Question of the Week # 170

170) A 41 year old woman is evaluated in the office for 20lb weight loss over the last three months. She has a history of Hodgkin’s disease involving mediastinal and cervical lymph nodes and was treated with chemotherapy and Involved field radiation therapy at the age of 12.  She is born in the USA and never traveled outside United States. Her recent tuberculin skin test was 2mm about 1 month ago. Recent mammogram was normal. She denies any night sweats or pruritus. She reports chronic cough over the last 6 months associated with intermittent mild hemoptysis. On physical examination, there is no peripheral lymphadenopathy. A Chest X-ray is shown below:

Which of the following is the most likely explanation for the patient’s abnormalities?

A)     Tuberculosis

B)      Long term sequel of Hodgkin’s therapy

C)      Recurrent Hodgkin’s disease

D)     Radiation fibrosis

E)      Radiation Pneumonitis

14 Responses

  1. ddddddddddddd

  2. i think its recurrent hodgkins cause in texts it says it has a recurrence usually in 20 years…. hmm…

  3. d

  4. if there is radiation fibrosis the trachea should be deviated towards the same side. doesnt seem to be in pic given. again i would say immunocompromised can have tb even in u.s. and so also anergy to tuberculin test.
    history is classic for tb hemoptysis, cough and lung change which are extensive.

  5. B) Long term sequel of Hodgkin’s therapy

  6. Good though provoking – a negative TB skin test should be repeated in 3 wks, but latent TB can produce complications like pleural effusions but not be infectious to others, a type II Hodgkins – more than one lymph node area, can respond to chemo and radiotherapy with high 10 yr survivabilities – around 80-90%..Those that don’t respond to initial radiation may be curable with chemo according to the texts, and some prefer stem cell transplants that according to CMDT have 35–50% chance if chemo sensitive….the answer is unlikely to be radiation related since the chief complaint seems to me to be unrelated to the PMhx, I found it helpful to see the symptoms of presentation, then signs, then tests to tell what is the main diagnosis. just a generalist but.hopefully helpful to others.

  7. * 20 lb weight loss over the last 3 months is a RED-FLAG. She received the radiation therapy at age 12. The patient also has hemoptysis which is a sign of the bronchial invasion by the tumor. This could also be metastasis but the etiology is clearly oncogenic. Recurrent Hodgkin’s Disease- “C”

    • good one mufydocs ,

      weight loss is indeed a red flag pointing towards cancer . I totally agree

      Radiation fibrosis and radiation pneumonitis do not developed after 20 years after the treatment . the patient should have it monhts after the radiation tx . Fibrosis does not gives blood (just my opinion)

      TB is highly unlikely : no traveling outside USA + <5mm induratoin with PPD

      Long term sequel of hodgkin therapy : Does the patient needs long term maintenance therapy ? question did not mention that . Im not sure .

      We are left with recurrent hodgkin .

      Im Stil confuse : the white out on the x ray picture : Pleural Invasion by cancer cell ?

      Please dr. redz enlighten us . hahha

  8. pt treated with chemo and radiation for hodgkin before age of 20 are at increase risk of secondary malignancy….answer is B

  9. CXR – shows an opacity. Is it lung tissue or something else? There is no air bronchogram sign meaning it is solid as liquid or rock but it is not lung tissue because there is no air filled alveoli in the opacity. This is not pneumonitis, TB, or lung fibrosis (Fibrosis in the lung causes RETICULO-nodular shadow, there is always air in lung tissue on cxr) Additionally, the trachea is not pulled to the side of the opacity as might have occurred if this were a fibrosis.
    So I feel option (a), (d), & (e) are unlikely.
    This is not air filled tissue, not liquid(abscess, gravitate to the lower lobes in this typical erect PA view of the chest)
    This is a solid mass. Is it chest lymph node or thymus? It could be relapse of Hodgkin’s lymphoma or a secondary cancer. A secondary cancer is a new cancer, which has higher incidence in patients who received radiation therapy at a young age( like this patient). Even though this has a high probability of been a relapse of Hodgkin’s lymphoma, I feel it is safer to call it long term sequel of Hodgkin’s therapy until there is biopsy confirmation. Only biopsy can label this solid mass as Hodgkin’s lymphoma. This is a Lab diagnosis.

  10. I think answer is B. she has consolidation of rt upper lobe, weight loss, hemoptysis, ppd negative, ho of radiation to chest. I think it is CA lung with consolidation.

  11. B.

  12. B
    The majority of relapses following an apparent complete remission of Hodgkin’s lymphoma will occur within three years of therapy. However the risk of developing secondary cancers happens after a longer duration. Leukemia peaks at five to nine years post treatment, whereas solid tumors (usu breat and lung) typically develop after at least 10 years

  13. long term sequelae of hodgkins treatment are second cancers of lung, stomach, non hodgkin’s, malignant melanoma and non leucocytic leukaemia. my answer B

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