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Pleura, mediastinum…
05 July 2008
Pleura
Anatomy
o a space within the thoracic cavity
o bounded by:
anterior sternum
posterior vertebral bodies A mass is considered to lie in the AMC when it
superior thoracic inlet is situated in the region anterior to the line
inferior diaphragm drawn along the anterior border of the trachea
lateral parietal pleura and posterior border of the heart
o divided into compartments by drawing a
line from the sternal angle to the 4th
thoracic intervertebral disk space
area above superior
compartment
area below inferior compartment
o anterior o Widened o Retrosternal area is
o middle mediatinum filled with mass
o posterior o Loss of cardiac
density
CT SCAN silhouette
o is the imaging modality of choice for o Intact silhouette
diagnosis, staging, and follow up of patients of descending
o offers the advantage of better localization aorta
and characterization of the disease process
o it can demonstrate compression and
involvement of the adjacent structures in
the mediastinum better than plain films.
Anterior Mediastinal Mass
o Thymus
Normal Thymus
Thymoma – Most common
o Lies in a retrosternal location behind the
Thymic cyst
manubrium
Thymolipoma
o Commonly seen anterior to the proximal
Thymic carcinoid
ascending aorta and distal superior vena
Thymic hyperplasia
cava
o Lymphoma
o Size of a normal thyroid is largets between
o Germ cell tumor
12-19 years of age.
Teratoma
Anterior mediastinal compartment Seminoma
Shoriocarcinoma
o Anteriorly by the sternum
o Thyroid
o Posteriorly by the pericardium, aorta, and
Goiter
brachiocephalic vessels
Tumor
Masses situated predominantly in the anterior o Mesenchymal tumors
mediastinal compartment (AMC) Leiomyoma
Liposarcoma
o Hemorrhage
1 of 16
1C ng 3B (jassie, viki, candz..ung iba support
group..hehe)
RADIOLOGY – Pleura and mediastinum by Dra. Bandong
NOTES:
Mediastinal mass: Pulmonary
mass:
o Margins are smooth o LYMPHOMA
Spiculated margins
o Bilateral o
Unilateral
o Loss of cardiac silhouette
Thymoma
Teratoma
Thyroid nodule / goiter
Lymphoma
2 types of lymphoma:
THYMOMA Hodgkin’s (HL)
o Most common neoplasm of the anterior o Bimodal age distribution—25-30 y/o and
mediastinum >70 y/o
o 30-35% are malignant o 67% intrathoracic involvement (anterior/
o Commonly occur in patients >40y/o superior mediastinal and hilar adenopathy)
o Asymptomatic o 15-40% pulmonary involvement by:
o CXR: Direct extension form involved nodes
Found in anterior mediastinum to Pulmonary nodules
the ascending aorta above the Parenchymal consolidation
right ventricular outflow tract and Pleural effusion
main pulmonary artery Sternal erosions
Maybe situated as low in the
mediastinum as the cardiophrenic Non Hodgkin’s (NHL)
angles o 4x more common than HL
o CT(Benign) o 3rd most common childhood malignancy
Well demarcated masses with o More frequently fatal than HL
homogenous density o Middle medisatinum – most frequently
Uniform contrast enhancement involved
Have areas of decrease o Posterior mediastinum and cariophrenic
attenuation angles can be altered
Punctuate or ring like o Appears as a single large conglomerate
calcifications o Other common nodal signs involvement
o CT (Malignant) include
Heterogenous attenuation Lung parenchyma
May obliterate adjacent Pleura
mediastinal fat Pericardium
May detect pleural spread
Germ Cell Tumors
Posterior mediastinum
Boundaries bounded anteriorly by the
posterior margin of
the pericardium and great vessels
and posteriorly by the thoracic
Middle and Posterior Mediastinum vertebral bodies
(MMC / PMC) Normal structures
Descending thoracic aorta
Masses predominantly in the MMC and PMC Esophagus
Thoracic dust
Azygous and hemiazygous
Autonomic nerves
Lymph nodes
Fat
Differential diagnosis
Neurogenic tumors
Paravertebral abnormalities
A lesion can be considered to properly lie in the Vascular abnormalities
MMC or PMC when it is located between a line Esophageal abnormalities
drawn through the anterior aspect of the Lymphadenopathy
trachea and posterior aspect of the heart and Neurenteric cyst
the line drawn through the anterior margins of Bochdalek’s hernia
the vertebral bodies Extramedullary hematopoeisis
Neuroblastoma
RADIOLOGY – Pleura and mediastinum by Dra. Bandong
o Tricuspid valve regulates blood flow allow blood to pass through the ventricles.
