Cancer Imaging (2007) 7, S56
S62

DOI: 10.1102/1470-7330.2007.9014

FOCUS ON: MEDIASTINAL NEOPLASMS

Monday 1 October 2007, 14:00
15:30

Imaging of anterior mediastinal masses

Leslie E. Quint

Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Drive,
Ann Arbor, MI 48109-0030, USA

Corresponding address: Leslie E. Quint, MD, Professor, Department of Radiology, University of Michigan Health System,
Box 0030, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0030, USA.
Email: [email protected]

Abstract
Multiple different types of anterior mediastinal masses may be encountered on computed tomography (CT)
imaging, and many of these lesions are neoplastic in etiology. These include masses arising from the thymus, thyroid
and parathyroid glands, as well as lymph nodes, pericardium, and vessels and nerves. Often, the CT attenuation of
the mass can be helpful in narrowing down the differential diagnosis, and attenuation values suggesting fat, water or
calcium may suggest certain diagnoses; significant enhancement of the mass with intravenous contrast may also
be a helpful feature. Lesions with fatty attenuation include teratomas, thymolipomas and Morgagni hernias. Lesions
that may manifest the attenuation of water include pericardial and thymic cysts, abscesses, and lymphangiomas,
as well as neurogenic and germ cell tumors. Multiple types of lesions may contain calcium, including thyroid goiters
and cancers, thymomas, thymic carcinomas and carcinoids, treated lymphoma, germ cell tumors, parathyroid ade-
nomas, and lymph nodes involved with silicosis, sarcoid, tuberculosis, fungal diseases and pneumocystis. Contrast
enhancement may be seen in lesions of vascular origin and in vascular neoplasms, such as parathyroid adenomas and
Castlemans disease. In addition to CT attenuation values, the exact location and morphology of the mass in question,
in conjunction with clinical features such as patient age, gender, signs, symptoms, and laboratory values, can usually
lead to a short list of possible etiologies, thereby directing appropriate additional diagnostic procedures or therapeutic
approaches.
Keywords: Thymic neoplasms; germ cell tumors; mediastinal neoplasms.

Introduction Fat attenuation masses

Anterior mediastinal masses are not uncommonly seen There are only three major entities in the category of
on imaging studies; many of these represent benign or fat attenuation anterior mediastinal masses: teratoma,
malignant neoplasms. Often, the CT attenuation of the thymolipoma and Morgagni hernia.
mass can be helpful in narrowing down the differential
diagnosis, and attenuation values suggesting fat, water
or calcium may suggest certain diagnoses; significant
Teratoma
enhancement of the mass with intravenous contrast Various different types of germ cell tumors may occur in
may also be a helpful feature. In addition, the exact loca- the anterior mediastinum; these masses arise from prim-
tion and morphology of the mass in question, in conjunc- itive germ cell elements, and many are of mixed cell type.
tion with clinical features such as patient age, gender, Mediastinal germ cell tumors are generally found in ado-
signs, symptoms, and laboratory values, can usually lescents and young adults. Approximately 80% of such
lead to a short list of possible etiologies, thereby directing lesions are benign, and most of the benign lesions repre-
appropriate additional imaging or other diagnostic proce- sent teratomas. Malignant germ cell tumors are seen
dures or therapeutic approaches. much more commonly in males compared to females.
1470-7330/07/000056 þ 07 ß 2007 International Cancer Imaging Society
 Monday 1 October 2007 S57

