Q. Do I have to consult a specialist about the mediastinal lesion on the computed tomography (CT) scan?
Hi doctor,
I had a CT scan 24 days back, and it was normal. I then had another CT scan nine days back, and it showed a 1.8 x 1.3 x 4.8 cm mediastinal lesion. An indeterminate anterior mediastinal lesion is likely related to thymic gland abnormality and possibly thymic gland rebound hyperplasia or thymic gland neoplastic process. It does not appear well in the prior study and likely reflects rebound hyperplasia. But after reviewing the images, it does appear to be on the previous CT scan report. I plan to consult another radiologist to get an opinion on these scans. What is the small jagged edge area inside the enlarged thymus tissue? It stands out and is very noticeable. Kindly help.
Hello,
Welcome back to icliniq.com.
I understand your concern. It is quite natural to be worried about mediastinal or thymic lesions, and CT (computed tomography) scan is the best modality for their detection. However, the images (attachment removed to protect the patient's identity) that you have provided are not the proper ones. You have uploaded the "lung window" images specialized for lung lesions. There is another set of images in the "mediastinal window," which shows the lesion properly. Also, those images are in plain and contrast phases, and we need both to make an assessment. Therefore, the best would be if you could upload CD (compact disc), DICOM (digital imaging and communications in medicine), or digital formats of those images, or if you are unable to do so, please provide images of mediastinal window (both plain and contrast).
I hope you understand.
Thank you.
Regarding follow up:
Upload DICOM (digital imaging and communications in medicine) images.
Hi doctor,
Thank you for the reply. I have attached the CT scan that you asked for. The prior chest CT reports showed no abnormality. I have had quite a few chest CT scans in the past six months because I had a very small pulmonary embolism before six months. So anytime I mention chest pain, they run me through a CT. The radiologist said it was a mixed soft tissue and fatty anterior mediastinal lesion on axial series four images 29 and sagittal series image 93. Two of the doctors I have spoken with are unsure what to do. Please provide feedback on what you believe it may be, and if you could send images back to me, maybe putting arrows at the areas of concern, I would greatly appreciate it to share them with my doctor. Kindly help.
Hi,
Welcome back to icliniq.com.
I have gone through the images (attachment removed to protect the patient's identity) that you have provided, and quite clearly, there is an enlargement of the thymus, having a sort of bulged-out outline than concave. However, if you would upload them, I could have compared these with your previous CT (computed tomography) images. Nonetheless, an enlarged thymus has not taken up much contrast, nor has any calcification, cystic, or necrotic change, or invasion (those are good signs). The concept of thymic rebound is that the naturally shrunken thymus regrows in patients having steroid therapy, chemotherapy, etc. Have you been on any such regimen? It may simply be a rebound and may not require any further action. But if not, then benign thymic neoplasm, that is, the tumor would be the first consideration. In that case, your doctors may suggest you get a biopsy for confirmation, staging, or directly proceed to treatment options, which may involve surgery, radiotherapy, chemotherapy, etc. They may also think of a chest MRI (magnetic resonance imaging), where a thymic rebound would show a chemical shift and a tumor would not. So at this stage, you need to get back to your treating doctors and follow their advice. If you prefer to, you can upload a previous CT to make a comparison with the new scan (not very urgent, though). Lastly, whatever "jagged area" you noticed maybe an artifact or other technical issue unrelated to our physiology or disease. So, ignore it.
I hope you get well soon.
The Probable causes:
Thymoma.
Investigations to be done:FNAC (fine needle aspiration cytology), Biopsy, and MRI (magnetic resonance imaging).
Differential diagnosis:Thymic rebound.
Probable diagnosis:Thymoma.
Treatment plan:Excision.
Regarding follow up:With previous images, if comparison is required.
