Contributed by Lawrence B Fialkow, DO, Beth Z Clark, MD, and Larry Nichols, MD
Published on line in December 2003
A male in his late 30s with a history of chronic alcohol abuse and depression presented the emergency room complaining of severe shortness of breath. A detailed history revealed that he had been relatively healthy until one month prior, when he began to experience progressively worsening shortness of breath. On physical examination, he was diaphoretic and in obvious distress, with a respiratory rate of 36, a heart rate of 120, and a seated blood pressure of 81/32. Decreased breath sounds were noted on the left side of his chest, and his trachea was deviated to the right. He was placed on a 100% non-rebreather mask and an arterial blood gas was taken: pH: 7.07, pCO2: 57, bicarbonate: 15.9, pO2: 96, O2 saturation: 91%. Initial radiographic studies revealed a large left pleural effusion with resultant mediastinal and tracheal shift into the right hemithorax. The patient was intubated and placed on a ventilator. A left chest tube was placed, with immediate drainage of approximately 4 liters of serous fluid. A repeat chest x-ray revealed a large superior mediastinal mass, suspicious for adenopathy or primary mediastinal tumor. He was started on intravenous fluids, antibiotics, and vasopressor support, but his condition continued to worsen. He was transferred to the MICU for further management, but went into cardiac arrest and was pronounced dead upon arrival.
Autopsy revealed a large mass in the superior mediastinum, measuring 20 x 16 x 10 cm, with a total weight of 1400 grams. The mass was firm, tan-white, and nodular, with areas of hemorrhage, and contained a foci of central necrosis measuring 1.5 cm. (Figs. 01 and 02)
There were extensive fibrous adhesions between the mass and the upper lobe of the left lung, and further examination revealed that the mass invaded through the pleural surface into the parenchyma. Completion of the autopsy revealed additional firm, tan-white nodules within the pericardium, liver, pancreas, jejunum, and rectum.
Leukocyte common antigen and CD20 were diffusely positive, staining the small cells and large anaplastic cells. CD30 stain showed positivity in large anaplastic cells and some positivity among small-to-medium-sized abnormal cells. Tumor cells were negative on the LeuM1 and CAM 5.2 stains, while CD3 and CD5 stains showed scattered positive small lymphocytes.