3 cases showed intense vascular enhancement and were cases of Aortic aneurysm with / without dissection.

Graph showing CT enhancement pattern of mediastinal masses

REM Inter Non 10.0% 6.0% 12.0% HOM 28.0% HET 44.0%

Enhancement

b. Distribution of the masses based on their nature No of cases Percentage

Solid masses Solid + Cystic masses Cystic Vascular masses Fatty masses Fatty + Cystic + Solid 27 11 6 4 1 1 54 22 12 8 2 2

In the study majority were solid masses constituting % (n=27) of the cases followed by solid +cystic masses % (n=11) of the cases.

Graph showing Distribution of the masses based on their nature

60 50

54

Percentages

40 30 20 10 0

22 12 8 2 S S/C C
Nature

2 F/S/C

c. Calcification

No of cases Present Absent 12 38

Percentage 24 76

In the study 24% (n = 12) of the cases showed calcification in the mediastinum mass. d. Mass effect on adjoining mediastinal structures

No of masses Present Absent 31 19

Percentage 62 38

In the study the mass effect was noted in 62% of the cases and was predominantly noted 7

on the tracheobronchial tree.

Presence of Calcification

Mass effect on adjoining mediastinal structures

Abs e nt 76.0%

Absent 38.0%

Pre s e n t 24.0%

Present 62.0%

calcifications

Mass effect

Table 11 : CT Diagnosis

CT Diagnosis Aortic Aneurysm Asc Aortic Aneu with Dissection Ascending Aortic Aneurysm Bronchogenic Cyst CA Lung with Adenopthy CA Lung with HLN Esophageal Duplication Cyst Esophageal Mass Germ Cell Tumour HLN with CA Lung Hydatid Cyst Lymphangioma Lymphoma Neuroblastoma Neuroenteric Cyst Neurogenic Tumour Paravertebral Abs Paravertebral Abscess

No 1 1 1 1 4 1 1 2 1 1 1 1 3 1 1 4 2 1

% 2.00 2.00 2.00 2.00 8.00 2.00 2.00 4.00 2.00 2.00 2.00 2.00 6.00 2.00 2.00 8.00 4.00 2.00

Paravertebral Hematoma Pretracheal And Paratracheal LNE with CA Lung Pretracheal/Hilar LNE with CA Lu Retrosternal Goitre Right Paratracheal LNE with CA Lung TB LNE Thymic cyst Thymic Hyperplasia Thymolipoma Thymoma Type A Aortic Dissection Total

1 1 1 2 1 8 1 2 1 3 1 50

2.00 2.00 2.00 4.00 2.00 16.00 2.00 4.00 2.00 6.00 2.00 100.00

Table 12 : Final Diagnosis

Diagnosis Ade C CA Lu Ade CA Aor Dissection Aor Ane Asc Ao Ane Asc Aor Aneu with Diss Bronchogenic Cyst Esophageal Duplication Cy Ganglioneuroma Hematoma Hodg Lym Hydatid Cyst Lymphangioma Lymphoma MNG Neuroblastoma Neuroenteric Cyst Neurofibroma NonHodgkins Lym Paravertebral Abs Schwannoma Squ C CA Lu TB LNE Teratoma No. 5 2 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 2 1 3 1 4 88 1 1 % 10.0 4.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 4.0 2.0 2.0 4.0 2.0 6.0 2.0 8.0 16.0 2.0 2.0

