Dr. Pepe’s Diploma Casebook: Case 50 – SOLVED!


Dear friends,

Today I am presenting radiographs and CT of a 27-year-old male with fever and malaise. Leave me your thoughts and diagnosis in the comments section and come back on Friday for the answer.


1. Teratoma
2. Thymoma
3. Lymphoma
4. None of the above





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    34 Responses to : Dr. Pepe’s Diploma Casebook: Case 50 – SOLVED!

    1. genchi bari italia says:

      …e la LL?….Comunque bulky-linfoma

      • genchi bari italia says:

        ….scusa…la TC ?…

        • Jose Caceres says:

          Sorry, they will correct the mistake promptly.

          • genchi bari italia says:

            ….la regola dell 4 T per le masse del mediastino anteriore…timo-t-linfoma-tiroide-tumore germinativo: la presenza delle calcificazioni depone per tumore germinale( a-f-p, innalzamento)….Prego correggere la primitiva diagnosi che non teneva conto delle calcificazioni visibili solo con la TAC….Scusami tanto professore!

            • genchi bari italia says:

              …la “massa” nonostante le sue dimensioni, non infiltra le strutture circostanti ma le disloca e le comprime: se escludi la variante “matura” del teratoma, dovremmo indirizzarci verso una patologia “benigna”….Castleman’s disease?…

    2. Dinesh says:

      None of the above..
      Definitive diagnosis of mediastinal mass can not be given by CXR only… Anterior mediastinal location of lesion can be seen as it is silhouting ascending aorta. D/D includes all above is plus ascending aortic aneurysms.

      • Dinesh says:

        ROFL…. didnt realized there were CT images also..
        CT demonstrates anterior mediastinal mass without lobulation and multiple hyperdense foci (i think calcification… though its CECT may be ??? vessels) and hypodense foci (likely fat) within the lesion.. so my first d/d would be Teratoma.

    3. Vilma says:

      It looks more like a teratoma, but can be thymoma tumor.

    4. DAG says:

      CT demonstrates anterior mediastinal mass with multiple hyperdense foci (calcifications) and hypodense foci (likely fat) within the lesion…so I’m thinking teratoma (but it’s dificil to exclude thymoma).

    5. Mila says:

      Proffesor is very tricky!
      It might be as well thymoma or teratoma. But as it is the young male and tumor seems to infiltrate aortic arch- so it is probably malignant. I vote for seminoma.
      I can`t see the lymph nodes or are they enlarged?

      • Jose Caceres says:

        I don´t believe you can evaluate aortic infiltration with just two views. It is difficult enough with the whole study!
        This two views do not show any enlarged lymph nodes.

        • Mila says:

          So maby it`s the mass growing from the heart or pericardium?
          The patient has fever and malaise- I think it`s significant. Lymphoma don`t have calcifications unless they`re after radiotherapy.

    6. John Vasilakis says:


    7. gus says:

      Anterior Mediastinal Mass

      we can use the 6 “T”s to help us remember the causes of anterior mediastinal masses.

      •Thyroid lesions
      •Thymic lesions (and parathyroid masses)
      •Teratomas (and other germ cell tumors )
      •”Terrible” lymphoma (Lymphadenopathy)
      •Tortuous vessels (dissecting aorta, right arch)

      is a dense solid mass with peripheral and internal calcifications in anterior-medial mediastinum ,smooth in contour ,with out faty or cystic elements in a 27-year-old male with fever and malaise.

      -is not thyroid there is no conection (except of ectopic thyroid tissue)
      -is not thymic lesion (thymomas which usually occur in 5th or 6th decade )
      -is a young boy to has so many calcifications in a ascending aorta aneurism.
      it remains to be seen lymphoma after therapy, Teratomas with other germ cell tumors and trauma.

    8. Murzin says:

      Sooo… First one to consider is teratoma (mature) because of lack of infiltrations (on the pictures posted) calcifications- cntral and rim like (which can be also seen in thymoma and treated lymphoma, areas of low (fat) attenuation- also the lesion is central more typical for teratoma.
      DDX thymoma, less probable treated lymphoma.

    9. Adela says:

      I vote for thymoma.

    10. Yp says:


    11. Klodi says:

      The first hypothesis for me it’s a seminoma. It’s in the anterior mediastinum, over the heart, the symptoms. The patient is a little bit younger, and the mass is ispected to be more heterogenes with thymoma. Limphoma has no calcification before treatment.

    12. sameh khodair says:

      from the PA x – ray , I suggest it is a pulmonary aneurysm , axial sections of the CT will be helpfull

    13. gus says:

      professor what is this calcified branch in posterior aspect of the mass on sagittal view?is partial volume effect?

      • Dr. Pepe says:

        It is an enhanced external vessel. When I selected the image I didn’t realize that this shadow could be misleading.

    14. marta says:

      There is an anterior mediastinal mass with well defined borders. There are calcifications and areas of low attenuation on TC that could correspond to fat (I would like to measure them with a ROI). With all this I would say Mature Teratoma.

    15. Dylan says:

      CXR: large mass silhoutting mainly the right mediastinal border, causing an obtuse angle with the right lung.
      CT: large, anterior mediastinal mass, with areas of calcifications and low attenuation spots (fat). Based on the above mentioned descriptions, I’m leaning towards Teratoma.

    16. mymy nabayra says:

      i think teratoma…

    17. Marcy says:

      Because the Fat and calcified areas I would vote for a Germ cell tumor, like a Teratoma, followed by a Seminoma, both can have that appearance. Nevertheles it could not be so simple, It has to be something more…

    18. Luigi Cocco says:

      A very, very, very wonderful lesson!!!!!!!!!!!!! Many thanks and congratulations dr Pepe!!!!!!!!! I mistaked only one case, because i’m Radiologist after 44 years, mu father was Radiologist and my grandfather soo………