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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 34-35

Signs may sometimes mislead you

Department of Pulmonology, Baby Memorial Hospital, Kozhikode, Kerala, India

Date of Submission10-Sep-2022
Date of Acceptance10-Oct-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Ravindran Chetambath
Navaneeth, Sarovaram Biopark Road, Kozhikode - 673 020, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jalh.jalh_29_22

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How to cite this article:
Kumar K P, Nandini V, Chetambath R. Signs may sometimes mislead you. J Adv Lung Health 2023;3:34-5

How to cite this URL:
Kumar K P, Nandini V, Chetambath R. Signs may sometimes mislead you. J Adv Lung Health [serial online] 2023 [cited 2023 Jun 11];3:34-5. Available from: https://www.jalh.org//text.asp?2023/3/1/34/365491

This elderly female patient, whose X-ray is shown in [Figure 1], was admitted with a short febrile illness. She had breathlessness on exertion for the past 3 years. There was no wheeze, stridor, or cyanosis. X-ray findings were disproportionate to her symptoms. There was a well-defined mass in the right upper zone with smooth margins. The medial border silhouettes with the superior mediastinum. There was a considerable mass effect on the trachea.
Figure 1: X-ray chest PA view of an 84-year-old female showing a well-circumscribed mass lesion in the right upper zone. What is the diagnosis? PA: Posterior anterior

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Being a superior mediastinal mass, it is important to distinguish whether it arises from the posterior mediastinum or anterior mediastinum. Cervicothoracic sign helps in differentiating the anterior from the posterior mediastinal mass.

  Cervicothoracic Sign Top

When the cephalic border of a mass is obscured at or below the level of the clavicles, it is deemed to be a "cervicothoracic lesion" involving the anterior mediastinum (positive cervicothoracic sign) [Figure 1]. Mediastinal masses posterior to the trachea are well outlined above the level of the clavicles (negative cervicothoracic sign) due to the interface with lung in the posterior aspects of the lung apices.[1] Superior mediastinal mass usually has a sharp well-delineated lateral border due to the aerated lung giving a good contrast. If it is in the anterior mediastinum, the superior border ends at the clavicle, as the anterior mediastinum does not extend beyond the clavicle [Figure 2]a. At the same time, the posterior mediastinal mass extends above the clavicle,[2] and the lateral border can be traced above the clavicle [Figure 2]b.
Figure 2: (a) Positive cervicothoracic sign, (b) Negative cervicothoracic sign

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On evaluating [Figure 1], the lateral border of the mass stops at the clavicle, and hence, the lesion is in the anterior mediastinum as shown in [Figure 3].
Figure 3: CT thorax - mediastinal window-showing a well-enhanced mass occupying the superior mediastinum. It compresses both trachea and esophagus. CT: Computed tomography

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The mass extends from the posterior mediastinum to the anterior mediastinum with a pressure effect on trachea and esophagus. It is a homogeneously enhancing mass with areas of necrosis. The base of the tumor is more toward the posterior aspect.

Then why the cervicothoracic sign is positive in the X-ray [Figure 1].

This can be explained by the projection of X-ray chest posterior-anterior (PA) view, where the anterior lesion is close to X-ray film and will be clearer and sharp when compared to the posterior part, which is distant from the film. Hence, in this case, even though the mass extends to the posterior mediastinum, the anterior part is denser and clearly visible to the eyes compared to more distant posterior part.[3] Hence, the onlooker has a visual illusion that the lesion stops at the clavicle like an anterior mediastinal mass. This is a fallacy of cervicothoracic sign.

Diagnosis: Index case [Figure 1]: Nerve sheath tumor.

Diagnosis: Comparator case [Figure 4]: Bronchogenic cyst.
Figure 4: X-ray chest PA view of a 35-year-old male patient presenting with chest pain. Is there any difference from X-ray shown in Figure 1? PA: Posterior-anterior

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Differential diagnosis for a posterior mediastinal mass includes:[4]

  • Neoplasm

    • Neurogenic tumors:

      • Schwannoma
      • Neurofibroma
      • Malignant peripheral nerve sheath tumor
      • Paraganglioma
      • Chemodectoma
      • Pheochromocytoma
      • Neuroblastoma
      • Ganglioneuroblastoma
      • Ganglioneuroma

    • Nonneurogenic tumors:

      • Chordoma
      • Chondrosarcoma
      • Ewing sarcoma
      • Esophageal neoplasm
      • Lymphoma
      • Metastasis

    • Infection

      • Paraspinal abscess

    • Vascular

      • Descending thoracic aortic aneurysm
      • Lymphangioma

    • Others

      • Neurenteric cyst
      • Esophageal duplication cyst
      • Bronchogenic cyst.

  Conclusion Top

Cervicothoracic sign and the lesions presenting with negative cervicothoracic sign are discussed in the article.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Felson B. Localization of intrathoracic lesions. In: Felson B, editor. Chest Roentgenology. Philadelphia: W.B. Saunders Company; 1973.  Back to cited text no. 1
Algın O, Gökalp G, Topal U. Signs in chest imaging. Diagn Interv Radiol 2011;17:18-29.  Back to cited text no. 2
George PP, Irodi A, Nidugala Keshava S, Lamont AC. 'Felson Signs' revisited. J Med Imaging Radiat Oncol 2014;58:64-74.  Back to cited text no. 3
Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors: Part II. Tumors of the middle and posterior mediastinum. Chest 1997;112:1344-57.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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