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Weekly Chest CasesArchive of Old Cases

Case No : 1492 Date 2026-05-25

  • Courtesy of Ji Young Lee, Jiyoung Song, Taehee Lee / Seoul National University Hospital
  • Age/Sex 65 / F
  • Chief ComplaintCough
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Mediastinal paraganglioma
Radiologic Findings
Fig 1. On the PA chest radiograph, a mediastinal bulging contour is noted, causing loss of the normal aortopulmonary window silhouette.
Fig 2. On contrast-enhanced chest CT, there is an intensely and heterogeneously enhancing soft-tissue mass with an internal necrotic area and prominently engorged peripheral vascular structures in the left paratracheal area of the middle mediastinum.
Fig 3. On MRI, a mass shows mixed high and low signal intensities on both T2-weighted and T1-weighted images, with internal T2 signal voids suggestive of high-flow vessels. Gadolinium-enhanced T1-weighted images demonstrate heterogeneous enhancement with suspected internal necrosis.
Fig 4. On PET-CT, the mass demonstrates hypermetabolism.
Brief Review
Paragangliomas are rare neuroendocrine tumors of extra-adrenal paraganglionic tissue and are indistinguishable from pheochromocytomas at the cellular level. They manifest clinically with mass effect, or symptoms of catecholamine excess such as episodic hypertension, tachycardia, palpitations, or diaphoresis.
Paragangliomas are usually located in the abdomen or skull base and neck area, along distributions of the sympathetic and parasympathetic ganglia, respectively. About 2% of paragangliomas are found in the mediastinum, where they represent a small percentage of mediastinal masses.
Mediastinal paragangliomas typically appear as intensely and heterogeneously enhancing hypervascular masses located adjacent to the airways, major vessels, or the heart. Due to their rich vascularity, they show marked enhancement after intravenous contrast administration. On MRI, high-velocity flow within intratumoral vessels produces the characteristic “salt-and-pepper” appearance, with flow voids on T2-weighted images. Additional imaging features may include cystic change, necrosis, intratumoral hemorrhage, and calcification.
The differential diagnosis of a hypervascular mediastinal mass is limited and includes vascular malformations, thymic carcinoids, Castleman disease, and certain metastatic tumors such as renal cell carcinoma. Chest CT with intravenous contrast is effective in diagnosing paragangliomas of the mediastinum. MRI or radioisotope whole body imaging such as the MIBG scintigraphy and Gallium 68 (68-Ga) 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-octreotate (DOTATATE) positron emission tomography (PET), can often help distinguish paragangliomas from other hypervascular mediastinal masses and help locate paragangliomas elsewhere in the body. In addition, delayed Gadolinium enhancement on MRI can provide valuable presurgical information by detecting tumor encapsulation and tissue invasion.
Surgical resection remains the preferred method of treatment for localized mediastinal paragangliomas, especially when symptomatic. Radiation therapy has also been used for advanced or unresectable tumor.
References
1. Kanj AN, Young WF, Ryu JH. Mediastinal Paraganglioma: A retrospective analysis of 51 cases. Respir Med. 2023;216:107296.
Keywords

No. of Applicants : 80

▶ Correct Answer : 44/80,  55.0%
  • - Chonnam National University Hwasun Hospital , Korea (South) KWANGKUN CHO
  • - Teikyo University Hospital , Japan ISSEI FUKUDA
  • - , Japan HIROKI SAKURADA
  • - Kyoto University , Japan AKIHIKO SAKATA
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Oita university , Japan AYUMI KAMEI
  • - Kyoto University Hospital , Japan YUSUKE UTSUNOMIYA
  • - Kyeongpook National University Hospital , Korea (South) JUNGMIN LEE
  • - Other , Korea (South) SEONGSU KANG
  • - Secomedic Hospital , Japan FUMINORI MIYOSHI
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Seoul Medical Center , Korea (South) HATAEK JEONG
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - QATIF CENTRAL HOSPITAL , Saudi Arabia HANI M ALSALAM
  • - Osaka University , Japan AKINORI HATA
  • - University of Yamanashi , Japan HIROYUKI MORISAKA
  • - The Catholic University of Korea Seoul St. Mary , Korea (South) JIHO PARK
  • - Teikyo University Hospital, Mizonokuchi , Japan TOSHIHIRO FURUTA
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - Otsu Red Cross Hospital , Japan JUN YOSHIDA
  • - , Korea (South) HYOUNG YEOB KIM
  • - Chonbuk National University Hospital , Korea (South) YEEUN LEE
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - , Japan SHUNJIRO NOGUCHI
  • - Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Chonnam National University Hospital , Korea (South) SANGYONG BAK
  • - Seoul Medical Center , Korea (South) HANSEUL CHO
  • - Kyung Hee University Medical Hospital , Korea (South) JEONG TAEK YOON
  • - Chonnam National University Hwasun Hospital , Korea (South) SEUNGSIK CHANG
  • - Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
  • - , Korea (South) LEE HYE IN
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Ehime University , Japan TOMOHISA OKADA
  • - Ehime University , Japan KOTARO MATSUMOTO
  • - Shiga University of Medical Science , Japan RYO UEMURA
  • - The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
  • - , Korea (South) JIYUN KIM
  • - University of Yamanashi , Japan KOJIRO ONOHARA
  • - Chonnam National University Hospital , Korea (South) JAEBONG YANG
  • - , Japan YUJI OHIZUMI
  • - Fukuoka Central Hospital , Japan YUKIHISA TAKAYAMA
▶ Correct Answer as Differential Diagnosis : 15/80,  18.8%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Chonnam National University Hospital , Korea (South) HYUNJIN KIM
  • - , Italy PAOLO BALDASSARI
  • - Chiba University Hospital , Japan HIROKI MIYAZAKI
  • - Chonbuk National University Hospital , Korea (South) JUNGHOON OH
  • - Other , Korea (South) CHAEHUN LIM
  • - Shiga General Hospital , Japan YUSAKU MORIBATA
  • - GHICL , France MANUEL TOLEDANO
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - , Japan TOMOHIRO KAWAJI
  • - Kyoto University , Japan SHO KOYASU
  • - URN , Japan PROTON SPIN CHAN
  • - Matsunami General Hospital , Japan TARO TAKEDA
  • - Kosin University Gospel Hospital , Korea (South) MINJUN SHIM
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