Case Presentation by Dr. John Wilburn
CC: Chest pain
24 year-old male presents to the emergency with complaints of chest pain, he points to the left upper sternal border and left upper chest. He reports it began about a month ago. He describes it as a constant, dull pressure. He reports the intensity of the pain has significantly increased over the past 5 days and is now radiating to the right side of his chest. Patient has not tried anything to alleviate this pain. He reports taking a deep breath exacerbates his pain. He denies any fevers. He reports a dry cough that is non productive, which he attributes to smoking. He denies any trauma or dyspnea.
Constitutional: Denies night sweats, fatigue or weight loss.
Cardiovascular: Denies syncope
Respiratory: Denies hemoptysis
Gastrointestinal: Denies Abdominal pain
Genitourinary: Denies scrotal masses
Musculoskeletal: Denies extremity pain or swelling
PMH: Denies hypertension, pneumothorax, or diabetes
FHx: Reports Hypertension denies CAD
Social Hx: Patient smokes cigarettes daily, and marijuana occasionally. Denies IVDU or Cocaine. Reports to socially drinking less than 3 times per month.
General/Psychiatric: WNWD non-toxic appearing male sitting upright in the stretcher in no acute respiratory distress, speaking in full sentences. A&Ox3.
Vital signs: 122/65 HR: 58 RR 14 Temperature 37 C Pulse oximetry 96% RA
HEENT: NC/AT PERRL EOMI. No nasal discharge, or nasal flaring.. Mucous membranes of the mouth are moist. No tonsil enlargement no erythema.
Neck: Supple, No JVD Trachea Midline. Full Range of Motion, No lymphadenopathy.
Back: No Tenderness to palpation
Chest: Left sided chest wall tenderness to palpation – front back level?.
Respiratory: CTAB no wheezes rhonchi or rales.
Cardiovascular: S1S2 present no M/R/G.
Abdomen: Thin Soft ND/NT no rigidity or rebound tenderness.
Musculoskeletal: Strength 5/5 in the upper and lower ext. Palpable and symmetric radial and dorsalis pedis pulses. No edema or asymmetry. No tenderness to palpation.
Neuro: Normal speech and gait..
Medical Decision Making/Course in the ED:
Patient Received Motrin and Maalox, ECG and CXR obtained
1) Where is the abnormality located in this patients chest radiograph?
a) Anterior Mediastinum
b) Ascending Aorta
d) Right Atrium
e) Posterior Mediastinum
2) Which of the following statements is correct?
a) The anterior mediastinum extends from the sternum anteriorly to the esophagus posteriorly.
b) The anterior mediastinum contains the thymus gland.
c) The anterior mediastinum contains the transverse arches of the aorta.
d) The middle mediastinum contains the esophagus.
e) All of the above are correct.
3) Which is the most appropriate next step in this patient’s management?
a) Obtain blood cultures, start antibiotics and consult cardiothoracic surgery.
b) Obtain a CT-Thorax with contrast.
c) Obtain a Transthoracic Echocardiogram.
d) Perform a Color Doppler Ultrasound Guided Thoracentesis.
e) Start the patient on Heparin and admit to the hospital.
4) Which of the following is the most common tumor of the anterior mediastinum?
a) Bronchogenic Cysts
b) Germ Cell Tumors
c) Lymphoma Hodgkin’s disease
d) Non-Hodgkin Lymphoma
5) What is the initial diagnostic study of choice?
6) Bonus Question: What was this patient’s final diagnosis?
b) Germ Cell Tumor
c) Lymphoma Hodgkin’s Disease
Answers & Discussion:
1) Answer: a. Anterior Mediastinum
Brief review of radiographic anatomy eliminates b, c, d.
Patient’s Radiograph: The radiograph does demonstrate two findings helpful in identifying the location of the mass. See below.
The Hilum overlay sign is a useful tool to help identify probable location of a mediastinal mass
Another way to evaluate for mass in either the middle or posterior mediastinum is look for the azygoesophageal recess reflection. (below)
2)Answer: b. the thymus is located in the anterior mediastinum
The mediastinum is divided into 4 compartments
- The Anterior Mediastinum– extends from the sternum anteriorly to the pericardium and brachiocephalic vessels posteriorly
- Thymus and residue of thymus
- Lymph glands
The Middle Mediastinum– lies between the anterior and posterior mediastina.
