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ITMIG Classification of Mediastinal Compartments and Multidisciplinary This copy is for personal use only. To order printed copies, contact [email protected] 413 CHEST IMAG ITMIG Classification of Mediastinal Compartments and Multidisciplinary I Approach to Mediastinal Masses1 NG Brett W. Carter, MD Marcelo F. Benveniste, MD Division of the mediastinum into specific compartments is ben- Rachna Madan, MD eficial for a number of reasons, including generation of a focused Myrna C. Godoy, MD, PhD differential diagnosis for mediastinal masses identified on imag- Patricia M. de Groot, MD ing examinations, assistance in planning for biopsies and surgical Mylene T. Truong, MD procedures, and facilitation of communication between clinicians Melissa L. Rosado-de-Christenson, MD in a multidisciplinary setting. Several classification schemes for Edith M. Marom, MD the mediastinum have been created and used to varying degrees in clinical practice. Most radiology classifications have been based Abbreviations: FDG = fluorodeoxyglucose, on arbitrary landmarks outlined on the lateral chest radiograph. A ITMIG = International Thymic Malignancy In- terest Group, JART = Japanese Association for new scheme based on cross-sectional imaging, principally multi- Research on the Thymus, SUVmax = maximal detector computed tomography (CT), has been developed by the standardized uptake value International Thymic Malignancy Interest Group (ITMIG) and RadioGraphics 2017; 37:413–436 accepted as a new standard. This clinical division scheme defines Published online 10.1148/rg.2017160095 unique prevascular, visceral, and paravertebral compartments based on boundaries delineated by specific anatomic structures at Content Codes: multidetector CT. This new definition plays an important role in 1From the Department of Diagnostic Radiol- ogy, University of Texas MD Anderson Can- identification and characterization of mediastinal abnormalities, cer Center, 1515 Holcombe Blvd, Unit 1478, which, although uncommon and encompassing a wide variety of Houston, TX 77030 (B.W.C., M.F.B., M.G., entities, can often be diagnosed with confidence based on location P.M.d.G., M.T.T.); Department of Radiology, Brigham and Women’s Hospital, Boston, Mass and imaging features alone. In other scenarios, a diagnosis may (R.M.); Department of Radiology, Saint Luke’s be suggested when radiologic features are combined with specific Hospital of Kansas City, University of Missouri– Kansas City School of Medicine, Kansas City, clinical information. In this article, the authors present the new Mo (M.L.R.d.C.); and Department of Radiol- multidetector CT–based classification of mediastinal compartments ogy, Chaim Sheba Medical Center, Tel Aviv, introduced by ITMIG and a structured approach to imaging evalu- Israel (E.M.M.). Recipient of a Certificate of Merit award for an education exhibit at the 2015 ation of mediastinal abnormalities. RSNA Annual Meeting. Received April 8, 2016; revision requested July 12 and received August ©RSNA, 2017 • radiographics.rsna.org 30; accepted September 20. For this journal- based SA-CME activity, the author M.L.R.d.C. has provided disclosures (see end of article); all other authors, the editor, and the reviewers have disclosed no relevant relationships. Address Introduction correspondence to B.W.C. (e-mail: bcarter2@ mdanderson.org). The mediastinum contains vital vascular and nonvascular structures See discussion on this article by Van Schil and and organs. Division of the mediastinum into specific compartments Heyman (pp 436–438). has traditionally been valuable in the identification, characterization, ©RSNA, 2017 and management of various mediastinal abnormalities. Numerous classification systems have been developed and used to varying de- SA-CME LeaRNiNg OBJectiVes grees by anatomists, surgeons, and radiologists. The most commonly used scheme in clinical practice is the Shields classification system, After completing this journal-based SA-CME activity, participants will be able to: whereas the traditional Fraser and Paré, Felson, Heitzman, Zylak, and Whitten models are used in radiologic practice (1–7). One scheme ■■Identify the boundaries and contents of the mediastinal compartments at mul- has been devised to bridge the gap between the various models (8). tidetector CT as outlined in the ITMIG Significant differences in the terminology and methods of mediastinal classification system. division or compartmentalization among these schemes have resulted ■■Describe the role of imaging modalities in confusion among health care providers and the inability to reliably such as multidetector CT, MR imaging, and FDG PET/CT in evaluating medias- localize some lesions to a specific mediastinal compartment because of tinal masses. inherent limitations in each classification. ■■Understand