Tumor versus bland thrombus: diffuse large B-cell lymphoma presenting as cavernous sinus and left superior ophthalmic vein thrombosis

A 66-year-old female with a history of sinusitis presented with persistent diplopia and worsening eyelid swelling. Examination revealed bilateral vision loss, cranial nerve palsies, left-sided chemosis, proptosis, and edema. Initial imaging showed sphenoid sinus opacification, bilateral ethmoid disease, lack of filling of bilateral cavernous sinuses, and partial thrombosis of the left superior ophthalmic vein. The sinus findings were evaluated with endoscopic sinus surgery, which was unremarkable. Subsequent orbital imaging suggested the lesions were in keeping with tumor thrombus as opposed to bland thrombus. CT scans revealed a large mass in the right axilla, which was biopsied and confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL). The patient was treated with anticoagulation, steroids, and chemotherapy resulting in marked improvement. Our report highlights a rare case of tumor thrombus from DLBCL causing bilateral cavernous sinus thrombosis and, to the best of our knowledge, the first documented case of superior ophthalmic vein thrombosis from tumor thrombus.

Fatal anterior mediastinal mass in a pregnant lady

We report a fatal case of a 26-year-old nulliparous woman who presented with an anterior mediastinal mass in her late pregnancy. She had complained of a progressively increasing neck swelling and occasional dry cough in the early second trimester, which was associated with worsening dyspnoea, reduced effort tolerance and orthopnoea. Ultrasound of the neck showed an enlarged lymph node, and chest X-ray revealed mediastinal widening. At 35 weeks' gestation, the patient was referred to a tertiary centre for a computed tomography (CT) scan of the neck and thorax under elective intubation via awake fibreoptic nasal intubation as she was unable to lie flat. However, she developed sudden bradycardia, hypotension and desaturation soon after being positioned supine, which required resuscitation. She succumbed after 3 days in the intensive care unit. An autopsy revealed a large anterior mediastinal mass extending to the right supraclavicular region, displacing the heart and lungs, encircling the superior vena cava and right internal jugular vein with tumour thrombus extending into the right atrium. Histopathology examination of the mediastinal mass confirmed the diagnosis of a primary mediastinal large B-cell lymphoma. This report emphasizes the severe and fatal outcome resulting from the delay and misinterpretation of symptoms related to a mediastinal mass.

Complications of lymphoma in the abdomen and pelvis: clinical and imaging review

Involvement of the abdomen and pelvis is common in lymphoma. Nodal and extranodal abdominal and pelvic lymphoma may present with various complications. Complications are most common in high-grade lymphomas, especially diffuse large B-cell lymphoma. Complications may occur as the initial manifestation of lymphoma, during treatment course, or late following complete disease remission. Most complications are associated with worse prognosis and increased mortality. Imaging is essential in evaluation of disease extent and diagnosis of complications. Therefore, radiologists should be familiar with the clinical context and imaging features of abdominal and pelvic lymphoma complications. We provide a comprehensive, organ system-based approach, and clinical and imaging review of complications of abdominal and pelvic lymphoma along with radiologic images of illustrated cases of the most commonly encountered complications.

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ^©RSNA, 2020.

Diffuse Large B-Cell Lymphoma in the Portal Vein

Tumor thrombus in the portal vein without any liver parenchymal abnormality is extremely rare. In the liver, the primary tumor most frequently presenting with intravascular tumor thrombi is hepatocellular carcinoma and lymphoma is rarely considered. Even though thrombosis occurs quite often in lymphoma, cases of tumor thrombus are rare and cases of tumor thrombus in the portal vein are even rarer. Only four cases of lymphoma with portal vein tumor thrombosis have been reported to date and all cases were the result of direct extensions of a dominant nodal or extra-nodal mass. To our knowledge, there has been no report on diffuse large B-cell lymphoma (DLBCL) presenting only within the lumen of the portal vein and not intravascular B-cell lymphoma. We present the first case of DLBCL presenting only within the lumen of the portal vein in an immunocompetent patient.