Figure 1- ANEURYSM OF ARCH OF AORTA

AXIAL IMAGE

CORONAL IMAGE

VRT IMAGE

Figure 2- HODGKINS LYMPHOMA

Figure 3- THYMOMA

Figure 4- THYMOLIPOMA

Figure 5- CARCINOMA OF LUNG WITH MEDIASTINAL LYMPHADENOPATHY

Figure 6- NEUROGENIC TUMOUR

Figure 7- METASTATIC LYMPHADENOPATHY WITH SVC OBSTRUCTION

Figure 8-

THYMIC CYST

Figure 9- BRONCHOGENIC CYST

Figure 10- TUBERCULAR LYMPHADENOPATHY

Figure 11- TUBERCULAR SPINE WITH PARAVERTEBRAL ABSCESS

Figure 12- CARCINOMA OF ESOPHAGUS

Figure 13- AORTIC DISSECTION

FIGURE 14-PATHOLOGY SLIDE -THYMOMA

FIGURE 15-PATHOLOGY SLIDE - HODGKINS LYMPHOMA

DISCUSSION
The mediastinum is the site for a vast range of diseases varying considerably, ranging from tumors-both benign and malignant, cysts, vascular lesions, lymph node masses and mediastinitis. Although conventional radiographs can show recognizable abnormalities in many patients with mediastinal abnormalities in many patients with mediastinal pathology, radiographs are limited in their sensitivity and ability to delineate the extent of mediastinal abnormalities and the relationship of masses to specific mediastinal structures. With the computed tomography these problems are overcome because of its

excellent density resolution and tomographic format and therefore CT plays an important role in the evaluation of the mediastinum. With the advent of CT, it has helped the clinicians and radiologists in identifying the precise location, extent and characterization of these masses. The following study was undertaken with the objectives of determining the disease pattern affecting the mediastinum and to correlate the CT findings with the histopathology reports whenever possible. Our study comprises a total of 50 patients from both ln and out-patient departments. The study was conducted for a period of 2 year from August 2005 to July 2007 in the department of Radio diagnosis. Majority of the symptoms were of non-specific nature like cough, chest pain, fever, dysphagia etc. These symptoms were mainly due to the mass effect from the mediastinal lesions and was dependent on the location or the mass. Anterior mediastinal masses mostly presented with cough and dyspnoea probably due to tracheal compression. Middle mediastinal lesions due to their location presented with dysphagia due to either involvement of the esophagus or its compression. Felson in 1978 in a series of 550 cases reported, there is no predilection for the masses to occur in the anterior mediastinum. But he reported more number of cases being seen in the anterior and posterior mediastinum followed by middle mediastinum in decreasing order of frequency. In our study, anterior mediastinal cases we are found to be the commonest accounting for 52 %. Posterior mediastinal cases accounted for 36%, followed by Middle mediastinal masses accounting for 20% of the cases.

In our study the 50 cases, which showed abnormal mediastinal shadow on radiographs or suspected involvement of the mediastinum were evaluated with computed tomography. The cases were analyzed in the following manner as discussed below:

A: Symptoms Distribution
Present study (52 cases) Cough Dyspnoea Fever Chest Pain 44% 36% 20% 20% Davis et al (400 cases) 16 % 16 % 20'% 30%

In our study of 52 cases, cough was the most common clinical symptom constituting 44 % followed by Dyspnoea 36%, fever 20% and chest pain 20%. According to the Davis et al
8

study in 400 consecutive patients with

mediastinal masses, chest pain constituted the most common symptom i.e. 30%, followed by fever 20%.

B: Compartmental distribution of mediastinal mass

Our study [children (n14)] 50 % 14.2 % 35.7 % Merten DF25 (508 children)

Our study

Strollo et a113,35

Anterior Mediastinum Middle Mediastinum Posterior Mediastinum

52% 18 % 30 %

50% 50 % -

46% 20% 34%

All age groups: In our study of 52 cases, the majority of the mediastinum masses were in the anterior mediastinum constituting 52% followed by middle and posterior mediastinal compartment which is similar to the study conducted by Strollo et a1[13,35] in 1997 wherein anterior mediastinum constituted 50% of the masses. C: Individual masses distribution (Based on the tissue of origin). Wychulis et Davis et al8 4 al (400 cases) (1064 cases) 19.9 19.4 10.1 9.3 6.3 5.3 3.4 14 17 16 11

Mediastinal Neural tumors Thymic tumors Lymphoma Teratoma!/GCT Granuloma Vascular Thyroid Miscellaneous

Our study (50 cases) 10 14 6 2 16 8 4

Bejamin et al5 (214 cases) 22.9 20.6 14.9 12.6 7.5 11.2 -

Cohen et al10 (230cases) 16.9 24.3 15.7 10.0 0 1.7 1.7 5.7

In our study Lymphoma constituted 6 % of the mediastinal masses which is similar to study conducted by Wychulis et al [1] (Le 10.1%).

