Pleura, chest wall & mediastinum Flashcards
@# 2. With regards to imaging of primary extranodal lymphomas, in which of the following sites does extranodal Hodgkin’s disease most commonly occur?
A. Spleen
B. Thymus
C. Thyroid
D. Small bowel
E. Lung
B. Thymus
When the main bulk of disease at an extranodal site, a lymphoma should be classified as the extranodal type, as these have distinctive pathological, radiological and clinical features from nodal lymphomas. The thymus is the only extranodal site where Hodgkin’s lymphoma commonly occurs, and almost all cases are of the nodular sclerosing subtype.
- A 76-year old man presents with newly diagnosed malignant mesothelioma. Which of the following findings would preclude resection of mesothelioma?
A. Enhancement of interlobular fissures on MRI
B. An area of chest wall invasion
C. Subdiaphragmatic extension
D. Stage T3 disease
E. Enlarged ipsilateral mediastinal nodes
C. Subdiaphragmatic extension
Imaging findings of deep myocardial invasion, multifocal chest wall invasion or subdiaphragmatic extension are contraindications to surgery. Patients with stage 1-3 may be surgical candidates but not necessarily cured. MRI findings of focal thickening and enhancement of the interlobular fissures are useful signs in the detection of early malignant pleural disease
@# 11. Which is the most common primary tumor to metastasize to the pleura?
A. Breast
B. Lymphoma
C. Lung
D. Ovary
E. Stomach
C. Lung
In order of decreasing frequency, metastases to the pleura arisefrom lung, breast, lymphoma, ovary and stomach cancers.
- A 50-year-old builder undergoing CT of the chest has pleural thickening and calcification along the diaphragmatic pleura. Which is the most specific distinguishing feature to indicate malignant rather than benign pleural disease?
A. Nodularity of the pleural thickening
B. Parietal pleural thickening greater than 1cm
C. Mediastinal pleural involvement
D. Pleural effusion
E. Circumferential pleural thickening
E. Circumferential pleural thickening
On multivariate analysis, the CT findings of rind-like pleural involvement, mediastinal pleural involvement and pleural thickness > 1 cm were independent findings in differentiating malignant pleural mesothelioma from other malignant pleural disease, with specificity values of 0.85, 0.67 and 0.82, respectively.
@# 29. Plain radiographs of a previously well 60-year-old man with lower limb pain show lamellar periosteal reaction in the diametaphyseal regions. Bone scintigraphy demonstrates symmetrical increased uptake along the cortical margins in the diametaphyseal regions. What is the most likely underlying thoracic cause?
A. Pulmonary haemangioma
B. Pleural fibroma
C. TB
D. Blastomycosis
E. Malignant mesothelioma
B. Pleural fibroma
Hypertrophic osteoarthropathy is commonly associated with primary bronchogenic carcinoma, typically non-small-cell lung cancer (NSCLC).
HOA is also seen in patients with pulmonary metastases from extrathoracic malignancies such as breast carcinoma, nasopharyngeal tumours, renal cell carcinoma, melanoma and osteosarcoma. Benign associations include pleural fibroma and bronchiectasis.
@# 17) A 65-year-old man presents with painful wrists and ankles. There is no digital clubbing. A chest radiograph shows a well-defined pleural mass, forming an obtuse angle with the chest wall. CT confirms an ovoid, plurally based, enhancing mass with no bone destruction, effusion or volume loss. Radiographs of the wrists and ankles show symmetrical periosteal reaction. What is the most likely diagnosis?
a. hypertrophic osteoarthropathy with bronchogenic carcinoma
b. hypertrophic osteoarthropathy with malignant mesothelioma
c. hypertrophic osteoarthropathy with pleural fibroma
d. rheumatoid arthritis
e. tuberculosis
c. hypertrophic osteoarthropathy with pleural fibroma
The periosteal reaction is typical of hypertrophic osteoarthropathy (HOA), which has many causes, both intra- and extra thoracic. It is associated with bronchogenic carcinoma and malignant mesothelioma, but features of the described lesion are not typical of either of these, and are more in keeping with pleural fibroma. These are associated with HOA in 20–35% of cases and rarely with clubbing. They may arise in pleura adjacent to the chest wall or in a fissure, and can vary in size from 2 cm to 30cm in diameter. Tuberculosis is a rare cause of HOA. Rheumatoid arthritis is associated with bilateral periosteal reactions, but not HOA.