Burkitt Lymphoma Presenting With Intracardiac Mass and Tumor Thrombosis in the Anterior Mediastinum With Literature Review

Burkitt lymphoma manifesting as an intracardiac mass is a rare entity. This report describes the case of a 10-year-old boy who presented with an intracardiac mass and tumor thrombosis in the anterior mediastinum that proved to be Burkitt lymphoma. The LMB-96 chemotherapy protocol was given and at the end of the treatment there was still residual mass. A biopsy was performed and the pathology revealed thymus tissue. The patient has been in complete remission for 3 months. Burkitt lymphoma has a short doubling time and an intracardiac lesion can become life threatening. Early recognition and prompt treatment are crucial in achieving optimal outcomes.

A primary retroperitoneal anaplastic lymphoma kinase-positive anaplastic large cell lymphoma with tumor thrombosis

Anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL) is a T cell subtype of non-Hodgkin’s lymphoma (NHL). Typically, lymphoma rarely infiltrates vascular structure. In this article, we present a case of retroperitoneal ALK-positive ALCL with splenic venous tumor thrombosis. A 62-year-old patient presented to our institute with the symptoms of epigastric pain, abdominal distension, and reduced bowel movement. Physical examination indicated no enlarged peripheral lymph nodes or abdominal mass. Laboratory workup revealed granulocytosis, abnormal coagulation function, and normal level of lactic dehydrogenase (LDH). Contrast-enhanced computed tomography (CT) showed a retroperitoneal mass with involvement of pancreas and duodenum and formation of splenic venous tumor thrombus. Ultrasonography-guided retroperitoneal lesion biopsy confirmed the diagnosis of ALK-positive ALCL. The patient was able to tolerate oral intake after two cycles of chemotherapy and showed no sign of lymphoma by positron emission tomography (PET)-CT after the fourth cycle of chemotherapy. In spite of its rarity, lymphoma should be taken into account as a differential diagnosis of other malignancies with tumor thrombosis.

Polytetrafluoroethylene or Acellular Dermal Matrix for Diaphragmatic Reconstruction?

BACKGROUND

We aimed to evaluate the impact of collagen matrix in the reconstruction of the diaphragm.

METHODS

We queried the electronic medical record for patients who had resection of the diaphragm and simultaneous pulmonary resection between 1999 and 2016. All reconstructions were performed with either polytetrafluoroethylene or acellular dermal matrix. We evaluated the rate of empyema and herniation in each group.

RESULTS

A total of 208 patients met inclusion criteria. Polytetrafluoroethylene was used in 168 cases (80.8%) and dermal matrix in 40 cases (19.2%). Dermal matrix was used in 8 extrapleural pneumonectomies (5.4%), in 26 pleurectomy decortications (55.3%), and in 6 other types of resections (40%). Follow-ups were for a median of 15.0 months in the polytetrafluoroethylene group and 11.6 months in the dermal matrix group. Patients in the dermal matrix group had a chest tube for a median of 2.5 days longer than patients with polytetrafluoroethylene (p = 0.006). Empyema occurred in 11 polytetrafluoroethylene reconstructions (6.5%) and 3 dermal matrix reconstructions (7.5%) (p = 0.735). Seven patients (63.6%) with polytetrafluoroethylene infection required removal of the graft, whereas none in the dermal matrix group needed removal (p = 0.351). There were nine herniations in the polytetrafluoroethylene group and four in the dermal matrix group (p = 0.281), all were acute and due to anchorage failure.

CONCLUSIONS

Although infection rates were similar between polytetrafluoroethylene and acellular dermal matrix, re-operation for removal was not necessary in the latter. The use of a thick acellular dermal matrix may be a reasonable option when diaphragmatic reconstruction is potentially associated with a higher risk of infection.

Disseminated Renal Burkitt Lymphoma With Malignant Inferior Vena Caval Thrombosis in a Child

The most common causes of renal mass with malignant venous thrombosis are Wilms' tumor and renal cell carcinoma. Although renal involvement may occur in disseminated lymphomas, primary renal Burkitt lymphoma (BL) is rare. Vascular tropism is not a usual feature of lymphoma; thus, primary renal BL with venous extension is distinctly unusual. However, it is important to diagnose this entity because such patients respond well to medical management and may not require surgery. We report a pediatric case of primary renal BL with malignant vascular thrombus and systemic dissemination where biopsy was diagnostic and enabled appropriate treatment.