Malignant lesions predominate in our study. Malignant lesions have predominated in the male population while benign lesions have occurred with equal frequency in both. Majority of the benign lesions have occurred in between the 2nd and 4th decade. In the case of malignancy, majority of the cases have occurred between 4th

and 6th decade. Tuberculous lesions In our study, Granuloma constituted 16%, which is greater in comparison to Wychulis et al [1] study (i.e. 6.3%) probably due to higher prevalence of Tuberculosis in comparison to the western population. Our study had 3 cases of paravertebral abscess (5.6%) which was associated with vertebral body destruction. According to Im et al [11] series, right paratracheal lymph node enlargement was seen in 87% of cases whereas our study showed 60 % involvement. Similarly in 1m et al [11] study 52% of the T8 lymph node enlargement showed central areas of low attenuation with rim enhancement on contrast study. Our study showed 40 % involvement. According to Choyke PL et al [72] in their study on adult onset pulmonary tuberculosis, reported 40% of adults showed presence of pleural effusion, whereas our study showed 50 % cases of Tuberculosis associated with pleural effusion. Thymic masses In our study the thymic tumors formed the majority with 14% which IS similar to studies conducted by Cohen et al [10] and Davis et al[8] In a study by Chen et al[9] on 34 patients with CT diagnosis of thymic mass, thymoma constituted 91 %, thymic cyst 2.9%. Whereas our study of 7 patients with thymic mass, thymoma constituted 42%, and thymic hyerplasia 28 %. According to Naidich et a123, Thymoma is most commonly seen between 5060 years which is comparable to our study in which the 3 patients with thymoma where of age 40, 48 years and 48 years respectively. Thyroid Masses:

Intrathoracic goiters are a common cause of mediastinal enlargement. Thyroid masses account for 11-15 % of mediastinal masses (A. Prasad et al, 2000. [73]). In our study they represented (only 3% of the cases).

SUMMARY AND CONCLUSION

Computed Tomography plays a significant role in the assessment of various mediastinal pathology which are initially detected on the chest radiographs .The maximum number or cases occurred in 4th to 6th decade. Mediastinal masses occur commonly in males.

In our study of 50 cases of mediastinal masses, the anterior mediastinum was the most common compartment to be involved with 52% involvement followed by posterior mediastinum (30%) and then middle mediastinum (18%). Thymic masses (26.9%), neural tumors (33.6%) and metastatic lymph node masses (44.5%) were the most common mediastinal masses in the anterior, posterior and middle mediastinal compartments respectively. In the pediatric group the neurogenic tumour is the most common mediastinal mass. Calcification is noted in 24 % of cases. Mass effect upon the adjacent mediastinal structures is observed in 62 % of the cases and is predominantly noted upon the airways. 86 percentages of {43 number} cases are histologically verified. And 4 cases {8 percentage} of aortic disorders are verified with conventional angiography. Totally 94 percentage of cases are verified with histopathology and angiography. With an accuracy of 94% CT is a highly useful modality for investigation of mediastinal masses So we conclude that computed tomography definitely has a major role to play in the evaluation of a mediastinal mass regarding the distribution pattern, CT diagnosis and mass effect upon adjacent structures.

