The document discusses various pathologies that can occur in the mediastinum and surrounding structures. It provides 18 figures showing radiographic images of different mediastinal masses in patients. The images demonstrate the appearance of masses such as goiters, thymomas, teratomas, neurofibromas, and lymphadenopathy on techniques such as CT, MRI, ultrasound, and radionuclide imaging. The case studies are used to illustrate the imaging features and diagnostic evaluation of common and uncommon mediastinal tumors and cysts.

1. 11
The Mediastinum, Including
the Pericardium
DR MUHAMMAD BIN ZULFIQAR
PGR III FCPS Services institute of Medical
Sciences/ Services Hospital Lahore
GRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY

2. • FIGURE 11-1 ■ Value of multiplanar reformations. A 45-year-old woman
with dyspnoea: (A) frontal radiograph and (B) oesophogram demonstrate
displacement of the trachea and oesophagus to the right, by a large
mediastinal mass in the thoracic inlet. (C) Transaxial contrast medium-
enhanced CT shows a large goitre arising from the left lobe of the thyroid.
(D) Coronal reformat depicts the craniocaudal extent of the mass and its
relationship with the adjacent structures.

3. • FIGURE 11-1 ■ Value of multiplanar reformations. A 45-year-old woman
with dyspnoea: (A) frontal radiograph and (B) oesophogram demonstrate
displacement of the trachea and oesophagus to the right, by a large
mediastinal mass in the thoracic inlet. (C) Transaxial contrast medium-
enhanced CT shows a large goitre arising from the left lobe of the thyroid. (D)
Coronal reformat depicts the craniocaudal extent of the mass and its
relationship with the adjacent structures.

4. • FIGURE 11-2 ■ Comparison of various techniques in assessment of goitre. A 90-year-old woman
presents with swelling of her face and shortness of breath. (A) Transaxial and (B) sagittal
reformatted images on contrast medium-enhanced CT imaging demonstrate a large intrathoracic
goitre. Ultrasound evaluation of the neck using colour Doppler shows an enlarged left lobe of the
thyroid with a mildly heterogeneous echogenicity. There are numerous tortuous venous collateral
vessels surrounding the goitre, rendering safe fine-needle aspiration under ultrasound guidance
impossible (C). 123I radionuclide imaging of the face and neck demonstrates iodine uptake of the
goitre (D).

5. • FIGURE 11-2 ■ Comparison of various techniques in assessment of goitre.
A 90-year-old woman presents with swelling of her face and shortness of
breath. (A) Transaxial and (B) sagittal reformatted images on contrast
medium-enhanced CT imaging demonstrate a large intrathoracic goitre.
Ultrasound evaluation of the neck using colour Doppler shows an enlarged
left lobe of the thyroid with a mildly heterogeneous echogenicity. There
are numerous tortuous venous collateral vessels surrounding the goitre,
rendering safe fine-needle aspiration under ultrasound guidance
impossible (C). 123I radionuclide imaging of the face and neck
demonstrates iodine uptake of the goitre (D).

6. • FIGURE 11-3 ■ Role of scintigraphy in detecting parathyroid adenomas. A 66-
year-old woman with hypercalcaemia. CT (not shown) did not reveal a
parathyroid adenoma. 99mTc-sestamibi radionuclide imaging demonstrates uptake
in both thyroid and parathyroid parenchyma in the 10-minute delayed image (left);
however, at 2-hour delay, imaging (right) demonstrates persistent uptake in the
right lobe of the thyroid gland, representing the parathyroid adenoma.

7. • FIGURE 11-4 ■ Cystic thymoma. (A) Frontal
and (B) lateral chest radiographs show an
anterior mediastinal mass extending along the
right heart border.

8. • FIGURE 11-4 ■ Cystic thymoma. (A) Frontal and
(B) lateral chest radiographs show an anterior
mediastinal mass extending along the right
heart border.