Hi doctor,
Thank you for the reply. I have attached the images from the previous CT scan so you can compare them. I do have a few more questions. So you believe this to be a benign process? I have not recently or in the past had any chemotherapy or steroids. My doctor told me about the new scan (series four image 37) that there is presumed thymic tissue with a nodule in the posterior aspect within the prevascular mediastinum. What measurements are you getting for the thymic tissue and the nodule sizes? I had an MRI two days back. My family doctor has never dealt with or treated a mediastinal mass, so he is not sure how to do this and solely relies on radiology reports. It makes me nervous because everyone has a different opinion. So I feel like he is leaving it up to me to research, get ideas, and develop a plan. I am already stressed enough. On the other hand, I worked in the medical field for 12 years, so I know quite a bit. I have also consulted a hematologist and oncologist because I had a small pulmonary embolism six months back. Would it be best to have a follow-up with them, or should I get a referral to a thoracic surgeon? Also, my doctor mentioned something about seeing an ENT? Not sure what they would do. Kindly help.
Hi,
Welcome back to icliniq.com.
Thanks for uploading the previous CT (attachment removed to protect the patient’s identity). I can feel your distress since you have to do the research yourself. I suggest you consult the hematologist or oncologist if that is easy for you. Then if they consider it necessary, they may refer you to a thoracic oncologist or thoracic surgeon. I have now seen both CT reports (previous and new). The thymic enlargement is crisp and clear on the new scan, which I described earlier. Without any other scans or history of chemotherapy and steroids, I would consider it a thymoma first. But on the previous scan, the lesion is not as prominent as to be identified outright and can be seen only in retrospect. That means there has been a sudden enlargement of the thymus, which considers a thymic rebound. That creates a dilemma since you do not have a history to explain rebound. One way to sort out the confusion may be MRI with chemical shift sequences, but the most definitive way is to do a biopsy. In this context, I would suggest you get in touch with the concerned specialists (oncologists or thoracic specialists) so that they can make a complete evaluation of your history, clinical condition, and previous medical records to make a precise diagnosis. I understand that it is stressful and confusing for you. Still, it will become effortless and easy once you attend the appropriate specialists since they have adequate experience directly dealing with mediastinal lesions. I do not think you need to consult an ENT (ear, nose, and throat) specialist for the thymus; maybe your doctor mentioned this for another purpose.
The Ambra viewer in our software does not offer measurement tools, but it provides a scale from which the lesion is around 2 x 2 x 4 cm. So, to sum up, I suggest you consult an oncologist or thoracic surgeon and follow their advice further.
Kindly revert in case of further queries.
The Probable causes:
Thymic rebound.
Investigations to be done:MRI (magnetic resonance imaging), biopsy, and FNAC (fine needle aspiration cytology).
Differential diagnosis:Thymoma.
Regarding follow up:Consult a oncologist.
So then I started researching more as over the last year I’ve been experiencing a lot of weird issues. A lot of the stuff I have wrong with me or symptoms I’ve been experiencing I thought maybe I had developed another autoimmune like lupus or RA. But all those blood tests came back fine. Then I discovered hyperparathyroidism.
Which then could possibly explain my bad episodes of PVS, and tachycardia’s, the left ventricle hypertrophy, the frequent kidney stones, the medullary
nephrocalcinosis, the kidney cysts, the extreme fatigue, body aches, brain fog, headaches, forgetfulness, GI issues, a lot of degeneration in my entire spine for someone who is 38.
So I went back and looked at prior blood work to look at the calcium in my blood. It’s normal. Usually between 9.5 and 10 whenever they run a comprehensive metabolic panel. But I also read that some people will have a normal calcium level with primary hyperparathyroidism.
I don’t know but it kinda makes sense. All I know is for the past year I haven’t felt well almost every single day.
now that you recollect some significant history including nephrocalcinosis, osteoporosis, ventricular hypertrophy etc... the idea of parathyroid adenoma indeed makes sense. perhaps that's why your drs considered consulting ENT. however, whether the mediastinal lesion is an ectopic parathyroid remains to be established, since it doesn't have significant enhancement.
therefore, it's now good that you'd be consulting oncologist who can guide you to the best next steps.
best wishes.
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