---t" medical imaging

Current Use of Imaging in the Evaluation of Primary

Mediastinal Masses·
Kathleen Brown, M.D., F.C.C.R; Denise R. Aberle, M.D.;
Poonam Batra, M.D., F.C.C.R; and Richard] Steckel, M.D.

A wide variety of lesions occur in the mediastinum in normal structures in the region, localization of lesions to
patients of every age. Twenty 6ve to 50 percent of these compartments of the mediastinum may assist in diagnosis.
primary mediastinal masses may be malignant, making This article reviews imaging techniques for lesions origi-
early diagnosis and therapy crucial. Since most arise from nating in the mediastinum. (Chat 1990; 98:466-73)

Plesions
rimary mediastinal masses are a diverse group of
which present a diagnostic and therapeutic
thoracic vertebral bodies separates the middle and
posterior mediastinum. All methods of division are
challenge to clinicians, as well as radiologists. In a arbitrary but are intended to facilitate understanding
combined series of 1,000 patients with mediastinal of the complex anatomy of the mediastinum. For the
tumors and cysts, the relative incidence was as follows: purposes of this review, the traditional method of
neurogenic tumors, 24 percent; cysts, 21 percent; dividing the mediastinum is used.
germ cell tumors, 17 percent; thymomas, 12 percent; Nonvascular lesions that tend to occur in each of
lymphomas, 13 percent; and others, 13 percent. 1 A the compartments of the mediastinum are listed in
thorough understanding of mediastinal anatomy is Table 1. Thymomas, primary mediastinal germ cell
essential for the evaluation ofa mediastinal mass, since tumors, lymphomas, mesenchymal tumors, and sub-
specific lesions have a predilection for certain sites. In sternal extensions of the thyroid are major considera-
order to formulate reasonable differential diagnoses in tions in the differential diagnosis of primary anterior
the evaluation of mediastinal abnormalities, several mediastinal masses. Middle mediastinal masses in-
methods have been suggested to divide the mediasti- clude lymph node enlargement from a variety of
num into compartments.v' With the classic (tradi- causes, pericardial cysts, and bronchogenic cysts.
tional) anatomic method," the anterior mediastinum Posterior mediastinal masses are usually neurogenic
has been defined as being bounded anteriorly by the in origin, but they may also arise from the esophagus
sternum and posteriorly by the pericardium, aorta or represent gastroenteric cysts. Nodal enlargement
and brachiocephalic vessels; the middle mediastinum from metastatic disease, including extrathoracic as
contains the pericardium and heart, the ascending well as bronchogenic primaries, may occur in any
and transverse portions of the aorta, the vena cavae, mediastinal compartment.
the phrenic and vagus nerves, the trachea, mainstem
GENERAL IMAGING CONSIDERATIONS
bronchi and contiguous lymph nodes, and the central
pulmonary arteries and veins. The posterior mediasti- High kilovoltage posteroanterior and lateral radio-
num is bordered anteriorly by the pericardium and
posteriorly by the spine.! With the radiologic method Table I-NonfXJlJCU1ar LaionB Occurring in Mediaatinum
ofclassification, the mediastinum is divided into three Anterior Middle Posterior
compartments based on the lateral chest radiograph.
A line drawn from the diaphragm to the thoracic inlet Thymic tumors Lymphoma Neurogenic tumors
Germ cell tumors Pericardial cyst Neurenteric cyst
along the back of the heart and anterior to the trachea Intrathoracic goiter Bronchogenic cyst Gastroenteric cyst
divides the anterior and middle mediastinum, and a Lymphoma Meningocele
line drawn 1 cm behind the anterior margin of the Parathyroid adenoma Esophageal lesions
Mesenchymal tumors
Lipoma .
*From the Department of Radiological Sciences, and the Jonsson
Comprehensive Cancer Center, UCLA School of Medicine, Los Lymphangioma
Angeles. Fibroma
Reprint requests: Dr. Brown, UCLA School of Medicine/Radiology, Hemangioma
10833 Le Conte Avenue, Los Angeles 90024