between RA and RV During systole, the ventricles contracts
o Pulmonary valve controls blood flow from triggering the atria to contract. The RA empties
right ventricle into the pulmonary artery its contents into RV. The tricuspid valve
which carry blood to the lungs to puck up O2 prevents blood from flowing back into the RA.
o Mitral valve lets O2 rich blood from lungs to
pass from LA to LV NOTES:
o Aortic valve opens the way for O2 rich blood Common Imaging modalities:
to pass from LV to the aorta, the largest a. Ionizing radiation – Radiography, CT,
artery, where it is delivered to the rest of Nuclear Scintigraphy
the body b. Non-ionizing radiation – MRI and 2D Echo
Calcium Score
o Identifies calcification of coronary
arteries
o Screening
o Increased calcification = MI
CARDIAC CONTOURS
o Children – 0.55
o Cardiac contours:
• Ascending aorta
o Enlargement 20 to atherosclerosis
o Enlargement is called: Double
Sometimes, CTR is more than 50% BUT heart is density sign
normal • Left atrium
Extracardiac causes of heart enlargement • Aortic knob
Portable AP films o Normal: not > 0.35 mm
Obesity o If enlarged, there is atherosclerotic
Pregnancy aorta
Ascites o >0.5 cm: aneurysm
Straight back syndrome
• Pulmonary artery
Pectus excavatum
o Congenital disease
CTR is less than 50% BUT heart is abnormal o Dilatation of artery
Obstruction to outflow of the ventricles
Ventricular hypertrophy
Must look at cardiac contours
Here is an
example of a
heart which is
< 50% of the
CTR, in which
the heart is
still abnormal.
This is
recognized
because there
is an
abnormal contour to the heart.
RADIOLOGY – Pleura and mediastinum by Dra. Bandong
Aortic knob
o The first bump on the left side
o Can be measured from the lateral border
of air by the trachea to the edge of the
aortic knob.
o Enlarged by
Increased pressure
Increased flow
Changes in the aortic wall
RADIOLOGY – Pleura and mediastinum by Dra. Bandong
NOTES:
Small pulmonary artery: TOF, Truncus Which ventricle is enlarged?
arteriosus If heart is enlarged and main pulmonary
Apex of ventricle goes down: Enlargement of artery is big RV is enlarged
left ventricle
Apex of ventricle goes up: Enlargement of
right ventricle
5. Decreased flow
o Unrecognizable most of the time
o Rapid cutoff on size of peripheral vessels
o Small hila
relative to the size of central vessels
o Fewer than normal blood vessels
o Central vessels appear to large for size
o No vessels in lower lobes (which is
of peripheral vessels which come from
normally present)
them = Pruning
4. Increased flow
o Distribution of flow is maintained as
normal
o Gradual tapering from central to
peripheral
o L lobe bigger than U lobe CONGESTIVE HEART FAILURE
Hg
Kerley B lines 15-20 mm
Hg
Pulmonary Interstitial 20-25
edema
Pulmonary Alveolar >25
edema
**C lines probably don’t exist (huh??) o Fluid collects in the subpleural space
Between visceral pleura and lung
parenchyma
o Normal fissure is thickness of a sharpened
pencil line
o Fluid may collect in any fissure
Major, minor, accessory fissure,
azygous fissures
Minor fissure: thickened fluid
Pleural effusion: there is obliteration
of costophrenic sulcus
PERIBRONCHIAL CUFFING
PLEURAL EFFUSION
fluid seen here (white arrow) is a laminar Fluid in the subpleural space in
effusion separating aerated lung from the inner continuity with interlobular septa
rib margin o Pleural effusions
o Cephalization
CEPHALIZATION