• contains central

cardiovascular,
tracheobronchial structures
and the esophagus enveloped
in fat with intermixed lymph
nodes
• divided into:
– Superior (thoracic inlet)
– Inferior mediastinum;
subdivided into:
• anterior, middle, and posterior
compartments.
 Classification of Mediastinum
ANATOMIC CLASSIFICATION

The mediastinum is divided into 4 parts

Superior mediastinum
Apex of thorax to a plane
passing through the
manubrio-sternal junction
and fourth dorsal vertebral
body
Posterior mediastinum
Contains descending thoracic
aorta, azygous/hemiazygous
veins,esophagus, thoracic
Anterior mediastinum
duct, nerves & lymph nodes
Is anterior to heart &
great vessels

Middle mediastinum
Contains heart & great
vessels, lymph nodes
3
SUPERIOR MEDIASTINUM
• Marginated by the first
rib and represents the
junction between the
neck and thorax
• Most common masses:
– Thyroid masses Clinical presentation:
Neck masses or with
– Lymphomatous nodes symptoms of upper airway
– Lymphangiomas obstruction resulting from
tracheal compression
 CERVICOTHORACIC SIGN
Helps to localize
a mass in the
superior
mediastinum on
frontal chest
radiographs as
either anterior or
posterior. Anterior mediastinum ends at
the level of the clavicles
Posterior mediastinum may
extend above the clavicle.
 Most common
superior mediastinal
mass extending to
thoracic inlet
• Arise from the lower
pole of the thyroid or
thyroid isthmus
Chest radiograph:
an superior
mediastinal mass
typically deviates
the trachea laterally
and either
posteriorly (anterior
masses) or
anteriorly (posterior
masses) Note Tracheal Deviation
154 slides 10 10
• well-defined margins
• continuity of the mass
with the cervical thyroid
• coarse calcifications
• cystic or necrotic areas
• baseline high CT
attenuation (because of
intrinsic iodine content
• intense and prolonged
enhancement
 Posteroanterior
chest radiograph
demonstrates a
thyroid goiter
(arrow) extending
into the middle
mediastinum,
obliterating the
right paratracheal
stripe, and causing
deviation of the
trachea to the left.
CT scan shows the mass (arrow) between the trachea and right lung, a
location that explains the obliteration of the right paratracheal stripe.
ANTERIOR MEDIASTINUM
• Boundaries:
 Anteriorly : sternum
 Posteriorly:
pericardium, aorta,
and brachiocephalic
vessels
 Superiorly: thoracic
inlet
 Inferiorly: diaphragm Contents: thymus, lymph nodes, adipose
tissue, and internal mammary vessels
ANTERIOR MEDIASTINAL MASSES
Prevascular - Thymic masses
- Retrosternal Thyroid
- Teratoma
- Lymph nodal mass/Terrible lymphoma
Precardiac - Epicardial fat pad
- Morgagni ‘ s hernia
- pleuropericardial cyst
HILUM OVERLAY SIGN

NORMAL HILAR
STRUCTURES
PROJECT
THROUGH A
MASS
Posteroanterior
chest radiograph
clearly depicts the
hila (white arrow),
which indicates that
the mass is either
anterior or posterior
to the hila. In
addition, the
descending aorta is
clearly seen (black
arrow), indicating
that the mass is not
within the posterior
mediastinum.
 Chest CT scan
demonstrates an
anterior
mediastinal mass.
The anterior
junction line is
obliterated,
whereas the lung
interfaces with the
hilar vessels
(arrow) and aorta
(arrowhead) are
preserved.
 Posteroanterior
chest radiograph
shows loss of the
cardiac silhouette
at the border of the
right side of the
heart and an
epicardial fat pad
with relatively low
density
CT scan shows
the fat pad
(arrow) as an
area of
homogeneous
fat attenuation
adjacent to the
right border of
the heart.
• Hodgkin disease or non-Hodgkin lymphoma
• most common primary mediastinal neoplasm in
adults
• Hodgkin disease involves the thorax (85%); NHL 40%
• majority of patients with intrathoracic involvement
have mediastinal lymph node enlargement (90%);
this most commonly involves the anterior
mediastinal and hilar nodal groups.
• on conventional radiographs, lymphoma involving the
anterior mediastinum is indistinguishable from thymoma or
germ cell neoplasm  presents as a lobulated mass
projecting to one or both sides
• calcification is uncommon
• Involvement mediastinal or hilar lymph nodes
• Enlarged spleen displacing the gastric air buddle medially.