466 Imaging in Evaluation of Primary Mediastinal Masses (Brown et aI)

graphs of the chest continue to be the most valuable and the current difficulty in imaging the lung paren-
technique for the initial evaluation of mediastinal chyma, the overall utility of MRI for evaluating the
masses. Contour distortions of the normal interfaces thorax remains limited at this time. 7
between the lung and the mediastinum may occur A brief discussion follows of diagnostic imaging
even with small mediastinal masses which, with en- applications for the major masses which occur in the
largement, may project into the adjacent hemithorax. mediastinum.
Oblique views may also be useful in the evaluation of
THYMOMA
patients with an equivocal chest radiograph. Careful
fluoroscopy may allow optimal determination of obliq- Thymoma is the most frequent tumor occurring in
uity to visualize a lesion better and may assist by the anterior mediastinum. Although it may occur at
demonstrating intrinsic or transmitted pulsations with any age, it is most common in patients over the age of
masses. Occasionally, calcifications within lesions are 40. Thymomas arise from both the epithelial and the
also identified initially in this way thymocytic elements of the gland and can be classified
Although conventional tomography has been used into the following four subtypes based on the predom-
in the past to evaluate the mediastinum, computed inant cell: (1) lymphocytic; (2) epithelial; (3) mixed
tomography (CT) has now largely replaced conven- lymphoepithelial; and (4) spindle cell. Histologic ex-
tional tomography in most institutions as the most amination alone does not allow the differentiation of
useful imaging modality following routine radiogra- benign from malignant lesions, and the presence at
phy" In fact, CT has been shown to be more useful in surgery of complete encapsulation or local invasion is
evaluating the mediastinum than any other region in used to estimate malignancy and prognosis.
the thorax. Mediastinal pathology may easily be de- The association between thymic neoplasms and
tected by CT even in the presence of a normal chest myasthenia gravis is well known. Thymic tumors occur
radiograph. Superior contrast resolution permits dif- in approximately 8 to 15 percent of patients with
ferentiation of normal mediastinal structures from myasthenia gravis, and approximately 25 to 50 percent
mediastinal masses, allows accurate delineation of the of patients with thymic tumors have been shown to
densities of tissues within a mass, and with intravenous have myasthenia. Other associated conditions that
contrast, may distinguish between vascular and non- have been reported include red blood cell hypoplasia,
vascular lesions. The transaxial imaging plane of CT hypogammaglobulinemia, and/or Cushing's syndrome.
allows clear definition of normal structures in the Radiographically, these lesions appear as round,
mediastinum, most of which course perpendicular to oval or lobulated masses in the anterior mediastinum,
the imaging plane (eg, major vessels and airways). usually just anterior to the junction of the heart and
Computed tomography can also assist in determining the great vessels (Fig 1). Nearly one-quarter of thy-
the best approach for the biopsy of mediastinal lesions. momas may not be detected initially on routine
More recently, magnetic resonance imaging (MRI) posteroanterior chest radiographs, but diagnostic ac-
has been used to evaluate the mediastinum. The lack curacy is increased to 94 percent when both postero-
of ionizing radiation, the availability of direct cross- anterior and lateral views are considered." Calcifica-
sectional images in multiple imaging planes, and the tion has been reported both throughout the lesion and
ability to distinguish vascular structures without using in the periphery of a thymoma, in benign as well as
intravenous contrast has made MRI a potentially malignant types. While thymomas usually appear as
valuable alternative to CT scanning. Multiple studies circumscribed soft tissue masses in the mediastinum
have now shown MRI to be equivalent to CT for on CT, this modality cannot reliably differentiate
detecting mediastinal lymph nodes and masses. 5-7 benign from malignant lesions. Thymomas may exhibit
Although initially it was hoped that differences in fibrous adherence to the mediastinum in the absence
signal intensity would allow differentiation between of tumor infiltration, causing partial obliteration of the
benign and malignant masses, MRI has been unable interfaces between tumor and mediastinal fat without
to discriminate between enlarged benign and malig- tumor invasion." Thymomas typically spread by local
nant nodes. However, there is evidence to suggest that invasion and by direct extension to the pleura, major
in the future, MRI may prove to be useful in the blood vessels and lungs with distant metastases un-
differentiation of residual tumor from fibrosis." Inva- common. Computed tomography remains superior to
sion or encasement of major cardiovascular structures MRI for imaging the thymus in patients with myasthe-
by tumor may be demonstrated better on MRI than nia gravis because of better spatial resolution and
CT. The direct sagittal and coronal images afforded thymic definition in a shorter scan time. 10
by MRI may also allow better evaluation of lesions in Thymolipoma is an uncommon benign lesion in the
the thoracic apex and the diaphragmatic areas than thymus, representing approximately 2 to 9 percent of
CT. However, because of diminished spatial resolution, thymic tumors." This tumor may occur at any age and
inability to detect small calcifications, long scan time, has no sex predilection. Because the tumor is quite

