Expansion of the upper mediastinum in a child. Mediastinum in x-ray image

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The following observation can serve as an example of a typical retgenological picture in isolated mediastinal lymphogranulomatosis.

Patient U., aged 30, was admitted to the clinic on 25/IV 1962 with a diagnosis of mediastinal tumor.
With multiaxial fluoroscopy and on radiographs in two standard projections in the anterior upper mediastinum on the left, a large pathological shadow with a doubled polycyclic contour and enlarged lymph nodes in the root of the lung, which are more clearly visible on lateral and direct tomograms, is determined.
The radiological conclusion of the mediastinal form of lymphogranulomatosis was confirmed by histological examination.

With reticulo- and lymphosarcomas, the expansion of the shadow of the mediastinum is determined radiographically. Paramediastinal shadows in sarcomas have irregular outlines, jagged edges. In a dynamic study, a one-way process soon becomes a two-way one. Very often, sarcoma is manifested by exudation into the pleura, a progressive increase in the syndrome of compression of the superior vena cava, and cervical lymphostasis.

Patient K., aged 27, was admitted to the clinic on June 11, 1966 with suspicion of left-sided exudative pleurisy.
He fell ill acutely on May 20, 1966, when, against the background of complete well-being, he rose heat, pain appeared in the left side chest, dry cough, loss of appetite, severe weakness. X-ray examination on the left and right, intense, heterogeneous darkening without clear boundaries is determined paramediastinally. The median shadow is unevenly expanded. Pulmonary pattern is strengthened, fibrous heaviness is expressed. The shadow of the heart is not differentiated due to massive changes in the roots of the lungs and mediastinal space. Soon an upper cavasyndrome developed, combined with cervical lymphostasis and bilateral chylothorax. After 5 months from the onset of the disease, death occurred.
The section revealed an extensive lymphosarcoma of the anterior mediastinum with germination in the large vessels of the mediastinum, lungs, pericardium and chest wall.

As with lymphogranulomatosis, and mediastinal sarcomas on radiographs in the lateral projection, the pathological shadow is located anterior to the lung root, diffusely filling the anterior mediastinum.

mediastinal form lung cancer It has distinctive features. The expansion of the shadow of the mediastinum is more often unilateral. The pathological shadow has the form of a semi-disk facing the middle part of the mediastinum with typical radiant polycyclic contours.

On the tomograms, homogeneous shadows are defined, covering the trachea, bifurcation, main bronchi with a transition to the opposite side. Characterized by deformation of the bronchi, narrowing of the lumen without changes in the mucosa, which is clearly visible during bronchoscopy. These data coincide with the clinical and radiological studies of A. E. Baranova (1959).

Patient M., aged 52, was admitted to the clinic on 4/VI 1966 with complaints of cough with sputum up to 100 cm3 per day, weakness, malaise, periodic fever to subfebrile figures, aching pain in the lumbar region.
He considers himself ill since March 1966. During the last 2 months he lost 14 kg. General state moderate. The patient is exhausted, severe shortness of breath at rest. Peripheral lymph nodes are not enlarged. Radiologically, the lung fields are emphysematous, the lung pattern is reinforced, deformed. On the right, in the root zone from the 1st rib to the diaphragm, there is an intense inhomogeneous darkening without clear boundaries, merging with the median shadow. The right root of the lung and the right contour of the heart are not differentiated.
On the tomograms of the bronchi, the right stem bronchus is unevenly narrowed, its upper contour is uneven, the upper lobar bronchus is narrowed. In the right root - large lymph nodes. During bronchoscopy, the mucosa of the right stem bronchus was edematous, hyperemic, the lumen of the bronchus was narrowed, and the angle of the tracheal bifurcation was obtuse. A mediastinal form of lung cancer was diagnosed in an inoperable stage. On June 26, 1966, he was transferred to the hospital at the place of residence.

Differential diagnosis of benign and malignant tumors with the help of X-ray therapy has not found wide application, which is associated with low radiosensitivity of mediastinal neoplasms (IA Pereslegin, 1959).

For the recognition of malignant tumors in last years the use of mediastinoscopy has found considerable distribution (B. K. Osipov, V. L. Manevich, 1965; Reynders, 1963; Fiynn et al., 1967, etc.).

Diagnosis of pathomorphological essence presents great difficulties. In foreign literature, this type of diagnosis is known as "etiopathogenetic diagnosis" (Borek, Teichmann, 1960). Recognition of the pathomorphology of the pathological shadow is given great importance(B. Ya. Lukyanchenko, 1958; B. K. Osipov, 1960; E. A. Nemiro, 1962, and many others).

Our data obtained using diagnostic pneumothorax convincingly showed the importance of the latter in the differential diagnosis of neurogenic tumors with neoplasms of a different histomorphological structure. The absence of changes in the position and shape of the tumor, which has clear contours and originates from the posterior mediastinum, against the background of a large diagnostic aneurysm, undoubtedly indicates the neurogenic nature of the tumor. If the pathological shadow shifts under the influence of a diagnostic pneumothorax, then the diagnosis of a neurogenic tumor is excluded.

Patient R., aged 22, was admitted to the clinic on January 24, 1964 with a diagnosis of a tumor of the posterior mediastinum. Complaints of aching pain in the chest, aggravated after physical activity, general weakness.
Sick for about 8 years. In 1956, radiologically above the root of the left lung, a pathological shadow was detected, which was interpreted as tuberculous bronchoadenitis. Until 1963, he systematically received anti-tuberculosis treatment, which did not have a positive effect, and therefore the diagnosis of pulmonary tuberculosis was excluded. The general condition of the patient is good. An x-ray examination on the left in the region of the posterior middle mediastinum shows an oval-shaped, intense, homogeneous formation 6x3 cm in size, with clear upper-outer contours. A neurogenic tumor of the mediastinum was suspected. On January 23, 1964, a large (4000 cm) diagnostic left-sided pneumothorax was imposed for differential diagnostic purposes. The pneumothoraxgram showed complete collapse of the left lung. The cardiovascular shadow is shifted to the right. The pathological shadow, localized in the posterior superior mediastinum, also shifted noticeably to the right, so that only the left edge of this shadow formation protruded somewhat from behind the left edge of the spine. Based on the fact that the pathological mediastinal shadow changed its shape and position under the influence of maximum pneumothorax, a thin-walled cyst of the posterior superior mediastinum was diagnosed.
On operation 10/IIP 1964, the diagnosis was confirmed; histological examination of the cyst wall revealed a mature teratoma. Recovery.

