Fibrosing mediastinitis

Case contributed by Dr Gaurav Som Prakash Gupta

Presentation

Hoarseness of voice (left vocal cord palsy), cough with hemoptysis

Patient Data

Age: 65
Gender: Male
CT
There is evidence of almost contiguous soft tissue seen in the region of the carina and extending into aorto-pulmonary window and laterally along the left main bronchus and subsequently along the left lower lobe bronchus. Superiorly it is extending in left paratracheal region, causing obliteration of mediastinal fat and dislacing the arch of aorta. Inferirly, it is extending minmally into the posterior mediastinum and causing obliteration of fat planes in this region. It is also extending alon the posterior wall of the intermedeate bronchi and anterior wall of the esophagus. Posterior it is extending along
This soft tissue appears to be encasing the left main pulmonary artery; as a result the calibre of the left main pulmonary artery is reduced and it shows smooth luminal narrowing. The main pulmonary trunk and the right main pulmonary artery as a result of the narrowing of left pulmonary artery appear to have increased in calibre as a compensatory dilatation. (The pulmonary trunk measures approximately 28mm while the aorta at the same level measures approximately 25mm. The right main pulmonary artery measures approximately 19mm to 21mm while the left main pulmonary artery measures only approximately 9.2mm.)
There is evidence of at least two discrete lymph nodes in the pre-tracheal region in the superior mediastinum, largest of them measuring upto 15mm x 11.3mm.
This soft tissue is also seen encasing the segmental branches of the left pulmonary artery in the lower lobe region.
There is also evidence of obliteration and encasement of the superior segment of left lower lobe, due to presence of mass like lesion which is also getting merged with the rest of the soft tissue lesion described above. This mass like lesion measures approximately 16mm x 20mm and shows lobulated margin.
 
This soft tissue appears to have attenuation values in the range of 25 to 30HU in pre-contrast images and shows mild homogeneous contrast enhancement in post contrast images with attenuation values reaching upto 45 to 50HU.
 
There is evidence of at least 2 patch of wedge shaped subpleural lesions, seen in relation within the superior segment of the left lower lobe. No definite air bronchogram is noted in these patches and no signficant contrast enhancment is noted in this region- in present clinical context, these wedge shapd lesions may reperesent pulmunory infarctions.
There is also evidence of a small area of ground glass haziness seen in the apical segment of left upper lobe. A band-like shadow is also noted in the left lower zone which may represent plate atelectasis. 3 to 4 randomly distributed pulmonary nodules are noted in the superior segment of right lower lobe showing tree and bud appearance.
Rest of the lung fields appears normal.
 
There is evidence of extensive osteoarthritic changes in the dorsolumbar spine, otherwise visualized bones appear normal. Few small insignificantly appearing axillary lymph nodes are noted. No obvious significant lymph node detected in the supra-clavicular region.
 

CECT findings are consistant with  (noncalcified diffuse type) mediastinal fibrosis (fibrosing mediastinitis).

 

Case Discussion

Other less likely differential diagnosis may include- 

  • lymphomatous lesion
  • small cell carcinoma with mediastinal involvement
  • desmoid tumor.
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Case information

rID: 25857
Case created: 12th Nov 2013
Last edited: 30th Sep 2016
System: Chest
Inclusion in quiz mode: Included

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