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Pulmo Radiology > BRANT: Chapter 11 - MEDIASTINUM AND HILA > Flashcards

BRANT: Chapter 11 - MEDIASTINUM AND HILA Flashcards

1
Q

Name the sign used when the border of a superior mediastinal mass becomes indistinct as it extends beyond the level of the clavicles.

A

Cervicothoracic sign or thoracic inlet sign

This sign helps localize thoracic inlet masses if located anteriorly vs posteriorly/paravertebrally (since lung apex extends higher posteriorly than anteriorly)

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2
Q

Diagnosis

A

Mediastinal teratoma

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3
Q

19/F with chest pain and nonproductive cough

A

Castleman disease or angiofollicular lymph node hyperplasia

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4
Q

Diagnosis

A

Azygos Continuation of the Inferior Vena Cava (IVC)

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5
Q

Diagnosis

A

Bronchogenic cyst

Majority of bronchogenic cysts (80% to 90%) arise within the mediastinum in the vicinity of the tracheal carina

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6
Q

Diagnosis

A

Pericardial cyst

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7
Q
A

Enlarged Epipericardial Fat Pad

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8
Q

Diagnosis

A

Hiatal hernia

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9
Q

Diagnosis

A

Neurenteric cyst

When an enteric cyst has a persistent communication with the spinal canal (canal of Kovalevsky) and is associated with congenital defects of the thoracic spine (anterior spina bifida, hemivertebrae, or butterfly vertebrae), it is termed a neurenteric cyst

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10
Q

Primary cross-sectional modality used to evaluate mediastinal masses.

A

Contrast-enhanced multidetector row CT (MDCT)

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11
Q

MR is most useful for evaluation of mediastinal masses in the following circumstances, except:
a. Asessing lesions in patients who cannot receive iodinated contrast
b. Likely vascular lesions
c. Confirming the cystic nature of lesions that have high attenuation due to proteinacious contents
d. Distinguishing thymic hyperplasia from thymic neoplasms
e. All of the above justify the use of MRI

A

e. All of the above justify the use of MRI

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12
Q

The following are indications to do PET, except:
a. Confirm increased metabolic activity in suspected malignancy
b. Assess response of mediastinal tumors to therapy, particularly lymphoma
c. Distinguish residual or recurrent tumor from fibrosis
d. All of above are indications to do PET

A

d. All of the above are indications to PET

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13
Q

T/F: In contrast to other masses in the thoracic inlet, a tortuous vessel is usually associated with tracheal deviation toward the side of the mass, whereas most goiters and other inlet masses displace the trachea contralaterally.

A

True

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14
Q

Most common thoracic inlet mass

A

Tortuous vascular structures

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15
Q

Cystic or cavernous tumors that are comprised of dilated lymphatic channels and are most commonly discovered in infancy and is often associated with chromosomal abnormalities, including Turner syndrome, trisomies 13, 18, and 21

A

Cystic hygroma
(Lymphangioma)

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15
Q

CT findings which suggest that the mediastinal mass is likely part of an ongoing thyroid pathology are the following, except:
a. Coarse calcifications
b. Cystic or necrotic areas
c. Baseline high CT attenuation
d. Intense enhancement (>25 HU) but rapid washout

A

d. Intense enhancement (>25 HU) but rapid washout

Intense enhancement (>25 H) as a result of the hypervascularity of most thyroid masses and prolonged enhancement (resulting from active uptake of iodine from contrast media) following intravenous contrast administration

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16
Q

Second most common primary mediastinal neoplasms in adults after lymphoma

A

Thymomas (Thymic Epithelial Neoplasms)

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17
Q

The average age at diagnosis of thymoma is

A

45 to 50

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18
Q

Of patients with myasthenia gravis, ____ have a thymoma, while a larger percentage of patients with thymoma ( ____ ) have or will develop myasthenia.

A

10% to 15%
30% to 50%

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19
Q

Modality that is best for characterizing thymomas and detecting local invasion preoperatively

A

CT

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20
Q

T/F: Drop metastases to dependent portions of the pleural space are a recognized route of spread of thymoma that has invaded the pleura.

A

True

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21
Q

60-year-old male with hypercalcemia. Diagnosis

A

Parathyroid adenoma

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22
Q

Congenital unilocular thymic cysts are rare lesions that represent remnants of the ____ and contain thin or gelatinous fluid.

A

Thymopharyngeal duct

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23
Q

It is defined as enlargement of a thymus that is normal on gross and histologic examination. This rare entity occurs primarily in children as a rebound effect in response to an antecedent stress, discontinuation of chemotherapy, or treatment of hypercortisolism.

A

Thymic hyperplasia

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24
Q

T/F: Like most cases of true thymic hyperplasia, lymphoid hyperplasia does produce thymic enlargement.

