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CXR: Lung Mass - Mediastinal Mass

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CXR: Lung Mass - Mediastinal Mass

  1. 1. <ul><li>PROF DR MAGESHKUMAR SIR UNIT </li></ul><ul><li>DR.VANITHA </li></ul>AN INTERESTING X-RAY OF THE WEEK
  2. 2. <ul><li>65 years old male, chronic smoker presented with the c/o cough, </li></ul><ul><li>chest pain, </li></ul><ul><li>breathlessness </li></ul><ul><li>for the duration of 1 month </li></ul><ul><li>H/o loss of wt + </li></ul><ul><li>H/o loss of appetite + </li></ul>
  3. 4. <ul><li>In Lung or mediastenum? </li></ul><ul><li>Anterior / middle / posterior compartment ? </li></ul><ul><li>Narrows down your diagnosis </li></ul>
  4. 7. <ul><li>ACUTE ANGLE– so it is in the lung probably </li></ul><ul><li>If it is mediastinum - </li></ul><ul><li>Which compartment? </li></ul><ul><li>HILUM OVERLAY sign helps here </li></ul>
  5. 8. Hilum overlay sign <ul><li>an anterior mediastinal mass will overlap the main pulmonary arteries, therefore they will be seen within the margins of the mass </li></ul><ul><li>Principle of hilum overlay </li></ul><ul><ul><li>the proximal segments of the R and L main pulmonary arteries lie lateral to the cardiac silhouette on PA film </li></ul></ul><ul><li>With pericardial effusion or cardiac enlargement , this relationship is unchanged </li></ul>
  6. 9. Overlies aorto- pulmonary window and hilum
  7. 10. Hilum overlay sign <ul><li>: this must be an anterior mediastinal mass because it overlaps rather than “pushes out” the main pulmonary arteries </li></ul>
  8. 12. Can easily see anterior location
  9. 13. DD of anterior mass <ul><li>The 4 T’s </li></ul><ul><ul><li>Thymoma </li></ul></ul><ul><ul><ul><li>Generally over age 40 </li></ul></ul></ul><ul><ul><li>Teratoma </li></ul></ul><ul><ul><ul><li>Generally under age 40 </li></ul></ul></ul><ul><ul><li>Thyroid </li></ul></ul><ul><ul><ul><li>Goiter or neoplasm </li></ul></ul></ul><ul><ul><li>Terrible lymphoma </li></ul></ul>
  10. 14. <ul><li>Eg 2 </li></ul>
  11. 15. Sharp margin, overlies hilum
  12. 16. See well- defined anterior mass
  13. 17. Middle Mediastinum <ul><li>Between anterior and posterior mediastinum </li></ul><ul><li>Contains esophagus, trachea, aortic arch, lymph nodes and vessels, pulmonary vessels </li></ul><ul><li>Accounts for 30% of masses </li></ul>M
  14. 18. DD of middle mass <ul><li>The 4 A’s </li></ul><ul><ul><li>Adenopathy </li></ul></ul><ul><ul><ul><li>TB/fungal </li></ul></ul></ul><ul><ul><ul><li>Sarcoid </li></ul></ul></ul><ul><ul><ul><li>Neoplasm (bronchogenic CA, mets, lymphoma, leukemia) </li></ul></ul></ul><ul><ul><ul><li>Infections (EBV, AIDS) </li></ul></ul></ul><ul><ul><li>Awful primary neoplasm </li></ul></ul><ul><ul><ul><li>Tracheal, esophageal </li></ul></ul></ul><ul><ul><li>Aneurysm/vascular </li></ul></ul><ul><ul><li>Abnormalities of development </li></ul></ul><ul><ul><ul><li>Bronchogenic cyst- often between carina and esophagus </li></ul></ul></ul><ul><ul><ul><li>Pericardial cyst </li></ul></ul></ul><ul><ul><ul><li>Esophageal duplication cyst </li></ul></ul></ul>
  15. 21. <ul><li>Eg 2 </li></ul>
  16. 23. Mass posterior to trachea
  17. 24. Posterior Mediastinum <ul><li>Contains thoracic duct, azygos and hemiazygos veins, lymph nodes, sympathetic chains, inferior vagus nerves </li></ul>P
  18. 25. DD of posterior mass <ul><li>Neurogenic tumors most common </li></ul><ul><ul><li>Sympathetic ganglion tumors: neuroblastoma, ganglioneuroma </li></ul></ul><ul><ul><li>Nerve root tumors: schwannoma, neurofibroma </li></ul></ul><ul><li>Less common </li></ul><ul><ul><li>Vertebral body abscess or tumor </li></ul></ul><ul><ul><li>Vascular: aneurysm or hematoma </li></ul></ul><ul><ul><li>Developmental: neurenteric cyst, Bochdalek hernia </li></ul></ul>
  19. 27. Can easily see posterior location
  20. 28. <ul><li>Is it in the lung or mediastenum? </li></ul><ul><li>If in mediastenum, which compartment? </li></ul><ul><li>Then what is the differential diagnosis of the mass? </li></ul>
  21. 31. <ul><li>Hilum convergence </li></ul><ul><ul><li>To distinguish between enlarged pulmonary artery and mediastinal mass </li></ul></ul><ul><li>If branches of the pulmonary artery converge toward a central mass  enlarged PA </li></ul><ul><li>If branches of PA converge toward the heart rather than the central mass  mediastinal tumor </li></ul>

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