Clinical and Radiologic Review of the Normal and Abnormal Thymus: Pearls and Pitfalls

At imaging, the thymus appears in a variety of shapes and sizes, even in the same individual. It gradually involutes with age and may acutely shrink during periods of bodily stress. During the recovery period, it grows back to its original size or even larger, a phenomenon known as thymic rebound hyperplasia. These anatomic variations and dynamic changes appear to be the main source of confusion with pathologic conditions. In turn, these misinterpretations may lead to prolongation or alteration of the chemotherapy regimen or to unnecessary radiation therapy, biopsy, or thymectomy. Familiarity with the embryology, anatomy, and dynamic physiology of the thymus is essential to avoid unnecessary imaging or invasive procedures. Radiologists play a major role in differentiating normal thymic variants, ectopic thymic tissue, and nonneoplastic thymic conditions such as rebound hyperplasia from neoplastic conditions. Knowledge of the imaging findings of thymic tumors and their mimics may help radiologists arrive at the correct diagnosis.