35) A 78-year-old man presents with superior vena caval syndrome. A CT scan shows an irregular mass in the superior mediastinum causing near-total occlusion of the superior vena cava. There is no sign of respiratory compromise or raised intracranial pressure. Which of the following would be the most appropriate next step in the patient’s management?
a. obtains tissue diagnosis
b. chemotherapy
c. radiotherapy
d. stenting of superior vena cava
e. surgical bypass
a. obtains tissue diagnosis
Wherever possible, definitive diagnosis should be obtained, as it will enable the best possible treatment. Dependent upon the cause of the obstruction, the correct therapeutic option can then be employed.
Radiotherapy often gives a good response, but, in small-cell lung cancer, chemotherapy often gives good results.
Stenting should be used when radiotherapy or chemotherapy has failed.
Surgical therapy is usually reserved for benign causes where conservative options have failed.
38) A 65-year-old male presents with a 2-month history of cough and dyspnea and has had swelling of the face, neck and arms for 1 week. He has had tuberculosis in the past. CT shows an irregular right paratracheal mass with calcification that is compressing the superior vena cava and right main bronchus, with patchy consolidation in the right lung. What is the most likely diagnosis?
a. small-cell carcinoma
b. lymphoma
c. malignant teratoma
d. fibrosing mediastinitis
e. bronchogenic cyst
d. fibrosing mediastinitis
Fibrosing mediastinitis is a rare condition which has two forms: focal (usually secondary to tuberculosis or histoplasmosis) or diffuse (often idiopathic).
When associated with tuberculosis, it is thought to be secondary to rupture of lymph nodes in the neck or mediastinum.
Calcification is seen in 63% of cases, but the mass may be difficult to differentiate from malignant conditions when calcification is not present.
Symptoms and signs are due to compression/obstruction of mediastinal structures.
Small-cell carcinoma and lymphoma can produce middle mediastinal masses, but calcification is rare, unless in treated lymphoma when progressive symptoms would be unlikely.
Malignant teratomas are typically anterior mediastinal masses which have well-defined lobulated margins, and usually do not calcify.
46) A 27-year-old female with known sickle cell disease has an outpatient appointment. She is feeling unwell and bloods show an anaemia. A chest radiograph shows a right-sided, lobulated, paramediastinal mass in the lower thorax with widening of the rib spaces. CT shows no calcification or bone erosion. What is the most likely diagnosis?
a. neurogenic tumor
b. bronchogenic cyst
c. Bochdalek’s hernia
d. tuberculous abscess
e. extramedullary haematopoiesis
e. extramedullary haematopoiesis
Extramedullary haematopoiesis occurs in conditions where there is prolonged anaemia. This can occur in the spleen, liver, lymph nodes, adrenals and many other sites. In the mediastinum it produces a rounded/lobulated, paraspinal soft-tissue mass, usually between T8 and T12.
Unlike other causes of paraspinal masses, there is usually no pain or bone erosion.
Bronchogenic cysts are of fluid density.
Bochdalek’s hernia can present in adults as a paravertebral mass, which is usually asymptomatic and contains fat as well as abdominal organs (bowel, kidney or spleen). It is usually left sided.
Tuberculous abscesses are usually associated with bone destruction.
Neurogenic tumors are rounded/ovoid and may extend through the intervertebral foramen into the spinal canal and/or produce bone erosion.
55) A 58-year-old male presents with malaise and left chest discomfort. A chest radiograph shows a well-defined mass in the left paravertebral region. CT shows that this is fatty but has soft-tissue stranding within it. Some enhancement of soft-tissue elements is seen along with foci of calcification. What is the most likely diagnosis?
a. lipoma
b. liposarcoma
c. hamartoma
d. neurofibroma
e. Thymolipoma
b. liposarcoma
Liposarcoma is an uncommon tumor in the thorax. It contains variable amounts of fat, with soft-tissue components that may enhance following intravenous contrast. Calcification may occur within these lesions.
Lipomas are more common and occur anywhere within the mediastinum.