It is especially difficult to recognize the pathomorphological essence of rare tumors of the mediastinum - fibromas, chondromas, etc.

The diagnosis of coelomic cysts of the pericardium of a number of patients can be established (I. I. Neimark, 1963; I. D. Kuznetsov et al., 1967), given the characteristic location of cysts in the pericardio-diaphragmatic angle, the presence of transmission pulsation, changes in shape and position in diagnostic pneumomediastinum or pneumothorax. The accumulation of materials on the pathomorphological diagnosis of tumors and cysts of the mediastinum, especially the data of functional X-ray diagnostics, made it possible to more reliably assess the symptoms obtained. A certain importance is attached to percutaneous azigography and phlebography of the system of the superior vena cava. As an example, we present one of our observations.

Patient Zh., aged 39, was admitted to the clinic on January 13, 1964 with a diagnosis of a tumor of the posterior mediastinum.
A month ago, pain appeared in the left subscapular region, dry cough. The general condition of the patient is satisfactory. Peripheral lymph nodes are not enlarged. Radiologically on the left in the posterior superior mediastinum, an intense, clearly defined shadow formation is determined, 12X8 cm in size. No changes in the trachea and bronchi were detected on tomograms, the pathological shadow is homogeneous. On the pneumomediastinogram, a strip of gas is visible along the outer contour of the additional shadow. To determine the involvement of the unpaired and semi-unpaired veins in the pathological process, transcostal azygo-hemiasigography was performed. The radiograph shows a contrasted vein of the X rib and a vein evenly filled with a contrast agent, which flows into the superior vena cava at the level of the IV thoracic vertebra.
On the left, the veins of the VIII-IX and X intercostal spaces were filled with a contrast medium. The semi-unpaired vein is constricted along the length from the 11th to the 8th thoracic vertebrae. In addition, reflux into the lumbar veins was detected. Filling with a contrast agent of the three intercostal veins on the left and reflux into the lumbar veins suggested significant compression of the semi-azygous vein by the tumor. During the operation, a large tumor of the posterior mediastinum was revealed, growing large venous trunks and lung tissue. The tumor was inoperable.
Histological examination of the removed piece of the tumor made it possible to establish ganglioneuroblastoma. After the wound healed, the patient was discharged for chemotherapy.

Valuable data for determining operability can be obtained from a contrast study of the superior vena cava system. The reliable symptoms of inoperability include the following: 1) ectasia of the superior vena cava and innominate veins in the presence of a narrowing of its mouth; 2) the presence of defects in the filling of the superior vena cava; 3) the development of a large network of collateral venous trunks with the presence of contrast agent refluxes into intramammary and other veins.

Patient R., aged 59, was admitted to the clinic on 9/V 1964 with a diagnosis of tumor of the right lung.
About 2 months ago there were pressing pains in the chest, shortness of breath. The condition progressively worsened, the phenomena of cavasyndrome rapidly increased. X-ray: lung fields without pathological changes. On the right from I to III ribs, adjacent to the median shadow, an intense, homogeneous, with clear oval contours formation is determined, localized in the anterior superior mediastinum on the right.
To resolve the issue of operability of the mediastinal tumor on 28/V 1964, an upper cavography was performed. On the kavagram, the defect in the filling of the superior vena cava is clearly defined, which indicates the germination of its tumor. The patient was declared operable. Chemotherapy was prescribed.

One of the varieties of kavagraphic data in patients with malignant mediastinal tumors is our following observation.

Patient Sh., aged 22, was admitted to the clinic on 10/VII 1965 with suspected retrosternal goiter.
Complaints of pressing pain behind the sternum, severe shortness of breath even with slight physical exertion, while walking. I considered myself sick for about 3 months. The general condition is satisfactory. Draws attention to the puffiness of the face, neck, extended subcutaneous venous network in the upper half of the body. Skin and visible mucous membranes are cyanotic. X-ray examination is determined to the right of the dome of the pleura to the III rib intense, homogeneous darkening, closely merging with the median shadow. The pathological shadow is tuberous, pushes the trachea and esophagus to the left and backwards. The kavagram shows a sharp expansion of the bulb of the right subclavian vein with departing from it in in large numbers collaterals. The right innominate and superior vena cava are significantly thinned, deformed, and poorly contrasted. Along the outer contour of shadowing, a bypass vascular collateral can be traced, connecting the bulb of the subclavian vein with the proximal section of the superior vena cava. On the left, a well-contrasted innominate vein with even contours, up to 1 cm in diameter, is clearly visible. Diagnosis: a malignant tumor of the anterior superior mediastinum, compressing the superior vena cava.
On operation 16/VII 1965, a large tumor (18X14 cm) was revealed, emanating from the upper intercostal-vertebral sections, spreading to the anterior mediastinum, sharply squeezing the superior vena cava. With some technical difficulties, the mediastinal tumor was removed. The top immediately filled with blood. vena cava and took up her normal position. Histologically, the resected tumor is a neurosarcoma.
The patient was discharged with improvement, but 7 months after the operation she died from recurrence and tumor metastases.

Successful clinical and radiological diagnosis of tumors and cysts of the mediastinum has become possible due to the introduction of additional differential diagnostic methods of radiodiagnosis.

K.T. Ovnatanyan, V.M. Kravets

The mediastinum is also divided into top floor(located above the bifurcation of the trachea) and ground floor(located below the bifurcation of the trachea). Or the mediastinum is divided into three floors:

Upper- above the level of the fifth thoracic vertebra
Average- located at the level from the V thoracic vertebra (located approximately at the level of the bifurcation of the trachea) to the VIII thoracic vertebra
Lower- below the level of the VIII thoracic vertebra

The most common radiological sign of the presence of a neoplasm in the mediastinum is expansion of the median shadow. At the same time, on the roentgenogram in a direct projection, smoothing of the arches formed normally by the aorta and the cardiac shadow is noted. The expansion of the mediastinum is also accompanied by the formation of "protrusions" (additional shadows of a semicircular, semioval or irregular shape) along the contour of the mediastinum (on one or both sides), the wide base of which merges with the median shadow (Figure 1, 2). The contours of the extended median shadow are clear and even, and in the case of development malignant neoplasms- fuzzy and bumpy.