Teratomas are usually predominately cystic in nature, omental fat that has herniated from the abdomen into
although they frequently have a soft tissue component, the thorax via the foramen of Morgagni; the fat lies in
often showing a thin outer capsule. Fat and calcium a retrosternal or parasternal location, usually on the
are also common elements (Fig. 1). Fat/fluid levels are right side[3]. Occasionally Morgagni hernias also contain
said to be a specific finding for teratomas; however they small or large bowel or portions of the liver. On CT,
are rarely seen. Entirely solid teratomas are occasionally a Morgagni hernia appears as a fat containing mass in
encountered; these lesions are usually malignant. Benign the lower, anterior mediastinum, usually large in size.
teratomas are usually encapsulated and well defined on The key to the diagnosis on CT is the detection of
computed tomography (CT) scan. However, they may linear-appearing soft tissue opacities in the fat which
hemorrhage, leading to a complicated CT appearance. represent omental vessels; with close scrutiny, the vessels
Malignant teratomas are most often large, multinodular can be traced down into the upper abdomen.
in appearance and poorly defined at CT. Both benign
and malignant teratomas may grow and may rupture or
fistulize with adjacent structures in the mediastinum Water attenuation masses
or with lung, pleura or pericardium[1]. There are several entities in the category of water atten-
uation anterior mediastinal masses, including cysts aris-
Thymolipoma ing from thymus or pericardium, foregut duplication
cysts, neurogenic tumors, abscesses and lymphangiomas
Thymolipomas are benign lesions that arise from the (particularly in children); many of these lesions may be
thymus gland and may grow slowly over time. Despite neoplastic in nature[4].
their usually large size, they are generally asymptomatic;
occasionally, however, they may compress or displace Thymic cyst
adjacent structures, leading to symptoms. On CT scan-
ning, they may clearly lie within the thymus. Frequently, Thymic cysts may be congenital in nature, arising from
however, they are pedunculated, filling a large portion of remnants of the thymophargyngeal duct. Such lesions
one hemithorax; in these cases, it may be difficult to may occur anywhere along the course of thymic descent
discern the thymic origin of the mass. These tumors from the neck during development; however, they often
are usually predominately fatty in attenuation, with a occur in the anterior mediastinum. Acquired thymic cysts
variable component of soft tissue elements (Fig. 2)[2]. are much more common than congenital cysts, and may
Surgical excision is curative. arise in association with neoplasms such as thymomas,
lymphomas or germ cell tumors. Although teratomas are
the most common type of germ cell tumor to develop
Morgagni hernia
cystic areas, other cell types may contain cysts (Figs. 1
The major entity in the differential diagnosis of a thymo- and 3). Thymic cysts may also be seen in the anterior
lipoma is a Morgagni hernia. These hernias contain mediastinum after radiation therapy for Hodgkins dis-

Figure 2 Thymolipoma composed mostly of fat, with

Figure 1 Malignant teratoma showing areas of fat minor, strandy soft tissue elements (white arrow). Yellow
(white arrow), calcium (yellow arrow) and fluid attenua- arrow denotes atelectasis and black arrow indicates a
tion (black arrow). pleural effusion related to metastatic breast cancer.
S58 Focus on: Mediastinal Neoplasms

Figure 3 Mixed, malignant germ cell tumor with

necrotic/cystic components (arrow) after treatment with
chemotherapy.
ease, and occasionally multilocular thymic cysts are seen
in patients with AIDS, particularly in children[5]. Figure 4 Cystic, septated benign thymic cyst (arrow).
Sometimes acquired cysts are unassociated with neo-
plasms, likely related to an inflammatory process
(Fig. 4)[6]. Such lesions may contain cellular debris, cho-
lesterol crystals and/or hemorrhage, leading to a compli-
cated appearance at CT and magnetic resonance imaging
(MRI). The cystic material may leak into the surrounding
mediastinal tissues, inciting an inflammatory response.

Pericardial cyst
Pericardial cysts may occasionally mimic thymic cysts.
However, the former are usually simple in appearance
at CT, unlike the latter which often have associated
soft tissue. Moreover, pericardial cysts are generally Figure 5 Bilateral, low attenuation mediastinal (white
located more inferiorly in the anterior mediastinum com- arrows) and axillary (black arrows) neurofibromas in a
pared to thymic cysts: approximately 90% are tucked patient with neurofibromatosis.
down between the heart and the hemidiaphragm, usually
on the right side[7]. Pericardial cysts may change in shape Neurogenic tumor
on follow-up imaging studies. These lesions are benign, Neurogenic tumors may occasionally occur in or adja-
and they are thought to be congenital in nature. cent to the anterior mediastinum. Lipid-like material in
the tumors leads to their low attenuation appearance,
Foregut duplication cysts mimicking a fluid-containing lesion. Such lesions are
often easily diagnosed if they are elongated in shape
Foregut duplication cysts are uncommon congenital and occur in the characteristic location of the phrenic
abnormalities of enteric origin[8]. Most duplication nerve; the diagnosis is clinched if there are bilateral
cysts occur in the middle or posterior mediastinum; how- lesions in a patient with known neurofibromatosis
ever, bronchogenic cysts may occasionally be seen in the (Fig. 5).
anterior mediastinum. These lesions may appear as
simple, water attenuation lesions, or they may be compli-
Calcified masses
cated, showing soft tissue attenuation and heterogeneity
due to mucus, proteinaceous or cellular debris and/or There are a multitude of entities in the category of calci-
hemorrhage[9]. fied anterior mediastinal masses, including lesions arising
 Monday 1 October 2007 S59

