Lung Cancer |

A Rare Cause of a Mediastinal Mass With Adenopathy FREE TO VIEW

Tuhina Raman, MD; Mary Iacocca, MD
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Christiana Care Health System, Newark, DE

Chest. 2014;145(3_MeetingAbstracts):311A. doi:10.1378/chest.1827798
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SESSION TITLE: Cancer Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

PURPOSE: An 80 year old female nonsmoker presented with a 20 lb weight loss and dysphagia. She had a normal colonoscopy and esophagogastroduodenoscopy. She had no risk factors for tuberculosis and no travel to Midwestern or South eastern United States. On PE she had a BMI of 24 with no palpable adenopathy and a normal exam

METHODS: The chest tomography showed an anterior mediastinal mass in the retrocaval pretracheal space with a deviation of the trachea to the left and adenopathy in the aortopulmonary and subcarinal areas. There were no lung nodules, pleural effusions or lytic bony lesions. There were subcentimetre paraortic lymph nodes but no lesions in the liver, spleen, adrenal glands or kidneys. Labs revealed an LDH of 212 U/L with a normal CBC and chemistries.

RESULTS: She underwent bronchoscopy with EBUS guided TBNA of the mass and adenopathy. Additional biopsies were obtained using a 19G needle. Pathology confirmed an adequate sample with lymphocytes, scattered granulomata and necrotic debris. She went on to have a mediastinoscopy with partial excision of the mass which showed necrosis with scattered histiocytes and lymphocytes. All cultures were negative. Histoplasma serology was negative. Peripheral blood and lymph node flow cytometry was normal. The biopsy was sent to the Mayo clinic and a Congo red stain was performed showing apple green birefringence under polarized light microscopy consistent with amyloid further characterised as AL amyloid on mass spectrometry. Bone marrow analysis is pending at the time of this abstract.

CONCLUSIONS: Pulmonary involvement occurs in light-chain (AL) amyloidosis and includes laryngeal, tracheobronchial, parenchymal (localized and diffuse), and mediastinal adenopathy. Isolated adenopathy is exceedingly rare. Surgery is reserved for those cases with symptoms from obstruction or compression of the airways, vascular lumen or esophagus. Alternatively intraluminal stenting can be considered.

CLINICAL IMPLICATIONS: The differential diagnosis for mediastinal adenopathy includes lymphoma and metastatic malignancies, granulomatous diseases such as sarcoidosis and Castlemans disease and caseating infections such as tuberculosis and histoplasmosis. Amyloidosis should also be considered in this differential albeit rare

DISCLOSURE: The following authors have nothing to disclose: Tuhina Raman, Mary Iacocca

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