MEDIASTINAL DISEASE

• The mediastinum is the region in the chest between

the pleural cavities that contain the heart and other
thoracic viscera except the lungs
• Boundaries
• Lateral - parietal pleura
• Anterior - sternum
• Posterior - vertebral column and paravertebral
gutters
• Superior - thoracic inlet
• Inferior - diaphragm
Anatomy of the Mediastinum
Anatomy of the Mediastinum
Normal Contents
• Anterosuperior: thymus, extrapericardial aorta
and branches, IVC, SVC, lymphatic tissue
• Middle: heart, intrapericardial great vessels,
pulmonary hila, pericardium, trachea
• Posterior: esophagus, vagus nerves, thoracic
duct, sympathetic chain, descending thoracic
aorta, azygous venous system
Anatomy of the Mediastinum
Normal Contents
• Anterosuperior: thymus, extrapericardial aorta
and branches, IVC, SVC, lymphatic tissue
• Middle: heart, intrapericardial great vessels,
pulmonary hila, pericardium, trachea
• Posterior: esophagus, vagus nerves, thoracic
duct, sympathetic chain, descending thoracic
aorta, azygous venous system
Mediastinal Masses
Compartment % Malignant

Anterosuperior 59

Middle 29

Posterior 16
 Anterosuperior Masses
Thymus Germ Cell Tumor
• Thymoma • Teratoma
• Thymic carcinoma • Mature
• Thymic carcinoid • Immature
• Thymolipoma • Seminoma
Mediastinal Lymphoma • Nonseminomatous Germ Cell
• Embryonal cell carcinoma
• Hodgkin’s Lymphoma
• Endodermal sinus tumor
• Non-Hodgkin’s Lymphoma
• Poorly differentiated • Choriocarcinoma
lymphoblastic • Malignant teratoma
• Diffuse lymphocytic • Mixed
• Primary Mediastinal B-cell
Lymphoma Thyroid/Parathyroid
Thymoma
Presentation
• Most common primary anterior mediastinal tumor
• M=F, most >40
• Most patients are asymptomatic
• Half of patients suffer have associated
parathymic syndromes
• myasthenia gravis
• hypogammaglobulinemia
• pure red cell aplasia
Thymoma
Radiology
• Well-defined, rounded/lobular, mass arising from
the thymus
• May give rise to pleural implants, rarely
associated with effusions
• CT evaluation should evaluate the lung apices
through the diaphragm to evaluate for vascular
invasion and to rule out intrathoracic metastases
Primary Mediastinal Lymphoma
• 5-10% of patients with lymphoma present with
primary mediastinal lesions
• Primary mediastinal lymphoma represents 10-
20% of primary mediastinal masses in adults
and are usually in the anterosuperior
compartment
• Usually present with fever, weight loss and
night sweats
• Pain, dyspnea, stridor, SVC syndrome due to
mass effects are uncommon
Primary Mediastinal Lymphoma
Two Types
• Primary Mediastinal Hodgkin’s Lymphoma
• Primary Mediastinal Non-Hodgkin’s Lymphoma
• Poorly differentiated lymphoblastic
• Diffuse lymphocytic
• Primary Mediastinal B-cell Lymphoma
Primary Mediastinal Hodgkin’s Lymphoma
Presentation
• Incidental mediastinal mass on chest xray is the 2nd
most common presentation after asymptomatic
lymphadenopathy
• Mass is usually large, rarely causes retrosternal chest
pain, cough, dyspnea, effusions or SVC syndrome
• Bimodal age distribution maintained, however, first peak
is larger in patients with mediastinal involvement
• “B” symptoms: fever, weight loss (>10% body wt in 6
months), night sweats
• Generalized pruritus may precede the diagnosis by up to
a year and, if severe, is a negative prognostic indicator
• EtOH-induced pain, most common in nodular sclerosing
subtype
Primary Mediastinal Hodgkin’s Lymphoma
Radiology
• Multiple rounded masses (lymph nodes)
• Mediastinal nodal groups: prevascular,
aortopulmonary, paratracheal, pretracheal,
subcarinal, posterior mediastinal
• Hilar nodes are considered separately
• Dominant mass (nodal coalescence)
• Thymic mass
• May be associated with infiltration and
displacement of mediastinal structures and/or
extranodal extension into the sternum, chest wall,
pleura, pericardium or lung
• Usually homogenous attenuation on CT, but large
masses may have necrosis, hemorrhage or cysts
DD of Mediastinal Masses
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Mediastinitis
• Acute suppurative mediastinitis is a rapidly
progressive infection which continues to carry a
high mortality rate

• Pre-antibiotic era mortality rate of 50% has

improved to only 40% in last 60 years

• Lethality is due to rapid spread and development

of fulminant sepsis
 20

Etiology and Pathophysiology

• Etiology
• Esophageal perforation (most common)
• Infections upper respiratory tract
• Odontogenic infections
• Trauma and procedures in airway, neck, chest
• Impacted foreign body
• Microbiology
• Polymicrobial with both aerobes and anaerobes
 21

Clinical Presentation
• Initial Symptoms
• Often very subtle
• Fever, dyspnea, cough chest pain, abdominal pain, back pain
• Physical Findings
• Variable
• Edema of face, neck, arms chest
• With progression, possible pericardial effusion, tracheobronchial
compression
• Further Complications
• Empyema
• Erosion of aorta
• Aspiration pneumonia
• Costal Osteomeyelitis
• Terminal Complications
Hypotension, Shock, Renal failure, CV collapse