9. • FIGURE 11-4, Continued(C) Transaxial and (D) coronal
reformatted CT images demonstrate the cystic and solid
components of the mass. (E) T1- and (F) T2-weighted sequences
reveal that the cystic portion has a low T1 and high T2 signal
intensity and the solid portion is isointense to myocardium. T1-
weighted, fat-saturated 3D acquisition (G) before and (H) after
contrast media administration demonstrate heterogeneous
enhancement of the solid component

10. • FIGURE 11-4, Continued(C) Transaxial and (D) coronal
reformatted CT images demonstrate the cystic and solid
components of the mass. (E) T1- and (F) T2-weighted
sequences reveal that the cystic portion has a low T1 and
high T2 signal intensity and the solid portion is isointense to
myocardium. T1-weighted, fat-saturated 3D acquisition (G)
before and (H) after contrast media administration
demonstrate heterogeneous enhancement of the solid
component

11. • FIGURE 11-4, Continued(C) Transaxial and (D) coronal
reformatted CT images demonstrate the cystic and
solid components of the mass. (E) T1- and (F) T2-
weighted sequences reveal that the cystic portion has a
low T1 and high T2 signal intensity and the solid
portion is isointense to myocardium. T1-weighted, fat-
saturated 3D acquisition (G) before and (H) after
contrast media administration demonstrate
heterogeneous enhancement of the solid component

12. • FIGURE 11-5 ■ Invasive thymoma. A 74-year-old
man with weight loss. (A) Chest radiograph
displacement of the trachea and carina to the
right and lobulation of the left pleura. CT
demonstrates (B) multiple confluent pleural
masses involving the medial and posterior pleura
and (C) a mass arising from the thymus. A B C

13. • FIGURE 11-6 ■ Thymic carcinoma. A 16-year-old man with history
of weight loss and night sweats. Contrast medium-enhanced CT
images show a heterogeneously enhancing anterior mediastinal
mass arising from the right lobe of the thymus (A), with cystic (or
necrotic) components. It extends inferiorly in the retrosternal space
(B) and has no clear fat plane between it and the mediastinal
structures (B). It was surgically excised and pathological
examination revealed thymic carcinoma.

14. • FIGURE 11-7 ■ Thymic carcinoid. A 58-year-old
woman with palpitations. Contrast medium-
enhanced CT images of the upper thorax (A–C)
show an infiltrative soft-tissue mass arising from
the anterior mediastinum, surrounding the
mediastinal vasculature.

15. • FIGURE 11-7 ■ Thymic carcinoid. A 58-year-old
woman with palpitations. Contrast medium-
enhanced CT images of the upper thorax (A–C)
show an infiltrative soft-tissue mass arising from
the anterior mediastinum, surrounding the
mediastinal vasculature.

16. • FIGURE 11-8 ■ Thymic hyperplasia with Graves’
disease (thyrotoxicosis). A 35-year-old woman with
dysphagia, palpitations, tremors, exophthalmos and
weight loss and elevated serum thyroid hormone.
Contrast medium-enhanced CT demonstrates (A)
enlarged thyroid and (B) thymus. Following treatment
with I-131, (C) the thyroid gland and (D) thymus
became much smaller.

17. • FIGURE 11-8 ■ Thymic hyperplasia with Graves’ disease
(thyrotoxicosis). A 35-year-old woman with dysphagia,
palpitations, tremors, exophthalmos and weight loss
and elevated serum thyroid hormone. Contrast medium-
enhanced CT demonstrates (A) enlarged thyroid and (B)
thymus. Following treatment with I-131, (C) the thyroid
gland and (D) thymus became much smaller.

18. • FIGURE 11-9 ■ Thymic cyst. Thoracic CT images (A) of a 64-
year-old woman with diabetes and weight loss show an
incidental finding of a well-circumscribed, low-attenuation
anterior mediastinal mass. MR demonstrates low T1 signal
intensity (B) and high T2 signal intensity (C) without
evidence of enhancement following intravenous contrast
medium administration (D).

