COMPUTED TOMOGRAPHIC EVALUATION OF

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COMPUTED TOMOGRAPHIC EVALUATION OF



MEDIASTINAL LESIONS.



BACKGROUND

AND OBJEC
T
IVES:





Objective

of

our

study

was to

characterize

the

Mediastinal

lesions

/
m
a
s
ses

in

plain

and
contrast

enhanced

Computed

Tomography.

To

study

the

distribution

of

mediastinal
m
asses.

To

study

the

involve
m
ent

of

ne
i
ghbouring

structures

by

m
ediastinal

m
asses

and To

co
m
pare

Co
m
puted

To
m
ography

finding

with

Pathological

Diagnosis

where

ever possible.


MATER
IA
LS AND
METHODS:



This

study

was

perfor
m
ed

from

August

2012 to February 2013

in

the

Department

of
Radio
-
diag
n
osis

in Konaseema Institute
of Medical Sciences,Amalapuram,AP
. Referred

patients

from

Medicine,

Surgery

and

Paediatrics

were

evaluated

through detailed

history,

necessary

physical

exa
m
in
a
tion

and

co
m
pu
t
ed

to
m
ography

is

carried

out using

Double
slice

CT

scan

-

GE.

Scans

o
b
tained

with

both


Plain

and

Contrast

study.


RESULT:



This

study

included

50

cases

of

media
s
tinal

lesions

between

age

groups

6
-
76 years.

W
e

c
l
assified

our

m
ediastinal

lesions

into

three

cate
g
ories

as

anterior,

m
iddle

and posterior

m
ediastinal

m
a
sses.

Characterize

t
h
e

nature

of

the

lesion,

enhance
m
ent

pattern of lesion,
presence of c
a
lcifications and presence of
m
ass
effect.




INTERPRETATION

AND CONCLUSION
:



Co
m
puted

To
m
ography

plays

a

sign
i
ficant

role

in

the

assess
m
ent

of

v
a
rious
m
ediastinal pathology
w
hich are initially detected on the chest radiographs.

The

m
ax
i
m
u
m number

of

cases

occurred

in

4th

to

6th

decade.

In

our

study

of

50

cases

of
m
ediastinal

m
asses,

the

anterior

m
ediastinum

was

the

m
ost

common

compart
m
ent

to

be
involved

with

52%

involve
m
ent

followed

by

posterior

m
ediastinum

(30%)

and

then
m
i
ddle

m
ed
i
astinum

(18%).

So

we

conclude

that

co
m
puted

to
m
ography

definitely

has

a
m
ajor

role

to

play

in

the

eval
u
ati
o
n

of

a

m
ediastinal

m
ass

regarding

the

distribution
pattern, CT diagnosis and
m
ass
e
ffect upon adjacent structures.

Key

w
ords
:
-

Co
m
puted to
m
ography, Anterior Mediastinum,Middle
Mediastinum,Posterior
Mediastinum






















D
I
SCUSSION



The

m
ediastinum

is

the

site

for

a

vast

range

of

diseases

var
y
ing

considerably,

ranging from

tu
m
or
s
-
both

benign

and

m
alignant,

cysts,

vascular

lesions,

ly
m
ph

node

m
asses

and
m
ediastiniti
s
.

Although

conventional

radiographs

can

show

recogniza
b
le

abnor
m
alities

in
m
any

patients

with

m
ediastinal

abnor
m
alities

in

m
any

patients

with

m
ediastinal
pathology,

radiographs

are

li
m
ited

in

their

sensitivity

and

ability

to

delineate

the

extent

of
m
ediastinal

abnor
m
alities

and

t
h
e

relations
hi
p

of

m
asses

to

specific

m
ediastinal
structures.

W
ith

the

computed

tomography

these

proble
m
s

are

overco
m
e

because

of

its

excellent

density

resolution

and

tomographic

for
m
at

and

therefore

CT

plays

an

i
m
portant role

in

the

evalu
a
tion

o
f

the

m
ediastinu
m
.

W
i
t
h

the

advent

of

CT,

it

has

helped

the clinicians

and

radiologists

in

identifying

the

precise

location,

extent

and

characterization of these
m
asses.

The

following

study

was

undertaken

w
ith

the

objectives

of

deter
m
ining

the

disease
patt
e
rn

a
ff
ecting

the

m
ediasti
n
um

and

to

cor
r
el
a
t
e

the

CT

f
i
ndings

with

the
histopathology reports whenever possible.

