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Weekly Chest CasesArchive of Old Cases

Case No : 750 Date 2012-03-12

  • Courtesy of Jeung Sook Kim / Dongguk University Ilsan Hospital
  • Age/Sex 40 / M
  • Chief ComplaintIncidentally found abnormality
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Figure 1.

Diagnosis With Brief Discussion

Diagnosis
Thymoma, type AB (mixed)
Radiologic Findings
Chest PA and lateral views show sharply marginated large ovoid soft tissue mass in right cardiophrenic angle with obliteration of right cardiac border. Enhanced chest CT scans show heterogenous large ovoid solid masses with heterogenous enhancement and inner low density portion in right cardiophrenic angle.
Brief Review
Thymomas are benign or low-grade malignant tumors arising from the thymic epithelium. Thymomas represent 20% of all mediastinal neoplasms in adults; they are the most common anterior mediastinal primary neoplasm in adults. The peak prevalence of thymoma is during the fifth and sixth decades of life. Thymomas have no sex predilection. About one-half of thymomas are found in the upper and middle thirds of the mediastinum, and the remainder are found in the lower third. Patients with thymoma are frequently asymptomatic; however, 20%-30% of patients have pressure-induced symptoms such as cough, chest pain, dyspnea, dysphagia, hoarseness, or superior vena cava syndrome. One-third to one-half of thymoma patients develops myasthenia gravis. Patients with thymoma may also develop pure red blood cell aplasia, hypogammaglobulinemia, connective tissue disease, autoimmune disease, or inflammatory bowel disease.

At radiography, thymomas typically appear as sharply marginated retrosternal areas of increased opacity with smooth or lobulated borders. Thymomas may project to either side of the mediastinum and obscure the heart border.

On CT scans, thymomas usually appear as homogeneous solid masses with soft-tissue attenuation and well-demarcated borders. Thymomas may be oval, round, or lobulated and usually do not conform to the shape of the thymus. Large thymomas may show areas of cystic or necrotic degeneration. Calcification may be present in the capsule or throughout the mass. Well-defined fat planes between the thymoma and adjacent structures generally indicate absence of extensive local invasion. Certain findings, such as encasement of mediastinal structures, infiltration of fat planes, and an irregular interface between the mass and lung parenchyma, are highly suggestive of invasion. Pleural thickening, nodularity, or effusion generally indicates pleural invasion by the thymoma.

At MR imaging, thymomas commonly appear as homogeneous or heterogeneous masses with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. MR imaging can be used to help identify vascular invasion. Chemical shift MR imaging, which makes use of the difference in chemical shift ratio, can be valuable in differentiating thymic hyperplasia from thymomas and other thymic tumors.
References
1. Clinical and Radiologic Review of the Normal and Abnormal Thymus: Pearls and Pitfalls. RadioGraphics 2010;30:413-428
2. Lesions of the Cardiophrenic Space: Findings at Cross-sectional Imaging. Pineda et al. RadioGraphics 2007; 27:19-32
3. A Diagnostic Approach to Mediastinal Abnormalities. Whitten et al. RadioGraphics 2007; 27:657-671
4. The Thymus: A Comprehensive Review. Nishino et al. RadioGraphics 2006; 26:335-348
Keywords
mediastinum, benign tumor,

No. of Applicants : 111

▶ Correct Answer : 39/111,  35.1%
  • - University of British Columbia , Canada Amr Ajlan
  • - Kurashiki Seijin-byo Center , Japan Akihiro Tada
  • - Heart Center Pontica , Bulgaria VLADISLAV RUSINOV
  • - SNUH , Korea (South) Euijin Hwang
  • - radiologist, aditya imaging centre , India vivek patel
  • - Eulji Hospital Eulji University , Korea (South) Yunjung Kim
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Montreal , Canada Drago Le King
  • - Az Osp Santa Maria Terni , Italy angelo carloni
  • - Travancore Medical College , India Chary D
  • - Dong-A University Hospital , Korea (South) Ji-yeon Han
  • - Korea university , Korea (South) Sumin Ha
  • - McGill University Health Center , Canada Alexandre Semionov
  • - CHRU Lille , France Paul Lebert
  • - Hopital du Sacre Coeur , Canada Andrea Ojanguren
  • - Kohka Public Hospital , Japan Akitoshi Inoue
  • - All India Institute of medical sciences , India Justin Moses
  • - China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Hanyang University Hospital , Korea (South) Yo Won Choi
  • - Maimonides Medical Center , United States naomi twersky
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Asan Medical Center , Korea (South) Sang Min Lee
  • - Asan Medical Center , Korea (South) Hye Jeon Hwang
  • - Asan medical center , Korea (South) Hyun Joo Lee
  • - Saga University , Japan Ryoko Egashira
  • - Asan Medical Center , Korea (South) Ji Eun Kim
  • - Asan medical center , Korea (South) sang young oh
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - AMCH , India hage tadu
  • - Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
  • - Paramount Diagnostic & Research Centre , India Mahavir Swami
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - Goa Medical College , India Paresh Desai
  • - CHU Saint Pierre , Belgium Abd Alla Fares
  • - National Taiwan University Hospital , Taiwan Li-Ta Keng
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Centre Hospitalier Lyon Sud , France matthieu ROUSSET
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
▶ Correct Answer as Differential Diagnosis : 33/111,  29.7%
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - Kangdong Sacred Heart Hospital , Korea (South) Soo Jeong Yoon
  • - Onomichi municipal hospital , Japan Ryotaro Kishi
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - HIA Legouest - METZ , France Alban Gervaise
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - CHRU lille , France manuel toledano
  • - All India Institute of Medical Sciences , India Jitesh Ahuja
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
  • - Seoul St Mary Hospital , Korea (South) Chae Lim
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - chp st martin , France Mariotte benoit
  • - Kyung Hee University Medical center , Korea (South) Myung-Won
  • - Kyung Hee Universitiy Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - royal melbourne hospital , Australia kimchi kings
  • - Hanam sungshim hospital , Korea (South) CHANG IL KIM
  • - KOREA UNIVERSITY ANSAN HOSPITAL , Korea (South) in choi
  • - Seoul Soonchunhyang Univ Hospital , Korea (South) Seo Choi
  • - Inha Univ. hospital , Korea (South) JONGBUM KIM
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Iwate Medical University , Japan Akio Akahane
  • - IRSA , France, Metropolitan BIGOT
  • - Kangdong Kyunghee university medical center , Korea (South) Soyoun Shin
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - XiangYa hospital , China Xia Yu
  • - Private sector , Greece Vasilios Tzilas
  • - CLCC , France nicolas gautier
  • - Scans world , India Philson Mukkada
  • - Fukuyama daiichi Hospital , Japan Mototsugu Saeki
▶ Semi-Correct Answer : 12/111,  10.8%
  • - Japanese Red Cross Society Himeji Hospital , Japan Yuichiro Kanie
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - korea university , Korea (South) Hyelarn Lee
  • - MASAN , Korea (South) Kim Sang Hyeon
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
  • - Chonnam national univ. hospital , Korea (South) Choi Seul Gi
  • - Sunchun university hospital, Bucheon , Korea (South) So Young Bae
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - UWO , Canada S Lee
  • - NASA SCANS , India RAKESH BHATIA
  • - Chonnam national university hospital , Korea (South) SeungJin Lee
  • - Okayama university , Japan Mayu Uka
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