CC: 3 weeks of chest pain and dry cough

ID: 56 yo female with migraines and uterine cyst presents with sharp, non-exertional chest pain and dry cough for the past 3 weeks.  She was found to have a mediastinal mass on CXR and 6% peripheral blasts.  Bone marrow biopsy revealed B-lymphoblastic leukemia/lymphoma.

Don’t forget:

• To evaluate whether a mass on an upright CXR arises from the mediastinum or the lung, consider the following:
  • does the mass seem to touch the mediastinum or heart border?
  • are the borders of the mass smooth and sharp (instead of spiculated)?
  • are the angles at which the mass meets the mediastinum obtuse?
  • are the borders of the mass smooth (instead of lobulated or undulating)?

If the above answers are “yes,” it suggests that the mass is mediastinal rather than from the lung.

• The anterior, middle, and posterior mediastinal compartments are theoretical – there are no surgical or anatomical planes that create a clear division (hence, different radiology groups define each compartment a little differently).  Therefore, a mediastinal mass can be found in more than one compartment.

Mediastinal Masses (PDF)

Pearls from morning report:

• Lymphomas encase, but do not compress adjacent structures.
• Not all malignancies will result in tumor lysis syndrome (TLS).  TLS is seen most frequently in high grade lymphomas, acute leukemia, and rapidly proliferating tumors
• Indications for HD in TLS include hyperphosphatemia-induced symptomatic hypocalcemia, persistent hyperkalemia, and severe oliguria or anuria.

Random trivia:

Wilhelm Röntgen, a German physicist and mechanical engineer, produced and detected X-rays in 1895.  X-rays are named as such to signify an unknown quantity.  They are also known as roentgenograms (röntgenograms) – named in his honor.

Want to read more?

The Tumor Lysis Syndrome (New England Journal of Medicine)

References: 

Whitten CR, Khan S, Munneke GJ, Grubnic, S. A diagnostic approach to mediastinal abnormalities. Radiographics. 2007;27(3):657-71.