Our

study

co
m
prises

a

total

of

50

p
a
tients

from

both

ln

and

out
-
patient

depart
m
ents. The

study

was

conducted

for

a

period

of

2

y
ear

from

August

2005

to

July

2007

in

the
depart
m
ent of Radio diagnosis.

Majority

of

the

sympto
m
s

were

of

non
-
specific

nature

like

cough,

chest

pain,

fever,
dysphagia

etc.

These

sympto
m
s

were

m
ainly

due

to

the

m
ass

effect

fr
o
m

the

m
ediastinal
lesions

and

was

dependent

on

the

location

or

the

m
ass.

Anterior

m
ediastinal

m
asses
mostly

presented

with

cough

and

dyspnoea

p
r
obably

due

to

tracheal

co
m
pression.

Middle
m
ediastinal

lesions

d
u
e

to

their

location

presented

with

dysphagia

due

to

either
involve
m
ent of the esophagus or its co
m
pression.


Felson

in

1978

in

a

series

of

550

cases

reported,

there

is

no

predilection

f
or

the
m
asses

to

occur

in

the

a
n
te
r
ior

m
ediastinu
m
.

But

he

reported

more

nu
m
ber

of

cases

being seen

in

the

anterior

and

posterior

m
ed
i
astinum

followed

by

m
i
ddle

m
ediastinum

in
decreasing

order

of

frequency.

In

our

study,

anterior

m
ediasti
n
al

cases

we

are

found

to

be the

com
m
onest

accou
n
ting

for

52

%.

Posteri
o
r

m
ediastin
a
l

cases

acc
o
unted

for

36%, followed
by Middle
m
ediastinal
m
asses accounting for 20% of the cases. In

our

study

the

50

cases,

whi
c
h

showed

abnor
m
al

m
ediastinal

shadow

on radiographs

or

suspected

involve
m
ent

of

the

m
ediastinum

w
e
re

evaluated

with

co
m
puted to
m
ography. The cases were analyzed in the
following
m
anner as discussed below:

A:

Sym
p
toms

Di
s
t
ribution





Present

s
tu
d
y

(52

case
s
)


Davis

et al

(400

cases)

Cough

44%

16

%

Dyspn
ea

36%

16

%

Fever

20%

20
'
%

Chest

Pain

20%

30%


In

our

study

of

52

cases,

cough

was

the

m
ost

common

c
l
inical

sy
m
p
t
o
m

constituting


44

% followed by Dyspnea 36%, fever 20% and chest pain 20%.


Accordin
g

t
o

th
e

D
avi
s

e
t

a
l

8
stud
y

i
n

40
0

consecutiv
e

patient
s

with

mediastina
l

masses
,

ches
t

pai
n

constitute
d

th
e

mos
t

co
m
mo
n

sy
m
pto
m

i.e
.

30%,

followe
d

b
y

fev
er

20%.


B
:

Compartmenta
l

distributio
n

o
f

m
e
diastina
l

mass






Ou
r

study



Stroll
o

et
a1
1
3
,35


Ou
r

study

[childre
n

(n
-

14)]


Merte
n

D
F
25

(50
8

children)


Anterior

Mediastinum


52%


50%


5
0

%


46%


Middle

Mediastinum


1
8

%


5
0

%


14.
2

%


20%

P
o
steri
or

Mediastinum


3
0

%


-


35.
7

%


34%




Al
l

ag
e

groups
:

I
n

ou
r

stud
y

o
f

5
2

cas
e
s
,

th
e

majorit
y

o
f

th
e

mediastinum

masse
s

wer
e

i
n

th
e

anter
i
o
r

medi
a
stinu
m

constitutin
g

52
%

followe
d
b
y

middl
e

and

posterio
r

mediastina
l


com
p
artmen
t


whic
h

is

simila
r

t
o

th
e

stud
y

conducte
d

by

S
t
roll
o

e
t

a
1
[
13
,
35]

i
n

199
7

wherei
n

anterio
r

medi
a
stinu
m

constitute
d

50
%

o
f

the

mass
e
s.

C:

Individual masses distribution (
B
ased on the tiss
u
e of origin).




