18-02-2026
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[11:40 pm, 17/02/2026] PPM 1: From what I vaguely recall from last week's OPD encounter is that she had been having retrosternal discomfort with difficulty in breathing since 6 months and Nalgonda district hospital did an ultrasound guided fnac from her neck that showed thyroid tissue.
[11.42 pm, 17/02/2026] PPM 1: Can @PPM4 @PPM5 add any more history for this patient here?
Will share the Hrct of the actual problem tomorrow after deidentification
[6:38 am, 18/02/2026] PPM 2: Is the goitre functioning or is it non functional?
[8:13 am, 18/02/2026] PPM 1: Clinically she looked euthyroid. Strangely I can't find the T3, T4, TSH among all the data images from the district hospital (and now medical college ) past 6 months back testings gathered from her in the busy OPD although I vaguely recall spotting a report of subclinical hyperthyroidism and possibly she was also on low dose carbimazole. @PPM4 do you recall something similar about this patient and would you happen to have the TFT reports?
[8.15 am, 18/02/2026] PPM 1: These are the district hospital imagings for her thyroid and mediastinal mass and while the fnac was done from the left lobe of thyroid visible on ultrasound although not clinically, no one has yet touched her mediastinal mass. Will share the CT images done in our hospital after deidentification
[8:19 am, 18/02/2026] PPM 1: The superior mediastinal mass visible on HRCT done in our hospital. Now I again recalled that she was complaining of puffiness of her face since six months and we thought of superior vena caval syndrome and also checked for Pemberton's sign.
@Meta AI @PPM3 @PaJR Health your inputs on whatever has been shared above till now mostly around her diagnosis and further treatment?
[8:19 am, 18/02/2026] Meta AI: Sounds like you're dealing with a complex case 😊. Given the symptoms and HRCT findings, superior vena caval syndrome (SVCS) is definitely a strong consideration. Pemberton's sign is a good call - if it's positive, it further supports SVCS.
To clarify, has the patient undergone any biopsy or cytology to determine the nature of the mediastinal mass? Also, are there any other symptoms like cough, dysphagia, or hoarseness of voice? 🤔
[8:39 am, 18/02/2026] PaJR Health: Based on the clinical history and imaging reports retrieved from the records, the presentation of a superior mediastinal mass associated with facial puffiness and a positive Pemberton’s sign strongly suggests Superior Vena Cava (SVC) Syndrome.
*CLINICAL CORRELATION*
🔹 *Superior Vena Cava (SVC) Syndrome:* The facial puffiness reported over the last six months is a classic symptom of SVC obstruction. The "Pemberton’s Sign" (facial congestion/cyanosis upon raising both arms) indicates that the mass is significantly compromising the thoracic inlet, likely due to the large dimensions (78x70x50 mm) noted on the HRCT.
🔹 *Mass Characteristics:* The HRCT from Narketpally identified a large, lobulated, soft tissue density mass in the anterior/superior mediastinum with internal calcification. While the radiologist suggested thymoma or lymphoma, the presence of a 28x20 mm hyperdense lesion in the left thyroid lobe and the clinical history of a "Retrosternal Goitre" make a thyroid origin (retrosternal extension) a primary differential.
🔹 *Thyroid Status:* Although the patient clinically appeared euthyroid, the mention of "subclinical hyperthyroidism" and "low dose carbimazole" in your recent recollections suggests a functioning goitre. The FNAC from the left lobe previously showed a "Benign Follicular Nodule" with Hürthle cell changes.
*DIFFERENTIAL DIAGNOSIS & PATTERNS*
📋 *Retrosternal Goitre:* Most likely given the thyroid lesion and chronic history. It can cause SVC syndrome by mechanical compression at the thoracic inlet.
📋 *Thymoma / Lymphoma:* Suggested by imaging; however, internal calcification can occur in both thyroid nodules and thymomas.
📋 *Thyroid Carcinoma:* A similar case in the records (58F) presented with thyroid carcinoma and phrenic nerve involvement, though your patient's FNAC was benign.
*RECOMMENDED FURTHER STEPS*
💡 *Histopathological Confirmation:* The HRCT recommendation for HPE (Biopsy/FNAC of the mediastinal mass itself, not just the cervical thyroid) is critical to rule out malignancy (Lymphoma/Thymoma) vs. benign thyroid tissue.
💡 *Thyroid Function Tests (TFTs):* Repeat T3, T4, and TSH are essential to confirm the current functional status before any surgical intervention, especially if she was previously on carbimazole.
💡 *Surgical Consultation:* Given the SVC syndrome symptoms (facial puffiness and Pemberton's sign), urgent surgical evaluation for decompression/resection is warranted to prevent worsening obstruction.