Figure 1. Neoplasm in the mediastinum (schematic representation of the radiograph in frontal and lateral projections). In this image, the neoplasm belongs to the anterior mediastinum.

Figure 2. Mediastinal mass. BUT - expansion of the shadow of the mediastinum to the left in the middle floor, due to the neoplasm (see arrow). B- radiograph of another patient: the picture shows the expansion of the mediastinal shadow with a polycyclic contour to the right in the upper floor, there is also an expansion (to a lesser extent) of the mediastinal shadow to the left (see arrows)

You can establish the "belonging" of the pathological shadow to the mediastinum in the following way: if on the radiograph in frontal projection you mentally extend the contours of the shadow to a full circle or oval, then the "center" of the shadow will be located outside the lung field, in the mediastinum (Figure 3), and the "corners » between the contour of the mediastinum and the shadow of the neoplasm will be blunt. Also, the shadows caused by neoplasms in the mediastinum do not correspond to the lobes and segments of the lung, they can be projected onto several lobes at the same time (as well as other extrapulmonary formations, for example, encysted effusions; see the article). It is necessary to pay attention to the fact that these signs do not “work” in all cases (for example, with neurogenic tumors that are localized in the posterior mediastinum near the shadow of the spine, the “center” of the neoplasm shadow is often projected not onto the mediastinum, but onto the lung field).

Figure 3. Difference in projection of neoplasm shadow (schematic representation of the radiograph in frontal projection). BUT- projection of the neoplasm into the mediastinum; B- intrapulmonary formation

On the radiograph in the lateral projection in the corresponding department of the mediastinum, an additional shadow can be determined, but it is not always clearly visualized, especially if the neoplasm is localized in the upper mediastinum. It is necessary to pay due attention to the analysis of the retrosternal space - in case of damage to the anterior mediastinum, it is shaded. If changes in the mediastinum are determined only on a radiograph in direct projection, and on a picture in lateral projection pathological changes are not reliably detected, the patient needs to conduct an additional study on CT.

The most common neoplasms of the mediastinum

The expansion of the upper mediastinum is often due to an increase thyroid gland- intrathoracic goiter, which on the radiograph in direct projection is defined as an expansion of the upper floor of the mediastinum due to an additional shadow of a semi-oval or semi-circular shape with usually clear and even contours, the base of which merges with the shadow of the mediastinum. Often this widening of the mediastinal shadow occurs to the right as the aortic arch deviates the goiter to the right (figure 4), but the mediastinal shadow can expand to both sides (figure 5), especially if the goiter is large (figure 6).

Figure 4. Intrathoracic goiter. BUT - radiograph in direct projection: the mediastinum in the upper floor is expanded to the right due to an additional formation with a clear and even contour (see arrow); the mass significantly displaces the trachea to the left (see pointers). B- X-ray in the right lateral projection: goiter (see arrows) is located behind the trachea - in the posterior mediastinum

Figure 5. Intrathoracic goiter. The expansion of the mediastinum in the upper floor in both directions is determined, the contours of the shadow are clear and even (see arrows)

Figure 6. Large intrathoracic goiter. Goiter expands the shadow of the mediastinum in both directions; trachea is displaced to the right (see arrows)

When the goiter is located in the upper floor of the posterior mediastinum, the trachea usually moves forward, which can be determined on the radiograph in the lateral projection. In some cases, the shadow of the goiter is not clearly visualized in the picture in the lateral projection. In some cases, the shadow of the enlarged upper mediastinum continues upward into the shadow of the soft tissues of the neck. Also in the structure of the goiter, calcifications (lumpy, or in the form of diffuse calcification or a rim) can be noted. Note that intrathoracic goiter often causes compression of the superior vena cava, narrowing and displacement of the esophagus and trachea (Figure 7).

Figure 7. Displacement of the contrasted esophagus and trachea to the left by intrathoracic goiter. The shadow of the mediastinum is enlarged due to goiter to the right in the upper section (see arrow)

Lipomas

Lipomas are often located in anterior mediastinum, in ground floor. A mediastinal lipoma on radiographs is usually defined as an irregularly round mass adjacent to the heart, anterior chest wall, and diaphragm. In some cases, the shadow of the lipoma can merge with the shadow of the heart, thereby "simulating" an increase in the size of the heart.

Abdomino-mediastinal lipomas

The so-called abdomino-mediastinal lipomas are found quite often. In fact, this is not a neoplasm, but a prolapse of preperitoneal fat into the mediastinum through the gaps in the diaphragm. The radiological picture of abdomino-mediastinal lipomas is characterized by additional shadows of a semi-circular, semi-oval or irregular shape in the lower floor of the anterior mediastinum, localized in the region of the cardiophrenic sinuses, often on the right. On the roentgenogram in direct projection, the abdomino-mediastinal lipomas are adjacent to the cardiac shadow and diaphragm; on the radiograph in the lateral projection, obtuse "angles" are determined, formed by this lipoma with the diaphragm and the anterior wall of the chest (Figure 8, 9).

Figure 8. Abdomino-mediastinal lipoma (schematic representation)

Figure 9. Abdomino-mediastinal lipoma in the right cardio-phrenic sinus. A - radiograph in direct projection, B - radiograph in the right lateral projection

Coelomic cysts of the pericardium

Coelomic cysts of the pericardium radiological signs resemble abdomino-mediastinal lipomas, but are less common and localized in the cardiodiaphragmatic sinuses. On x-ray, coelomic pericardial cysts are defined as a shadow of a semi-circular or semi-oval shape. Experts note that on the radiograph in the lateral projection, the "corners" formed by the coelomic cyst with the diaphragm and the anterior chest wall are sharp (Figure 10, 11).