A A

Figure 6 Lobulated anterior mediastinal mass (black

arrows) (A) is arising from the thyroid more superiorly
(B). Thyroid enlargement is due to thyroiditis; white
arrow in (B) indicates calcification.

from the thyroid, thymus or parathyroid glands, germ cell

tumors, treated lymphoma, and lymph nodes involved Figure 7 Heterogeneous anterior mediastinal mass
with diseases such as silicosis, sarcoidosis, tuberculosis, (black arrow) with areas of calcification and cysts (A) is
histoplasmosis or pneumocystis. arising from the thyroid more superiorly (white arrow) (B).
The mass represents a unilateral goiter.
Thyroid masses
Both benign and malignant thyroid masses, including mediastinal mass as a thyroid lesion is to follow the
goiters, thyroiditis, and thyroid neoplasms, may calcify lesion up into the neck and look for evidence of thyroid
and contain areas of heterogeneity due to hemorrhage, lobe involvement (Figs. 6 and 7). Most commonly goiters
fibrosis or cysts (Figs. 6 and 7). Goiters tend to be well are bilateral and cancers are unilateral, but this rule is not
marginated. A lesion with ill-defined margins and nearby absolute.
lymph node enlargement suggests the diagnosis of thy-
roid cancer; invasion of an adjacent structure, such as the
trachea, is diagnostic for a neoplasm. The finding of Thymic masses
multiple concomitant small lung nodules is suspi-
Thymomas
cious for metastatic disease from thyroid cancer.
Occasionally goiters and thyroid cancers coexist in the Thymomas are common tumors of the anterior medi-
same gland: carcinoma may be found in up to 10% of astinum, generally showing a slow growth pattern.
resected goiters[10,11]. The key to diagnosing an anterior They manifest as soft tissue density masses at CT,
S60 Focus on: Mediastinal Neoplasms

although they often have areas of cysts, hemorrhage, A

necrosis and/or coarse clumps of calcification (Fig. 8).
These lesions are usually asymmetric, commonly draping
along one side of the heart. Rarely thymomas may occur
in the neck, along the lines of thymic descent during
development. Thymomas are the most common type of
thymic neoplasm, usually occurring in patients between
the ages of 45 and 60, and rarely below the age of 20[12].
Approximately half to a third of patients with this tumor
either have or will develop myasthenia gravis. On the
other hand, only approximately 10% of patients with
myasthenia gravis develop a thymoma. Thymomas are
occasionally seen in association with other disorders
such as hypogammaglobulinemia, red cell aplasia, con-
nective tissue diseases, and paraneoplastic syndromes.
Approximately 20% of patients with thymoma have B
a malignant neoplasm such as lymphoma, lung cancer
or thyroid cancer.
Thymomas are classified as low-risk or high-risk
tumors, based on histological features, and as non-
invasive or invasive, based on whether the capsule of
the gland has been transgressed; approximately 30%
of thymomas are invasive. Once the tumor has breached
the capsule, it commonly invades adjacent structures
such as lung, phrenic nerve, central airways, chest wall,
superior vena cava, and great vessels. Elevation of a hemi-
diaphragm at imaging is highly suggestive of phrenic
nerve involvement (Fig. 8). Thymomas typically spread
along pleural and pericardial surfaces, leaving behind
discrete tumor droplets which are visible at CT as
small nodules, masses or plaque-like lesions (Fig. 8).
Tumor may cross into the abdomen either directly C
across a hemidiaphragm or via the retrocrural space
(Fig. 8). Thymomas may spread to mediastinal, supracla-
vicular and cervical lymph nodes, leading to lymph node
enlargement in these regions (Fig. 8); however, hemato-
genous metastases are exceedingly rare.

