An Incidental Lymphoma

Abstract

Introduction:Hodgkin's lymphoma is a diagnosis noted among 7% of childhood cancers and is responsible about 1% of childhood cancer related deaths in the US, with the age presentation between 15 to 19 years. The most common symptoms include lymphadenopathy, fatigue, anorexia, weight loss, low-grade fevers, night sweats that are classified as B symptoms and a mediastinal mass that may cause dysphagia dyspnea orthopnea cough stridor or superior vena cava syndrome. Though occasionally identified as an incidental finding on chest x-ray, it is crucial to identify and differentiate from other mediastinal masses as they have a favorable prognosis. We present a 19-year-old Navy recruit found to have a large mediastinal mass on routine chest x-ray that was later diagnosed to be Hodgkin's lymphoma with extensive mediastinal, hilar and paratracheal and pericardiac lymphadenopathy. Case report:A 19-year-old recruit with no significant past medical history was being evaluated during military intake, was found to a mediastinal mass on routine chest x-ray. He denied any symptoms, and had a normal physical examination without any abnormal heart or lung sounds. His labs showed an erythrocyte sedimentation rate of 33 mm/hr, lactate dehydrogenase 231 U/L, ferritin 140 ng/mL, covid 19 negative. A CT of the abdomen and pelvis showed large multilobulated hypo enhancing mass in the superior mediastinum, paratracheal region, pericardiac region, cardio phrenic region consistent with a lymphoid mass, without splenomegaly, or evidence of enlarged abdominal or pelvic lymph nodes ( Figure 1). PET scan showed extensive hypermetabolic mediastinal and hilar lymphadenopathy with largest nodal conglomerate measuring 8 cm in the anterior mediastinum with an SUV max of 13.1, additional large nodal conglomerate in the right paratracheal region measures up to 5.6 cm, hypermetabolic pericardiac lymph nodes extends along the pericardium identified both anteriorly and inferiorly without any aggressive osseous or other metabolically active lesions. Flow cytometry analysis showed predominantly T cells with some polytypic B cells that exhibit no immunophenotypic abnormalities. The mediastinal mass was biopsied and showed classic Hodgkin's lymphoma, nodular sclerosing subtype. He was subsequently started on Adriamycin bleomycin vinblastine, dacarbazine [ABVD] regimen. Discussion: The mediastinum is divided into various compartments namely the anterior middle and posterior compartments. Mass in the mediastinum mediastinal masses have a broad differential and can vary based on location in the compartments. The differential can include thymomas, teratomas, germ cell tumors, enlarged or ectopic thyroid, lymphomas. Early identification and treatment is crucial for a favorable prognosis and survival.