Case 9 – update 3

*For start of case see https://teamhaem.wordpress.com/2013/05/07/case-9-may-2013/  The rest of the updates are below*

What we know so far:

Our patient has an itch, some weight loss and SOB on lying down.  There’s no overt signs of SVCO such as venous distension but the team are suspicious and this is the main concern.  A chest XR confirms mediastinal mass.  A lateral is not done to see where it is located as we’re going to proceed to CT in anyway.  Differential diagnoses include:

  • Lymphoma – non-Hodgkin’s or Hodgkin’s
  • Thymoma
  • Thyroid-related
  • Sarcoid
  • Teratoma/germ cell tumour
  • Lipoma
  • Bronchogenic

Some of the results from previous have come back

  • LDH 340 u/L (reference range <250)
  • HIV 1&2 -ve

The team have been crying out for a CT scan and the radiologist agrees to do it.  As the suspicion is lymphoma a full CT staging is done.  A pregnancy test is negative.  The report shows:

“There is an irregular mass in the anterior mediastinum at widest diameter 12cm.  There is local compression of the SVC but not complete obstruction.  No pericardial or pleural effusion.  Lung fields normal.  In the rest of the chest there are no size significant lymphadenopathy.  No supraclavicular or axilliary lymphadenopathy.  No abdominal or inguinal lymphadenopathy.  No splenomegaly and no other abdominal abnormalities.  Bones normal.”

The reporting radiologist states she is suspicious of lymphoma.  Biopsy is advised.

So, we are suspicious of lymphoma. The cardiothoracic surgeons will perform a VATS biopsy in the next few days.

Questions:

  • What other staging investigations for lymphoma would you like to perform, bearing in mind chemotherapy and possibly radiotherapy will be used?
  • What would be your concerns about starting steroids immediately?

Please reply on Twitter and always include #teamhaem to allow others to follow your comments. Please join in the debate and learn about haematological problems along the way. The case will continue to  evolve over the coming week so keep checking #teamhaem for more information.

Please note – all cases on TeamHaem are entirely fictional to protect patient confidentiality.

TeamHaem are not a position of authority.  It is an educational platform to allow discussion

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Online education and discussion about all things haematological
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