Thymic carcinomas
Whereas thymomas cannot be classified as benign or
malignant at histopathology, thymic carcinomas are his-
topathologically malignant, occurring with various
different cell types. These lesions tend to very aggressive
biologically, with a strong tendency to metastasize to dis-
tant locations such as lungs, liver, brain and bone.
Patients have a very poor prognosis, even after surgical
resection. Thymic carcinomas generally show a similar
appearance to thymomas at CT and MR, including fre- Figure 8 Invasive thymoma with calcifications (black
quent tumor spread along the pleural and pericardial arrow) and enlarged paratracheal lymph nodes (white
surfaces. However, if there are findings suggestive of dis- arrow) (A). Pleural tumor deposit is seen in (B) (arrow);
tant metastases, for example lung nodules, then the diag- elevated left hemidiaphragm is due to left phrenic nerve
nosis of carcinoma should be entertained, and irregular invasion by the mediastinal tumor. (C) Tumor has crossed
contour, necrotic or cystic component, heterogeneous over the left hemidiaphragm into the retroperitoneum
enhancement, lymphadenopathy, and/or great vessel (arrows).
invasion are also more common in thymic carcinomas
compared to thymomas (Fig. 9)[13]. Preliminary data sug-
gest that fluorodeoxyglucose (FDG)-positron emission
 Monday 1 October 2007 S61

A
B

Figure 9 Thymic carcinoma manifesting as an anterior mediastinal mass with calcifications (A). There is invasion,
with near obliteration, of the superior vena cava (B arrow) and multiple venous collaterals are present.

tomography (PET) scanning may help in distinguishing Masses showing significant contrast
thymomas from thymic carcinomas based on standar- enhancement
dized uptake values (SUV)[14].
Anterior mediastinal lesions showing significant contrast
enhancement include those that arise from vessels, such
as aneurysms or pseudoaneurysms, and vascular neo-
Thymic carcinoids
plasms, such as parathyroid adenomas and Castlemans
Thymic carcinoids arise from cells of neural crest origin, disease[20].
i.e. amine precursor uptake and decarboxylation (APUD)
cells. Approximately one-half of thymic carcinoids are Parathyroid adenomas
hormonally active, usually secreting adrenocorticotropic Parathyroid adenomas usually occur immediately lateral
hormone (ACTH) which may lead to Cushings to the thyroid gland; occasionally, however, they may be
syndrome[15]. Occasionally patients may present with seen in ectopic locations such as within the thymus,
syndrome of inappropriate antidiuretic hormone secre- the tracheoesophageal groove, retroesophageal region or
tion (SIADH), although they do not show carcinoid syn- posterosuperior mediastinum. They tend to be small, oval,
drome. Approximately 20% of patients with a thymic well-defined soft tissue attenuation structures that
carcinoid have underlying MEN I or MEN II enhance strongly with intravenous contrast material and
disease[16,17]. may contain calcifications at CT[21]. Sestamibi scanning
Thymic carcinoids are usually malignant, and patients or ultrasonography of the neck are often the first imaging
tend to have locally invasive disease, distant metastases modalities used to search for a parathyroid adenoma in
and a poor prognosis[18]. The tumors often recur locally a patient with primary hyperparathyroidism[22]; if these
after surgical resection. Thymic carcinoids are generally studies are inconclusive, then CT or MR may be per-
indistinguishable from thymomas and thymic carcinomas formed to look for an ectopic focus in the mediastinum.
at CT. If a thymic carcinoid is clinically suspected,
somatostatin receptor scintigraphy, for example with
[111In]diethylene triamine pentaacetic acid (DTPA) Conclusion
(Octreotide) or [99mTc]EDDA/HYNIC-octreotate, may The attenuation of an anterior mediastinal mass at CT is
be performed to confirm the diagnosis[19]. helpful in narrowing down the differential diagnosis, and
S62 Focus on: Mediastinal Neoplasms