- Ascending aorta
- Main bronchi
- Lymph nodes
- Pulmonary artery
- Pulmonary veins
- Phrenic nerve
Posterior Mediastinum– bounded by the pericardium/trachea anteriorly and the vertebral column posteriorly.
- Descending aorta
- Azygous vein
- Hemiazygous veins
- Lymph glands
- Thoracic duct
- Autonomic nerves
- Vagus nerve
Superior Mediastinum– bounded superiorly by the thoracic inlet and inferiorly by and arbitrary plane passing horizontally and posteriorly from the manubriosternal joint to the junction of T4/T5 vertebra. Anteriorly bounded by the sternum and posteriorly by the upper thoracic vertebra.
- Great vessels
- Arch of aorta
- Thoracic portions of left common carotid and left subclavian arteries
- Innominate veins
- Upper ½ superior vena cava
- Phrenic and vagus nerves
- Thoracic duct
- Lymph glands
3) Answer: b. CT Thorax w/ contrast should be ordered next. (Explanation below).
4) Answer: e. Thymoma
The most common causes of anterior mediastinal masses: Thymoma (20%) Germ Cell Tumors (seminoma, teratoma, etc(15%)); thyroid disease (15%); and lymphoma HD and non-HD (10%). Masses of the middle mediastinum are typically congenital cysts. Neurogenic tumors are the most common cause of posterior mediastinal masses. Overall, two thirds of mediastinal tumors are benign, however masses in the anterior compartment are more likely to be malignant.
The clinical sequelae can range from asymptomatic to symptoms of cough, chest pain, dyspnea, and fevers/chills. The likelihood of malignancy is influenced by mass location, patient age, and the degree of symptoms. Age is a strong predictor of malignancy, lymphomas and germ cell tumors (GCTs) occur mostly during the second and fourth decades. Symptomatic patients are more likely to have a malignancy. Symptoms may be delineated between localizing symptoms (mass effect) and systemic symptoms (hormonal/antibody effect). In Davis et al,7 85% of patients with a malignancy were symptomatic at presentation, compared to 46% of patients with benign neoplasms.
The initial workup of a suspected mediastinal mass involves obtaining posteroanterior and lateral chest radiographs. CT scanning is used to further characterize mediastinal masses (cystic, vascular, and soft-tissue structures) and their relationship to surrounding structures.
Other more rare imaging modalities include, fluoroscopy, and barium swallow. MRI may be used in evaluating a neurogenic tumor, and identifies vascular invasion and cardiac involvement.
Tissue diagnosis is almost always required. Biopsy may be obtained via, transthoracic or transbronchial needle aspiration, mediastinoscopy, anterior mediastinotomy, or video-assisted thoracic surgery. Modality of choice is sometimes case dependent. Fluoroscopic or CT guided transthoracic needle biopsy, has been shown to be faster, cheaper, and better tolerated by patients. It has been shown to have good diagnostic accuracy, although sometimes specimens are inconclusive requiring further investigation.
5) Answer: CT Guided Transthoracic Needle Biopsy, however some evidence suggests Thoracoscopic biopsy is just as safe and slightly more accurate.
6) Answer: b. Germ Cell Tumor (Seminoma)
A Diagnostic Approach to Mediastinal Abnormalities
2)Tumors of the Mediastinum
Beau V. Duwe, MD; Daniel H. Sterman, MD. FCCP; Ali I. Musani, MD, FCCP
Chest. 2005; 128(4):2893-2909.
4)Harrison’s Principles of Internal Medicine 16th edition
5) Anterior mediastinal masses: utility of transthoracic needle biopsy.
Department of Radiology, Toronto General Hospital, Ont, Canada.
Thoracoscopic diagnosis and treatment of mediastinal masses
Ann Thorac Surg 1993;56;92-96
7)Davis, RD, Jr, Newland Oldham, H, Jr, Sabiston, DC, Jr Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management and results. Ann Thorac Surg 1987; 44, 229-237 [CrossRef] [PubMed]
Percutaneous Transthoracic Needle Biopsy
Jack L. Westcott, MD
Department of Radiology, Hospital of Saint Raphael, New Haven, CT.