Mediastinal lymphoma

Case contributed by Dr Bruno Di Muzio

Presentation

Chest pain and fever.

Patient Data

Age: 24-year-old
X-ray

Chest radiograph

There is a large left perihilar rounded opacity measuring almost 5 cm in size a further small focus of patchy airspace opacification laterally within the left upper lobe. The right hilar region and lung are clear. No evidence of cavitation. No rib erosion or splaying. The opacity is either mediastinal (favoured) or intrapulmonary. CT chest is recommended for further evaluation.

CT

CT Chest

Large heterogeneous mediastinal mass with involvement of mediastinal structures. In particular, there is encasement and mass effect on the main and left pulmonary artery as well as the left main bronchus. Nodular parenchymal opacities are seen within the left upper lobe. Although, the exact aetiology is uncertain, the differential diagnosis includes lymphoma.

Nuclear medicine

PET CT (selected images)

Selected image of PET-CT demonstrating markedly increased uptake by the anterior mediastinal tumour with some central areas of lower uptake probably reflecting necrosis. 

CT

CT-guided mediastinal biopsy

With the patient in supine position, the target mass was identified by CT imaging and correlated with previously contrasted scans. The skin was prepped and draped in usual sterile fashion. Local anaesthesia was performed using 1% lidocaine. Under CT guidance the core biopsy procedure using an 18G true-cut needle was performed, and three samples were obtained. 

MICROSCOPIC DESCRIPTION: The core biopsy contains lymphoid proliferation. There are scattered atypical lymphoid cells forming sheets and nodules, surrounded by fibrous tissue. The atypical lymphocytes are large in size. They have enlarged clefted and hyperchromatic nuclei, prominent nucleoli and scanty cytoplasm. The background contains small mature lymphocytes and histiocytes. No granulomas are noted. The tumour cells are CD20, CD30 (weak, focal), CD45, PAX-5, OCT-2, BOB-1, bcl-2 (focal), bcl-6 (focal), p53 and MUM1 positive. The Ki-67 index is about 95% (counting only the large cells). c-Myc stains about 30% of the large cells. They are CD3, CD10, CD15, TdT, ALK-1 and EBER-CISH negative. The features are those of diffuse large B-cell lymphoma, with activated B-cell-like phenotype. It is not possible to determine whether this is primary mediastinal large B-cell lymphoma or from systemic lymphoma on histology and immune profile alone.

DIAGNOSIS: Anterior mediastinal mass biopsy: Diffuse large B-cell lymphoma.

Report courtesy of the Royal Melbourne Hospital radiology department. 

Case Discussion

This case shows the full workup in a young patient since his presentation in ED with chest pain and fever until the final diagnosis provided by CT-guided core biopsy

Case confirmed as diffuse large B-cell lymphoma.

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Case information

rID: 48287
Case created: 29th Sep 2016
Last edited: 16th Jan 2017
System: Chest
Tag: rmh
Inclusion in quiz mode: Included

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