Figure 10 Coelomic pericardial cyst (schematic representation)

Figure 11. Coelomic cyst of the pericardium. BUT - an enlarged fragment of the radiograph in direct projection: on the right, in the projection of the cardiophrenic sinus, a poorly distinguishable additional shadow of a semi-oval shape with an even contour is determined (see arrow). B- radiograph in the right lateral projection: the shadow of the cyst above the diaphragm is well defined, located not strictly in the cardiophrenic sinus, but slightly posteriorly (see arrows)

Accurate differential diagnosis Abdomino-mediastinal lipomas and coelomic pericardial cysts can be performed by CT (CT allows you to determine both the accumulation of adipose tissue and the cyst with liquid contents). Often additional shadows are found in the cardiophrenic sinuses due to mooring lines(massive fibrous layers on the pleura). Mooring lines are characterized by less convex contours, and their shape is similar to triangular (see article and)

thymoma

Thymoma - tumor thymus. On x-ray, thymoma is usually found in the anterior mediastinum, on the middle floor. Thymoma forms a pear-shaped or oval shadow with smooth, sometimes wavy contours. Experts believe that benign thymomas usually expand the mediastinal shadow only in one direction on the radiograph in frontal projection, and the shadow may not be determined on the radiograph in the lateral projection, since the thymoma has a flat configuration and has a low intensity of the shadow. Malignant thymomas are often identified on a lateral radiograph; the contours of the shadow of a malignant thymoma are indistinct, bumpy. The x-ray picture of malignant thymomas resembles lymphoma (see article).

Teratodermoid formations

Teratodermoid formations include teratoma and dermoid cysts- neoplasms of the mediastinum, formed as a result of a violation of the development of tissues and organs during the period of embryonic development, which contain tissues that are not characteristic of this anatomical region. On the radiograph, such formations are localized in the anterior mediastinum, on the middle floor (rarely in the upper floor) in the form of an additional shadow with a clear and even contour. In teratodermoid formations, calcifications, adipose tissue, a cystic component with liquid contents, bone inclusions (bone fragments, teeth) can be determined. When performing conventional radiography, such inclusions are rarely detected, that is, it is impossible to differentiate teratodermoid formations from other mediastinal neoplasms in most cases. Dermoid cysts sometimes break into the esophagus or bronchus (in this case, a horizontal liquid / gas level is determined on the x-ray in the formation). If teratodermoid formations are malignant, the contours of the shadow have fuzzy, bumpy contours; however, the exact nature of the mass can only be determined by biopsy and further histological examination obtained biopsy.

cysts

Cysts in the mediastinum may be bronchogenic(bronchial origin) and enterogenic(caused by a violation of the digestive canal). Sometimes it is possible to differentiate these types of cysts only by conducting histological analysis. It is often very difficult to detect mediastinal cysts during routine x-rays, since the shadows of these cysts may not go beyond the contour. midline. As a rule, mediastinal cysts are filled with contents (on the radiograph they are defined as oval or rounded homogeneous shadows), and in the wall of bronchogenic cysts, calcifications of the "shell" type can be determined.

Bronchogenic cysts often localized in the central mediastinum, in the upper or middle floor, near the bifurcation of the trachea or under it, and also close to the main bronchi. At the same time, on the radiograph, an expansion of the median shadow with a clear arcuate contour is noted in a limited area.

Enterogenic cysts often located in the posterior mediastinum (more precisely, in that part of the posterior mediastinum that is anterior to the spine - in the Goltzknecht space), on the lower floor, close to the esophagus.

Mediastinal cysts can compress and displace the trachea and esophagus. In the case of a cyst rupture into the esophagus, bronchus or trachea, a thin-walled cavity with a horizontal level of liquid/gas content is determined on the radiograph.

Neurogenic tumors

Neurogenic tumors form in the mediastinum from membranes peripheral nerves (neurofibroma, schwannoma), as well as from sympathetic and parasympathetic ganglia ( neuroblastomas, ganglioneuromas). Such neoplasms are localized in the paravertebral space - the costovertebral groove - traditionally belong to the posterior mediastinum and can be found on any floor (upper, middle, lower).

On the radiograph, neurogenic tumors are defined as additional shadows of an oval (semi-oval) or round (semi-circular) shape with clear, even contours. In the later stages of tumor development, the contours of the shadow may become fuzzy and uneven (bumpy). In some neurogenic tumors, calcifications can be determined. In addition to the expansion of the median shadow on radiographs in frontal and lateral projections, an additional shadow is determined, which is visualized against the background of the spine or adjacent to the spine. Sometimes it is difficult to differentiate neurogenic tumors from intrapulmonary neoplasms, since when a neurogenic tumor grows in the direction of the lung, it is projected mainly onto the pulmonary field. Neurogenic tumors are also capable of causing changes in adjacent bone structures - deformation and usuration of the ribs and vertebrae due to pressure, expansion of the intervertebral foramens.

In case of suspicion of a mass formation of the mediastinum, the patient should be assigned an CT scan to clarify the localization and structure of the formation (presence of fluid, bone tissue, calcifications, adipose tissue, cystic component in the formation), to determine the signs of a malignant process, to detect an increase in lymph nodes in the mediastinum.

Other causes of mediastinal shadow enlargement

Esophageal diverticula

Diverticula of the esophagus occur anywhere in the esophagus and may cause dilation of the median shadow. "Cervical" (Zenker's) diverticula The esophagus is located in the upper mediastinum. Diagnosis of diverticula by radiography requires a contrast study of the esophagus.

aortic aneurysm

An aortic aneurysm may cause median shadow enlargement. Ascending aortic aneurysm median shadow expands to the right, with an aneurysm of the descending aorta, the median shadow expands to the left (Figure 12, 13)

Figure 12 Descending aortic aneurysm (see arrow). BUT- X-ray in direct projection; B- radiograph in the left lateral projection.

Figure 13 Descending aortic aneurysm. BUT - X-ray in direct projection: there is a significant expansion of the median shadow to the left due to the aorta. B- radiograph in the left lateral projection: the expansion of the entire descending aorta is determined

Note that an aneurysm of the descending aorta in its lower section (above the diaphragm) on the radiograph can simulate changes in the lung (additional round formation) or hiatal hernia (see Figure 14).

Figure 14. Descending aortic aneurysm located supraphrematically. BUT - radiograph in direct projection: in the lower part of the mediastinum is expanded to the left due to an additional shadow, which is partially defined behind the heart (see arrow). B- radiograph in the left lateral projection: an additional shadow is determined above the diaphragm, which is a "continuation" of the shadow of the descending aorta (see arrows)

Note that on x-ray, aortic dissection is not always defined as aortic dilation, since in some cases dissection occurs in the absence of aortic aneurysm. An existing aortic aneurysm can also be complicated by dissection. If an aortic dissection is suspected, the patient should undergo multislice CT with angiography.

