A 47-year-old man had a 2-month history of dysphagia and weight loss. Results of physical examination and chest radiography were essentially normal (Fig. 1). Subsequently, computed tomographic (CT) scanning revealed a large tumor in the middle mediastinum, with infiltration of the descending thoracic aorta and distal esophagus (Figs. 2A and 2B). The tumor compressed and partially invaded the heart (Fig. 2C).
Fig. 1 The appearance of the chest radiograph was normal except for a slight left diaphragmatic elevation.
Fig. 2 A) A necrotic lymph node is shown by a contrast-enhanced computed tomographic scan of the axial section at the subcarinal level (arrows). B) Invasion by the tumor mass, of the superior pulmonary vein, left atrium, descending thoracic aorta, and esophagus, in soft-tissue density, is visible on the axial section at the left atrial level (arrows). C) A lower section of the computed tomographic scan shows invasion of the left ventricle, inferior pulmonary vein, and descending aorta by the tumor mass (arrows).
Esophagoscopy showed external compression to the esophagus, 30 cm from the incisors, with intact esophageal mucosa; esophagography also showed the compression (Fig. 3). The patient underwent an exploratory thoracotomy. The tumor was stiff, and the visceral mediastinum was quite rigid. It was difficult to determine the degree of atrial and esophageal invasion. Incisional biopsy and lymph node sampling (stations 6 and 9) were performed. Pathologic examination showed diffuse, large B-cell lymphoma in both the tumoral tissue and the lymph nodes (Fig. 4). This case showed us that lymphoma at this location can be as invasive as a bronchial carcinoma.1,2
Fig. 3 Barium esophagography shows compression and a filling defect at the distal esophagus (arrows).
Fig. 4 A) Follicular structures with anthracotic pigmentation on 1 side and diffuse large uniform proliferation of malignant lymphoma cells (H & E, orig. ×10). B) Malignant lymphoma of diffuse, large B-cell type. There is intense staining for CD 20 (Immunohistochemistry, orig. ×100).
Footnotes
Address for reprints: Melih Kaptanoglu, MD, PK:702, 58141 Sivas, Turkey
E-mail: melih@ttnet.net.tr
References
- 1.Barth TF, Leithauser F, Joos S, Bentz M, Moller P. Mediastinal (thymic) large B-cell lymphoma: where do we stand? Lancet Oncol 2002;3:229–34. [DOI] [PubMed]
- 2.Wilder RB, Rodriguez MA, Medeiros LJ, Tucker SL, Ha CS, Romaguera JE, et al. International prognostic index-based outcomes for diffuse large B-cell lymphomas. Cancer 2002;94:3083–8. [DOI] [PubMed]