PARAESOPHAGEAL VARICES MIMICKING A MEDIASTINAL MASS MADE APPARENT BY ENDOSCOPIC ULTRASOUND

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A 77 year old male with alcoholic cirrhosis was admitted for progressive dyspnea. A chest x-ray showed a large right pleural effusion. Percutaneous catheter drainage was performed confirming a transudative effusion consistent with hepatic hydrothorax. Computed tomography (CT) scan of the chest with intravenous contrast demonstrated a large, lobulated, mediastinal mass extending from the superior mediastinum to the peri-aortic retroperitoneal space. CT-guided core needle biopsy obtained only bloody material. Cytology was hypocellular, consisting mainly of blood. No malignancy was seen and no clonality was demonstrated on flow cytometry. Due to suspicion of lymphoma referral was made for endoscopic ultrasound (EUS)-guided sampling of the mass. Radial array EUS revealed multiple round and oval anechoic masses in the posterior mediastinum extending inferiorly to the retroperitoneum. Using linear array EUS with doppler it became apparent the described masses were of vascular origin and biopsy was aborted. Subsequent CT of the chest and abdomen revealed large paraesophageal, mesenteric and splenic varices, superior mesenteric vein thrombosis and dilatation and a nodular liver consistent with cirrhosis. The inferior vena cava (IVC) was uninterrupted and without thrombosis. The hemiazygous and azygous veins were markedly dilated at their origins. The large paraesophageal varices enhanced with contrast on venous phase imaging. In the setting of portal hypertension, dilatation of vascular anomolies, the normal azygous vein or paraesophageal varices can mimic mediastinal masses. Observational studies have shown the azygos vein is often significantly dilated in patients with varices. However, periazygos collaterals are only occasionally observed. A variety of mediastinal venous anomalies have also been described. One uncommon anomaly, azygos continuation, involves interruption of the IVC with absence of it's hepatic portion and hepatic vein drainage directly to the right atria. Our patient had large paraesophageal varices and no obvious vascular anomaly. The presence of vascular structures mimicking mediastinal masses highlights the importance of using delayed venous phase CT imaging or EUS with doppler flow to evaluate mediastinal masses in patients with portal hypertension. Percutaneous or transbronchial biopsy without the use of doppler may subject these patients to an unnecessary and high-risk procedure.