• ADVANTAGES OF CHEST CT :
– ability to better characterize and localize masses seen on chest
radiographs;
– detection of subradiographic sites of involvement that can alter
disease staging, prognosis, and therapy; guidance for transthoracic
or open biopsy; the ability to monitor response to therapy; and
detection of relapse
• second most common primary mediastinal
neoplasms in adults after lymphoma.
• arise from thymic epithelium and contain
varying numbers of intermixed lymphocytes
• average age is 45 to 50 yrs old
• rare in patients under the age of 20
• most often associated with myasthenia gravis
and has been associated with other
autoimmune diseases
• On chest radiographs: thymomas are seen as
round or oval, smooth or lobulated soft tissue
masses arising near the origin of the great
vessels at the base of the heart
• CT is best for characterizing thymomas and
detecting local invasion preoperatively.
154 slides Normal 30 30
154 slides
NORMAL 31 31
 Thymoma

154 slides 32 32
• include teratoma, seminoma, choriocarcinoma,
endodermal sinus tumor, and embryonal cell carcinoma
• arise from collections of primitive germ cells that arrest
in the anterior mediastinum on their journey to the
gonads during embryologic development
• detected in patients in the third or fourth decade of life
• TERATOMA - the most common benign mediastinal germ
cell neoplasm (60-70%)
CYSTIC OR MATURE TERATOMA
• the most common type of teratoma seen
in the mediastinum.
• commonly contains tissues of
ectodermal, mesodermal, and
endodermal origins
SOLID TERATOMAS
• usually malignant
• Radiographically, these tumors have a
distribution similar to that of thymomas
• Benign teratomas are usually round or oval
and smooth in contour.
• Malignant: irregular, lobulated or ill defined
margin.
• On CT, benign teratomas are cystic and may
contain soft tissue, bone, teeth, fat, or,
rarely, fat-fluid levels on CT
• SEMINOMA is the most common malignant
germ cell neoplasm
– The radiographic findings are nonspecific.
– CT typically shows a large lobulated soft tissue
mass that may contain areas of hemorrhage,
calcification, or necrosis
MIDDLE MEDIASTINUM
• Boundaries
– Anteriorly:
pericardium
– Posteriorly:
pericardium
and posterior
tracheal wall
– Superiorly: Contents: heart and pericardium; the
thoracic inlet ascending and transverse aorta; SVC and
IVC; the brachiocephalic vessels; the
– Inferiorly by pulmonary vessels; the trachea and main
the diaphragm bronchi; lymph nodes; and the phrenic,
vagus, and left recurrent laryngeal nerves.
• Lymph node enlargement and masses
• Most middle mediastinal lymph node masses
are malignant
• Represent metastases from bronchogenic
carcinoma, extrathoracic malignancy or
lymphoma
• Seen projecting through the
SVC.
• It is formed by the trachea,
mediastinal connective
tissue, and paratracheal
pleura and is visible due to Posteroanterior chest radiograph shows the right
the air–soft tissue interfaces paratracheal stripe (arrow). The azygos vein is seen at
on either side. the inferior margin of the stripe at the tracheobronchial
angle.
 CT scan shows the
right wall of the
trachea with medial
and lateral air–soft
tissue interfaces
caused by air within
the tracheal lumen
and right lung.
Paratracheal
stripe should be
uniform in width
with a normal
width ranging
from 1 to 4 mm.

Can be widened due

to abnormality of
any of its
components, from
the tracheal mucosa
to the pleural space.
• On plain radiograph, presence of multiple
bilateral mediastinal masses that distort the
lung/mediastinal interface  relatively
specific for lymph node enlargement.
• Abnormal lymph nodes are seen as round or
oval soft tissue masses that measure larger
than 1.0 cm in short axis diameter.
CT scan demonstrates lymphadenopathy (arrow), which accounts for
the distortion of the AP window
POSTERIOR MEDIASTINUM
• Boundaries:
– Anteriorly :
posterior trachea
and pericardium,
– Anteroinferiorly:
diaphragm
– Posteriorly:
Contents -Esophagus, descending aorta,
vertebral column azygos and hemiazygos veins, thoracic
– Superiorly: thoracic duct, vagus and splanchnic nerves, lymph
nodes, and fat
inlet
• Esophageal lesions, hiatal hernia
• Foregut duplication cyst
• Descending aorta aneuyrsm
• Neurogenic tumour
• Paraspinal abscess
• Lateral meningocele
• Extramedullary haematopoiesis
• Vertebral anomalies
Interface between the right
lung and the mediastinal
reflection, with the
esophagus lying anteriorly
and the azygos vein
posteriorly within the
mediastinum.
 Pre-vertebral
structure and is,
therefore, disrupted
by prevertebral
ESOPHAGUS disease.
• It has an interface with
the middle
mediastinum; thus, the
AZYGO resulting line seen at
ESOPHAG
EAL
radiography can be
RECESS interrupted by
AZYGOS VEIN abnormalities in both
the middle and
posterior
compartments.
 NORMAL

subcarinal abnormality with increased opacity (*), splaying of the carina,

and abnormal convexity of the upper and middle thirds of the
azygoesophageal line (arrowheads)
NORMAL

Corresponding CT scan helps confirm a subcarinal mass (arrow),

which proved to be a bronchogenic cyst.
• Seen above
the level of
the azygos
vein and
aorta and
that is
formed by
CT scan shows the
the posterior junction line
apposition posterior junction line (arrow), which is
(arrow) projecting formed by the interface
of the lungs through the tracheal air between the lungs
posterior to column. posterior to the
mediastinum and
the consists of four pleural
esophagus. layers.
 NORMAL

Posteroanterior chest radiograph shows a mass (arrow) obliterating

the posterior junction line. Note that the mass extends above the
level of the clavicle and has a well-demarcated outline due to the
interface with adjacent lung (arrowhead).
CT scan helps confirm the posterior location of the mass (arrow),
which proved to be a bronchogenic cyst.