Hamartomas usually present as soft-tissue nodules within the peripheral lung and classically show popcorn calcification. They may contain fat.
Neurofibromas present as paravertebral masses, often extending into the intervertebral canal, and may have fatty attenuation due to the presence of myelin.
Thymolipomas occur in the anterior mediastinum and are found in young adults.
59) A 52-year-old male presents with mild dyspnea. A chest radiograph shows a raised left hemidiaphragm which demonstrates paradoxical movement on fluoroscopy. Which of the following would be the likely cause?
a. Pancoast’s tumor
b. left lower lobe tumor
c. mediastinal small cell carcinoma
d. eventration
e. cerebrovascular accident
c. mediastinal small cell carcinoma
Diaphragmatic elevation with paradoxical motion is usually due to phrenic nerve paralysis. Mediastinal tumors are one of the commonest causes.
Pancoast’s tumors invade the brachial plexus, though they can uncommonly invade the phrenic nerve.
Eventration tends not to show paradoxical motion, though it can if large.
Strokes may cause diaphragmatic elevation, but due to bilateral innervation of the diaphragm, this is not usually due to phrenic nerve involvement and has other causes, such as weakness of chest wall muscles.
65) A 43-year-old female presents with stridor. A chest radiograph shows a superior mediastinal mass with narrowing of trachea and displacement to right. Foci calcification are seen within. What is the likely diagnosis?
a. thymoma
b. teratoma
c. aneurysm of the aortic arch
d. thyroid goitre
e. lymph node mass
d. thyroid goitre
Thyroid goitres extend into the mediastinum in 3–17% of cases. Tracheal displacement may occur due to any adjacent enlarging mass, but narrowing is specific for thyroid lesions, especially goitre. Calcification is common. Teratomas tend to arise more often in the anterior mediastinum, though they may involve the superior mediastinum by extension. Thymomas may arise in the superior or anterior mediastinum. Either of these may show calcifi
67) A 20 year old presents with shortness of breath and cough. A chest radiograph shows a well-defined right hilar mass. CT shows a 4 cm, rounded, soft-tissue mass arising from the mediastinum adjacent to the right side of the carina. The attenuation value of the lesion is 10 HU. No other abnormal findings are seen. What is the most likely diagnosis?
a. bronchogenic cyst
b. pericardial cyst
c. carcinoid tumor
d. lymphoma
e. bronchogenic carcinoma
a. bronchogenic cyst
Bronchogenic cyst is an abnormality of the ventral diverticulum of the primitive foregut and is the most common foregut abnormality in the thorax. Typical appearances are of a thin-walled cyst containing mucus or fluid. CT shows a well-defined mass of water density in 50% (0–10 HU) or slightly higher density in the rest (10–50 HU); 86% are mediastinal and 50% pericarinal. Pericardial cysts largely occur in the cardiophrenic angle and are rarely mediastinal. Like bronchogenic cysts, these may change shape with position and respiration. Carcinoids occur in the lungs within bronchi and are mainly central. These are solid and may calcify. Bronchogenic carcinomas are usually solid, and centrally located in 38% of cases, where they are usually small cell tumors. These occur in the older population. Lymphadenopathy secondary to lymphoma is usually solid (unless treated) and involves multiple nodes in 95% of cases. The anterior mediastinum and retrosternal lymph nodes are usually affected first.
80) A CT scan performed on a patient shows a soft-tissue mass in the medial aspect of the left lung, invading the mediastinum between the aortic arch and pulmonary artery. Neither vessel is compromised. Which symptom may the patient have presented with?
a. stridor
b. dysphagia
c. pain
d. swelling of face and neck
e. hoarse voice
e. hoarse voice
The space between the pulmonary artery and aortic arch is the aortopulmonary window, which contains the ligamentum arteriosum and the left recurrent laryngeal nerve. Invasion here by tumors can lead to paralysis of the left vocal fold, which attains a fixed adducted position, by involvement of the recurrent laryngeal nerve. Stridor and dysphagia could result from deeper invasion into the mediastinum, as the trachea and esophagus form the medial border of the aortopulmonary window. Swelling of the face, neck and upper limbs occurs with superior vena cava obstruction, which is a feature of right sided mediastinal disease.
