Paediapaedia: Chest Clinical and Radiographic Presentations, DDX, Approach to Imaging

Approach to Mediastinal Masses

Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed

Clinical Presentation:
33% of all masses present in patients less than 15 years old
If small, usually asymptomatic and found incidentally (cautious work up)
If large, usually present with respiratory distress (frantic work up)

Anatomy of the Mediastinum

• Anterior - lymph nodes, thymus
• Superior - thyroid, esophagus, trachea
• Middle - esophagus, trachea, lymph nodes
• Posterior - spine, nerve roots, sympathetic chain
• Lateral Chest Film

DDX:
Anterior Mediastinal Masses: (4 T's) (30% of mediastinal masses)

• Thymoma
• Teratoma
• Thyroid (Ectopic)
• (Terrible) Lymphoma

Middle Mediastinal Masses (A + B) (30% of mediastinal masses)

• Adenopathy (infection [bacterial, granulomatous], neoplasm [leukemia / lymphoma, metastases])
• Bronchopulmonary foregut malformations (Esophageal duplication cyst, bronchogenic cyst, sequestration)

Posterior Mediastinal Masses: (N) (40% of mediastinal masses)

• Sympathetic ganglion tumors: neuroblastoma, ganglioneuroblastoma, ganglioneuroma (95% of posterior mediastinal masses)
• Neurofibroma
• Neurenteric cyst
• Extramedullary hematopoesis
• Paravertebral soft tissue mass from infection

Approach/Discussion:

 
• PA and lateral chest films are the first step in distinguishing from which mediastinal compartment the mass is arising from.
• Computed tomography or magnetic resonance imaging is the next step, better characterizing the nature and extent of the lesion, thus narrowing the differential diagnosis. MRI is especially good at looking for spinal canal invasion in posterior mediastinal masses
• Tissue biopsy is required for definitive diagnosis, and surgical resection for definitive cure.

Cases

• TAP Case 37 - Eight year old male with a heart murmur
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 50 - Three year old male with an incidentally noted chest mass
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 51 - Eighteen year old female with an incidentally noted chest mass
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 34 - Eleven year old male with upper respiratory symptoms and wheezing
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 6 - Five year old male with cough and fever
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 40 - Twelve year old female with a chest mass
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 42 - Six year old male with cough and fever
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 39 - Ten year old female with fatigue and dyspnea on exertion
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 47 - Six year old male with an intrathoracic mass
  Presentation CXR
  Presentation CT
  Followup

• TAP Case 16 - Six month old male with fever and respiratory distress
  Presentation CXR
  Presentation MR
  Followup

• TAP Case 70 - Fifteen month old female with weight loss
  Presentation CXR
  Presentation CT
  Followup

Summary
Radiologist's job is to detect, characterize (benign vs. malignant), and follow the lesion

References:
See References Chapter.

Section Top | Title Page

URL: http://www.virtualpediatrichospital.org/