19. • FIGURE 11-9 ■ Thymic cyst. Thoracic CT images (A) of a 64-
year-old woman with diabetes and weight loss show an
incidental finding of a well-circumscribed, low-attenuation
anterior mediastinal mass. MR demonstrates low T1 signal
intensity (B) and high T2 signal intensity (C) without
evidence of enhancement following intravenous contrast
medium administration (D).

20. • FIGURE 11-10 ■ Cystic teratoma. A 51-year-old man with prostate
cancer was found to have an anterior mediastinal mass on chest
radiograph (A, B). (C) CT shows a heterogeneous mass with areas of
fat attenuation. (D) Gross pathological examination after surgical
resection demonstrated sebaceous material and pieces of hair (not
shown).

21. • FIGURE 11-10 ■ Cystic teratoma. A 51-year-old
man with prostate cancer was found to have an
anterior mediastinal mass on chest radiograph (A,
B). (C) CT shows a heterogeneous mass with
areas of fat attenuation. (D) Gross pathological
examination after surgical resection
demonstrated sebaceous material and pieces of
hair (not shown).

22. • FIGURE 11-11 ■ Seminoma. A 19-year-old
man with chest pain found to have a large
anterior mediastinal mass on non-enhanced
CT of the chest. The mass has a
heterogeneous attenuation (A) and exerts
mass effect upon the heart and airway (B).

23. • FIGURE 11-12 ■ Metastatic choriocarcinoma. A 23-
year-old man presented with haemoptysis for 2
weeks. Chest CT demonstrates an anterior
mediastinal mass of soft-tissue attenuation with
slightly enhancing margins (A, B). (A) Mediastinal
lymphadenopathy adjacent to the mass and (C)
multiple pulmonary nodules dispersed throughout
the lung are sites of metastases

24. • FIGURE 11-12 ■ Metastatic choriocarcinoma. A 23-
year-old man presented with haemoptysis for 2
weeks. Chest CT demonstrates an anterior mediastinal
mass of soft-tissue attenuation with slightly enhancing
margins (A, B). (A) Mediastinal lymphadenopathy
adjacent to the mass and (C) multiple pulmonary
nodules dispersed throughout the lung are sites of
metastases

25. • FIGURE 11-13 ■ Large B-cell lymphoma. A 33-
year-old man found to have a lobular soft-tissue
mass in the anterior mediastinum (A) extending
to the right paratracheal and hilar regions (B).

26. • FIGURE 11-14 ■ High-attenuation lymph nodes.
Transaxial image of chest CT shows a calcified
mediastinal lymphadenopathy. Such dystrophic
calcification is common as a sequela of Histoplasma
capsulatum infection; however, it can also be seen with
metastatic lymphadenopathy of mucinous
adenocarcinomas.

27. • FIGURE 11-15 ■ Low-
attenuation lymph nodes.
Transaxial contrast medium-
enhanced CT image of the
chest in a 51-year-old woman
with fever and chest pain
shows subcarinal
lymphadenopathy with
central low attenuation
caused by necrosis (A). Axial
CT image in lung window
setting lower in the chest
reveals numerous confluent
nodules in bilateral lower
lobes caused by acute
Histoplasma capsulatum (B).

28. • FIGURE 11-16 ■ Castleman’s
disease. A 33-year-old
woman with shortness of
breath was further evaluated
by contrast medium
enhanced CT. Transaxial CT
images show a normal
thyroid (A), but narrowing
and displacement of the
trachea by a
heterogeneously enhancing
mediastinal mass located
more inferiorly (B). The mass
was surgically excised and
pathological examination
revealed hyaline vascular
type of Castleman’s disease.

29. • FIGURE 11-17 ■ Bronchogenic cyst. A 58-year-old man with
hoarseness for several months. (A) Frontal and (B) lateral chest
radiographs reveal a round middle mediastinal mass. (C) Coronal
reformatted and (D) transaxial images of contrast medium-
enhanced CT displayed in soft-tissue and lung-window settings,
respectively, demonstrate a smooth-bordered, thin-walled mass of
fluid attenuation located at the carina, closely associated with the
right mainstem bronchus.

