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Mediastinal mass

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Approach to mediastinal masses has been provided with a case of week

Publicado en: Salud y medicina
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Mediastinal mass

  1. 1. JSS Medical College, Mysuru CASE OF THE WEEK DR KAVITHA K. DR SHIKHAR GARG (Post Graduate Residents-Radiology)
  2. 2. PRESENTING COMPLAINT 27 year old man came with history of chronic dry cough. No h/o fever, hemoptysis, loss of weight. He was referred to the radiology department for further evaluation.
  3. 3. What is the imaging modality? What are your findings?
  4. 4. What is the imaging modality? What are your findings? What are your differential diagnosis?
  5. 5. FINDINGS
  6. 6. Chest X-Ray PA view shows a well defined round radio-opaque lesion in the left perihilar region. CHEST X-RAY - PA VIEW
  7. 7. OBTUSE ANGLE WITH LUNG Based on the findings of the radiograph we can say that it’s a medisatinal mass FINDINGS
  8. 8. DIFFERENTIALDIAGNOSIS The mass seems to be arising from left main bronchus.
  9. 9. LEFT LATERAL X RAY Left lateral xray of the chest showing a well defined radio- opaque lesion middle mediastinum abutting the left main bronchus and carina(arrowhead).
  10. 10. SO HOW DO WE DIFFERENTIATE MEDIASTINAL MASS FROM PARENCHYMAL MASS?
  11. 11. MEDIASTINAL VS PARENCHYMAL MASS • Unlike lung lesions, a mediastinal mass will not contain air bronchograms. • Margins with the lung will be obtuse. • Will not move with resipration on fluoroscopy. • Pencil sharp borders. • Broad based towards the mediastinum.
  12. 12. A lung mass abutts the mediastinal surface and creates acute angle with the lung.
  13. 13. • A mediastinal mass will sit under the surface of the mediastinum, creating obtuse angles with the lung.
  14. 14. SUPERIOR MEDIASTINUM Above the level of the pericardium and plane of Ludwig.
  15. 15. INFERIOR MEDIASTINUM Below the plane of ludwig
  16. 16. Anterior mediastinum: Anterior to the pericardium Middle mediastinum: Within the pericardium Posterior mediastinum: Posterior to the pericardium DIVISIONS OF INFERIOR MEDIASTINUM
  17. 17. Anterior mediastinum Thymus, lymph nodes and retrosternal thyroid CONTENTS OF INFERIOR MEDIASTINUM Middle mediastinum The heart, Pericardium, Great vessels, Tracheal bifurcation and both main bronchi. Posterior mediastinum Descending aorta, Oesophagus, Thoracic duct, Azygous & hemiazygous venous systems.
  18. 18. LETS LEARN THE SIGNS WHICH HELP US TO LOCALISE A MEDIASTINAL MASS ON A FRONTAL RADIOGRAPH
  19. 19. The differential attenuation of x-ray photons by two adjacent structures defines the silhouette SILHOUETTE SIGN Loss of right cardiac silhouette due tor right lung middle lobe pneumonia
  20. 20. When a mass arises from the hilum, the pulmonary vessels are in contact with the mass and their silhouette is obliterated. Visible vessles implies that the mass is not contacting the hilum, and is either anterior or posterior to it. HILUM OVERLAY SIGN
  21. 21. Helps to distinguish a bulky hilum due to pulmonary artery dilatation from a mass. Vessels can be seen to converge and join a dilated pulmonary artery. HILUM CONVERGENCE SIGN A CASE OF PULMONARY ARTERY HYPERTENSION
  22. 22. A mass in the posterior mediastinum, is surrounded by the lung tissue from all sides. This leads to a well- defined cephalic border seen above the clavicle CERVICO THORACIC SIGN Negative cervico-thoracic sign- s/o posterior mediastinal mass Well defined borders above the clavicle
  23. 23. ABDOMINO THORACIC SIGN A thoracic lesion which has its caudal end visible below the dome of diaphragm must be in the posterior mediastinum. Mass Extending below the Diaphragm
  24. 24. DIVISIONS ON LATERAL IMAGING
  25. 25. DIFFERENTIAL DIAGNOSES OF MEDIASTINAL MASSES
  26. 26. CT AND MRI WILL HELP US TO LOCALIZE, FURTHER CHARACTERISE VARIOUS MEDISTINAL MASS AND ALSO HELPS IN EVALUTING INVASION INTO ADJACENT STRUCTURES. FURTHER IMAGING
  27. 27. Final conclusion: Well demarcated radio-opaque mass in the middle mediastinum arising from the left main bronchus.
  28. 28. BASED ON THE XRAY FINDINGS DIFFERENTIALS – Oesophageal duplication cysts - Thick walled cysts found adjacent to the oesophagus Bronchogenic Duplication cysts - Sharply demarcated round/ oval thin walled mass filled with proteinacious fluid usually in the medial 1/3 of lungs arising from the bronchus.
  29. 29. FINAL DIAGNOSIS BRONCHOGENIC CYST
  30. 30. BRONCHOGENIC CYST Bronchogenic cysts are congenital malformations of the bronchial tree. They can present as a mediastinal mass that may enlarge and cause local compression. It is also considered the commonest of foregut duplication cysts.
  31. 31. Bronchogenic cysts are asymptomatic and are found incidentally. When large, mass effect may result in bronchial obstruction leading to air trapping and respiratory distress. CLINICAL PRESENTATION
  32. 32. Sharply demarcated round mass in the medial 1/3 of lungs. They do not communicate with the bronchial tree, and are therefore not air filled. They contain fluid ,variable amounts of proteinaceous material, blood products, and calcium oxalate . It is the latter three components that result in increased attenuation mimicking solid lesions. FEATURES
  33. 33. CT findings Well circumscribed spherical mass of variable attenuation with variable fluid composition explaining the different CT attenuations observed. The degree of CT attenuation often depends on the amount of internal proteinaceous content . FURTHER IMAGING
  34. 34. MRI T2WI High signal intensity due to fluid content

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