Sandbox:Trusha

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Trusha Tank, M.D.[3]

Differential diagnosis of mediastinal mass

Wide variety of medical conditions can present as a mediastinal mass on radiological imaging.

• Mediastinal mass may cause obstruction, entrapment or infiltration of other mediastinal organs such as: Trachea, bronchi, esophagus, aorta, superior vena cava (SVC) or heart.
• Disorder caused by any kind of mediastinal mass is collectively known as: Mediastinal syndromes
• Mediastinal syndrome includes:
  • Compression of the trachea: Dyspnea and respiratory insufficiency.
  • Compression of the esophagus: Dysphagia.
  • Compression of SVC causes superior vena cava syndrome: Vein distention, edema of the face or upper extremities and a positive Pemberton's sign.
    • Superior vena cava syndrome is the most severe complication of mediastinal syndrome and a medical emergency.

ABBREVIATIONS: N/A: Not available, SOB: Shortness of breath, M/C: Most common, RI: Respiratory insufficiency, NM: Neuromuscular system, SVCS: Superior vena cava syndrome, SLE: Systemic lupus erythematosus disease
Class	Disease	Clinical presentation				Etiology	Paraclinical findings
			Mediastinal syndrome
		Symptoms	Dyspnea/ RI	Dysphagia	SVCS		Gold standard	Image	Additional findings
Anterior mediastinal mass
Tumors	Thymoma	Cough wheezing Chest pain Muscle weakness (MG) Anemia	+	+	+	Human foamy virus Epstein-Barr virus Human T-cell lymphotropic virus MEN 1 syndrome	Biopsy: Epithelial cells Immature lymphocytes Immature T cells		Associated condition NM Myasthenia gravis Neuromyotonia Rippling muscle disease Polymyositis/dermatomyositis Encephalitis (limbic, cortical and brain stem) Intestinal pseudoobstruction Hematological Anemia: pure red cell aplasia, pernicious anemia, hemolytic anemia, aplastic anemia Other isolated cytopenias: eosinophils, basophils neutrophils Immunodeficiencies: hypogammaglobulinemia/- T-cell deficiencies (Good syndrome) Dermatological Pemphigus (foliaceus or paraneoplastic) Lichen planus Alopecia areata Endocrine Addison disease Grave's disease Cushing's disease Hepato-renal Glomerulonephritis Autoimmune hepatitis Systemic Autoimmune Diseases SLE Sjögren's syndrome Systemic sclerosis Graft-versus-host disease
	Fatty mass	Mostly asymptomatic	-	-	-	Steroid use Cushing's syndrome Obeses	MRI: Well-defined encapsulated mas Extensive fat content Small amounts of solid areas Fibrous septa		Fatty mass can be: Lipoma Liposarcoma Thymolipoma
	Non-Hodgkin lymphoma	Painless lymphadenopathy Fever Weight loss and anorexia Night sweats Constant fatigue Itchy skin Cough Shortness of breath Abdominal pain or swelling Constipation Nausea Vomiting Headache Personality changes Seizures	±	±	±	Age (above 60 years) Caucasians > African and Asian Americans Positive family history of first degree relative B-cell activating autoimmune disorders Radiation exposure Infections (HIV, Hep C, HTLV-1, EBV, HHV-8, H. pylori, psittacosis, Campylobacter jejuni) Previous cancer treatment Exposure to chemicals and drugs (pesticides, methotrexate, TNF inhibitors, trichloroethylene) Cigarette smoking for ≥ 40 years BMI ≥30 kg/m2 Diet Hair dyes Breast implants	Excisional lymph node biopsy with immunohistochemical study CD 20+ cells		Anemia: Involvement of bone marrow Autoimmune hemolysis and bleeding. Thrombocytopenia, leukopenia, or pancytopenia Lymphocytosis with malignant cells Thrombocytosis
	Teratoma	Benign Asymptomatic Malignant Cough Chest pain Trichoptysis	±	±	±	Benign equal in men and women Malignant more common in men Pediatric population higher risk	Chest CT scan: Location Metastasis Intrinsic structure Soft tissue Fat Calcification		N/A
