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This is a case of a 24 year old woman who presented to the ED with a history

0:05

of shortness of breath, generalized malaise and fatigue

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and received a PA and lateral view of the chest.

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So again, we want to go through this in our standard fashion.

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And what we see here in the left lung field is that the lung field is clear.

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The right lung field, there is this little nodular density here,

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it's not clear if it's sitting in the bone or if it's sitting within the parenchyma,

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but the rest of the lung fields are really clear.

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A lot of these little punctate densities, I would probably say, are vessels on end.

0:34

What does grab my eyes when we go into our heart and mediastinal structures,

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while the heart is not enlarged, we do see an abnormal contour here

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in the right hilar region and this is actually just too large and big and bulky.

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So certainly concerned about adenopathy

0:51

that might be present in the right hilar area.

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But let's take a look at the lateral to see if we can better localize that.

0:59

And here on the lateral view,

1:01

we see nicely that the spine aligns, we see that the sternum aligns.

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But what we're missing here is a lot

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of the retrosternal clear space that we oftentimes see.

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And so where we did see a lot of the bulkiness on the frontal

1:14

on the right side, where I think it's really localizing here

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on the lateral, it's more in the anterior mediastinal region and it's the filling

1:21

in of this anterior clear space that's a little concerning to me.

1:24

So if we come back to our view here,

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we're seeing it here, maybe more right predominant, but it's more anterior.

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So you've got an anterior mass or lymph node sitting in a young patient here.

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We don't want to get so fixated on this

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that we don't actually complete our pattern of search.

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And so, we always want to take a look at our bones.

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And the ribs on the right look fine.

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The clavicle, scapula,

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what we see of the glenohumeral joint look fine. Looking at our ribs here on the left,

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but the clavicle on the left, here

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at the distal portion, it's not completely seen,

1:59

has a very permeative, almost a moth-eaten appearance.

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Let me blow that up for you so that you can see it more deliberately.

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And perhaps, if you weren't paying attention and didn't go through your

2:09

pattern of search each and every time, you'd have satisfaction of search,

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you've got this big mass that's capturing your eye, but not really noticing

2:16

that there's also a lytic lesion here in the distal clavicle.

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So in a very young patient,

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while malignancies are unusual, one of the malignancies that is actually

2:27

not uncommon is lymphoma, and certainly can have permeative bone lesions.

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So let's just go back and look at the big picture here.

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And what we would recommend in this case

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is, or certainly, we would report out that there is an anterior mediastinal mass

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with lytic permeative lesion involving the left clavicle.

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This constellation of findings is

2:47

concerning for lymphoma with metastatic disease.

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A CT would be recommended for further evaluation.

2:53

And we would recommend that CT with IV

2:56

contrast. Certainly, this little nodule here, it's not clear if it's in bone,

3:00

but when we get the CT, we'll be able to figure out whether or not

3:03

that's something that's parenchymal, or whether or not that's something in bone,

3:06

if it's benign or part of this larger constellation.

3:09

So let's take a look at the CT that followed.

3:12

So again, encourage everyone to take a look at their scout view.

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And again, you see that this anterior

3:17

mediastinal mass is sitting right here. On the scout view,

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again, loss of the retrosternal clear space.

3:27

You see nicely the spine.

3:28

Let's see if we can see the lytic lesion in the clavicle.

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It's out of the field of view on this side, but we will see it on the CT itself.

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So let's go through the axial images.

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And for ease of our conversation,

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we'll really focus on the pertinent findings here as we're coming into view.

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This large anterior mediastinal lesion, soft tissue in attenuation.

3:54

It's not avidly enhancing. The heart itself is normal in size.

4:00

There's no pericardial effusion.

4:03

There was a very small,

4:05

I would even say a trace, right pleural effusion. Right along here.

4:11

We'll take a quick look at just the aorta

4:13

to make sure that there's no aneurysm or dilatation, no dissection.

4:16

As we're coming through the soft tissues,

4:18

we're also getting opportunities to look at the thyroid, which is normal and can be

4:23

included in the differential of an anterior mediastinal mass,

4:26

except we're able to clear the thyroid really nicely.

4:29

In a patient who's older, thymoma might be something to consider.

4:33

We don't see other large bulky mediastinal nodes.

4:37

There are a few nodes here in the AP window, but they're normal in size.

4:43

No evidence of pulmonary emboli.

4:46

Taking a look at the soft tissues, nothing aggressive in the soft tissues.

4:50

The solid abdominal organs below the diaphragm are normal in appearance.

4:55

So let's switch to bone windows and just take

4:58

a look at that lesion that we saw in the clavicle.

5:02

We'll take a look at all of our bones.

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But you can see right here,

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not only is there kind of a permeative nature to it all,

5:10

there's actually a pathologic fracture through the clavicle that we didn't

5:14

appreciate on radiograph, that we see very clearly on CT.

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And so, we do want to report that, not only

5:20

is there a permeative lesion, but there's a pathologic fracture through that lesion.

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And that is implication, obviously, for management and understanding.

5:29

And we're just looking through to see if there's any other bony involvement.

5:32

Encourage you to look at the coronal views, as well as the sagittal views.

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So the vertebra look normal, as do the ribs and the sternum.

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And really just have the involvement of the clavicle, which is poorly defined.

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And so, just to kind of look back at a view

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that's similar to our x-ray, we'll take a look at the coronal views.

6:04

Okay, so left clavicle here.

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We're getting into that permeative area

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along here through the fracture that's been described.

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And we don't see the full component

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because of just how it's been reconstructed.

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But you get enough to see that it's abnormal, it's permeative.

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And in a patient with this large anterior mediastinal mass, that is very concerning

6:26

for pneumonia. This looks like a metastatic focus.

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So, again, a couple of lessons here.

6:33

The patient's age and demographics are

6:35

important in terms of forming your differential.

6:38

There are lots of things that can create

6:39

anterior mediastinal masses in a patient of this age and presentation.

6:42

I would say that at the top of my diagnosis, differential diagnosis, would be lymphoma.

6:47

The fact that we have a bony lesion here

6:49

is just to, one, remind us that don't get caught up in the satisfaction of search.

6:54

Make sure you complete your approach to looking at everything every single

6:58

time, because the one time you don't look for it, you're not going to see it,

7:03

and that's going to make a difference in the patient's outcome.

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So we want to make sure that we also mentioned the bone lesion here.

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CT is helpful for further evaluation.

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So it not only shows us really nicely the extent of the anterior mediastinal mass,

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the presence of the bone lesion, but also that there's a pathologic fracture.

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And then, at least from a staging

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perspective, we don't see any other bony issues.

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We don't see any other lymph node stations that are involved.

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And so this is very helpful to mention.

7:32

The other lesion that we had seen very

7:34

peripherally, was this little ditzel that was here.

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We weren't sure if it was sitting in the bone, and we can see it really

7:40

nicely here, and it's actually just a calcified nodule.

7:43

And she's got a couple of others that are sitting around, and that's not anything

7:46

that we'd need to really worry about, given its benign appearance.