A

False

In contrast to most cases of true thymic hyperplasia, lymphoid hyperplasia does NOT produce thymic enlargement.

Most patients with thymic hyperplasia have normal sized or diffusely enlarged glands on CT

Chemical shift MR with in- and out-of-phase sequences can distinguish hyperplasia, which shows signal decrease on out-of-phase chemical shift imaging due to the presence of microscopic fat within hyperplastic tissue, from thymic neoplasms that do not decrease in signal intensity.

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25
Q

Which MR technique can distinguish thymic hyperplasia from thymic neoplasm?

A

Chemical shift MR

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26
Q

55-year-old woman, s/p chemotherapy for left breast cancer. Diagnosis

A

Thymic hyperplasia

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27
Q

It is the most common primary mediastinal neoplasm in adults.

A

Lymphoma

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28
Q

Of the various subtypes of NHL that present with mediastinal masses, ____ and ____ are the most common

A

Lymphoblastic lymphoma and diffuse large B-cell lymphoma

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29
Q

Which of the following is true about lympoma?
a. Lymphoma involving a single mediastinal or hilar nodal group is much more common in Hodgkin disease than in NHL.
b. NHL most commonly involves middle mediastinal and hilar lymph nodes
c. Juxtaphrenic and posterior mediastinal nodal involvement is uncommon but is seen almost exclusively in Hodgkin disease
d. NHL involves the thorax in approximately 85% of patients at presentation.

A

b. NHL most commonly involves middle mediastinal and hilar lymph nodes

a. NHL > HD
b. True
c. NHL
d. 40%

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30
Q

T/F: Calcification in untreated lymphoma is extremely uncommon, and its presence within an anterior mediastinal mass should suggest another diagnosis.

A

True

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31
Q

T/F: On MR, untreated lymphoma appears as a mass of uniform low signal intensity on T1WIs and uniform high signal intensity or intermixed areas of low and high signal intensity on T2WIs. The areas of low signal intensity on T2WIs of untreated patients may be a result of foci of fibrotic tissue in nodular sclerosing Hodgkin disease.

A

True

Patients with successfully treated mediastinal Hodgkin disease often have residual soft tissue density in the affected mediastinal compartments, with dystrophic calcification commonly seen within treated nodes

In general, the appearance of high signal intensity regions on T2WIs more than 6 months after treatment should suggest recurrence.

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32
Q

A key in distinguishing primary from metastatic mediastinal germ cell neoplasm is the presence of ____ lymph node involvement in metastatic gonadal tumors.

A

Retroperitoneal

33
Q

The most common benign mediastinal germ cell neoplasm is ____, comprising 60% to 70% of mediastinal germ cell neoplasms.

A

Teratoma

Teratomas may be cystic or solid.

34
Q

____ is the most common type of teratoma seen in the mediastinum

A

Cystic or mature teratoma

35
Q

Most common malignant solid germ cell tumor, comprising 25% to 50% of such lesions

A

Seminoma

Most germ cell neoplasms are detected in patients 20 to 40 years of age. While benign tumors have a slight female preponderance (female/male, 60%/40%), malignant tumors are seen almost exclusively in males

36
Q

Diagnosis

A

Mature teratoma

37
Q

Benign and malignant tumors arising from the fibrous, fatty, muscular, or vascular tissues of the mediastinum may present as mediastinal masses, most commonly in the ____ mediastinum.

A

Anterior

38
Q

Hemangiomas are benign tumors composed of vascular channels and may be associated with the syndrome of hereditary hemorrhagic telangiectasia. A pathognomonic sign on chest radiographs is the recognition of ____ within a smooth or lobulated soft tissue mass.

A

Phleboliths

39
Q

T/F: The presence of multiple bilateral mediastinal masses that distort the lung/mediastinal interface is relatively specific for lymph node enlargement.

A

True

40
Q

In general, abnormal lymph nodes are seen as round or oval soft tissue masses that measure ____ in their short-axis diameter.

A

> 1.0 cm

41
Q

Most common source of metastases to the middle mediastinal nodes is ____

A

Lung cancer

Paratracheal and aorticopulmonary nodes are most commonly involved.

42
Q

T/F: In sarcoidosis, the enlarged nodes produce a lobulated appearance on chest radiographs and CT, because the enlarged nodes do not coalesce.