Thyroid disease	Thyroid cancer	Lump in the neck Dysphonia Lymphadenopathy Cough Sore throat Neck pain	+	+	-	Hx of goiter Family Hx of thyroid disease Female gender Asian race Radiation exposure MEN syndrome	US guided biopsy: Papillary thyroid cancer Follicular thyroid cancer Medullary thyroid cancer Anaplastic thyroid cancer Lymphoma		TFT Elevated T3 Elevated T4 Low TSH
	Goiter	A visible swelling at the base of your neck Tight feeling in throat Cough Hoarseness Fatigue	+	+	-	Iodine deficiency Female gender Age over 50 years Personal or family history Certain medications Immunosuppressants Antiretrovirals Amiodarone Lithium Radiation	Radioactive iodine scan: Nodules Size Function of the gland: ↑ or ↓		Hyperavtive gland (hyperthyroid): Grave's disease Hypoactive gland (hypothyroid): Hashimoto thyroiditis Normal functioning gland (euthyroid): Benign thyroid enlargement (non toxic multinodular goiter)
Class	Disease	Symptoms	Dyspnea/ RI	Dysphagia	SVCS	Etiology	Gold standard	Image	Additional findings
Middle mediastinal mass
CVS disease	Pericardial effusion	Chest pain The positional change affecting the chest pain Orthopnea symptoms of infection, injury or systemic disease causing the effusion	+	±	-	Acute myocardial infarction Aortic dissection Aortic rupture Myocardial rupture Rupture of ventricular aneurysm Uremic pericarditis Rheumatic pericarditis Tuberculous pericarditis Uremic pericarditis Viral pericarditis Dressler's syndrome Cardiac catheterization Cardiomyopathy Chemotherapy Chest trauma Collagen vascular disease Congestive heart failure Neoplasm Postpericardiotomy syndrome Postirradiation
	Aortic dissection
	Superior vena cava obstruction
	Partial anomalous pulmonary venous connection
GI disease	Esophageal achalasia
	Esophageal cancer
	Esophageal rupture
	Hiatus hernia
Pulmonary disease	Hilar lymphadenopathy
	Pneumomediastinum
	Sarcoidosis
Mediastinal tumor	Mediastinal tumor
	Mediastinal germ cell tumor
Infection	Mediastinitis
	Anthrax
	Tularemia
Cystic disease	Dermoid cyst
	Bronchogenic cyst
Chronic inflammatory	Churg-Strauss syndrome
Class	Disease	Symptoms	Dyspnea/ RI	Dysphagia	SVCS	Etiology	Gold standard	Image	Additional findings
Posterior mediastinal mass
CNS disease	Meningocele
	Neurilemmoma
ABBREVIATIONS: N/A: Not available , SOB: Shortness of breath, M/C: Most common, RI: Respiratory insufficiency, NM: Neuromuscular system, SVCS: Superior vena cava syndrome, SLE: Systemic lupus erythematosus disease

1. Superior vena cava obstruction
2. Partial anomalous pulmonary venous connection
3. Esophageal achalasia
4. Esophageal cancer
5. Esophageal rupture
6. Hiatus hernia
7. Hilar lymphadenopathy
8. Pneumomediastinum
9. Sarcoidosis
10. Lymphoma
11. Neurilemmoma
12. Non-Hodgkin lymphoma
13. Teratoma
14. Thymoma

1. Thyroid cancer
2. Goitre
3. Mediastinal germ cell tumor,
4. Mediastinal tumor,
5. Mediastinitis

1. Churg-Strauss syndrome
2. Bronchogenic cyst,
3. Dermoid cyst
4. Anthrax:
5. Tularemia

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CT scan showing a smooth anterior mediastinal mass, with a mixed internal density of containing both enhancing soft tissue and cystic areas. The outline of the mass is relatively well defined. No lymphadenopathy, pleural effusion or infiltration. Case courtesy of Dr. Abdallah Al Khateeb (Picture courtesy: Radiopedia)

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CT scan showing excessive fatty tissue deposition within the posterior mediastinum with anterior displacement of the esophagus. Case courtesy of Dr. Ahmed Abdrabou (Picture courtesy: [1])