CHEST I 98 I 2 I AUGUS'T. 1990 487

 FIGURE lA (left) and 18 (right). PA and lateral chest radiographs demonstrate a lobulated anterior
mediastinal mass (arrows) . Surgically proven thymoma.

soft in consistency and slowly growing, patients are in approximately 30 percent ofcases. Radiographically,
usually asymptomatic and the tumor can attain a large the solid lesions often appear lobulated and the cystic
size. It is usually discovered on routine chest radiog- lesions more smooth and circumscribed. Peripheral
raphy. Large thymolipomas may sag toward the dia- calcification may occur and rarely ossification, with
phragm and adapt themselves to the diaphragmatic skeletal parts or teeth, allowing a definitive diagnosis.
contours. There is no known association between Malignant teratomas are less likely to demonstrate
thymolipoma and myasthenia gravis or any other well differentiated structures. Computed tomography
syndrome. On plain chest radiographs, a clear differ- is particularly useful in evaluating these lesions, since
ence between the fatty mass and the adjacent water the sensitivity to contrast differences allows for the
density structures may often be noted. identification of fat and calcifications.12
GERM CELL TUMORS
Primary mediastinal seminomas or dysgerminomas
The anterior mediastinum is the most frequent site are much more frequent in young men and appear
for primary extragonadal germ cell tumors. This roentgenographically as lobulated anterior mediastinal
category of tumor includes teratoma (benign or malig- masses. These lesions are radiosensitive and poten -
nant), seminoma or dysgerminoma, embryonal cell tially radiocurable, as compared to the nonsemino-
carcinoma, choriocarcinoma, endodermal sinus (yolk matous mahgnancies." Primary embryonal cell carci-
sac) tumors, and benign dermoid cysts. Incomplete nomas, choriocarcinomas, and endodermal sinus
migration or persistence of primitive germinal cells tumors are highly malignant lesions and also occur in
during embryogenesis is theorized to account for the young men. There are no radiographic features that
presence of these lesions in the mediastinum. The allow their differentiation from other mediastinal
germ cell tumors usually become manifest during masses on chest radiography. On cr scanning, these
adolescence or early adulthood. Eighty percent of lesions appear as lobulated anterior mediastinal
primary germ cell tumors in the mediastinum are masses. While obliteration of normal mediastinal fat
benign teratomas. Benign lesions occur more often in planes may suggest malignancy, this finding may also
women and malignant lesions more frequently in men. occur with fibrous adherence of benign masses to
Teratomas are the most common primary medias- vessels," Because of differences in prognosis and
tinal germ cell tumor. These anterior mediastinal therapy, differentiation between seminomas and non-
lesions are comprised of all three embryonic layers seminomatous tumors is crucial, and biopsy is essential
and may be either cystic or solid. They are malignant for diagnosis.

468 Imaging In Evaluation of Primary Me<iastinal Masses(Brown et aI)

 MEDIASTINAL THYROID lobulated lesions, and because of the lower radio-
Mediastinal extension of cervical thyroid tissue is a graphic density of fat, may appear less dense than
frequent cause of a mediastinal mass. Intrathoracic other mediastinal masses and also less dense than the
thyroid tissue is usually located in the anterior medi- adjacent mediastinal soft tissues. Liposarcomas may
astinum, but occasionally it may be middle or poste- lead to symptoms when they invade contiguous struc-
rior mediastinal in location. Mediastinal thyroid tissue tures, and they occur most often in the posterior
is rarely malignant. Radionuclide scanning with iodine mediastinum. On CT scans, islands of soft tissue
1311, WI, or llIlmTc is the usual method for identifying density may be interspersed within fat density in
intrathoracic thyroid tissues, and contiguity with cer- these mass lesions.
vical thyroid is usually present. False negative radio- Fibromas may occur anywhere in the mediastinum
nuclide scans may occur because of nonfunctioning but are more frequently found in the anterior medi-
thyroid within the thorax, and CT scanning may be a astinum. Fibrosarcomas are more often posterior in
useful adjunct to radionuclide scanning. Characteristic location. Radiographically, they appear as soft tissue
features that may be identified on CT and aid in a masses without any distinguishing radiographic fea-
specific diagnosis include the following: (1) anatomic tures.
continuity with the cervical thyroid; (2) high attenua- Neoplasms arising from mediastinal blood vessels
tion on the CT scan; (3) rise in attenuation after bolus are all rare and include hemangiomas, endotheliomas,
administration ofIV contrast with prolonged enhance- hemangiopericytomas, and hemangiosarcomas. He-
ment; and (4) focal calcification which may occur in mangioma is the most common mediastinal blood
approximately 25 percent of cases. IS vessel tumor and is located most often in the anterior
mediastinum. When visible radiographically, phlebo-
liths are a useful diagnostic sign. The spinal canal and
MESENCHYMAL TUMORS vertebral bodies may be involved in posterior lesions,
Primary mesenchymal tumors of the mediastinum requiring evaluation with myelography, CT with intra-
are an unusual and heterogeneous group of tumors thecal contrast, or MRI.
arising from connective tissue, fat, muscle, blood Lymphangiomas may be cystic or cavernous and
vessels and/or lymphatics. Lipomas are the most occur in an anterior location. Continuity with a neck
frequent of these lesions and are usually benign, mass in children may be evident. With recent advances
originating in the anterior mediastinum. They are in ultrasound technology and performance, intrauter-
usually asymptomatic. Roentgenographically, they are ine diagnosis has become possible.