A

True

This is in contrast to lymphoma and nodal metastases, in which the intranodal tumor extends through the nodal capsule to form conglomerate-enlarged nodal masses

Right and left paratracheal lymph nodes are typically involved

43
Q

Lymphoproliferative disorder characterized by enlargement of hilar and mediastinal lymph nodes, predominantly in the middle and posterior mediastinal compartments. Histologically, there is replacement of normal nodal architecture with multiple germinal centers and multiple small vessels with hyalinized walls that course perpendicularly toward the germinal centers to give a characteristic “lollipop” appearance on light microscopy. The vascular nature of these masses accounts for the intense enhancement seen on contrast-enhanced CT. Calcification within these masses has been described.

A

Angiofollicular or giant lymph node hyperplasia, known as Castleman disease (CD)

44
Q

It results from anomalous budding of the tracheobronchial tree during embryologic development, with characteristic low signal intensity on T1WIs and high signal intensity on T2WIs.

A

Bronchogenic cyst

The majority of bronchogenic cysts (80% to 90%) arise within the mediastinum in the vicinity of the tracheal CARINA.

The term foregut cyst has been used to describe those lesions that cannot be specifically characterized

45
Q

True of pericardial cysts, except:
a. Arise from the parietal pericardium and contain clear serous fluid surrounded by a layer of mesothelial cells
b. Most often, they arise in the posterior cardiophrenic angle, with left-sided lesions being twice as common as right-sided lesions
c. CT typically shows a unilocular cystic mass adjacent to the heart
d. Approximately 20% arise more superiorly within the mediastinum.

A

b. Most often, they arise in the posterior cardiophrenic angle, with left-sided lesions being twice as common as right-sided lesions

Most often, they arise in the ANTERIOR cardiophrenic angle, with RIGHT-sided lesions being twice as common as left-sided lesions;

46
Q

Diagnosis

A

Achalasia

47
Q

A common cause of a mass in the inferior visceral mediastinum is a hiatal hernia. This results from a separation of the superior margins of the diaphragmatic crura and stretching of the ____ ligament.

A

Phrenoesophageal

48
Q

Most common structure within a hiatal hernia

A

Stomach

49
Q

What do you call a hiatal hernia which involves the folllowing structures:
a. Gastric cardia
b. Fundus

A

a. Sliding hernia
b. Paraesophageal hernia

50
Q

When an enteric cyst has a persistent communication with the spinal canal (canal of Kovalevsky) and is associated with congenital defects of the thoracic spine (anterior spina bifida, hemivertebrae, or butterfly vertebrae), it is termed a ____.

A

Neurenteric cyst

50
Q

38/M with odynophagia. Diagnosis

A

Esophageal duplication cyst

51
Q

Diagnosis. Be specific

A

Paraesophageal hernia

52
Q

Diagnosis. Be specific

A

Sliding hernia

53
Q

Neurogenic tumors arising from the sympathetic ganglia include the following, except:
a. Ganglioneuroma
b. Ganglioneuroblastoma
c. Paraganglionoma
d. Neuroblastoma

A

c. Paraganglionoma

Neurogenic tumors based on their origin:
a. Intercostal nerves - schwannoma, neurofibroma
b. Sympathetic ganglia -a, b, and d
c. Paraganglionic cells - c

54
Q

2 of the most common neurogenic tumors in the following age groups:
a. Children
b. Adults

A

a. Neuroblastoma and Ganglioneuroma (sympathetic ganglia)
b. Schwannoma and neurofibroma (intercostal nerves)

55
Q

True of neurogenic tumors originating from intercostal nerves:
a. These are most commonly seen in children
b. Schwannoma and neurfibroma are comprised of spindle cells that arise from the Schwann cell
c. Neurofibroma is not encapsulated but with interspersed neurons
d. Schwannoma is encapsulated with no interspersed neurons

A

b. Schwannoma and neurofibroma are comprised of spindle cells that arise from the Schwann cell

a. These are more frequently seen in ADULTS
b. True
c. Neurofibroma - encapsuled + with neurons
d. SchwanNOma - NOT encapsulated, NO neuronal elements

56
Q

39/F. Diagnosis

A

Neurogenic tumor
(Schwannoma)

57
Q

15/F. Diagnosis

A

Neurogenic tumor
(Ganglioneuroma)

INTERCOSTAL NERVE TUMORS -ACUTE
SYMPATHETIC NERVE TUMORS -BROAD

These tumors generally present as elongated, vertically oriented paravertebral soft tissue masses with a broad area of contact with the posterior mediastinum. These findings may help distinguish these lesions from schwannomas or neurofibromas, which usually maintain an acute angle with the vertebral column and posterior mediastinum and therefore tend to show sharp superior and inferior margins on lateral chest radiographs.

Both may erode the surrounding osseous structures

58
Q

These tumors that arise from neural crest or chromaffin cells that lie in proximity to the thoracolumbar sympathetic ganglia of the autonomic nervous system.