Media
s
tin
a
l



Our

study

(50

case
s
)


Beja
m
in et al
5

(214

cases)


Cohen

et a
l
10

(230case
s
)


Wychulis

et
a
l
4

(1064

cases)


Davis

et al
8

(400

cases)

Neural

tu
m
ors

10

22.9

16.9

19.9

14

Thy
m
ic tumors

14

20.6

24.3

19.4

17

Ly
m
pho
m
a

6

14.9

15.7

10.1

16

Terato
m
a/GCT

2

12.6

10.0

9.3

11

Granulo
m
a

16

-

0

6.3


Vascular

8

7.5

1.7

-


Thyroid

4

11.2

1.7

5.3


Miscella
n
e
o
us


-

5.7

3.4








In

our

stu
d
y

Ly
m
pho
m
a

constit
u
ted

6

%

of

the

m
ediastin
a
l

m
asses

which

is
si
m
ilar to study conducted by
W
ychulis et al

[1]
(Le

10.1%).




Malignant

lesions

predo
m
inate

in

our

study.

Malignant

lesions

have

predo
m
inated
in

the

m
ale

population

while

benign

lesions

have

occurred

with

equal

frequency

in
both.

Majority

of

the

benign

lesions

have

occurred

in

b
e
tw
een

t
he

2n
d

a
n
d

4th

decade.

In

the

ca
s
e

of

m
alignancy,

m
ajority

of

the

cases

h
ave

occ
u
rr
e
d

between

4
t
h

and

6th decade.


Tuberculous

lesions


In

o
u
r

study,

Granulo
m
a

constit
u
ted

1
6
%,

which

is

greater

in

co
m
parison

to
Wychulis

et

al

[1]

study

(i.e.

6.3%)

probably

d
u
e

to

higher

prevalence

of

Tuberculosis

in
co
m
parison

to

the

western

population.

Our

s
t
udy

had

3

cases

of

paravertebral

abscess (5.6%)
which was associated
w
ith vertebral body destruction.

According

to

Im

et

al

[11]

series,

right

paratracheal

ly
m
ph

node

enlarge
m
ent

was

s
e
en

in 87%

of

cases

whereas

our

study

showed

60

%

involve
m
ent.

S
i
m
ilarly

in

1m

et

al

[11]
study

52%

of

the

T8

lymph

node

enlarge
m
ent

showed

central

are
a
s

of

low

attenuation with rim

enhance
m
ent on contrast st
u
dy. Our study showed 40 % involvement.

According

to

Choyke

PL

et

al

[72]

in

their

study

on

adult

o
n
set

pul
m
onary

tuberculosis,
reported

40%

of

adults

showed

presence

of

pleural

effusion,

whereas

our

study

showed

50

% cases of Tuberculosis associated with pleural effusion.







Thymic

masses:


I
n

ou
r

stud
y

th
e

thymi
c

t
u
mor
s

forme
d

th
e

majorit
y

wit
h

14
%

whic
h

IS

simila
r

t
o


studi
es


conducte
d

b
y

Cohe
n

et

a
l

[10
]

an
d

Dav
is

e
t

al[8]


I
n

a

stud
y

by

Che
n

e
t

al[9
]

o
n

3
4

patien
ts

wit
h

C
T

diagnos
is

o
f

thymi
c

mass
,

thymom
a

const
i
tuted

9
1

%
,

thymi
c

cys
t

2.9
%.

Wherea
s

ou
r

stud
y

o
f

7

p
a
tient
s

wit
h

thymi
c

mass,

thymom
a

c
onstitute
d

42%
,

an
d

thymi
c

hyerplasi
a

2
8

%.


Accordin
g

t
o

Naidich

et

a1
2
3
,

Thymom
a

is

mos
t

commonl
y

see
n

betwee
n

50
-


6
0

ye
a
r
s

whic
h

i
s

comparabl
e

t
o

ou
r

s
t
ud
y

i
n

whic
h

th
e

3

patien
ts

wit
h

t
hymoma

wher
e

o
f

ag
e

40
,

4
8

year
s

an
d

4
8

year
s

r
e
spectively.


T
h
y
r
o
i
d

M
a
s
se
s
:


In
t
r
athoraci
c

goiter
s

ar
e

a

commo
n

caus
e

o
f

mediastina
l

enlargement
.

Thyroid

mass
es

accoun
t

fo
r

11
-
1
5

%

o
f

medi
a
stina
l

mass
es

(A.