FIGURE 2A: (left) and 2B (right). Twenty-seven-year old woman with a historyofHodg\dns disease. PAand
lateral radiographs of the chest show abnormal soft tissue densities in the anterior mediastinum and the
left cardiophrenic angle (arrows). Residuallympbangiogram contrast is identified (arrowhead).

CHEST I 98 I 2 I AUGUST, 1990 488

 LYMPHOMA chest radiographs." Modifications in treatment were
Nodal enlargement from lymphomatous involve- based on these findings in approximately 9 percent of
ment is one of the most frequent causes of a medias- the patients, with the most significant changes occur-
tinal mass. Accurate localization of the extent of tumor ring in those patients undergoing radiation therapy
and a tissue diagnosis may both be crucial in deter- alone.
mining therapy. Anterior mediastinal, paratracheal, or Serial cr studies may also be useful in the evalua-
tracheobronchial adenopathy is seen in approximately tion of response to therapy and for detection of
90 percent of those with intrathoracic involvement in recurrent disease (Fig 2). Persistent soft tissue masses
Hodgkins disease;" In patients with intrathoracic in the mediastinum do not necessarily represent
involvement in non- Hodgkin's lymphoma, these lymph residual tumor, but may be secondary to one or more
node groups are affected in approximately 46 percent. fibrotic, sterilized lymph nodes. Nodal calcifications
Posterior mediastinal and pericardial nodal groups, as may be detected on cr scan following therapy. Thymic
well as the lung parenchyma, are more frequently cysts have also been reported following therapy in
involved in non-Hodgkins lymphoma. patients with Hodgkin's disease." Magnetic resonance
Mediastinal lymph node enlargement can be de- imaging may prove to be useful in the future to
tected on initial chest radiography in approximately differentiate residual or recurrent tumor from fibrosis
50 percent of patients with Hodgkin's disease. Calci- following therapy"
fication is not seen within the enlarged nodes initially,
PERICARDIAL CYSTS
but it may be demonstrated following radiation therapy
or chemotherapy. Computed tomography can confirm Pericardial cysts are relatively uncommon lesions
mediastinal involvement in patients with equivocal and are presumed to arise from congenital defects
findings on chest radiography and can detect addi- related to ventral and parietal pericardial recesses. 19
tional sites of disease not demonstrated on the initial They are lined by a single layer of mesothelial cells
plain films. In one study, occult disease was demon- and are most often unilocular. These cysts are usually
strated by cr in one-third of patients with "normal" asymptomatic, but occasionally patients may present
with chest pain, dyspnea, or cough. Approximately 70
percent of pericardial cysts arise in the right cardio-
phrenic angle, but lesions remote from the cardio-
phrenic angle may occur and may be more difficult to
diagnose .
Typically, pericardial cysts appear on plain radio-
graphs as smooth, round homogeneous soft tissue
masses in the cardiophrenic angle, contiguous with
the anterior chest wall and the hemidiaphragm, Cal-
cification may rarely occur within the wall of the cyst.
Occasionally, a pointed superior contour is identified,
presumably due to drooping of the thin-walled cyst
from its point of origin. Fluoroscopic examination may
show changes in the contour of a cyst with changes in
patient position.
Cardiac ultrasound may allow determination of the
cystic nature of the mass if the lesion is adjacent to
the chest wall. Computed tomography is diagnostic
when the mass is in a classic location, does not enhance
with intravenous contrast, and has an attenuation
coefficient consistent with a cystic lesion." A pointed
contour and variations in shape with changes in
position also point to a cystic lesion.21 When the
clinical and radiographic presentation is consistent
with pericardial cyst, thoracotomy is generally not
required in the asymptomatic patient.
FOREGUT DUPLICATION CYSTS
FIGURE 2C (upper) and 2D (lower). CT scan better demonstmtes Foregut duplication cysts are rare congenital anom-
the relationship of the soft tissue masses (arTVW8) to adjacent
mediastinal structures. Biopsy of the prevascular mass under CT alies, accounting for approximately 10 percent of
guidance yielded the diagnosis of recurrent Hodgkin's disease. mediastinal masses in the adult.P Bronchogenic cysts,

