대한흉부영상의학회 Weekly Chest Cases

Case No : 921 Date 2015-06-22

Courtesy of Hyun Jung Kim, Myung Hee Chung / Bucheon St. Mary’s Hospital, The Catholic University of Korea
Age/Sex 42 / M
Chief ComplaintCough, blood tinged sputum for one month

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Diagnosis With Brief Discussion

Diagnosis: Nodular, sclerosing, Hodgkin lymphoma of the thymus with endobronchial involvement
Radiologic Findings: Chest PA shows a large lobulated mass in the Rt. hilar area. Chest CT scans show a low density consolidation with bronchial obstruction in the anterior segment of the right upper lobe. Another elongated nodule in the RML is observed closely attached to the RUL lesion. A necrotic large nodule in the Rt. anterior mediastinum and several small LNs in the Lt. prevascular space are noted. No direct continuation between the lung lesion and Rt. mediastinal nodule is noted.
Abscess was present on CT guided biopsy. Thereafter, TBLB and Rt. mediastinal nodule biopsy were done and nodular sclerosing Hodgkin lymphoma of thymic origin was confirmed.
On immunohistochemistry, normal thymic tissue with fat replacement was found in the mass. Classical Reed-Sternberg cells and its mononuclear variant were in a mixed inflammatory cell background. CD3 and CD20, which indicate normal T cells and B cells, were negative. Reed-Sternberg cells and its variants were CD30 and Pax5 positive.
Brief Review: Thymic enlargement is seen in 30–56% of patients with intrathoracic involvement at presentation. However, Hodgkin disease involving only the thymus is rare.
Patients with thymic involvement are younger (second to third decades of life) than those without enlargement. Most of the series showed male predominance.
Thymic lymphoma appears as a discrete or lobulated mass with typically homogeneous low attenuation. However, it can sometimes appear heterogeneous secondary to necrosis, hemorrhage, or cystic changes. The two morphologic criteria that can suggest the presence of an enlarged thymus are a triangular configuration of the mass or the presence of cysts.
Involvement of the lung parenchyma is relatively rare. In cases of unilateral hilar adenopathy, parenchymal involvement (if present) is seen in the ipsilateral lung.
The most common feature of primary pulmonary Hodgkin disease is the direct extension from hilar nodes toward the lung. The second most common feature is peripheral nodules with or without cavitation. There is a predilection for the upper lobes.
Radiologic patterns also include mass or mass-like consolidations and atelectasis of a lobe or segment. This may be due to bronchial compression by the nodes or to endobronchial disease.
On histologic study, nodular sclerosing Hodgkin disease is characterized by microscopic nodularity. Identification of Reed–Sternberg cells confirms the diagnosis.
References: Ali Guermazi, et al. Radiographics 2001;21:161-179
K. Wajdi, et al. Respiratory Medicine CME 3;2010:15-17
Eiser, N.M. and Samarrai, A.A.R. Thorax 30;1975:588-591
Keywords: Mediastinum, Airway, Lymphproliferative disorder,

No. of Applicants : 80

▶ Correct Answer : 2/80, 2.5%

- Niigata University , Japan Atsushi Uehara
- National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida

▶ Correct Answer as Differential Diagnosis : 25/80, 31.3%

- Juntendo University Hospital , Japan Akifumi Hagiwara
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- Avrasya Hospital , Turkey Murat Ulusoy
- Oita University, Faculty of Medicine , Japan Fumito Okada
- DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
- McGill University Health Center , Canada Alexandre Semionov
- Okayama University Hospital , Japan Toshiyuki Komaki
- Niigata City General Hospital , Japan Takao Kiguchi
- chp st martin , France Mariotte benoit
- Kashan University of Medical Sciences, kashan , Iran Ebrahim Razi
- The University of Tokyo Hospital , Japan Takeyuki Watadani
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Asan Medical Center , Korea (South) Soyeoun Lim
- Asan Medical Center , Korea (South) Jooae Choe
- Kizawa Memorial Hospital , Japan Yo Kaneko
- chungbuk university hospital , Korea (South) Hyeonmi Ryu
- IRSA La Rochelle , France Denis Chabassiere
- Gifu Central Hospital , Japan Haruo Watanabe
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- CHP St Martin , France mathieu namur
- Kizawa Memorial Hospital , Japan Shoji Okuda
- Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
- Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
- Medicheck health care , Korea (South) Chae Lim

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 921 Date 2015-06-22

Discussion

No. of Applicants : 80