Prasad

et

al,

2000.

[73]).

In

ou
r

stud
y

the
y

represente
d

(onl
y

3
%

o
f

th
e

cas
e
s
).


























S
UMM
A
R
Y

AN
D

CONC
L
USION



Compute
d

Tomograph
y

play
s

a

s
i
gnifican
t

rol
e

i
n

th
e

a
ss
e
ssmen
t

o
f

various

mediastina
l

pa
t
holog
y

whic
h

ar
e

i
nitiall
y

detecte
d

o
n

th
e

ches
t

radiograph
s

.The
maximum

number

o
f

cases


occurred

in

4
t
h

to

6
t
h

decade.

Mediastinal

masses

occur

co
m
m
only

in

males.
In

our

study

of

50

cases

of

m
ediastinal

m
a
sses,

the

anterior

m
ediastinum

was

the most

common

co
m
part
m
ent

to

be

involved

w
i
th

52%

involve
m
ent

fol
l
owed

by

posterior
m
ediastinum (30%) and then
m
i
ddle
m
ediastinum (18%).

Thy
m
ic

m
asses

(26.9%),

neural

tu
m
ors

(33.6%)

and

m
e
tastatic

lymph

node

m
asses
(44.5%)

were

the

m
ost

com
m
on

mediastinal

m
a
sses

in

the

anterior,

posterior

and

m
i
ddle
m
ediastinal co
m
par
t
m
ents res
p
ectively.

In

the pediatric group the neurogenic tu
m
our is the
m
ost common
m
ediastinal
m
ass.
Calci
f
ic
a
ti
o
n

is

noted

in

24

%

of

cases.

Ma
s
s

e
ff
ect

upon

the

adj
a
cent

m
ediastin
a
l
structures

is

observed

in

62

%

of the cases and is
predo
m
ina
n
tly noted upon the airways.

86

percentages

of

{43

nu
m
ber}

cases

are

histologically

verif
i
ed.

And

4

cases

{8
percentage}

of

aortic

disorders

are

verified

with

conventional

angiography.

Totally

94
perce
n
tage

of

cases

are

verified

with

histopath
o
l
ogy

and

a
n
giography.

W
ith

an

accuracy of
94% CT

i
s

a

highl
y

usefu
l

modalit
y

fo
r

i
nve
s
tigatio
n

o
f

mediastina
l

masses

So

we

conclude

that

co
m
puted

to
m
og
r
aphy

definitely

has

a

m
aj
o
r

role

to

play

in

the
evaluation

of

a

m
ediastinal

m
ass

regarding

the

distribution

pattern,

CT

diagnosis

and
m
ass
effect upon adjacent structures.




Compartmental

distribution

of

mediastinum

lesions



Compartment

No

of Cases

Percentage


Anterior

Mediastinum


26


52


Middle

Mediastinum


9


18


Posterior

Mediastinum


15


30




Compartmental

distrib
u
tion of mediastinal
lesions









A
n
t
e
r
i
o
r

M
ed
i
a
s
t
i
num


M
i
dd
l
e

M
ed
i
a
s
t
i
num


P
o
s
t
e
r
i
o
r

M
ed
i
a
s
t
i
num



















Anterior

Med
i
astinal

Lesions

distribution



NO

of CA
S
ES

Percentage

Thy
m
ic

m
asses

7

26.9

Metastatic

ly
m
ph Node

5

19.2

TB

Ly
m
ph

Node

4

15.4

Aortic

Mass

4

15.4

Ly
m
pho
m
a

3

11.6

Thyroid

Mass

2

7.7

Germ

cell Tu
m
our

1

3.8


26

100


M
i
ddle

mediastinal

Lesions

distribution




No

of

ca
s
es

Percentage

Metastatic

L
y
m
ph Node

4

44.5

TB

Ly
m
ph

Node

2

22.2

Neuroenteric

cyst

1

11.1

Esophageal

Duplication

Cyst

1

11.1

Bronchogenic

cyst

1

11.1


9

100







Posterior

m
e
diastinal

lesions

distribution




No

of masses

Percentage

Neural

tu
m
ors

5

33.3

Para

vertebral abscess

3

20

TB

Ly
m
ph

Node

2

13.3

Oesophageal

m
ass

2

13.3

Hydatid

cyst

1

6.7

Para

vertebral he
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100

















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