A

Mediastinal paraganglioma

Anterior/Middle > Posterior

59
Q

3 of the most common primary sites of thoracic spinal metastases

A

Bronchogenic CA
Breast CA
Renal cell CA

60
Q

Determine if neoplastic, infectious, or extramedullary hematopoeisis
a. Expansion and destruction of vertebral bodies, with sparing of intervertebral disks
b. Presence of paravertebral mass centered at the point of maximal bone destruction
c. Narrowing of the adjacent disk space and destruction of vertebral end-plates
d. Expansion of the medullary space and cyst formation within long bones, ribs, and vertebral bodies, with associated lobulated paraspinal soft tissue masses

A

a. Neoplastic
b. Infectious
c. Infectious
d. Extramedullary hematopoiesis

61
Q

T/F: Osteophytes are more common in the left due to inhibitory effect of the inferior vena cava

A

False

Osteophytes are most commonly RIGHT sided because of the inhibitory effect of the pulsating descending AORTA on left-sided osteophyte formation.

62
Q

Most common posterior mediastinal mass in patients with neurofibromatosis

A

Meningoceles

They represent an anomalous herniation of the spinal meninges through an intervertebral foramen, resulting in a paravertebral soft tissue mass.

Chest radiographs typically reveal a round, well-defined paraspinal mass that is indistinguishable from a neurofibroma. Additional clues to the diagnosis include rib erosion, enlargement of the adjacent neural foramen, vertebral anomalies, or kyphoscoliosis. When a lateral meningocele is associated with kyphoscoliosis, it is usually found at the apex of the scoliotic curve on the convex side.

Conversely, approximately two-thirds of patients with meningoceles have neurofibromatosis.

63
Q

Infectious or Neoplastic

A

Infectious
(Discitis/Osteomyelitis of the Thoracic Spine)

Disc space narrowing and vertebral end-plate destruction with a paravertebral inflammatory mass (arrows). Biopsy showed staphylococcal infection.

64
Q

Spontaneous esophageal perforation following prolonged vomiting is termed ____

A

Boerhaave syndrome

In this condition, a vertical tear occurs along the LEFT POSTEROLATERAL wall of the distal esophagus, just above the esophagogastric junction, leading to signs and symptoms of acute mediastinitis.

65
Q

The sensitivity of the esophagram for detecting contrast leakage is highest when the study is obtained within ____ hours of the perforation.
a. 6
b. 12
c. 24
d. 48

A

c. 24

66
Q

T/F: The hallmarks of chronic fibrosing mediastinitis are chronic inflammatory changes and mediastinal fibrosis.

A

True

67
Q

Most common cause of chronic fibrosing mediastinitis

A

Granulomatous infection, usually secondary to Histoplasma capsulatum

68
Q

Most commonly affected structures in chronic fibrosing mediastinitis

A

Superior vena cava
(up to 75% of symptomatic patients)

SVC syndrome results

69
Q

Most common finding in chronic fibrosing mediastinitis on MDCT

A

Enlarged LNs with calcification

70
Q

Most common cause of mediastinal hemorrhage:
a. Injury to mediastinal vessels from blunt of penetrating thoracic trauma
b. Iatrogenic trauma
c. Spontaneous hemorrhage from coagulopathy or aortic rupture from aneurysm or dissection
d. Bleeding mediastinal mass

A

a. Injury to mediastinal vessels from blunt of penetrating thoracic trauma

71
Q

54/M, asymptomatic. Diagnosis

A

Mediastinal lipomatosis

72
Q

Most comon source of pneumomediastinum and via what mechanism

A

Air from the lungs via Macklin effect

73
Q

Sign and diagnosis

A

Continuous diaphragm sign in
pneumomediastinum

74
Q

It is the extrathoracic neoplasm with the highest incidence of intrathoracic nodal metastases

A

Malignant melanoma

75
Q

Characteristic feature in primary pulmonary tuberculosis in distinction to postprimary tuberculosis

A

Unilateral hilar or mediastinal lymph node enlargement

76
Q

T/F: The most frequent solid tumors producing bilateral hilar disease are small cell carcinoma of the lung, lymphoma, and malignant melanoma.

A

True

77
Q

Most likely diagnosis

A

Sarcoidosis

78
Q

The pattern of lymph node involvement in sarcoidosis has been termed the ____

A

1-2-3 sign, with 1 = right paratracheal, 2 = right hilar, and 3 = left hilar lymph node enlargement

79
Q

Eggshell calcification of hilar nodes is highly suggestive of this entity, although this may also be seen in sarcoidosis, histoplasmosis or amyloidosis

A

Chronic berylliosis

80
Q

T/F: The most common causes of a small hilum are atelectasis and resection of a portion of lung

A

True

Pulmo Radiology (5 decks)

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