Today I am showing radiographs of a 40-year-old man with chest pain.
What do you see?
More images will be shown on Wednesday.
showing today enhanced CT images of the case.
Do they help?
Click here to see the answer
Findings: PA radiograph shows a mediastinal mass (A, arrow) superimposed to the right hilum. In the lateral view the mass is faintly visible behind the distal trachea (B, circle). This location excludes a right hilar mass, because the right hilum is anterior to the trachea.
Enhanced coronal and sagittal CT confirm a posterior mediastinal mass (C-D, arrows) with necrotic areas and marked contrast enhancement. This is an important finding because it limits the differential diagnosis to four conditions: intrathoracic goiter, Castleman’s disease, paraganglioma and hemangioma.
Some of you have mentioned extramedullary hematopoiesis. In my (limited) experience I don’t recall seeing avid contrast enhancement in it. I have asked some friends and searched the web without finding a clear answer. If any of you have better information I am willing to be corrected. At any rate, this patient does not have any bone abnormalities, which makes the diagnosis of extrapulmonary hematopoiesis very unlikely.
Final diagnosis: posterior mediastinal paraganglioma surgically proved. A similar case was presented in case 168 of Caceres’ corner.
Congratulations to MK, who was the first to suggest the correct diagnosis.
Teaching point: remember the four mediastinal processes with avid contrast enhancement: intrathoracic goiter (frequent), Castleman´s disease and paraganglioma (uncommon) and hemangioma (never saw a case).
19 thoughts on “Cáceres’ Corner Case 203 – SOLVED!”
Engorgmnet of the right hilum,
Or Hilaryano mass
It should not be a hilar mass or adenomegaly. Can you tell me why?
Hilar overlay sign.
Yes, and more. Look at the lateral film.
Because there is no silhouette sign with the hilum…
Sorry, i ment
Right hilar mass, in lateral view it appears extrapulmonary, hilar based anteriorly and well defined posteriorly.
Trachea is central, patent right and left main bronchi.
It is solitary well defined middle mediastinal lesion, mostly bronchogenic cyst, can be Pericardial cyst. less likely vascular origin or LN.
It is not pericardcial cyst for sure.
I agree. Would very unusual. Wait for the CT on Wednesday
Thickening of posterior wall of bronchus intermedius. Mass-like lesion between trachea and oesophagus.
Mass overlying right hilum.
On lateral view seen overlying D5-D7 vertebrae suggestive of pathology in Superior segment of right lower lobe.
it is in my opinion a posterior mediastinal mass, located in upper part at the level of T1 to T3/T4 vertebra, posterior and separate from trachea. There is long list of differentials like foregut duplication cyst, neurogenic tm, infection of vertebrae or posterior ribs , infection of posterior mediastinum.No obvious vertebral erosions/ neural foramina widening seen. Could be diverticula arising from upper oesophagus.
There is a right parahiliar lesion and in tle lateral view I think it´s extrapulmonary, so we have a medium mediastinal lesion (posterior to the trachea). I think it colud be a broncogenic cyst.
or an esophageal duplication cyst
Paraspinal heterogeneous mass in posterior mediastinum with anterior expansion. No evidence of bone destruction (no bone window available). Small lesion nonenhanced in spleen (could be a cyst). History of hematologic disease? Extramedullary hematopoiesis?
Posterior mediastinal heterogeneous mass. Avid enhancement. No costal destruction.
Neurogenic tumor (paraganglioma?)
Posterior mediastinal mass un the paravertebral área with heterogéneos enhancing with tiny fat attenuation foco: extramedullary hematopoiesis
…le patologie del mediastino posteriore sono principalmente tumori neurogeni, ad origine intra ed extracanale….tuttavia la presenza di immagini adipose e l’aspetto circoscritto della massa, possono indicare una eritropoiesi extramidollare, anche se non è la sede tipica….nella DD vedere il tipo di CE tra le due patologie…PET-TC?Saluti PROFESSORE::::