Rad Mediastinum FKUnLam

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    Radiology Examination ofMediastinum

     Arlavinda A. Lubis

    Radiology Department,Ulin Hospital / Faculty of Medicine, Lambung Mangkurat University  

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    Introduction

     The mediastinum is the region in the chest between the pleural cavities that contain the heart and other thoracic viscera except the lungs

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    Mediastinal anatomy

    Boundaries

     Lateral - parietal pleura

    Anterior - sternum  Posterior - vertebral column and

    paravertebral gutters

     Superior - thoracic inlet

     Inferior - diaphragm

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     Felson ”Radiologists”   Anterior mediastinal, is bounded anteriorly by

    the sternum and posteriorly by a line drawn from the

    anterior aspect of the trachea and along the posterior heart border 

     Middle mediastinal compartment lies between the anterior and posterior mediastinum 

     Posterior mediastinal, anterior border is

    defined by a line that is 1 cm posterior to the anterior edge of the vertebral bodies 

    Mediastinal compartment by Felson

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    (Meschan, 1981;

    resited by Lange & Walsh, 2007)

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    Diseases of the Mediastinum

     Pneumomediastinum

     Mediastinitis

     Neoplasma

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    Pneumomediastinum  Air in the mediastinum is a common complication of

    mechanical ventilation is also commonly encountered in some conditions

     Pain is the most common symptom

     Results from stretching of the mediastinal tissues

     Substernal and aggravated by breathing and changing position

     Dyspnea, dysphagia, subcutaneous crepitation

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    Mediastinitis  Acute inflammation of the mediastinum

     Substernal chest pain, chills, high fever, prostration

     Chronic mediastinitis

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    Neoplasma

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    Clinical Presentation

     Asymptomatic mass

     Incidental discovery – most common

    50% of all mediastinal mass are asymptomatic  80% of such mass are benign

     More than half are malignant if with symptoms

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    Clinical Presentation

     Effects on Compression or invasion of adjacent tissues

     Chest pain, from traction on mediastinal mass, tissue invasion, or bone erosion is common

     Cough, because of extrinsic compression of the trachea or bronchi, or erosion into the airway it self

     Hemoptysis, hoarseness or stridor

     Pleural effusion, invasion or irritation of pleural space

     Dysphagia, invasion or direct invasion of the esophagus

     Pericarditis or pericardial tamponade

     Right ventricular outflow obstruction and cor pulmonale

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    Clinical Presentation

     Superior vena cava  Vulnerable to extrinsic compression and obstruction because it is thin

    walled and its intravascular pressure is low, and relatively confined by lymph nodes and other rigid structures

     Superior vena cava syndrome  Results from the increase venous pressure in the upper thorax , head

    and neck  characterized by dilation of the collateral veins in the upper portion of

    the head and thorax and edema and phlethora of the face, neck and upper torso, suffusion and edema of the conjunctiva and cerebral symptoms such as headache, disturbance of consciousness and visual

    distortion  Bronchogenic carcinoma and lymphoma are the most

    common etiologies

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    Clinical Presentation

     Hoarseness, invading or compressing the nerves

     Horners syndrome, involvement of the sympathetic

    ganglia [dropping eyelid, decreased pupil size,decreased sweating on the ipsilateral face]

     Dyspnea, from phrenic nerve involvement causing diaphragmatic paralysis

     Tachycardia, secondary to vagus nerve involvement

     Clinical manifestations of spinal cord compression

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    Clinical Presentation

     Systemic symptoms and syndromes

     Fever, anorexia, weight loss and other non specific

    symptoms of malignancy and granulomatous inflammation

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    Computed tomography

     Can identify normal anatomic variations and fluid filled cyst

     Site of the origin of the mass can be better identified

     100% specificity for the CT appearance of teratomas, thymolipoma, omental fat herniation

     Overall accuracy for predicting mediastinal mass is only 48%

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    Computed tomography

     Limitation

     Horizontal oriented structures and boundaries are difficult to

    evaluate

     Abnormalities in the aortopulmonary window area and the

    subcarinal area

     CT has become the initial imaging procedure of choice for

    evaluation of mediastinum in patients with primary mediastinal mass or with lung cancer

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    Magnetic Resonance Imaging

     Assesses tissue by measuring the radiofrequency induced nuclear resonance instead of measuring the attenuation of transmitted ionizing radiation

     Coronal and sagittal planes are better viewed, vertical structures and boundaries are better evaluated

     Superior sulcus tumors, lesions invading the medistinum, chest wall and diaphragm

     And possible invasion of the brachial plexus, and for evaluating vertebral invasion

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    Magnetic Resonance Imaging

     Limitations

     Distinguish poorly between hilar mass and adjacent

    collapsed or consolidated lung

     Cannot distinguish between a benign and a malignant causes

    for lymph node enlargement

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    Ultrasonography

     For cystic nature of mediatinal mass

     Useful in guiding endoscopic biopsy technique

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    Radionuclide imaging

     Rely on the localization of markers based on specific metabolic or immunologic properties of the target tissue

     Potential ability to diagnose and stage a malignancy and identify distant metastasis

     Planar imaging with gallium 67 and thallium-201

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    POSITRON EMISSION TOMOGRAPHY

     The single most notable addition to the staging armamentarium for the evaluation of lung cancer

     Based on the biologic activity of neoplastic cells

     PET is a metabolic imaging technique based on the function of a tissue

    rather than its anatomy  Lung cancer cells demonstrate increased cellular uptake of glucose

    and a higher rate of glycolysis when compared to normal cells

     The radiolabeled glucose analogue [18F] fluoro-2-deoxy-d-glucose undergoes the same cellular uptake as glucose, but after

    phosphorylation is not further metabolized and becomes trapped incells

     Accumulation of the isotope can then be identified using a PET camera

    Specific criteria for an abnormal PET scan are either a standard

    uptake value of greater than 2.5 or uptake  in the lesion that is greater than the background activity of the mediastinum

    It has proved useful in dif ferentiating neoplastic  from normal tissues

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    POSITRON EMISSION TOMOGRAPHY

     The technique is not infallible because certain non- neoplastic processes, including granulomatous and other inflammatory diseases as well as infections,  may also demonstrate positive PET imaging

     Size limitations are also an issue, with the lower limit of resolution of the study being approximately 7 to 8 mm depending on the intensity of uptake of the

    isotope in abnormal cells

     One should not rely on a negative PET finding for lesions less than 1 cm on CT scan

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    Dealing with mediastinal mass

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    Conventional radiographic signs

     The "silhouette sign“ 

     The hilar overlay sign

     The hilar convergence sign

     The cervicothoracic sign

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    Foto thoraks normal