Presentation
Mediastinal lymphadenopathy for investigation.
Patient Data
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The mediastinal nodal disease is intensely metabolically active. Above the diaphragm, metabolically active nodes extend from the bilateral cervical level 5 nodes inferiorly with almost all mediastinal nodal stations involved. The lowest metabolically active thoracic node is located in a lower para-esophageal station.
Intense uniform symmetrical uptake is also evident in the submandibular glands although this may be physiological. Heterogeneous uptake is apparent in the parotids bilaterally.
Below the diaphragm focal uptake in the right pelvis is noted. A small 8mm right iliac node is seen adjacent to the activity, and there may be slight misregistration. The alternative is that of physiological urinary activity.
Mild uptake in subcapsular hepatic segment 4a noted.
Mild uptake in the lung bases is evidently associated with mild basal interstitial thickening, likely inflammatory.
Physiological uptake is evident elsewhere.
Macroscopy: "Left neck lymph node biopsy". Six fragments of core biopsy less than 1 mm, 2 mm, 4 mm, 4 mm and 6 mm.
Microscopy: The sections show fragments of lymphoid tissue composed of mature lymphocytes within which are numerous compact, non-necrotizing granulomata. Additional fragments of benign skeletal muscle and fibroadipose tissue are also present. No fungal elements or acid-fast bacilli are identified on special stains. There is no evidence of malignancy.
Conclusion: Non-necrotizing granulomatous inflammation.
Case Discussion
This case brings the appearances of mediastinal lymphadenopathy related to sarcoidosis without lung involvement (equivalent to stage 1). Note that the distribution of the nodes is relatively symmetrical, feature not commonly seen on lymphoma, although this is still a less likely differential diagnosis. Neck lymph-node biopsy has confirmed a granulomatous process.
Further workup with liver lesion has not shown any abnormalities in the segment IV (images not available).
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