PRIMARY MEDIASTINAL B CELL NON-HODGKIN’S LYMPHOMA PRESENTING AS SUPERIOR VENA CAVA SYNDROME AND PERICARDIAL EFFUSION IN TAMPONADE IN A 28-YEAR-OLD FEMALE: A CASE REPORT

Abstract

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mediastinal infiltration due to lymphoma occurs as a systemic dissemination of the disease in the majority of patients but can occur as a primary tumor in up to 10% of cases. Among primary mediastinal lymphomas, only less than 3% of all Non Hodgkin's lymphoma cases correspond to a rare subtype of lymphoma known as primary diffuse large B cell mediastinal lymphoma. CASE PRESENTATION: This is a case of a 28 year old female with no hypertension, diabetes, asthma or history of pulmonary tuberculosis treatment. She is a non smoker presenting with two week history of productive cough. Consult was done with diagnosis of upper respiratory tract infection with cefuroxime and ambroxol given. Subseqent onset of facial puffiness was noted with no dyspnea or dysphagia. Physical examination findings showed facial puffiness,engorged neck veins,indistinct heart sounds and vesicular breath sounds.No lymphadenopathy noted.Chest X-ray revealed a right superoanterior mediastinal soft tissue density and 2D echo showed moderate pericardial effusion with tamponade physiology. Insertion of pericardiostomy catheter was performed and pericardial fluid sent for analysis revealing negative results for Tuberculosis gene Xpert. Chest CT scan with contrast revealed a large, noncalcified heterogenously enhancing mass measuring 7.5 x 12.5 x 9.0 cm with marked compression of the left brachiocephalic vein and superior vena cava. IV dexamethasone initiated with referral to Interventional Radiology for CT scan guided core needle biopsy which showed histologic findings of Non Hodgkin’s B cell lymphoma. Referral to Oncology ensued and chemotherapy was done with vincristine, doxorubicin, cyclophophamide and prednisone with radiotherapy. Patient had resolution of symptoms and repeat chest CT scan after four months showed interval decrease in size of the anterior mediastinal mass. DISCUSSION: Primary mediastinal large B-cell lymphoma (PMLBCL) was first described by Van Heerdemn and collaborators in 1970. It is an aggressive lymphoma with diffuse proliferation of large B-cells occurring in young females.Our patient's presentation is typical of PMBCL which is almost always associated with superior vena cava syndrome responsive to IV steroids. 50% of patients have systemic B signs (fever, night sweats, and weight loss), pleural, or as seen in this case, pericardial effusion. Following pathologic confirmation of PMBCL, the decision was made to treat with CHOP therapy and radiotherapy which was well tolerated. Repeat imaging showed significant regression of the mediastinal mass with resolution of cough and SVC. CONCLUSIONS: PMLBCL lymphoma is a rare tumor with atypical behaviour given the tendency for secondary invasion to the pleura, pericardium,thoracic wall and lung resulting in superior vena cava syndrome and pericardial effusion. Prompt histologic diagnosis leads to timely intervention with radiotherapy and chemotherapy. Reference #1: Juanpere S, Cañete N, Ortuño P, et al. A diagnostic approach to the mediastinal masses. Insights Imag. 2013; 29-52. Reference #2: Duwe BV, Sterman DH, Musani AI. Tumors of the mediastinum. Chest. 2005;128:2893-909. Reference #3: Van Heerden JA, Harrison EGJ, Bernatz PE, et al. Mediastinal malignant lymphoma. Chest. 1970;57:518-29. DISCLOSURES: No relevant relationships by Eden Castro, source=Web Response