Presentation
Chest pain.
Patient Data
There is enlargement of the hear silhouette and widening of the superior mediastinum contours with obliteration of the retrosternal region on the lateral projection. Also, there is a small right pleural effusion. The lungs and the left pleural space are clear.
There is an enhancing solid mass within the superior/anterior mediastinum that partially encases the ascending aorta, aortic arch, and supra-aortic branches, with likely compression of the left brachiocephalic vein and IVC. A large pericardial effusion is also present. Right-sided small pleural effusion with associated restrictive lung atelectasis. The lungs are otherwise clear. No suspicious osseous lesions.
Marked tracer uptake within the mediastinal mass with no other suspicious lesions identified on PET. Uptake within the colon was felt to reflect prominent physiologic uptake or inflammation.
CT-guided core-biopsy was then performed:
Macroscopy: Five pale core biopsies measuring 1, 5, 8, 12 & 14mm.
Microscopy: Multiple cores of tissue, show areas of necrosis, that subdivided by bands of dense fibrous connective tissue within which there is a cellular infiltrate. The cellular infiltrate varies, but in foci shows an admixture of scattered eosinophils, histiocytes and large atypical lymphoid cells, some appearing binucleate or with irregular multi nucleated appearing cells with moderately amount of cell cytoplasm. Many of the cells appear compressed due to the dense fibrous connective tissue. The large lymphoid cells immunoreactive CD30 and CD15 do not react with CD30 and CD20. A background population of CD 3 T lymphocytes and very scant CD 20 B lymphocytes. CD3 lymphocytes are seen and in places surround the large atypical lymphoid cells. PAX5 is weakly positive in some large cells. ALK immunoreaction is negative.
Conclusion: nodular sclerosing Hodgkin's disease.
Compared to the prior study, there has been metabolic resolution and a significant reduction in the size of the anterior mediastinal mass compatible with a complete metabolic response. Minimal FDG activity in the residual mediastinal mass is similar to mediastinal blood pool activity (Deauville score = 2). There has been metabolic and anatomic resolution of the previously demonstrated superior mediastinal, supraclavicular, pericardial and left pulmonary hilar disease also compatible with a complete metabolic response.
Diffuse moderate FDG activity in the marrow and spleen is compatible with reactive change post-chemotherapy. There has been the resolution of the previously demonstrated metabolic activity in the large bowel suggesting the resolution of inflammation/colitis.
Case Discussion
This case illustrates typical appearances of mediastinal Hodgkin's lymphoma, presenting as enlarged mediastinum contours due to a confluent lymph node mass that encases the vessels.
Follow-up CT and PET-CT after 2 cycles of chemotherapy (ABVD - doxorubicin, bleomycin, vinblastine, dacarbazine) are compatible with a complete metabolic response.
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