Interesting case! 46-year-old male with shortness of breath. Thoughts? Ddx?

Chest radiograph... Huge lobulated mediastinal mass with bilateral hilar overlay sign most likely due to anterior mass.

CT Large heterogeneous lobulated anterior mediastinal mass, measures 17 x 11.9 x 16 cm (in transverse, AP and CC) showing heterogeneous enhancement with multiple central areas of non-enhancing necrosis. The mass compresses the SVC and invades it just proximal to its origin.

SVC obstruction is bypassed by collateral veins causing early quadrate lobe enhancement which has been called focal hot spot sign of liver. The mass encases the ascending aorta and compresses the major airways, pulmonary arteries and left atrium.

Minor bilateral pleural effusion more prominent on the left side with maximal thickening measures about 2.3 cm. Collateral vessels noted in the anterior chest wall and mediastinum.

Superior vena cava obstruction with hot quadrate sign Focal hepatic hot spot sign or quadrate lobe focal hot spot sign is a sign described originally in nuclear medicine. This pattern of early marked enhancement in the quadrate lobe is typical of SVC obstruction.

The differential diagnosis of prevascular mediastinal mass includes the 4 Ts: thymoma, terrible lymphoma, mixed cell germ cell tumor (e.g. teratoma) and thyroid mass. The patient had elevated B-HCG levels making germ cell tumor the more likely diagnosis.

The histopathologic examination revealed mixed germ cell tumor with morphological and immunohistochemical profile of seminoma and choriocarcinoma.

Sources: https://t.co/EpTNACitEZ https://t.co/WyyKKeGNyX https://t.co/6WTBZ3rC1l

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