Discussion Author: Matthew J Hoffman
The differential diagnosis of mediastinal masses depends on the imaging technique demonstrating the mass and the precise findings. The first step in the differential diagnosis of mediastinal masses, regardless of imaging modality, is to be sure the mass arises within the anterior mediastinum rather than from contiguous lung, pleura or sternum. With few exceptions a mass with a speculated, nodular or irregular edge arises in the lung, and a mass with a broad base on the mediastinum and a smooth edge arises from the medastinum or mediastinal pleura. Masses arising from the mediastinal pleura project into the lung and usually show obtuse rather than acute angles at their margins. It is traditional to divide mediastinal masses by their location and then subdivide them according to shape and size. Age is also a significant factor in considering a differential diagnosis in general for all mediastinal masses. Malignant lymphoma, benign thymic enlargement, germ cell tumors, foregut cysts and neurogenic tumors (ganglion cell range) make up 80% of mediastinal masses in children, whereas adults, lymphoma, metastatic carcinoma to lymph nodes, intrathoracic thyroid, thymoma, neurofibroma, aortic aneurysms, germ cell tumors and foregut cysts become the prime considerations.
Almost all masses in the Anterior Mediastinum are thyroid masses, thymic masses, germ cell tumors/cysts or lymphadenopathy. The rarer causes of masses anterior to the aorta or its major branches are parathyroid adenoma, lymphangioma (cystic hygroma), pericardial cyst, aortic body paraganglioma, lipoma/liposarcoma, other mesenchymal tumors, or aneurysms. Many of these masses have specific features that permit a specific diagnosis to be made (using CT for additional information to the plain film).
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