Presentation
SOB. Worsening dyspnea on exertion. Night sweats and weight loss. Reduced air entry left lower zone. Malignancy?
Patient Data
Mild elevation of the left hemidiaphragm.
Widening of the left superior mediastinum and the left paraspinal line at the level of the heart.
Lungs clear.
1.8cm left supraclavicular node.
4,2cm anterior mediastinal nodal mass. Further discrete prevascular, aortopulmonary, precarinal adenopathy measuring up to 2cm.
Posterior mediastinal adenopathy close to the descending aorta up to 4 cm.
Extensive retrocrural adenopathy measuring up to 4.5 cm.
No suspicious lung nodules. Moderate pericardial effusion. Left basal atelectatic change.
Large discrete para-aortic adenopathy, the largest measures 5 cm. 2.5 cm left para-aortic node shows areas of necrosis within.
No destructive bony lesions.
1.9cm supraclavicular node.
Verbal consent.
Three 16G cores taken.
An ultrasound of the scrotum was recommended at the suggestion of the pathologist attending the MDT, as a result of the supraclavicular node biopsy.
Several areas of ill-defined focal reduced echogenicity in the left testicle, the largest measuring 2.4 cm.
Normal right hemiscrotum.
Case Discussion
The final histological diagnosis was of metastatic testicular seminoma.
This was an interesting presentation both clinically and radiologically.
The paraspinal/mediastinal line abnormalities being the first radiological evidence of lymphadenopathy, which led to further investigations.
A lymphoma was by far the more likely diagnosis until the lymph node biopsy results led to ultrasound of the scrotum, that revealed the silent primary malignancy.
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