evidence of fat, water or calcium may suggest certain [11] Miccoli P, Minuto MN, Galleri D, et al. Incidental thyroid carci-
noma in a large series of consecutive patients operated on for
diagnoses; significant enhancement of the mass with
benign thyroid disease. ANZ J Surg 2006; 76: 123
6.
intravenous contrast may also be a helpful feature. In [12] Strollo DC, Rosado-de-Christenson ML. Tumors of the thymus.
addition, the exact location and morphology of the J Thorac Imaging 1999; 14: 152
71.
mass in question, in conjunction with clinical features, [13] Sadohara J, Fujimoto K, Muller NL, et al. Thymic epithelial
can usually lead to a short list of possible etiologies, tumors: comparison of CT and MR imaging findings of low-risk
thymomas, high-risk thymomas, and thymic carcinomas. Eur
thereby directing appropriate additional imaging or J Radiol 2006; 60: 70
9.
other diagnostic procedures or therapeutic approaches. [14] Sung YM, Lee KS, Kim B-T, Choi JY, Shim YM, Yi CA. 18F-FDG
PET/CT of thymic epithelial tumors: usefulness for distinguishing
and staging tumor subgroups. J Nucl Med 2006; 47: 1628
34.
References [15] Wang WQ, Ye L, Bi YF, et al. Six cases of ectopic ACTH syn-
drome caused by thymic carcinoid. J Endocrinol Invest 2006; 29:
[1] Sasaka K, Kurihara Y, Nakajima Y, et al. Spontaneous rupture: a 293
7.
complication of benign mature teratomas of the mediastinum. [16] Ferolla P, Falchetti A, Filosso P, et al. Thymic neuroendocrine
Am J Roentgenol 1998; 170: 323
8. carcinoma (carcinoid) in multiple endocrine neoplasia type 1
[2] Gamanagatti S, Sharma R, Hatimota P, Guleria R, Arvind S. syndrome: the Italian series. J Clin Endocrinol Metab 2005; 90:
Giant thymolipoma. AJR Am J Roentgenol 2005; 185: 283
4. 2603
9.
[3] Sirmali M, Turut H, Gezer S, et al. Clinical and radiologic eval- [17] Gibril F, Chen YJ, Schrump DS, et al. Prospective study of
uation of foramen of Morgagni hernias and the transthoracic thymic carcinoids in patients with multiple endocrine neoplasia
approach. World J Surg 2005; 29: 1520
4. type 1. J Clin Endocrinol Metab 2003; 88: 1066
81.
[4] Kim JH, Goo JM, Lee HJ, et al. Cystic tumors in the anterior [18] Moran CA, Suster S. Neuroendocrine carcinomas (carcinoid
mediastinum. Radiologic-pathological correlation. J Comput tumor) of the thymus. A clinicopathologic analysis of 80 cases.
Assist Tomogr 2003; 27: 714
23. Am J Clin Pathol 2000; 114: 100
10.
[5] Leonidas JC, Berdon WE, Valderrama E, et al. Human immuno- [19] Hubalewska-Dydejczyk A, Fross-Baron K, Mikolajczak R, et al.
deficiency virus infection and multilocular thymic cysts. 99mTc-EDDA/HYNIC-octreotate scintigraphy, an efficient
Radiology 1996; 198: 377
9. method for the detection and staging of carcinoid tumours: results
[6] Choi YW, McAdams HP, Jeon SC, et al. Idiopathic multilocular of 3 years experience. Eur J Nucl Med Mol Imaging 2006; 33:
thymic cyst: CT features with clinical and histopathologic corre- 1123
33.
lation. Am J Roentgenol 2001; 177: 881
5. [20] McAdams HP, Rosado-de-Christenson M, Fishback NF,
[7] Wang ZJ, Reddy GP, Gotway MB, Yeh BM, Hetts SW, Templeton PA. Castleman disease of the thorax: radiologic fea-
Higgins CB. CT and MR imaging of pericardial disease. tures with clinical and histopathologic correlation. Radiology
Radiographics 2003; 23: S167
80. 1998; 209: 221
8.
[8] Rattan KN, Magu S, Rohilla S. Mediastinal foregut duplication [21] Rodger SE, Hunter GJ, Homberg LM, et al. Improved preopera-
cysts. Indian J Pediatr 2004; 71: 103
5. tive planning for directed parathyroidectomy with 4-dimensional
[9] McAdams HP, Kirejczyk WM, Rosado-de-Christenson ML, computed tomography. Surgery 2006; 140: 932
40 (discussion
Matsumoto S. Bronchogenic cyst: imaging features with clinical 940
1.
and histopathologic correlation. Radiology 2000; 217: 441
6. [22] Lo C-Y, Lang BH, Chan WF, Kung AWC, Lam KSL. A prospec-
[10] Cakir M, Arici C, Alakus H, Altunbas H, Balci MK, tive evaluation of preoperative localization by technetium-99m
Karayalcin U. Incidental thyroid carcinoma in thyrotoxic patients sestamibi scintigraphy and ultrasonography in primary hyperpar-
treated by surgery. Horm Res 2007; 67: 96
9. athyroidism. Am J Surg 2007; 193: 155
9.