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PROFORMA
COMPUTERIZED TOMOGRAPHIC EVALUATION OF MEDIASTINAL LESIONS

NAME: ADDRESS: IPD/OPD NO CLINICAL EXAMINATION:

AGE: CT NO:

SEX:

I. CHIEF COMPLAINTS: FEVER CHEST PAIN BREATHLESSNESS COUGH HAEMOPTYSIS / HAEMATEMESIS DYSPHAGIA OTHER COMPLAINTS II. H/O PRESENT ILLNESS IN BRIEF:

III. PAST HISTORY:

IV. PERSONAL HISTORY: : TUBERCULOSIS, OCCUPATION SMOKING, OTHERS:

V. FAMILY HISTORY VI. PHYSICAL EXAMINATION PULSE B.P R.R CYANSOSIS PALLOR CLUBBING CVS EXAMINATION RS EXAMINATION OTHER SYSTEMS CNS P/A VII. INVESTIGATIONS BLOOD PICTURE: SPUTUM EXAMINATION: ENDOSCOPY FINDINGS OTHERS: VIII. RADIOLOGICAL INVESTIGATIONS: 1. CHEST X RAY 2. BARIUM SWALLOW 3. USG THORAX

4. CT THORAX A. LOCATION OF MASS SUPERIOR INFERIOR ANTERIOR MIDDLE POSTERIOR

B. TISSUE CHARACTERISTICS : WELL /ILL DEFINED SOFT CYSTIC VASCULAR FAT C. SIZE: D. INITIAL DENSITY ON PLAIN STUDY E. CALCIFICATION F. BONE DESTRUCTION G. VASCULAR DISPLACEMENT H. PATTERN OF ENHANCEMENT I. LUNG FININGS

J.
5. MRI

ASSOCIATED FINDINGS

IX. RADIOLOGICAL FINDINGS

X .BIOPSY REPORT

XI. MANAGEMENT

XII. FOLLOW UP

KEY TO MASTER CHART NHL Oes PMM PM PS S Squ ST TB LNE V Y Non Hodkins Lymphoma Oesophagus Posterior Mediastinal Mass Posterior Mediastinum Pott's spine Solid Squammous Soft Tissue Tuberculous lymph node enlargement Vascular Year

A Ao Abs Ade AM Aneur B/L C CA Ce F Inten HLN Het Hom Lymp Lu M Mal MNG Met MM

Anterior Aortic Abscess Adenocarcinoma Anterior Mediastinum Aneurysm Bilateral Cystic Carcinoma Cell Fat Intense Hilar Nodes Heterogeneous Homogenous Lymphatic system Lung Male Malignancy Multi Nodular goiter Metastatic Middle Mediastinum

Clinical Symptoms Age /Sex Dyspnoea Location Others Cough

CT Findings Origin of Mass Enhancement Mass Effect Calcfication Nature

CT Diagnosis

Other I

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Mallayya Ibrahhim Irfan Ramanna Raju Kasim Pasha Parveen Taz Haseen Kumar Zakhir Vishwanath Rangaswamy Madegowda Pooja Parveen Taz Ranjitha Shruthi Ashwini Santhosh Sangeetha Vinod Sanjeev Kumar Prashanth Deepak Nagarajappa Sharan Dodda Madayya Yusuf Dodda Madegowda Preethi

58Y/M 65Y/M 40Y/M 48Y/M 10Y/M 48Y/M 47Y/F 6Y/F 8Y/M 10Y/M 62Y/M 48Y/M 53Y/M 28Y/F 40Y/F 48Y/F 30Y/F 46Y/F 6Y/M 4Y/F 6Y/M 59Y/M 25Y/M 10Y/M 63Y/M 2 Y/M 55Y/M 33Y/M 68Y/M 29Y/F

+ + + + + + + +

+ + + + + + + + + + + + + + -

+ + + + + + + + + + +

+ + + + + + + + -

AM /MM AM MM AM AM PM AM PM AM AM MM AM AM PM AM AM PM PM /MM PM PM AM AM AM AM AM MM AM PM/MM MM PM

+ + + + + + + +

+ + + + + + + + + + + + + + + + + +

Het Lymp S Inten Aorta V Het Lymp S Het Thym S Rim Lymp S/C Rim Verb S/C Hom Lymp S Het Neur S Hom Thym S Het Lymp S Het Lymp S/C Hom Thym S Hom Lymp S Het Verb S/C Hom Thym S Het Thyd S/C Non ST S Het Lymp S Hom Neur S Hom Neur S Hom Thym S Het Lymp S Hom Lymp S Rim Lymp S/C Hom Aorta V Non Cyst C Het Lymp S/C Rim Lymp S/C Het Lymp S Rim Verb S/C