basic approaches to diag- The existing schemes used in radiologic practice represent ar- nosing mediastinal masses on the basis of bitrary nonanatomic divisions of the chest based primarily on the imaging features and clinical information. lateral chest radiograph. The lack of a classification scheme based on See www.rsna.org/education/search/RG. cross-sectional imaging is problematic, as multidetector computed 414 March-April 2017 radiographics.rsna.org describe mediastinal abnormalities and formulate TeacHiNg PoiNts relevant differential diagnoses. ■■ The lack of a classification scheme based on cross-sectional im- In 2014, the Japanese Association for Research aging is problematic, as multidetector computed tomography on the Thymus (JART) developed a four-com- (CT) and magnetic resonance (MR) imaging are predominantly used for diagnosis, evaluation, and management of mediasti- partment multidetector CT–based classification nal abnormalities and a growing number of mediastinal le- scheme for division of the mediastinal compart- sions are detected with multidetector CT studies performed for ments, which was derived from a retrospective lung cancer screening, cardiac screening, and other purposes. analysis of 445 nonconsecutive pathologically Therefore, a standardized classification scheme based on mul- proved mediastinal masses (11). On the basis of tidetector CT is necessary to appropriately describe mediastinal abnormalities and formulate relevant differential diagnoses. discussions with experts in the field of mediastinal ■■ In some cases, the multidetector CT appearance of thymic hy- diseases, the International Thymic Malignancy perplasia is not straightforward and a more nodular or bulky Interest Group (ITMIG) has modified the JART configuration may be present, which can mimic a thymic model and introduced a new definition of medias- epithelial tumor, lymphoma, or other soft-tissue neoplasm. In tinal compartments to be used with cross-sectional this setting, two options are available: (a) follow-up multide- imaging and adopted as a new standard (12). tector CT can be performed in ~3 months to allow a decrease in thymic size or (b) chemical shift MR imaging with in-phase In this article, we describe the new ITMIG and out-of-phase gradient-echo sequences. Thymic hyperpla- mediastinal compartment classification system sia and the normal thymus characteristically demonstrate loss based on cross-sectional imaging that can be used of signal on out-of-phase images due to the suppression of to accurately localize and characterize mediastinal fat interspersed between nonneoplastic hyperplastic thymus, lesions and assist in the formulation of focused whereas thymic epithelial neoplasms, lymphoma, and other soft-tissue malignancies do not demonstrate suppression on differential diagnoses and management strategies. out-of-phase images. Use of either of these options ensures Specific approaches to evaluation of abnormalities that unnecessary biopsies or surgeries can be avoided. in the prevascular, visceral, and paravertebral com- ■■ Internal heterogeneity resulting in soft-tissue attenuation at partments are presented here and primarily based multidetector CT may be due to hemorrhagic or protein- on multidetector CT. It is important to note that aceous components or infection of the bronchogenic cyst; in these approaches are not intended to include every this setting, MR imaging can be performed to confirm the possible entity that may be encountered in the me- cystic nature of the lesion, which demonstrates high signal intensity on T2-weighted images regardless of the other con- diastinum, but instead to provide a practical and tents. The presence of hemorrhagic, proteinaceous, or mu- realistic algorithm for the radiologist. Although coid content results in variable patterns of signal intensity on management strategies such as biopsy and surgery T1-weighted images. may be included when necessary, detailed treat- ■■ When a previously stable neurofibroma suddenly increases in ment strategies for individual lesions are beyond size, develops regions of heterogeneity, and/or invades ad- the scope of this article. jacent tissues, malignant transformation to a malignant pe- ripheral nerve sheath tumor should be strongly considered. In patients with neurofibromatosis type 1, there is a 10% life- Rationale and Methodology time risk of developing a malignant peripheral nerve sheath ITMIG has an established method of develop- neoplasm, and these lesions account for most cancer-related ing international standards for mediastinal dis- deaths in these patients. FDG PET/CT has demonstrated utility eases, which was used in this instance to develop in distinguishing malignant peripheral nerve sheath tumors from benign neurofibromas, with sensitivity of 95% and a practical
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