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Mediastinal Lymphadenopathy and Interstitial Lung Disease in a Cancer Patient

Case Editor - Kamyar Afshar

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Aaron S. Bruns, M.D.

The Ohio State University

Columbus, OH

Ken Knox, M.D.

Indiana University

Indianapolis, IN

John Mastronarde, M.D.

The Ohio State University

Columbus, OH

Submit your comments to the author(s).

History

A 59-year old white woman presented to the clinic for evaluation of dyspnea and an abnormal chest computed tomography (CT). Three years ago, she was diagnosed with breast cancer. One of twenty-nine axillary lymph nodes were positive for tumor, which was estrogen receptor positive. She was treated with surgery, radiation, and chemotherapy that included doxirubicin, cyclophosphamide,paclitaxel, and gemcitabine. She was then given anastrozole. She was followed closely over the next two years and had no evidence of recurrence.

Before developing breast cancer, the patient was physically active, walking 3 to 4 miles daily. However, over the last two years she had increasing dyspnea on exertion and was able to walk only 1 mile. Just prior to the visit a chest radiograph revealed hilar and mediastinal lymphadenopathy. A chest CT confirmed bilateral hilar and mediastinal lymphadenopathy as well as perilymphatic nodules less than a centimeter in diameter throughout the lungs. In addition, a positron emission tomography (PET) scan revealed uptake in several mediastinal lymph nodes with a standard uptake value of 8. The patient denied any cough, weight loss, night sweats, fevers, or occupational or travel-related exposures. A repeat mammogram and breast ultrasound were both negative.

Physical Exam

On physical examination, the patient was afebrile with a normal blood pressure and pulse. Respiratory rate was 12, and pulse-oximetry revealed an oxygen saturation of 96% on room air. Physical examination was normal with the exception of some mild clubbing.

Lab

Based on the CT and PET findings, the patient underwent a bronchoscopy with bronchoalveolar lavage and trans-bronchial biopsies as well as a mediastinoscopy. Results of the specimens are shown in figure 3.

FEV1             2.77 (81%)

FVC               2.29 (86%)

FEV1/FVC      80.1%

TLC                4.18 (81%)

DLCO             20.3 (91%)

Chest CT: Multiple nodules smaller than a centimeter in diameter were present in both lungs with a perilymphatic distribution. A right paratracheal lymph node measured 1.9 cm. There was a 1.3 cm right precarinal lymph node, a 1.4 cm left anterior mediastinal lymph node, and a 1.4 cm subcarinal lymph node as well. There was no pleural effusion or pneumothorax (Figures 1 and 2).

PET scan: Uptake in several mediastinal lymph nodes with a standard uptake value of 8 (Images not available).

Figures


Figure 1. Axial view of high-resolution chest CT using lung windows showing multiple nodules less than one centimeter in diameter in a perilymphatic distribution.

Figure 2. Axial view of high-resolution chest CT using mediastinal windows showing bilateral hilar and subcarinal lymphadenopathy.

Figure 3. Slide of transbronchial biopsy showing multinucleated giant cells and epithelioid histiocytes in a granulomatous formation (Magnified 20x)

Question 1

What is the most likely diagnosis?


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