Pretracheal/Hilar LNE with CA Lu Ascending Aortic Aneurysm CA Lung with HLN Thymoma TB LNE Paravertebral Abs Lymphoma Neuroblastoma Thymic Hyperplasia TB LNE CA Lung with Adenopthy Thymoma CA Lung with Adenopthy Paravertebral Abs Thymoma Retrosternal Goitre Paravertebral Hematoma TB LNE Neurogenic Tumour Neurogenic Tumour Thymic Hyperplasia Right Paratracheal LNE with CA Lun Lymphoma TB LNE Type b Aortic Dissection Neuroenteric Cyst HLN with CA Lung TB LNE TB LNE Paravertebral Abscess

CXR + + + + + + + + + + + + + + + + + + + + + + + + + +

Sl No

Name

Fever

31 32 33 34 35 36 37 37 39 40 41 42 43 44 45 46 47 48 49 50

Manoj Saritha Pavithra Narasegowda Renukha Shirin Mallikarjun Nirmala Nagaraj Made Gowda Pramod Keerthi Smitha Pradeep Shankhare Gowda Shivakumar Swamy Teena Zulekha Karuna Shwetha

4Y/M 28Y/F 70Y/F 58Y/M 10Y/F 40Y/F 49Y/M 13Y/F 55Y/M 38Y/M 29Y/M 8Y/F 13Y/F 39Y/M 58Y/M 28Y/M 29Y/F 50Y/F 61Y/F 36Y/F

+ + -

+ + + + + + + + -

+ + + + + + + -

+ + + + + + + + -

PM AM MM AM MM MM PM PM PM AM/MM MM/AM PM AM PM AM MM AM AM AM AM

+ + + + -

+ + + + + + + + + + + + + -

Hom Neur S Neurogenic Tumour Het Lymp S TB LNE Het Lymp S/C CA Lung with Adenopthy Inten Aorta V Asc Aortic Aneu with Dissection Het Oes C Esophageal Duplication Cyst Non Bron C Bronchogenic Cyst Het Oes S Esophageal Mass Non ST C Lymphangioma Non ST C Hydatid Cyst Het Lymp S Pretracheal And Paratracheal LNE w Het Lymp S CA Lung with Adenopthy Hom Neur S Neurogenic Tumour Het Thym C Thymic cyst Het Oes S Esophageal Mass Inten Aorta V Aortic Aneurysm Het Lymp S TB LNE Het ST F/S/C Germ Cell Tumour Hom Thyd S/C Retrosternal Goitre Hom Lymp S Lymphoma Non Thym F Thymolipoma

+ + + + + + + + + + + + + + + -

nvestigations Barium Swallow

HPR + + + + + + + + + + + + + + + + + + + + + + + + + + Final Diagnosis Squ C CA Lu Asc Ao Ane Ade C CA Lu Thymoma TB LNE Paravertebral Abs Hodg Lym Neuroblastoma Thymic Hyperplasia TB LNE Ade C CA Lu Thymoma Ade C CA Lu Paravertebral Abs Thymoma MNG Hematoma TB LNE Neurofibroma Schwannoma Thymic Hyper Squ C CA Lu Lymphoma TB LNE Aor Dissection Neuroenteric Cyst Ade C CA Lu TB LNE TB LNE Paravertebral Abs

+ -

+ + + -

+ + + + + + + + + + + + + + + + +

Ganglioneuroma TB LNE Ade C CA Lu Asc Aor Aneu with Diss Esophageal Duplication Cyst Bronchogenic Cyst Ade CA Lymphangioma Hydatid Cyst Squ C CA Lu Squ C CA Lu Neurofibroma Thymic cyst Ade CA Aor Ane TB LNE Teratoma MNG NonHodgkins Lym Thymolipoma