Bulky Mediastinal Hodgkin Lymphoma: A Rare Case of Tracheal Compression, SVC Syndrome, and Early Tamponade

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Am J Respir Crit Care Med

Keywords

acetarsol, beta 2 microglobulin, corticosteroid, lactate dehydrogenase, adult, aspiration pneumonia, body weight loss, case report, central vein, clinical article, complication, conference abstract, coughing, diagnosis, drug therapy, dyspnea, echocardiography, edema, epistaxis, face edema, fever, follow up, hemodynamics, Hodgkin disease, human, human tissue, lymphadenopathy, male, mediastinal Hodgkin lymphoma, mediastinum disease, mediastinum mass, medical history, night sweat, nodular sclerosis Hodgkin lymphoma, pericardial effusion, respiratory distress, retrospective study, right pulmonary artery, subcutaneous tissue, swelling, thorax radiography, trachea compression, trachea stenosis, young adult

Abstract

Introduction: Hodgkin lymphoma is a generally slow growing malignancy that can classically be found as a mediastinal mass on routine chest radiograph. In this case, we describe a Hodgkin lymphoma with bulky mediastinal disease leading to grade III tracheal stenosis and pericardial effusion with IVC distension, SVC syndrome, and early tamponade physiology. Case: A 19-year-old male with no significant medical history, who presented with progressively worsening cough, dyspnea, and an 85-pound unintentional weight loss over the previous 1 to 1.5 years. Additional symptoms included fever, night sweats, and recurrent episodes of epistaxis. Initially, a plain radiograph of the chest showed anterior mediastinal mass and follow-up imaging with a CT of the chest demonstrated a large mass measuring approximately 12 cm in width, encasing and compressing the trachea, narrowing the right pulmonary artery, and exerting pressure on the adjacent mediastinal vasculature. CT of the neck showed bilateral supraclavicular lymphadenopathy with subcutaneous facial edema due to central venous compression. Additionally, an echocardiogram was performed which showed a preserved ejection fraction, moderate pericardial effusion, and dilated IVC consistent with early tamponade physiology. Initial lab work showed an LDH of 1025 and beta-2 microglobulin 2.7 with elevated ESR. Findings were suggestive of lymphoma and IR biopsy of the mass confirmed the diagnosis of classical nodular sclerosis Hodgkin lymphoma. The patient was evaluated by the oncology and pulmonology services for PFTs prior to initiation of ABVD. Initial management included high-dose intravenous corticosteroids to reduce tumor bulk, as well as supportive care measures such as antibiotics for potential aspiration pneumonia. Discussion: Hodgkin lymphoma is classically a slow growing lymphoma presenting with nonspecific symptoms that typically can be associated with findings of a mediastinal mass and lymphadenopathy. The size of the mass typically varies with NCCN guidelines defining bulky masses as those with mediastinal mass ratio (MMR) greater than 0.33 or a >10 cm diameter. This case illustrates the uncommon complications associated with bulky mass effect involving mediastinal structures. A previous retrospective study found that Hodgkin lymphoma only comprises 2.4% of malignancy associated SVC syndrome, highlighting the rarity of this complication. Additionally, tracheal compression rates in Hodgkin lymphoma were found to be 56% of cases with varying degrees of compression and higher-grade compression being less common. Due to the mass's substantial size and positioning, the patient was at high risk for respiratory distress and hemodynamic compromise, necessitating a multidisciplinary approach to prepare him for definitive treatment.

Volume

211

Issue

Supplement 1

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