A 49-years old Caucasian woman was admitted at our Emergency Department with shortness of breath and mild respiratory discomfort. She has no significant past medical history and she has never smoked. No history of cough, fever, weight loss or night sweat had been detected. There were no allergies, no exposure to active tuberculosis, but she reported a history of exposure to asbestos. Cardiovascular examination was normal. There was no significant lymphadenopathy or thyromegaly. Respiratory sounds were impaired on the right lung. No abnormalities were detected in blood chemistry.
A first chest X-Ray (Fig. 1) executed in posterior-anterior (PA) and lateral projection, showed multiple nodules, hilar-mediastinal enlargement and nodular radiopacity at right hilum; also, pleural effusion on the right lung and obliteration of ipsilateral costophrenic angle was detected.
Abdomen Ultrasound (US) has been performed in order to exclude any pathological masses, primary neoplasm or metastatic disease. As collateral findings, US confirmed the pleural effusion with multiple solid rounded masses at pulmonary bases (Fig. 2).
Total-body CT scan was performed using a Lightspeed VCT 64-slice (General Electric, Boston, Massachusetts USA), with a pre-contrast phase, and a parenchymal phase, 70 s after administration of 120 mL of non-ionic contrast agent injection (350 mg l/ml, 2,5 mL/s.). The CT (Fig. 3), revealed a large mediastinal mass overrunning the right hemithorax, with pleural free fluid and multiple solid pleural masses on the right. No displacement of mediastinal structures has been noted. After injection of iodinated contrast, the lesions appear hypo-vascular, with enhancing margins, internal lobulation and septation, and few calcific spots. No direct endoluminal invasion in the main mediastinal vessels has been detected.
Contrast Enhanced CT (CECT) scan of abdomen, pelvis and brain was negative.
During the hospitalization the patient underwent to 18 [F]-fluorodeoxyglucose (FDG)-PET (Fig. 4): the patient received intravenous injection of 18[F]-FDG (radioactivity: 371 m Bq) and rested for 45 min before PET-scan. The mass showed an increased uptake involving the parietal, mediastinal and diaphragmatic pleura of right lung. Two Region of Interest (ROI) were positioned (Fig. 5): the first one on anterior chest wall (ROI 1: SUV 3,6), the second one near the posterior cost-vertebral arch (ROI 2: SUV 4,4) and maximum standardized uptake values were calculated.
Subsequently a CT-guided percutaneous biopsy (14 G cutting needle) of the mass in the right hemithorax was performed. Histopathological examination (Fig. 6) revealed a tissue made-up by bands of sclerosis and average size lymphocytes with T-immature phenotype (precursor T cell, CD3+, CD5+/-, CD4+, CD8+, TdT+), associated also with irregular oval shape epithelial cells (CKAE1-AE3+, Calretinin-).
The above-mentioned histological findings are consistent with thymoma type B2 (cortical).
After definitive diagnosis of thymoma and disease staging, the patient chose to receive treatment in another Institute and so we lost her to follow-up.