30. • FIGURE 11-17 ■ Bronchogenic cyst. A 58-year-old man with
hoarseness for several months. (A) Frontal and (B) lateral chest
radiographs reveal a round middle mediastinal mass. (C) Coronal
reformatted and (D) transaxial images of contrast medium-
enhanced CT displayed in soft-tissue and lung-window settings,
respectively, demonstrate a smooth-bordered, thin-walled mass of
fluid attenuation located at the carina, closely associated with the
right mainstem bronchus.

31. • FIGURE 11-18 ■ Oesophageal duplication cyst. A 44-year-old woman
presented with complaint of food stuck in her throat. (A) Chest
radiograph shows an opacity causing rightward displacement of the azygo-
oesophageal line. (B) Barium oesophogram demonstrates leftward
deviation of distal oesophagus. (C) CT demonstrates a thin-walled cystic
lesion abutting the oesophagus. (D) Axial and (E) coronal T2-weighted MR
images demonstrate a homogeneous high T2 signal intensity of this mass
and no enhancement on the T1-weighted contrast medium-enhanced
sequence acquired after contrast agent administration (F).

32. • FIGURE 11-18 ■ Oesophageal
duplication cyst. A 44-year-old
woman presented with complaint
of food stuck in her throat. (A)
Chest radiograph shows an opacity
causing rightward displacement of
the azygo-oesophageal line. (B)
Barium oesophogram demonstrates
leftward deviation of distal
oesophagus. (C) CT demonstrates a
thin-walled cystic lesion abutting the
oesophagus. (D) Axial and (E)
coronal T2-weighted MR images
demonstrate a homogeneous high
T2 signal intensity of this mass and
no enhancement on the T1-
weighted contrast medium-
enhanced sequence acquired after
contrast agent administration (F).

33. • FIGURE 11-18 ■ Oesophageal duplication cyst. A 44-year-old woman presented
with complaint of food stuck in her throat. (A) Chest radiograph shows an opacity
causing rightward displacement of the azygo-oesophageal line. (B) Barium
oesophogram demonstrates leftward deviation of distal oesophagus. (C) CT
demonstrates a thin-walled cystic lesion abutting the oesophagus. (D) Axial and (E)
coronal T2-weighted MR images demonstrate a homogeneous high T2 signal
intensity of this mass and no enhancement on the T1-weighted contrast medium-
enhanced sequence acquired after contrast agent administration (F).

34. • FIGURE 11-18 ■ Oesophageal duplication cyst. A 44-year-old
woman presented with complaint of food stuck in her throat. (A)
Chest radiograph shows an opacity causing rightward displacement
of the azygo-oesophageal line. (B) Barium oesophogram
demonstrates leftward deviation of distal oesophagus. (C) CT
demonstrates a thin-walled cystic lesion abutting the oesophagus.
(D) Axial and (E) coronal T2-weighted MR images demonstrate a
homogeneous high T2 signal intensity of this mass and no
enhancement on the T1-weighted contrast medium-enhanced
sequence acquired after contrast agent administration (F).

35. • FIGURE 11-19 ■ Neurofibroma. A 7-year-old girl with a
large right apical mass associated with deformity of the
adjacent ribs and scoliosis of the thoracic spine (A, B). CT
demonstrates a homogeneous low-attenuation mass
arising from the posterior mediastinum and extending to
the right apex consistent with a plexiform neurofibroma
causing mass effect on the trachea and vessels (C, D).

36. • FIGURE 11-19 ■ Neurofibroma. A 7-year-old girl with
a large right apical mass associated with deformity of
the adjacent ribs and scoliosis of the thoracic spine (A,
B). CT demonstrates a homogeneous low-attenuation
mass arising from the posterior mediastinum and
extending to the right apex consistent with a plexiform
neurofibroma causing mass effect on the trachea and
vessels (C, D).

