Cáceres’ Corner Case 226 – SOLVED

Dear Friends,

Today’s radiographs belong to a 27-year-old woman who came for a routine check-up.

Most likely diagnosis:

1. Thymic tumor
2. Enlarged lymph nodes
3. Aortic arch malformation
4. None of the above

CT images will be shown next Wednesday.

Click here to see the first images

Dear Friends,

Today I am showing enhanced CT images of the mediastinum in the early (A-B) and late phases (C-E).
What do you think?

Click here to see more images

Click here to see the answer

Findings: PA chest radiograph shows a right upper mediastinal mass with undulated border (A, arrow). There is increased opacity of the anterior clear space in the lateral view (B, circle). In my opinion, the most likely diagnosis would be thymic tumor, although the undulated border favors enlarged lymph nodes.

Enhanced axial CTs in the arterial phase show an anterior mediastinal mass with minimal enhancement (C-D, arrows) and a vascular space in the center (C, yellow arrow).

Coronal and axial CTs in the late phase show partial washout of the vascular space (E, yellow arrow). The clue to the diagnosis lies in the presence of several punctate calcifications within the mass (F-G, red arrows) consistent with phleboliths, which are practically diagnostic of hemangioma. The central vascular space also supports the diagnosis.

The patient had been diagnosed of mediastinal hemangioma two years earlier and comparison with previous chest films and CTs did not show any change.
 
Final diagnosis: Mediastinal hemangioma
 
Congratulations to Naegleria and MK who gave similar diagnosis both at exactly 12:55 P.M.
 
Teaching point: This case is unusual (I have seen only two of them in the mediastinum) but can be easily diagnosed if phleboliths are present (and recognized). Early in my residency I learned that, when finding phleboliths within a mass, the diagnosis should be hemangioma until proven otherwise.
 
Ref. HP McAdams, ML Rosado de Christenson, CA Moran. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology 1994; 193:399-402

12 thoughts on “Cáceres’ Corner Case 226 – SOLVED

  1. Good afternoon!!!

    The patient has scoliosis. The right main bronchus and the vascular right hila are displaced downwards. In the PA there is an increased density in the right border of the mediastinum, theorical position of the superior vein cava, and in the upper mediastinum we can see an enlarged brachiocephalic vein….

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  2. Hello!!

    There is an aterior right mediastinal solid lesion. This lesion has a vacular appearance: enhanced like the superior vein cava in the arterial phase and in the venous phase, and washout in the late phase. The lesion presents calcifications.

    So vascular solid lesion… I think in paraganlioma, but indeed this lesion only has a level, not a diffusse enhancement

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  3. I see an enlarged superior cava vein, and anterior to it there is a low density, well defined mass, with a vascular component that has vein contrast enhancement, same as the SCV. In the coronal image we see calcifications in the mass, that seems phleboliths.
    I think the most probable diagnosis is a low flow venous malformation.

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