Aortic anomalies such as the right aorta can cause the median shadow to expand to the right. In this case, the aortic arch and descending aorta in typical place(along the left contour of the median shadow) are not determined, since they are located on the right (Figure 15)

Figure 15. Right aorta. BUT - X-ray in direct projection: in the upper section, the mediastinal shadow is enlarged to the right, in a typical location on the left, the aortic arch is not visualized. B- radiograph in the right lateral projection: behind the trachea, the aortic arch is determined (see arrow)

hiatal hernia

Large hernias of the esophageal opening of the diaphragm can cause expansion of the median shadow in the lower section. On the radiograph in the lateral projection, such hernias are detected behind the shadow of the heart in the form additional formations rounded (rarely irregularly rounded) with clear contours. As a rule, they determine the horizontal level of the contents that is in the stomach, less often this level is not determined. Diagnosis of hernia of the esophageal opening of the diaphragm is carried out by contrast examination of the esophagus and stomach (Figure 16).

Figure 16. Intrathoracic location of the stomach. BUT - X-ray in direct projection: in the lower mediastinum is determined by the expansion of the shadow of the mediastinum to the right (see arrow). B- radiograph in the right lateral projection: an additional shadow behind the heart is determined (see arrows); this is a somewhat atypical picture, since the liquid/gas level typical of the stomach is not visualized. AT- contrast study of the stomach: the stomach is almost completely located to the chest cavity (this is due to the "short esophagus")

Figure 17. Mediastinal dilatation due to a giant aneurysm of the aberrant subclavian artery on the right

Figure 18. A - X-ray taken in the supine position: the expansion of the mediastinal shadow in the upper section to the right is determined. B- X-ray of the same patient in a standing position: mediastinal shadow is not dilated

- a group of morphologically heterogeneous neoplasms located in the mediastinal space of the chest cavity. Clinical picture consists of symptoms of compression or germination of a mediastinal tumor in neighboring organs (pain, superior vena cava syndrome, cough, shortness of breath, dysphagia) and general manifestations (weakness, fever, sweating, weight loss). Diagnosis of tumors of the mediastinum includes X-ray, tomography, endoscopic examination, transthoracic puncture or aspiration biopsy. Treatment of tumors of the mediastinum - operational; at malignant neoplasms complemented by radiation and chemotherapy.

ICD-10

C38.1 C38.2 C38.3 D15.2

General information

Tumors and cysts of the mediastinum account for 3-7% in the structure of all tumor processes. Of these, in 60-80% of cases are detected benign tumors mediastinum, and in 20-40% - malignant (mediastinal cancer). Tumors of the mediastinum occur with the same frequency in men and women, mainly at the age of 20-40 years, that is, in the most socially active part of the population. Tumors of mediastinal localization are characterized by morphological diversity, the likelihood of primary malignancy or malignancy, the potential threat of invasion or compression of the vital organs of the mediastinum ( respiratory tract, main vessels and nerve trunks, esophagus), technical difficulties of surgical removal. All this makes mediastinal tumors one of the urgent and most complex problems of modern thoracic surgery and pulmonology.

The anatomical space of the mediastinum in front is limited by the sternum, retrosternal fascia and costal cartilages; behind - surface thoracic spine, prevertebral fascia and rib necks; on the sides - by sheets of the mediastinal pleura, from below - by the diaphragm, and from above - by a conditional plane passing along the upper edge of the sternum handle. Within the boundaries of the mediastinum are the thymus gland, the upper parts of the superior vena cava, the aortic arch and its branches, the brachiocephalic trunk, the carotid and subclavian arteries, the thoracic lymphatic duct, the sympathetic nerves and their plexuses, branches vagus nerve, fascial and cellular formations, The lymph nodes esophagus, pericardium, tracheal bifurcation, pulmonary arteries and veins, etc. In the mediastinum, 3 floors are distinguished (upper, middle, lower) and 3 sections (anterior, middle, posterior). The floors and departments of the mediastinum correspond to the localization of neoplasms emanating from the structures located there.

Classification of mediastinal tumors

All tumors of the mediastinum are divided into primary (originally arising in the mediastinal space) and secondary (metastases of neoplasms located outside the mediastinum).

Primary tumors of the mediastinum are formed from different tissues. In accordance with the genesis, among the tumors of the mediastinum, there are:

neurogenic neoplasms (neurinomas, neurofibromas, ganglioneuromas, malignant neuromas, paragangliomas, etc.)
mesenchymal neoplasms (lipomas, fibromas, leiomyomas, hemangiomas, lymphangiomas, liposarcomas, fibrosarcomas, leiomyosarcomas, angiosarcomas)
lymphoid neoplasms (lymphogranulomatosis, reticulosarcomas, lymphosarcomas)
disembryogenetic neoplasms (teratoma, intrathoracic goiter, seminomas, chorionepithelioma)
tumors of the thymus gland (benign and malignant thymomas).

Also in the mediastinum there are so-called pseudotumors (enlarged conglomerates of lymph nodes in tuberculosis and Beck's sarcoidosis, aneurysms of large vessels, etc.) and true cysts (coelomic pericardial cysts, enterogenic and bronchogenic cysts, echinococcal cysts).

In the upper mediastinum, thymomas, lymphomas and retrosternal goiter are most often found; in the anterior mediastinum - mesenchymal tumors, thymomas, lymphomas, teratomas; in the middle mediastinum - bronchogenic and pericardial cysts, lymphomas; in the posterior mediastinum - enterogenic cysts and neurogenic tumors.

Symptoms of mediastinal tumors

AT clinical course Mediastinal tumors distinguish between an asymptomatic period and a period of severe symptoms. The duration of the asymptomatic course is determined by the location and size of mediastinal tumors, their nature (malignant, benign), growth rate, and relationships with other organs. Asymptomatic mediastinal tumors are usually found during prophylactic fluorography.

Period clinical manifestations mediastinal tumors are characterized by the following syndromes: compression or invasion of neighboring organs and tissues, common symptoms and specific symptoms characteristic of various neoplasms.