470 ImagingIn Evaluation 01Primary Mediastinal Masses (Brown et 111)

esophageal duplication cysts, and neurenteric cysts variable radiographic appearances and are not always
are part of the spectrum of malformations which are distinguishable from bronchogenic cysts.16 They are
thought to share a common embryogenesis arising usually located in the posterior mediastinum and tend
from the primitive foregut early in fetal development. to be larger than respiratory cysts. Barium esophagram
Bronchogenic cysts are the most common form of may show extrinsic compression of the esophagus by
foregut cysts.1 They result from abnormal budding of the cyst. .
the ventral lung bud or abnormal branching of the Neurenteric cysts originate earlier in embryonic life
tracheobronchial tree. 22.13 These lesions may occur and result from incomplete separation of the endo-
either within the mediastinum or the lung paren- derm and notocord, resulting in the development of a
chyma, with the mediastinal cysts resulting from diverticulum of the endoderm.P Normal fusion of
earlier abnormal branching during embryogenesis. vertebral ossification centers is prevented and associ-
The cysts are lined by secretory epithelium; depend- ated vertebral anomalies including hemivertebra, but-
ing on whether a communication remains with the terfly vertebra, and scoliosis may occur. These lesions
tracheobronchial tree, they may vary from being also occur typically in the posterior mediastinum.
completely Huid-filled to completely air-filled.
NEUROGENIC TUMORS
Mediastinal bronchogenic cysts typically are asymp-
tomatic and are usually discovered on routine chest Neurogenic tumors arise most often in the posterior
radiograph}'. Symptoms, when present, frequently mediastinum and include benign and malignant neo-
result from compression of neighboring structures and plasms arising from the intercostal nerves or compo-
include chest discomfort or pain, nonproductive nents of the autonomic system. They are commonly
cough, wheezing, or dysphagia. divided into the following three groups: (1) those of
Radiographically, the mediastinal lesions present as peripheral nerve origin (neurilemomas, neurofibro-
smooth, homogeneous round or ovoid masses of water mas, malignant schwannomas); (2)those of sympathetic
density in close association with the trachea or major nervous origin (ganglioneuromas, neuroblastomas,
bronchi. While they may be located in the middle, ganglioneuroblastomas); and (3) those of parasympa-
posterior or superior mediastinum, the most typical thetic system origin (pheochromocytomas, paragangli-
location is subcarinal with extension inferiorly. Medi- omas).
astinal bronchogenic cysts rarely have a patent com- Nerve sheath tumors are the most common and are
munication with the tracheobronchial tree and are usually benign. Neurogenic tumors may occur at any
usually filled with mucoid material. Calcification age, but are most common in younger age groups.
within the wall of the cyst is rare. Neurilemoma (schwannoma) is the most common
Computed tomography is invaluable in character- benign tumor. rt
izing .these congenital cystic lesions. On CT, these Radiographically, these lesions are similar in ap-
cysts appear as well-defined, rounded masses without pearance with a smooth, round or oval mass in a
infiltration of adjacent mediastinal structures. Al- paravertebral location. Ganglia-related tumors tend to
though they are typically of water density, they may have an elongated or triangular density with a broad
contain sufficient mucoid material to give a high CT base towards the mediastinum and tapering superior
numberZ4·25 and do not enhance following intravenous and inferior margins, distiilguishing them from the
contrast administration. more oval nerve sheath tumors. rt Erosion, destruction,
Ultrasound may also be helpful in evaluating these or spreading of the ribs may occur, as may vertebral
congenital lesions because of its ability to establish abnormalities, including enlargement of the neural
the cystic nature of a mass. Lesions contiguous with foramina, erosion of the pedicles, and scoliosis. Mye-
the chest wall, in the anterior mediastinum, or in the lography is recommended when neurologic symptoms
subcarinal region may be imaged using standard or vertebral body changes occur in the presence of a
cardiac projections. Cysts in the posterior mediasti- posterior mediastinal mass. Also, MRI can be used
num are not assessible by ultrasound because of the now to evaluate intraspinal extension of these tumors, 7
absence of an acoustic window Diagnostic cyst punc- and additional imaging planes may better define the
ture may be approached percutaneously with CT or origin of the tumor (Fig 3).18
ultrasound guidance or by bronchoscopy
Esophageal duplications are presumed to result VASCULAR LESIONS

