Case of the Month

Patient Demographics

Age: 45-year-old

Sex: Male

Presentation: Chest pain and dyspnea

Clinical History

A 45-year-old male patient presents with acute onset chest pain and progressive dyspnea over the past 6 hours. The patient reports no recent trauma or significant past medical history. Initial vital signs show mild tachycardia and normal oxygen saturation on room air.

Imaging Findings

High-resolution CT of the chest reveals a moderately large anterior mediastinal mass measuring approximately 6 cm in greatest dimension. The mass demonstrates heterogeneous enhancement with areas of necrosis and appears to displace the heart posteriorly. There is mild pericardial effusion but no evidence of tamponade physiology. The remainder of the lungs are clear without focal consolidation or pleural effusion.

Diagnosis

Mediastinal Mass - Likely Lymphoma

The imaging findings are most consistent with an anterior mediastinal lymphoma, likely Hodgkin's lymphoma given the patient's age and presentation. The heterogeneous enhancement pattern with necrosis is characteristic of lymphoid malignancy. Differential considerations include primary mediastinal B-cell lymphoma or thymic tumors. Further workup would include PET-CT, tissue diagnosis via biopsy, and staging studies.

Key Teaching Points

Anterior mediastinal masses in adults commonly include lymphoma, thymic tumors, and germ cell tumors
Heterogeneous enhancement with central necrosis suggests lymphoid malignancy
Pericardial effusion may occur with mediastinal masses but requires assessment for hemodynamic significance
PET-CT is essential for staging and assessing metabolic activity of suspected lymphoma
Cross-sectional imaging accurately determines the relationship of the mass to adjacent structures, crucial for surgical planning

References

Müller NL, Chiles C, Kullnig P. The CT appearance of pulmonary lymphoma. AJR Am J Roentgenol. 1992;159(4):751-755.
Strollo DC, Rosado de Christenson ML, Jett JR. Primary mediastinal tumors: part I. Front Radiol. 1997;175(5):455-462.
Lam S, Schut J, Pehrson S, et al. Anterior mediastinal masses. J Thorac Imaging. 2003;18(2):96-106.