21 year-old man presenting with chest pain and shortness of breath, 15 lb weight loss, exercise intolerance, and anemia.
Normal physical exam.
Mildly anemic, normal cardiac enzymes.
The initial PA chest radiograph only showed non-specific enlargement of the cardiac sillhouette. An echocardiogram was performed(images not available), which demonstrated a right atrial mass. A CT and MRI was then performed. Both studies demonstrated a large mediastinal mass involving the SVC and right atrium. Supraclavicular lymphadenopathy was also seen. The MRI findings strongly indicated an infiltrative type process.
Dx: Hodgkin's Lymphoma
Dx Confirmed by: Ultrasound guided FNA and core needle biopsy of a supraclavicular lymph node.
Patient was found to have a large mass involving the right atrium on a recent echocardiogram.
This was an interesting case of a patient with vague symptomatology and a chest radiograph at presentation that was not very impressive, given the extent of disease that was later revealed with cross-sectional imaging. Ultrasound guided FNA was instrumental in clinching the diagnosis.
There are four classifications of Hodkin's Lymphoma. The first, nodular sclerosing, accounts for the majority of cases (40-75%)and has an intermediate clinical course. It is most common in young women. The least aggressive subtype is lymphocyte predominant and accounts for 5-15% of cases. The most aggressive is lymphocyte depleted (5-15%). Mixed cell is the other intermediate grade subtype accounting for 20 -40% of cases.
Hodkin's has a bimodal peak of incidence with the first and larger peak occurring in the 2nd and 3rd decades. The second peak occurs in the 5th or 6th decade. Symptoms are usually minimal initially with many patients presenting only with enlarged painless lymph nodes. Later signs and symptoms include systemic symptoms (fever,night sweats, anorexia, etc), bone pain following ETOH intake, and anemia.
Typically, the disease spreads in a contiguous fashion to adjacent lymph node groups. The Ann Arbor staging classification is commonly used for treatment planning which takes advantage of the predictable pattern of spread. Radiation therapy ports can thus be optimally directed.
Imaging characteristics of Hodkin's Lymphoma include anterior mediastinal and hilar adenopathy. These groups are almost invariably involved unlike nonHodkin's which presents without intrathoracic radigraphic abnormalities in approximately 50% of cases. Other intrathoracic lymph node groups are infrequently involved and virtually never involved without mediastinal involvement as well. Pulmonary, pleural, and chest wall involvement occur with varying frequency, but usually never without mediastinal involvement. CT is the imaging modality of choice for staging Hodkin's with PET scanning gaining prominence. CT is much less valuable for staging nonHodkin's lymphoma.
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