37. • FIGURE 11-19, Continued Sagittal images show
that the mass has an isointense signal with chest
wall musculature with T1-weighted sequence (E)
and hyperintense signal with inversion-recovery
sequence (F) imaging.

38. • FIGURE 11-20 ■ Malignant nerve sheath tumour. A 23-year-old with
left axillary mass and left shoulder pain. (A) Axial and (B) coronal
contrast medium-enhanced CT images show a large heterogeneously
enhancing mass in the left axilla, which encases the left subclavian
artery. Axial contrast medium-enhanced MR image demonstrates that
this enhancing mass expands the neural foramen of the spine, with no
erosion of the vertebral body, suggesting that this is a neurogenic
tumour (C).

39. • FIGURE 11-20 ■ Malignant nerve sheath tumour. A 23-year-old
with left axillary mass and left shoulder pain. (A) Axial and (B)
coronal contrast medium-enhanced CT images show a large
heterogeneously enhancing mass in the left axilla, which encases
the left subclavian artery. Axial contrast medium-enhanced MR
image demonstrates that this enhancing mass expands the neural
foramen of the spine, with no erosion of the vertebral body,
suggesting that this is a neurogenic tumour (C).

40. • FIGURE 11-21 ■ Paraganglioma. CT of the chest demonstrates an
enhancing mediastinal mass arising in the middle mediastinum
adjacent to the left atrium, and protruding into it (A). I-131
metaiodobenzylguanidine (MIBG) scintigraphy shows increased
uptake, revealing that it is a paraganglioma (B).

41. • FIGURE 11-21 ■ Paraganglioma. CT of the chest
demonstrates an enhancing mediastinal mass arising in the
middle mediastinum adjacent to the left atrium, and
protruding into it (A). I-131 metaiodobenzylguanidine
(MIBG) scintigraphy shows increased uptake, revealing that
it is a paraganglioma (B).

42. • FIGURE 11-22 ■
Extramedullary
hematopoiesis. Axial
contrast medium-enhanced
CT images optimised for (A)
soft tissue and (B) bone of a
40-year-old woman with
thalassaemia display
bilateral soft-tissue masses
closely associated with the
ribs and the spine. The ribs
are expanded by
trabeculated bone.

43. • FIGURE 11-23 ■
Lymphangioma. A 56-
year-old man found to
have a right paratracheal
opacity on chest
radiograph (A). CT shows a
smooth, well-defined right
paratracheal lesion which
has no perceptible wall
and is of fluid attenuation
(B). After surgical
resection pathological
examination revealed
lymphagioma.

44. • FIGURE 11-24 ■ Liposarcoma.
A 58-year-old man with
gradually worsening
dyspnoea was found to have a
large anterior mediastinal
mass when evaluated by
chest CT. This mass has a
predominantly fat
attenuation with internal
thick septations and mural
nodules and exerts significant
mass effect upon the airway
(A). PET-CT shows significant
FDG uptake of the soft tissue
components of the mass (B).

45. • FIGURE 11-25 ■ Mediastinal
abscess. An 83-year-old man
had a contrast medium-
enhanced CT of the chest (A–
D) caused by persistent fever
and chest pain following
mitral valve replacement and
ascending aortic graft repair.
There is a large fluid
collection with peripheral
enhancement consistent with
an abscess located posterior
to the sternum and in close
association with the aortic
graft (A).

46. • FIGURE 11-25 ■ Mediastinal
abscess. An 83-year-old man
had a contrast medium-
enhanced CT of the chest (A–
D) caused by persistent fever
and chest pain following
mitral valve replacement and
ascending aortic graft repair.
There is a large fluid collection
with peripheral enhancement
consistent with an abscess
located posterior to the
sternum and in close
association with the aortic
graft (A).