89) A 20-year-old male has a chest radiograph following a slow-to resolve chest infection. There is a mass arising from the mediastinum on the right side. Teratoma is suspected. Which feature on CT would suggest that the lesion is more likely to be benign?
a. lobulated margin
b. calcification
c. pleural effusion
d. pericardial effusion
e. mass projecting from both sides of the mediastinum
b. calcification
A definite diagnosis as to whether a teratoma is benign cannot be made on radiological features. Features suggestive of a benign nature are a rounded lesion, projection from one side of the mediastinum, and calcification (especially if in the form of a tooth). A fat–fluid level is characteristic of a benign lesion but is rare.
Features more suggestive of malignancy are lobulated margins, invasion into adjacent structures (may cause pleural or pericardial effusions), and projection from both sides of the mediastinum.
1-A 42-year-old fit and well male has a CXR for emigration purposes. There is a rounded opacity in the right mediastinum. Subsequent CT chest reveals a 4.5 cm nodal mass with central calcification and marked enhancement following contrast administration. There are no focal lung lesions. Which is diagnosis?
a) Castleman’s disease
b) Colorectal cancer metastasis
c) Langerhans’s cell histiocytosis
d) Non-Hodgkin’s lymphoma
e) Silicosis
a) Castleman’s disease
Castleman’s disease is a low-grade B-cell lymphoid proliferation of unknown etiology. It can be localized or multicentral (multiple LNs, typically with systemic symptoms, with a poorer prognosis). The nodes may be as large as 16 cm, classically enhance avidly, and may have central calcification. Resection is curative in 90% of patients with the localized form.
Metastases from vascular tumors may also produce similar findings (e.g. melanoma, RCC, papillary thyroid cancer).
NHL can have similar features, but untreated lymphoma is not expected to produce calcified lymph nodes.
The acute disseminated form of LCH can be associated with lymphadenopathy, but this is usually generalized, the patient would be expected to be systemically unwell, and these nodes do not typically calcify.
8- In the staging of pleural mesothelioma, which of the following constitutes T4 disease?
(a) Invasion of a rib
(b) Invasion of the endothoracic fascia
(c) Invasion of mediastinal fat
(d) Invasion of the soft tissue of the chest wall
(e) Non-transmural invasion of the pericardium
(a) Invasion of a rib
The remaining scenarios constitute T3 disease.
9- A CXR is performed and shows a unilateral right-sided pleural effusion. Which of the following extra-pulmonary conditions is most likely to produce these appearances?
(a) Boerhaarve’s syndrome
(b) Gastric neoplasm
(c) Stanford type B aortic dissection
(d) Transection of the proximal thoracic duct
(e) Traumatic aortic rupture
(d) Transection of the proximal thoracic duct
Unilateral right-sided pleural effusions are associated with congestive cardiac failure and proximal thoracic duct transaction and, rarely pancreatitis (Which can be unilateral left (68%), unilateral right (10%) or bilateral, in 22%)- Unilateral left-sided pleural effusions include those mentioned and transection of the distal thoracic duct- The vast majority of traumatic aortic transections occur at the isthmus, distal to the left SCA origin, thus result in left-sided pleural effusions.
30- With regard to the thymus, which of the following statements is true?
(a) 30—40% of patients with myasthenia gravis have a thymoma
(b) 10% of patients with a thymoma have myasthenia gravis
(c) Thymoma usually presents before the age of 40
(d) Cyst formation in the thymus is a feature of malignant degeneration
(e) The average age of thymoma diagnosis is less in patients with associated myasthenia gravis
(e) The average age of thymoma diagnosis is less in patients with associated myasthenia gravis
Thymoma typically presents around 50 years of age and is associated myasthenia gravis; the percentages values for (a) and (b) are reversed. Thymic cysts are benign and may be congenital or acquired, particularly after mediastinal radiotherapy.
34- According to the British Thoracic Society guidelines, ‘What distance between the lung edge and the chest wall constitutes a ‘large’ pneumothorax?
(a) >1 cm
(b) >2 cm
(c) >3 cm
(d) >4 cm
(e) >5 cm
(b) >2 cm
Measuring the volume of a pneumothorax from the 2—D chest film is difficult, not least because the distance from the chest wall to the lung edge varies along its course. These authors estimate 2 cm to be a 50% pneumothorax, although earlier papers would estimate it at 20%.