The earliest manifestations of both benign and malignant tumors of the mediastinum are chest pain caused by compression or germination of the neoplasm in the nerve plexuses or nerve trunks. Pain is usually moderately intense, can radiate to the neck, shoulder girdle, interscapular region.

Tumors of the mediastinum with left-sided localization can simulate pain, reminiscent of angina pectoris. With compression or invasion by a tumor of the mediastinum of the border sympathetic trunk, Horner's symptom often develops, including miosis, ptosis upper eyelid, enophthalmos, anhidrosis and hyperemia of the affected side of the face. When pain in the bones should think about the presence of metastases.

Compression of the venous trunks, first of all, is manifested by the so-called superior vena cava syndrome (SVCS), in which the outflow of venous blood from the head and upper half of the body is disturbed. SVC syndrome is characterized by heaviness and noise in the head, headache, chest pain, shortness of breath, cyanosis and swelling of the face and chest, swelling of the neck veins, and increased central venous pressure. In case of compression of the trachea and bronchi, cough, shortness of breath, stridor breathing occur; recurrent laryngeal nerve - dysphonia; esophagus - dysphagia.

General symptoms in tumors of the mediastinum include weakness, fever, arrhythmias, brady - and tachycardia, weight loss, arthralgia, pleurisy. These manifestations are more characteristic of malignant tumors of the mediastinum.

Some tumors of the mediastinum develop specific symptoms. So, with malignant lymphomas, night sweats and pruritus are noted. Mediastinal fibrosarcomas may be accompanied by a spontaneous decrease in blood glucose levels (hypoglycemia). Mediastinal ganglioneuromas and neuroblastomas can produce norepinephrine and epinephrine leading to seizures arterial hypertension. Sometimes they secrete a vaso-intestinal polypeptide that causes diarrhea. With intrathoracic thyrotoxic goiter, symptoms of thyrotoxicosis develop. Myasthenia is diagnosed in 50% of patients with thymoma.

Diagnosis of tumors of the mediastinum

The variety of clinical manifestations does not always allow pulmonologists and thoracic surgeons to diagnose mediastinal tumors according to anamnesis and objective examination. Therefore, instrumental methods play a leading role in the detection of mediastinal tumors.

A comprehensive x-ray examination in most cases allows you to clearly determine the location, shape and size of the mediastinal tumor and the prevalence of the process. Mandatory studies for suspected mediastinal tumors are chest x-ray, polypositional x-ray, x-ray of the esophagus. X-ray data are clarified using CT of the chest, MRI or MSCT of the lungs.

Among the methods of endoscopic diagnostics for tumors of the mediastinum, bronchoscopy, mediastinoscopy, videothoracoscopy are used. During bronchoscopy, bronchogenic localization of tumors and tumor invasion of the mediastinum of the trachea and large bronchi are excluded. It is also possible to perform a transtracheal or transbronchial biopsy of a mediastinal tumor during the study.

In some cases, taking samples of pathological tissue is carried out by means of transthoracic aspiration or puncture biopsy, performed under ultrasound or X-ray control. The preferred methods for obtaining material for morphological examination are mediastinoscopy and diagnostic thoracoscopy, which allow for a biopsy under vision control. In some cases, it becomes necessary to conduct a parasternal thoracotomy (mediastinotomy) for revision and biopsy of the mediastinum.

In the presence of enlarged lymph nodes in the supraclavicular region, a scaled biopsy is performed. With superior vena cava syndrome, CVP is measured. If lymphoid tumors of the mediastinum are suspected, a bone marrow puncture with a myelogram study is performed.

Treatment of mediastinal tumors

In order to prevent malignancy and the development of compression syndrome, all mediastinal tumors should be removed as soon as possible. early dates. For radical removal of mediastinal tumors, thoracoscopic or open methods are used. With a retrosternal and bilateral location of the tumor, longitudinal sternotomy is mainly used as an operative approach. With unilateral localization of the mediastinal tumor, an anterolateral or lateral thoracotomy is used.

Transthoracic ultrasonic aspiration of a mediastinal neoplasm can be performed in patients with a severe general somatic background. With a malignant process in the mediastinum, a radical extended removal of the tumor is performed or

4. Tumors of the mediastinum / Shepetko M.N., Prokhorov A.V., Labunets I.N. – 2012.

Home " Planning » The structure of the mediastinum in children. Diagnosis of the expansion of the shadow of the mediastinum using X-ray

When there are any signs of the disease, and visual examination of the patient cannot give clear information about the state of one or another internal organ, doctors prescribe x-ray examinations. X-ray of the mediastinal organs is one of the leading methods for diagnosing existing pathological processes. We will find out what kind of procedure it is, and what diseases will be reflected in the finished picture.

Indications and prohibition of the procedure

X-ray of the mediastinum is performed at the initial stage of the examination of the patient. The procedure is painless and more accessible in comparison with computed tomography.

Reasons why radiodiagnosis may be prescribed:

complaints of chest pain;
coughing,
labored breathing;
increase cervical lymph nodes(their clear visualization);
injuries of the esophagus, ribs and upper spine.

As in cases of examination of other organs, mediastinal x-rays are not performed for pregnant women (especially in the 1st trimester). If the question of diagnostics is urgent, and there are good reasons for this, then precautions should be taken during exposure, including protecting the patient's abdomen and pelvis with a lead apron. There are no other contraindications to the procedure. Despite this, it is important not to forget that the minimum radiation exposure is still present, so it is better not to undergo an overview radiography of the organ too often.

There is no special preparation for the passage of radiography of the mediastinum. There are also no food or drink requirements. The only thing to do is to remove all jewelry and remove metal objects from your pockets. During the scan, the patient stands with his chest pressed against the shield and holding his breath. The picture is taken in lateral and frontal projection.

What will the picture show?

Before proceeding to decipher the image, it is worth finding out what kind of organ it is - the mediastinum. In fact, this is a space that is localized in the chest and has clear boundaries.

For the convenience of diagnosis, the mediastinum is divided into three sections, each of which includes certain organs:

Anterior: blood vessels, lymph nodes, thymus;
Middle section: bronchi, pulmonary veins and arteries, lymph nodes, heart, trachea, pericardium;
Posterior: esophagus, thoracic ducts, descending aorta.