47. • FIGURE 11-26 ■ Fibrosing mediastinitis. Contrast medium-
enhanced CT shows a partially calcified mediastinal and
hilar mass consistent with fibrosing mediastinitis
secondary to histoplasmosis in a child with chronic cough
and facial swelling. The mass causes stenosis of the
superior vena cava (A), right upper lobe and mainstem
bronchi (A, B) and right pulmonary artery (C). There are
numerous mediastinal venous collaterals in the anterior
mediastinum (A, B).

48. • FIGURE 11-26 ■ Fibrosing mediastinitis. Contrast medium-enhanced CT
shows a partially calcified mediastinal and hilar mass consistent with
fibrosing mediastinitis secondary to histoplasmosis in a child with chronic
cough and facial swelling. The mass causes stenosis of the superior vena
cava (A), right upper lobe and mainstem bronchi (A, B) and right
pulmonary artery (C). There are numerous mediastinal venous collaterals
in the anterior mediastinum (A, B).

49. • FIGURE 11-27 ■ Ring
around the artery sign. A
13-year-old girl presented
with chest pain and a
burning sensation in the
throat. Lateral projection of
chest radiograph
demonstrates a lucent line
encircling the right
pulmonary artery (black
arrow), indicating that the
mediastinal air is tracking
into the right hilum.

50. • FIGURE 11-28 ■
Continuous
diaphragm sign in
pneumomediastin
um. Frontal chest
radiograph shows
an uninterrupted
outline of the
diaphragm
indicative of a
pneumomediastin
um.

51. • FIGURE 11-29 ■ Pneumomediastinum on CT. A 19-year-old woman
presents with 3 days of nausea, vomiting and retrosternal chest
pain. (A) Chest radiograph shows vertical lucent lines in the neck
extending into the mediastinum. (B–D) Axial and (E) coronal
reformatted CT images demonstrate air tracking around the
mediastinal structures. The presence of fine septations in the air-
containing areas is a typical finding of pneumomediastinum, not
seen with pneumothorax or pneumopericardium.

52. • FIGURE 11-29 ■ Pneumomediastinum on CT. A 19-year-old woman
presents with 3 days of nausea, vomiting and retrosternal chest
pain. (A) Chest radiograph shows vertical lucent lines in the neck
extending into the mediastinum. (B–D) Axial and (E) coronal
reformatted CT images demonstrate air tracking around the
mediastinal structures. The presence of fine septations in the air-
containing areas is a typical finding of pneumomediastinum, not
seen with pneumothorax or pneumopericardium.

53. • FIGURE 11-29 ■ Pneumomediastinum on CT. A 19-year-old woman presents with
3 days of nausea, vomiting and retrosternal chest pain. (A) Chest radiograph shows
vertical lucent lines in the neck extending into the mediastinum. (B–D) Axial and
(E) coronal reformatted CT images demonstrate air tracking around the
mediastinal structures. The presence of fine septations in the air-containing areas
is a typical finding of pneumomediastinum, not seen with pneumothorax or
pneumopericardium.

54. • FIGURE 11-30 ■ Pericardial cyst. (A, B) Frontal and lateral
chest radiographs of a 33-year-old woman show an
abnormal mass-like contour of the left ventricle. (C) Axial
and (D) coronal contrast medium-enhanced CT images
demonstrate a mass of fluid attenuation without internal
enhancement and no perceptible wall, located anterior and
to the left of the heart.

55. • FIGURE 11-30 ■ Pericardial cyst. (A, B) Frontal and lateral
chest radiographs of a 33-year-old woman show an
abnormal mass-like contour of the left ventricle. (C) Axial
and (D) coronal contrast medium-enhanced CT images
demonstrate a mass of fluid attenuation without internal
enhancement and no perceptible wall, located anterior and
to the left of the heart.

56. • FIGURE 11-31 ■ Pericardial effusion. A 27-year-old man with
chronic kidney disease presented with dyspnoea. Chest
radiographs (A, B) of an enlarged cardiac silhouette since prior
examination 6 months ago (C). The ‘sandwich sign’ (arrow)
represents the pericardial effusion (B). (D) Steady-state free
precession coronal MR image demonstrates uniformly hyperintense
fluid in the pericardial sac, confirming the pericardial effusion.