35- A 20-year-old woman undergoes a CXR as part of an occupational assessment. She is found to have an abnormal lesion in the right cardio phrenic space and subsequently undergoes CT examination which shows an anterior mass predominantly composed of fat fine higher attenuation linear structures within it. The lesion also contains some round, defined gas containing areas. What is the likeliest diagnosis?
(a) Liposarcom
(b) Pericardial fat necrosis
(c) Thymolipoma
(d) Diaphragmatic hernia
(e) Teratoma
(d) Diaphragmatic hernia
In the adult, congenital diaphragmatic hernias are typically asymptomatic.
The presence of gas within bowel loops is pathognomonic.
Mesenteric vessels typically appear as linear opacities.
If the lesion only contains omental fat, it can be difficult to differentiate from lipoma or liposarcoma.
5 You are asked to report the CXR of a 58 year old man. The request form simply states ‘shortness of breath’, there are no previous films available for comparison. There is bibasal atelectasis and pleural calcification is seen within the right hemithorax. What is the least likely of the following diagnoses?
(a) Berylliosis
(b) Prior haemothorax
(c) Radiation therapy
(d) Talcosis
(e) Tuberculosis
(a) Berylliosis
Pleural calcification can be due to infection (TB, healed empyema), trauma (healed haemothorax), radiation therapy, pneumoconiosis (asbestosis), talcosis, hyperparathyroidism. Berylliosis rarely involves the pleura.
@# 19 An adolescent male patient presents with dyspnoea, cough, and complains of feeling increasingly tired. The subsequent CXR shows a mass located within the anterior mediastinum. Which of the following is the most likely diagnosis?
(a) Bochdalek hernia
(b) Bronchopulmonary foregut malformation
(c) Extramedullary haemopoeisis
(d) Germ cell tumour
(e) Neuroblastoma
(d) Germ cell tumour
The other options are either exclusively or typically found within the posterior mediastinum.
The anterior mediastinum is the third most common site of primary germ cell tumour, after gonadal and sacrococcygeal location.
31 A 55 year old man undergoes a CT to assess pleural thickening previously noted on a chest radiograph. Which of the following features is not an indicator of malignancy?
(a) Involves mediastinal pleural surface
(b) Depth greater than 1 cm
(c) Volume loss
(d) Nodularity
(e) Pleural effusion
(e) Pleural effusion
Pleural effusions are seen in both benign and malignant pleural disease. In addition to the other signs, encasement of the lung by pleural disease is a feature of malignancy.
(MSK) 33 A 14 year old boy has a CXR which shows clear lungs, no cardiomegaly, an indistinct right heart border, decreased heart density and leftward displacement of the heart. Which of the following conditions is not associated with these findings?
(a) Prematurity
(b) Down’s syndrome
(c) Noonan’s syndrome
(d) Marfan’s syndrome
(e) Homocystinuria
(c) Noonan’s syndrome
These findings are those of pectus excavatum which is most usually an isolated abnormality, but in addition to the above is also associated with foetal alcohol syndrome. Other radiological signs include a horizontal course of the posterior portion of the ribs along with an accentuated downward course of the anterior ribs.
42 A 67 year old male non-smoker presents with cough, dyspnoea and weight loss. The CXR shows a large right sided pleural effusion which occupies three quarters of the hemithorax. There is no mediastinal shift. The film is otherwise normal. What is the most likely diagnosis?
(a) Congestive cardiac failure
(b) Bronchogenic carcinoma
(c) Meig’s syndrome
(d) Mesothelioma
(e) Pancreatitis
(d) Mesothelioma
Mesothelioma more typically produces a unilateral pleural effusion (only 10% of effusions will be bilateral) which is exudative and may be haemorrhagic. There is classically no mediastinal shift (‘frozen’ hemithorax) due to fixation by the pleural rind of neoplastic tissue. 5-10% of workers exposed to asbestos will develop mesothelioma (30x increased risk), with a latency period of 35 years; an occupational exposure history is not always present. Crocidolite is the most carcinogenic of the asbestos fibres (> amosite, > chrysotile).
