Presentation
Sudden onset of left sided chest pain, radiating to left arm/left neck
Patient Data
There is blunting of left costo-phrenic angle indicating left pleural effusion.
The cardio-mediastinal silhouette is widened.
An irregular soft tissue lesion is noted involving the anterior mediastinum.
Moderate left sided pleural effusion with adjacent basal atelectasis is noted.
There is moderate pericardial effusion.
Case Discussion
Macroscopic description
A: EBUSH, station 4R bottom third trachea: multiple pieces of dark brown and lighter brown stringy tissue measuring in aggregate 10 x 5 x 4 mm
B: EBUSH, station 4L bottom third trachea: multiple pieces of dark brown stringy tissue measuring in aggregate 10 x 5 x 4 mm
Microscopic description
A+B: Blood clots, tiny fragments of cartilage, strips of benign ciliated respiratory epithelium and very small pieces of partly crushed lymphoid tissue.
The latter shows fibrosis and a diffuse infiltrate of large atypical cells with pleomorphic nuclei, often hyperchromatic with variably prominent nucleoli and fairly abundant cytoplasm. Specimen A shows tumor necrosis.
On immunohistochemistry the infiltrating cells are CD45(+), CD20(+), CD79a(+), CD10(-), CD3(-), CD5(-), BCL2(+), CD30(+ weak, heterogenous staining), A subset express MUM1(+). A small number appears as CD23(+). In minimal tissue, they appear BCL6(+). CD21 shows no FDC networks. The MIB1 proliferation is around 50%.
Comment: these very small EBUS biopsies show high-grade large B-cell lymphoma. The histology would be compatible with primary mediastinal large B-cell lymphoma.
Conclusion
Lymph nodes, stations 4R and 4L (EBUS): High-grade B-cell lymphoma.
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