from a diverticulum of the dorsal bud of the primitive Vascular lesions may simulate mediastinal neo-
foregut or aberrant recanalization of the gut during plasms and may occur in any mediastinal compart-
embryogenesis.P While they are usually found adja- ment. 29•30 Clinical symptoms and physical examination
cent to or within the esophageal wall, these duplication may not distinguish vascular lesions from other me-
cysts may migrate with the lung bud and develop diastinal abnormalities, and an accurate radiographic
remote from the esophagus. Simple enteric cysts have diagnosis prior to intervention is crucial to prevent

CHEST I 98 I 2 I AUGUSt 1990 471

 FIGURE 3A (left). PAchest radiograph demonstrates a left apical mass (arrow). FIGURE 3B (right). Axial cr
scan demonstrates the mass (arrow), but the origin of the mass cannot be demonstrated.

inappropriate therapy. ties of the systemic veins including the superior vena
Kelley et al3D divided mediastinal vascular abnor- cava and the azygos, hemiazygos, and innominate
malities into the following four groups depending on veins, usually occur in the middle or superior medi-
their sites of origin; (1) systemic venous system; (2) astinum. Abnormalities of the pulmonary arterial
pulmonary arterial system; (3) pulmonary venous system, including abnormalities of the pulmonary
system; and (4) systemic arterial system. Abnormali- trunk and main pulmonary arteries, present as middle
mediastinal or perihilar masses and include pulmonary
valve stenosis, congenital absence of the pulmonary
valve, pulmonary arterial hypertension of any cause,
anomalous left pulmonary artery, or aneurysm of the
ductus arteriosus. Pulmonary venous system abnor-
malities including partial anomalous pulmonary ve-
nous return and pulmonary vein varix may present as
masses in the middle or superior mediastinum.s?
The most common vascular lesions to be confused
with mediastinal neoplasms are abnormalities of the
thoracic aorta and its branches. These lesions typically
occur in elderly patients with hypertension and arte-
riosclerosis. Aneurysms of the thoracic aorta may occur
from a variety of causes, including arteriosclerosis,
trauma, syphilis, or cystic medial necrosis. The major-
ity are discovered on routine radiographs. Peripheral
calcification of a mass may suggest a vascular etiology,
and fluoroscopy has been used to evaluate intrinsic
pulsations. Contrast-enhanced CT should allow differ-
entiation of vascular lesions and soft tissue masses,
but aneurysms filled with thrombus may fail to show
contrast enhancement. Angiography is performed in
most cases prior to definitive therapy.
Magnetic resonance imaging has been shown to be
an excellent modality for the evaluation of the thoracic
aorta and its major branches. The advantages of MRI
include lack of ionizing radiation, multiplanar imaging
FIGURE 3C (upper) and 3D (lower). Tl weighted coronal (upper)
capability, and excellent contrast between vascular
and sagittal (lower) MRI scans clearly demonstrate the extrapleural structures and soft tissues without the use of intrave-
origin of the mass (arrow), presumed to be a benign neurofibroma. nous contrast agents . While differentiation between

472 Imaging in Evaluation01Primary MedIastinal Masses (Brown lit aI)

slow-Howing blood and mural thrombus may be diffi- myasthenia gravis: correlation of chest radiography, CT, MR,
cult, and small calcifications are not detectable, our and surgical findings. AJR 1987; 148:515-19
11 Teplick JG, Nedwich A, Haskin ME. Roentgenographic features
experience suggests that MRI may eventually supplant
,. 9f~~?~poma. AJR 1973; 117:873-77
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aorta. 31 Watanabe Y. Computed tomography of mediastinal teratomas. J
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symptomatic. 15 Glazer GM, Axel L, Moss AA. CT diagnosis of mediastinal
An aberrant right subclavian artery originating from thyroid. AJR 1982; 138:495-98
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