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
In adults, the most common causes of mediastinal masses vary by location:
Anterior mediastinum: Thymomas and lymphomas Overview of Lymphoma Lymphomas are a heterogeneous group of tumors arising in the reticuloendothelial and lymphatic systems. The major types are Hodgkin lymphoma Non-Hodgkin lymphoma See table Comparison of Hodgkin... read more (both Hodgkin and non-Hodgkin)
Middle mediastinum: Lymph node enlargement and vascular masses
Posterior mediastinum: Neurogenic tumors and esophageal abnormalities
For other causes, see figure . Chronic fibrosing mediastinitis (eg, caused by tuberculosis, histoplasmosis) is a rare cause of mediastinal masses.
Some Causes of Mediastinal Masses in Adults
In children, the most common mediastinal masses are neurogenic tumors and cysts. For other causes, see table .
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 Non-Hodgkin lymphoma See table Comparison of Hodgkin... read more may manifest with fever and weight loss.
In children, mediastinal masses are more likely to cause tracheobronchial compression and stridor or symptoms of recurrent bronchitis Acute Bronchitis Acute bronchitis is inflammation of the tracheobronchial tree, commonly following an upper respiratory infection in the absence of chronic lung disorders. The cause is almost always a viral... read more or pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more .
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 or airway obstruction. Lesions in the posterior mediastinum may encroach on the esophagus, causing dysphagia Dysphagia Dysphagia is difficulty swallowing. The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach. Dysphagia should not be confused with globus sensation... read more or odynophagia.
Diagnosis of Mediastinal Masses
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 to provide sufficient tissue for diagnostic analysis whenever lymphoma, thymoma, or a neural mass is suspected.
If ectopic thyroid tissue is considered a cause, thyroid-stimulating hormone is measured.
Surgical excision is done when there is high suspicion of malignancy based on results of imaging or other tests and when complete resection can be achieved.
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 such as tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more or histoplasmosis Histoplasmosis Histoplasmosis is a pulmonary and hematogenous disease caused by Histoplasma capsulatum; it is often chronic and usually follows an asymptomatic primary infection. Symptoms are those... read more should be treated with the appropriate antimicrobial medication.
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 and systemic symptoms can occur in children and rarely in adults.
CT with IV contrast is the most valuable imaging technique.
Treatment depends on the etiology of the mass.