Thanks to this division, it is possible to make an assumption about the nature, structure and cause of the formation of the mediastinum, which was shown by x-rays. In the diagnosis of benign tumors, their localization is of paramount importance. For example, intrathoracic and retrosternal goiter, giving an expansion of the shadow of the mediastinum on x-ray, is formed in the upper part of the mediastinum, and brochoenterogenic cysts near the esophagus.

An image made using the right technology will show:

two or three vertebrae;
the location of the spinous processes between the clavicles (in the center);
diaphragm muscles located at the level of the 6th rib;
the shadow and any formations have a clear visualization.

Before proceeding to a detailed analysis, the radiologist conducts a primary study and writes a conclusion on it. It contains short description the location and condition of organs, information about the presence of expansion, shadows or tumors.

Decryption algorithm

After writing a brief conclusion, the radiologist proceeds to a detailed analysis of the image. What diseases can he see?

Pneumonia. On the pictures in the lateral and direct projection, additional tissues are clearly visible.
Tuberculosis. This disease increased venous pattern in the upper lung is characteristic.
congestive insufficiency. Manifested by enlargement of the heart.
Pleurisy. The picture shows that the trachea is pulled forward, which is due to the accumulation of fluid in this area.
Pulmonary edema. Flaky blackouts in the mediastinum indicate the presence of this pathology.
Goiter. Expansion of the mediastinum on x-rays in one or both directions is the main sign of goiter. Also, along with the expansion of the shadow, a narrowing of this area can also be observed. Shadows can be enlightened, compacted and with foci of calcification.

The detected tumor of the mediastinum on x-ray deserves special attention. Any neoplasm requires a more detailed diagnosis, which will include:

clarification of the location relative to other organs;
determination of the shape, contours, structure of the tumor;
assessment of behavior and characteristics of the neoplasm.

It is important to remember that reading a finished x-ray is a very difficult task, since the image is a collection of heterogeneous structures layered on top of each other. Therefore, only a highly qualified specialist with extensive experience can perform the analysis accurately and correctly. It depends on whether he sees the disease on early stage development.

Most of the masses of the upper mediastinum found on radiography and computed tomography mediastinum, comes from the tissue of the thyroid gland and is a goiter. More than 99.9% of all goiter localizations are in the upper mediastinum, and only 0.1% are other (atypical) localizations. Lymphomas, bronchogenic cysts, and tumors of the pleura (mesothelioma) may also be found.

The classification of goiters in relation to the mediastinum on CT is as follows: an intrathoracic goiter is isolated, which is completely located behind the sternum (retrosternally), is not palpated above the incisura jugularis; retrosternal goiter, located partly retrosternally, and partly on the neck; "diving" goiter, located entirely on the neck, the lower edge of which falls below the incisura jugularis only when swallowing.

Schematic division of the upper mediastinum into sections with computed tomography. So, a conditional line drawn parallel to the horizontal at the level of the handle joint of the sternum delimits the upper mediastinum from below; the upper border of the mediastinum is conventionally considered the upper aperture of the chest. The anterior superior mediastinum conditionally includes the retrosternal region, the posterior superior - the spinal column, paravertebral tissue; middle upper - tissues and organs between these two departments.

Conditional division of the upper mediastinum on radiographs

Conditional division of the upper mediastinum on radiographs.

Clinical picture of goiter

In most cases, goiters are colloidal, hormonally inactive, and do not provoke the development of symptoms of thyrotoxicosis. With a significant size of the goiter, it can provoke the occurrence of dysphagia (impaired swallowing) due to compression of the esophagus, as well as respiratory failure. The clinical picture characteristic of inflammation (changes in blood tests) may also be observed, but more often goiters occur without any symptoms.

Signs of goiter on radiographs of the mediastinum

The main sign of goiter on the radiograph is the expansion of the mediastinal shadow in one or both directions. The goiter causes a displacement of the trachea on the x-ray, as well as its narrowing. Along with the trachea, the esophagus also deviates (which can be detected by fluoroscopy of the mediastinum after oral administration of contrast - a suspension of barium sulfate). In the structure of the shadow with goiter, enlightenments can be detected (with necrosis and abscess formation), as well as dense objects (petrificates). Calcifications in the structure of the goiter may be a sign of its malignancy.

If an expansion of the shadow of the upper mediastinum is detected on x-rays of the chest, fluoroscopy and x-ray computed tomography of the mediastinum are indicated. With fluoroscopy of the mediastinum, the shadow shifts during swallowing movements - if this does not happen, then the desired formation is located in the lungs or in the pleura (in the chest wall), but not in the mediastinum. Pulsation of education in the mediastinum may be characteristic of goiter.

The method of visualization of functionally active parenchyma of the thyroid gland is scintigraphy. Radioisotope study allows to visualize areas of reduced or increased accumulation of the radiopharmaceutical and give a clear picture of goiter.

Differential diagnosis of formations of the upper mediastinum

In addition to goiters, bronchogenic cysts can also be found in the upper mediastinum (more than half of all bronchogenic cysts are localized in the upper mediastinum), as well as tumors from the nervous tissue (neurinomas and neurosarcomas), pleural tumors (mesothelioma) and tumors of the lymph nodes.

Thus, a smooth transition of the contour of the shadow of a parietal formation near the shadow of the spine may be characteristic of a neurogenic tumor. If the shadow is adjacent to the inner surface of the chest wall, one may suspect mesothelioma, a tumor of the soft tissues of the chest wall, or (less often) neurinoma of the intercostal nerves.

CT. A formation of the upper mediastinum was revealed, located partially behind the sternum handle, adjacent to the wall of the trachea in front and from the side, with no signs of invasive growth. It can be seen that the formation is not associated with the thyroid gland (located separately from it and separated by a "strip" of adipose tissue)

Computed tomography of the mediastinum in the patient revealed an increase in the left lobe of the thyroid gland due to goiter transformation (the increased proportion is marked by arrows in the images)

- a group of morphologically heterogeneous neoplasms located in the mediastinal space of the chest cavity. The clinical picture consists of symptoms of compression or germination of a mediastinal tumor in neighboring organs (pain, superior vena cava syndrome, cough, shortness of breath, dysphagia) and general manifestations (weakness, fever, sweating, weight loss). Diagnosis of tumors of the mediastinum includes X-ray, tomography, endoscopic examination, transthoracic puncture or aspiration biopsy. Treatment of tumors of the mediastinum - operational; in malignant neoplasms, it is supplemented with radiation and chemotherapy.

