Carrie Wasserman, MD

A 62-year-old man with a breast mass underwent mammography. A right breast mass measuring 3.5 × 2.5 cm was noted behind the retracted right nipple. Multiple pleomorphic calcifications were also noted, and these findings were confirmed on sonography, which confirmed a 2.9 cm poorly marginated lobulated solid mass that was extremely suspicious for carcinoma. Biopsy was recommended, but the patient was lost to the follow-up.

A 71-year-old woman presented to her physician after several months with enlarged cervical lymph nodes. A biopsy was done, confirming classical Hodgkin’s lymphoma. A staging FDG-PET/CT revealed extensive hypermetabolic cervical, axillary, mediastinal, left hilar, and abdominal lymphadenopathy and prominent activity throughout the bone marrow. However, a biopsy of the bone marrow was negative, and she was diagnosed with stage III Hodgkin’s lymphoma. Metabolic activity in the spleen was higher than that in the liver, raising the possibility of diffuse splenic infiltration with lymphoma. The patient underwent four cycles of standard chemotherapy with ABVD, and restaging FDG-PET/CT revealed decreased metabolic activity in the spleen relative to the liver, suggestive of positive response to therapy. It also revealed positive functional and anatomic response to therapy of all involved lymph node regions. Follow-up FDG-PET/CT two months after completion of chemotherapy confirmed this finding and FDG activity in the liver remained higher than in the spleen, consistent with ongoing response to treatment.

A 73-year-old woman presented with complaints of ongoing weight loss and intermittent abdominal discomfort. CT of the chest, abdomen and pelvis revealed a 4.3 cm × 3.8 cm spiculated left upper lobe mass and subcentimeter bilateral nonspecific pulmonary nodules. There was no evidence of mediastinal or hilar adenopathy. Imaging also revealed a 4.8 cm × 2.2 cm density in anterior abdominal wall involving the musculature, large amount of ascites, multiple omental masses. There was no evidence of bowel obstruction, but there was a 4.6 cm × 4.2 cm mesenteric mass contiguous with the walls of multiple small bowel loops, with infiltration of mesenteric fat. An FDG-PET/CT confirmed the left upper lobe spiculated mass with an standardized uptake value of 7, and several nonhypermetabolic subcentimeter bilateral lung nodules were also noted. The omental and peritoneal masses had mild-to-moderate metabolic activity with standardized uptake value between 1.7 and 3, and the mesenteric mass had standardized uptake value of 2.5. The anterior abdominal wall mass had standardized uptake value of 1.1.

The patient is a 40-year-old man diagnosed with HIV infection on routine screening in 2005. He was not started on antiretroviral therapy at that time. In January 2008, he developed fatigue, fevers, chills, night sweats, decreased appetite and a 5-lb weight loss. No acute infectious cause was found, and he was started on HAART therapy at that time. His fever did not abate with treatment, and he grew increasingly fatigued, eventually requiring hospitalization. He was found to have severe normocytic anemia with hemoglobin 6.6 gm/dL, white blood cell 4.2 with normal differential and platelets of 740,000 without evidence of hemolysis.

A 36-year-old man presented with several weeks of night sweats and enlarged left cervical lymph nodes. Imaging revealed extensive mediastinal lymphadenopathy with encroachment on the pericardium, enlarged supraclavicular lymph nodes. A staging bone marrow biopsy was negative. Lymph node biopsy revealed Hodgkin’s lymphoma, nodular sclerosis type and the patient’s clinical stage was IIB.

A 60-year-old man employed as a sanitation worker presented to his primary physician with several weeks of a dry cough. His past medical history was significant for chronic sinusitis. A chest X-ray revealed mediastinal fullness, and further imaging studies included a positron emission tomography and computed tomography scan that was notable for hypermetabolic cervical and mediastinal lymph nodes.

A 36-year-old healthy woman presented after several months of right hip pain not improved with physical therapy. Magnetic resonance image of the lumbar spine and pelvis revealed a compression fracture of the L2 vertebrae and abnormal signal enhancement of L4 and L5. Biopsy of the right iliac crest showed carcinoma of epithelial origin. Immunostains were not helpful in further characterizing the tumor. Full staging workup revealed bone only disease of the axial skeleton without a primary site of origin. The patient was treated with two cycles of chemotherapy for carcinoma of unknown primary site and palliative radiation to several painful bony lesions.

This 63-year-old woman presented with acute onset of pleuritic chest pain and shortness of breath. Her medical history was significant for left breast ductal carcinoma in situ treated four years earlier with lumpectomy, radiation and adjuvant hormonal therapy.