57. • FIGURE 11-31 ■ Pericardial effusion. A 27-year-old man
with chronic kidney disease presented with dyspnoea.
Chest radiographs (A, B) of an enlarged cardiac silhouette
since prior examination 6 months ago (C). The ‘sandwich
sign’ (arrow) represents the pericardial effusion (B). (D)
Steady-state free precession coronal MR image
demonstrates uniformly hyperintense fluid in the
pericardial sac, confirming the pericardial effusion.

58. • FIGURE 11-32 ■ Pericardial haemorrhage. A 63-year-old
with diaphoresis and tachypnoea. Chest radiograph (A)
shows enlargement of the cardiac silhouette since a
previous radiograph obtained 10 months ago (B). Contrast
medium-enhanced axial CT images (C, D) demonstrate a
large high-attenuation fluid collection in the pericardium
representing haemorrhage. The patient’s symptoms
suggest that there is tamponade physiology.

59. • FIGURE 11-32 ■ Pericardial haemorrhage. A 63-year-old
with diaphoresis and tachypnoea. Chest radiograph (A)
shows enlargement of the cardiac silhouette since a
previous radiograph obtained 10 months ago (B). Contrast
medium-enhanced axial CT images (C, D) demonstrate a
large high-attenuation fluid collection in the pericardium
representing haemorrhage. The patient’s symptoms
suggest that there is tamponade physiology.

60. • FIGURE 11-33 ■ Pericarditis. A 30-year-old
man with new-onset of left-sided chest pain.
Axial contrast medium-enhanced CT shows
diffuse pericardial thickening and a moderate-
sized pericardial effusion. This was caused by
viral pericarditis.

61. • FIGURE 11-34 ■ Constrictive pericarditis. A 48-year-old man with
end-stage renal disease presented with chronic shortness of
breath and poor exercise tolerance. Axial unenhanced (A) and
contrast medium-enhanced (B) CT images demonstrate pericardial
calcification most pronounced in the region of the atrioventricular
groove. There is flattening and indentation of the free wall of the
right ventricle and the base of the left ventricle. (C) Three-
dimensional reconstruction in the two chamber short-axis plane of
the heart shows the belt-like calcification surrounding the heart.

62. • FIGURE 11-34 ■ Constrictive pericarditis. A 48-year-old man with
end-stage renal disease presented with chronic shortness of breath
and poor exercise tolerance. Axial unenhanced (A) and contrast
medium-enhanced (B) CT images demonstrate pericardial
calcification most pronounced in the region of the atrioventricular
groove. There is flattening and indentation of the free wall of the
right ventricle and the base of the left ventricle. (C) Three-
dimensional reconstruction in the twochamber short-axis plane of
the heart shows the belt-like calcification surrounding the heart.

63. • FIGURE 11-35 ■ Pericardial metastasis. A 56-year-old
man with stage IV non-small cell lung cancer. Axial
contrast mediumenhanced CT images (A, B) demonstrate
nodular thickening of the pericardium (white arrow)
representing metastases. CT image optimised for the lung
(C) demonstrates a speculated nodule in the right upper
lobe consistent with known non-small cell lung cancer.

64. • FIGURE 11-35 ■ Pericardial metastasis. A 56-year-old man with
stage IV non-small cell lung cancer. Axial contrast mediumenhanced
CT images (A, B) demonstrate nodular thickening of the pericardium
(white arrow) representing metastases. CT image optimised for the
lung (C) demonstrates a speculated nodule in the right upper lobe
consistent with known non-small cell lung cancer.

65. • FIGURE 11-36 ■ Mesothelioma. Contrast
medium-enhanced CT images demonstrate
confluent left pleural thickening extending into
the oblique fissure caused by mesothelioma (A).
Nodular pericardial thickening indicates
pericardial involvement (B).