General information

Tumors and cysts of the mediastinum account for 3-7% in the structure of all tumor processes. Of these, in 60-80% of cases, benign tumors of the mediastinum are detected, and in 20-40% - malignant (mediastinal cancer). Tumors of the mediastinum occur with the same frequency in men and women, mainly at the age of 20-40 years, that is, in the most socially active part of the population.

Tumors of mediastinal localization are characterized by morphological diversity, the likelihood of primary malignancy or malignancy, a potential threat of invasion or compression of the vital organs of the mediastinum (respiratory tract, great vessels and nerve trunks, esophagus), technical difficulties of surgical removal. All this makes mediastinal tumors one of the urgent and most complex problems of modern thoracic surgery and pulmonology.

Anatomy of the mediastinum

The anatomical space of the mediastinum in front is limited by the sternum, retrosternal fascia and costal cartilages; behind - the surface of the thoracic spine, prevertebral fascia and necks of the ribs; on the sides - by sheets of the mediastinal pleura, from below - by the diaphragm, and from above - by a conditional plane passing along the upper edge of the sternum handle.

Within the boundaries of the mediastinum are the thymus gland, the upper parts of the superior vena cava, the aortic arch and its branches, the brachiocephalic trunk, the carotid and subclavian arteries, the thoracic lymphatic duct, the sympathetic nerves and their plexuses, the branches of the vagus nerve, the fascial and cellular formations, the lymph nodes, the esophagus , pericardium, tracheal bifurcation, pulmonary arteries and veins, etc. In the mediastinum, 3 floors (upper, middle, lower) and 3 sections (anterior, middle, posterior) are distinguished. The floors and departments of the mediastinum correspond to the localization of neoplasms emanating from the structures located there.

Classification

All tumors of the mediastinum are divided into primary (originally arising in the mediastinal space) and secondary (metastases of neoplasms located outside the mediastinum).

Primary tumors of the mediastinum are formed from different tissues. In accordance with the genesis, among the tumors of the mediastinum, there are:

neurogenic neoplasms (neurinomas, neurofibromas, ganglioneuromas, malignant neuromas, paragangliomas, etc.)
mesenchymal neoplasms (lipomas, fibromas, leiomyomas, hemangiomas, lymphangiomas, liposarcomas, fibrosarcomas, leiomyosarcomas, angiosarcomas)
lymphoid neoplasms (lymphogranulomatosis, reticulosarcomas, lymphosarcomas)
disembryogenetic neoplasms (teratomas, intrathoracic goiter, seminomas, chorionepithelioma)
tumors of the thymus gland (benign and malignant thymomas).

Symptoms of mediastinal tumors

In the clinical course of mediastinal tumors, an asymptomatic period and a period of severe symptoms are distinguished. The duration of the asymptomatic course is determined by the location and size of mediastinal tumors, their nature (malignant, benign), growth rate, and relationships with other organs. Asymptomatic mediastinal tumors are usually found during prophylactic fluorography.

Pain syndrome

Tumors of the mediastinum with left-sided localization can simulate pain, reminiscent of angina pectoris. With compression or invasion by a tumor of the mediastinum of the border sympathetic trunk, Horner's symptom often develops, including miosis, ptosis of the upper eyelid, enophthalmos, anhidrosis and hyperemia of the affected side of the face. With pain in the bones, one should think about the presence of metastases.

Compression syndrome

Compression of the venous trunks, first of all, is manifested by the so-called superior vena cava syndrome (SVCS), in which the outflow of venous blood from the head and upper half of the body is disturbed. SVC syndrome is characterized by heaviness and noise in the head, headache, chest pain, shortness of breath, cyanosis and swelling of the face and chest, swelling of the neck veins, and an increase in central venous pressure. In case of compression of the trachea and bronchi, coughing, shortness of breath, stridor breathing occur; recurrent laryngeal nerve - dysphonia; esophagus - dysphagia.

Specific manifestations

Some tumors of the mediastinum develop specific symptoms. So, with malignant lymphomas, night sweats and pruritus are noted. Mediastinal fibrosarcomas may be accompanied by a spontaneous decrease in blood glucose levels (hypoglycemia). Mediastinal ganglioneuromas and neuroblastomas can produce norepinephrine and epinephrine, leading to bouts of hypertension. Sometimes they secrete a vaso-intestinal polypeptide that causes diarrhea. With intrathoracic thyrotoxic goiter, symptoms of thyrotoxicosis develop. In 50% of patients with thymoma, myasthenia gravis is detected.

Diagnostics

X-ray diagnostics. A comprehensive x-ray examination in most cases allows you to clearly determine the location, shape and size of the mediastinal tumor and the prevalence of the process. Mandatory studies for suspected mediastinal tumors are chest x-ray, polypositional x-ray, x-ray of the esophagus. X-ray data are refined with the help of a bone marrow puncture with a myelogram study.
Surgical biopsy. The preferred methods for obtaining material for morphological examination are mediastinoscopy and diagnostic thoracoscopy, which allow for a biopsy under vision control. In some cases, it becomes necessary to conduct a parasternal thoracotomy (mediastinotomy) for revision and biopsy of the mediastinum. In the presence of enlarged lymph nodes in the supraclavicular region, a scaled biopsy is performed.

Treatment of mediastinal tumors

In order to prevent malignancy and the development of compression syndrome, all mediastinal tumors should be removed as early as possible. For radical removal of mediastinal tumors, thoracoscopic or open methods are used. With a retrosternal and bilateral location of the tumor, longitudinal sternotomy is mainly used as an operative approach. With unilateral localization of the mediastinal tumor, an anterolateral or lateral thoracotomy is used.

Transthoracic ultrasonic aspiration of a mediastinal neoplasm can be performed in patients with a severe general somatic background. In a malignant process in the mediastinum, a radical extended removal of the tumor or palliative removal of the tumor is performed in order to decompress the mediastinal organs.

The question of the use of radiation and chemotherapy in malignant tumors mediastinum is solved based on the nature, prevalence and morphological features of the tumor process. Radiation and chemotherapy treatment is used both independently and in combination with surgical treatment.