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Mediastinal Masses

By

Richard W. Light

, MD, Vanderbilt University Medical Center

Last full review/revision Jan 2021| Content last modified Jan 2021
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Mediastinal masses are caused by a variety of cysts and tumors; likely causes differ by patient age and by location of the mass (anterior, middle, or posterior mediastinum). The masses may be asymptomatic (common in adults) or cause obstructive respiratory symptoms (more likely in children). Testing involves CT with biopsy and adjunctive tests as needed. Treatment differs by cause.

Mediastinal masses are divided into those that occur in the anterior, middle, and posterior mediastinum. The anterior mediastinum extends from the sternum to the pericardium in the inferior region and from the sternum to the brachiocephalic vessels in the superior region. The middle mediastinum lies between the anterior and posterior mediastinum. The posterior mediastinum is bounded by the pericardium and trachea anteriorly and the vertebral column posteriorly.

Etiology of Mediastinal Masses

Symptoms and Signs of Mediastinal Masses

Many mediastinal masses are asymptomatic. In general, malignant lesions and masses in children are much more likely to cause symptoms. The most common symptoms are chest pain and weight loss. Lymphomas Overview of Lymphoma Lymphomas are a heterogeneous group of tumors arising in the reticuloendothelial and lymphatic systems. The major types are Hodgkin lymphoma and non-Hodgkin lymphoma (see table Comparison of... read more may manifest with fever and weight loss.

Symptoms and signs also depend on location. Large anterior mediastinal masses may cause dyspnea when patients are lying supine. Lesions in the middle mediastinum may compress blood vessels or airways, causing the superior vena cava syndrome Regional spread Lung carcinoma is the leading cause of cancer-related death worldwide. About 85% of cases are related to cigarette smoking. Symptoms can include cough, chest discomfort or pain, weight loss... read more Regional spread or airway obstruction. Lesions in the posterior mediastinum may encroach on the esophagus, causing dysphagia or odynophagia.

Diagnosis of Mediastinal Masses

  • Chest x-ray

  • CT and sometimes MRI

  • Sometimes tissue examination

Mediastinal masses are most often incidentally discovered on chest x-ray or other imaging tests during an examination for chest symptoms. Additional diagnostic testing, usually imaging and biopsy, is indicated to determine etiology.

CT with IV contrast is the most valuable imaging technique. With thoracic CT, normal variants and benign tumors, such as fat- and fluid-filled cysts, can be distinguished from other processes. An MRI is done if the structure is cystic. MRI may be useful in determining whether the mass is compressing or invading adjacent structures.

A definitive diagnosis can be obtained for many mediastinal masses with needle aspiration or needle biopsy Transthoracic Needle Biopsy Transthoracic needle biopsy of thoracic or mediastinal structures uses a cutting needle to aspirate a core of tissue for histologic analysis. Transthoracic needle biopsy is done to evaluate... read more . Fine-needle aspiration techniques usually suffice for carcinomatous lesions, but a cutting-needle biopsy should be done whenever lymphoma, thymoma, or a neural mass is suspected. If ectopic thyroid tissue is considered, thyroid-stimulating hormone is measured.

Treatment of Mediastinal Masses

  • Depends on cause

Treatment depends on etiology. Some benign lesions, such as pericardial cysts, can be observed. Most malignant tumors should be removed surgically, but some, such as lymphomas, are best treated with chemotherapy. Granulomatous disease should be treated with the appropriate antimicrobial drug.

Key Points

  • In adults, thymomas and lymphomas (both Hodgkin and non-Hodgkin) are the most common anterior lesions, lymph node enlargement and vascular masses are the most common middle lesions, and neurogenic tumors and esophageal abnormalities are the most common posterior lesions.

  • In children, the most common mediastinal masses are neurogenic tumors and cysts.

  • The most common symptoms are chest pain and weight loss, but many masses are asymptomatic.

  • Obstructive respiratory symptoms can occur in children and rarely in adults.

  • CT with IV contrast is the most valuable imaging technique.

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