When a physician tells a patient that he or she suspects a mediastinal mass, the first question that many people ask is, “What is the mediastinum?”
Mediastinum is in the chest, specifically the area that is between the lungs. It’s actually pretty large area—I vividly remember gross anatomy during my first year of medical school and how surprised I was to see the large size of the lungs. The mediastinum contains the heart, esophagus, trachea (windpipe) and the large blood vessels going to heart.
It follows, then, that mediastinal masses or cysts or tumors located in the mediastinum.
Mediastinal masses in adults
In adults, most mediastinal masses often don’t cause any symptoms. When they do, though, symptoms can include chest pain and weight loss.
The most common causes include thymomas, lymphomas (Hodgkin and non-Hodgkin), enlarged lymph nodes, vascular masses, neurogenic tumors, abnormalities of the esophagus.
Mediastinal masses in children
In children more than adults, mediastinal masses cause obstructive respiratory symptoms. Other common symptoms include repeated episodes of bronchitis or pneumonia. The most common causes of mediastinal masses in children are neurogenic tumors and cysts.
Diagnosis and treatment
The correct treatment for mediastinal mass depends on the underlying condition that caused it. Some require surgical removal, others require medical or chemotherapy, and yet others can simply be observed.
New radiology standards
While many physicians consider a CT scan with contrast to be the gold standard for diagnosing a mediastinal, the America College of Radiology released new criteria for imaging of mediastinal masses in 2020.
When a physician clinically suspects a mediastinal mass, the College guidelines state that the following diagnostic radiology is usually appropriate: chest x-ray, MRI of the chest with and without contrast, MRI of the chest without contrast, CT of the chest with contrast, and CT of the chest without contrast. The College guidelines contemplate that the following scans are usually not appropriate: chest ultrasound, image-guided transthoracic needle biopsy, CT of the chest without and with contrast, and FDG-PEG/CT of the skull base to mid-thigh.
The College also made recommendations for the next imaging study following initial radiography. Usually appropriate scans include: MRI of the chest without and with contrast, MRI of the chest without contrast, CT of the chest with contrast, and CT of the chest without contrast. Usually inappropriate scans include chest ultrasound, image-guided transthoracic needle biopsy, CT of the chest without him with contrast, and FDG-PEG/CT of the skull base to mid-thigh.
If a CT scan confirms an indeterminate mediastinal mass, College recommends the following scans is usually appropriate: MRI of the chest without and with contrast, or MRI of the chest without contrast. The guidelines state that two studies may be appropriate: image-guided transthoracic needle biopsy and FDG-PEG/CT of the skull base to mid-thigh. Two scans are usually not appropriate: chest ultrasound and chest x-ray.
If there is confirmation of an indeterminate mediastinal mass on MRI scan, the College recommends the following imaging studies or surveillance. Image-guided transthoracic needle biopsy and an MRI scan of the chest without with contrast are felt to be usually appropriate. These scans may be appropriate: MRI of the chest without and with contrast, MRI of the chest without contrast, CT of the chest with contrast, CT of the chest without contrast, and FDG-PEG/CT of the skull base to mid-thigh. Other studies are usually not appropriate, including chest ultrasound, chest x-ray, and CT of the chest without and with contrast.
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