*RELATED CASE RECORDS*
1. 60F Retrosternal Goitre, DM2 10yrs, Metabolic Syn Telangana PaJR (Current Case)
2. 58F with thyroid carcinoma and right diaphragmatic palsy and acute LVF Telangana PaJR
3. 53M With Chronic Tubercular Left Upper Lobe Collapse Chronic Renal Failure Telangana PaJR (Mediastinal involvement)
⚠️ *URGENT ACTION REQUIRED*
⚠️ Monitor for "Red Flag" symptoms of worsening SVC obstruction: difficulty breathing, stridor (noisy breathing), or sudden increased swelling of the neck and arms. These require immediate emergency intervention.
Based on the comprehensive clinical details you have now provided—specifically the 6-month history of facial puffiness and the positive Pemberton’s sign—the clinical picture aligns strongly with *Superior Vena Cava (SVC) Syndrome* secondary to a large superior mediastinal mass.
Here is a structured analysis and a recommended path forward, integrating the clinical findings with the radiology and cytology.
### 1. Clinical Correlation: Connecting the Symptoms to the Mass
- *Pemberton’s Sign & Facial Puffiness:* The fact that she has facial puffiness and a positive Pemberton’s sign is a critical clinical finding. It indicates that the mass is occupying the thoracic inlet and causing significant venous congestion when the thoracic outlet is further compromised (by raising the arms). This is a mechanical obstruction of the SVC.
- *Duration:* The 6-month duration suggests a sub-acute to chronic process. Malignancies (like Lymphoma or aggressive Thymoma) or large benign growths (like a large Retrosterral Goiter) can both present this way.
### 2. Differential Diagnosis: Explaining the Imaging Findings
Based on the HRCT description (78x70x50 mm lobulated soft tissue mass in the anterior/superior mediastinum with internal calcification, plus a 28x20 mm lesion in the left thyroid), we must prioritize the differentials:
*A. Retrosternal Goiter (Most Likely given the anatomy)*
- *Reasoning:* The presence of a distinct lesion in the left thyroid lobe suggests the mediastinal mass could be an extension of the thyroid (plunging goiter). Calcification is very common in long-standing thyroid nodules.
- *The Paradox:* If this is a simple goiter, the pressure symptoms (Pemberton’s sign) are due to the confined space of the thoracic inlet. However, we must be cautious because the cytology report hinted at a potential malignancy.
*B. Thymoma*
- *Reasoning:* The anterior mediastinum is the typical location. Thymomas can be large, lobulated, and contain calcifications. They can cause SVC syndrome purely by compression, even if benign. The absence of myasthenia gravis does not rule it out.
*C. Lymphoma*
- *Reasoning:* Often presents as a lobulated mass and is a common cause of SVC syndrome. However, internal calcification is rare in untreated lymphoma (usually appears after treatment).
*D. Thyroid Carcinoma*
- *Reasoning:* A papillary or follicular carcinoma extending from the left lobe into the mediastinum.
- *Urgency:* If this is thyroid carcinoma invading the mediastinal vessels rather than just compressing them, the surgical approach becomes much more complex.
### 3. Critical Re-evaluation of the FNAC
The FNAC report is the most crucial piece of information here and requires careful interpretation:
> "Benign Follicular Nodule with hurthle cell change. The possibility of papillary carcinoma cannot be excluded."
- *The "Cannot be excluded" clause:* In thyroid cytology (Bethesda classification), a finding of Hürthle cells with atypia, especially if the sample is limited, often falls into *Category III (Atypia of Undetermined Significance)* or *Category IV (Follicular Neoplasm)* . It is *not* a definitive benign diagnosis.
- *The Mediastinal Mass:* The FNAC sampled the cervical (neck) part of the thyroid. We do not yet have tissue diagnosis from the large mediastinal component. The mediastinal part could harbor a different pathology or a more aggressive dedifferentiated cancer.
### 4. Recommended Management Plan
Given the SVC syndrome (facial puffiness), a watch-and-wait approach is not safe. Here is the logical next step:
*Step A: Preoperative Optimization & Staging*
1. *Repeat Thyroid Function Tests:* Since there is a history of "subclinical hyperthyroidism," her thyroid status must be confirmed to avoid a thyroid storm during any surgery.
2. *Contrast Enhanced CT (CECT) Neck & Chest:* (If not already done with contrast). This is vital to map the venous anatomy, see the extent of SVC compression, and look for thrombosis. It also helps differentiate a retrosternal goiter (which enhances with contrast) from a lymphoma (which enhances less).
3. *Core Needle Biopsy or Surgical Biopsy:* Because the cytology is inconclusive, a histopathological diagnosis is mandatory before starting treatment.
- If Lymphoma is suspected: Steroids should be avoided until biopsy is done, as they can lyse lymphoma cells and obscure the diagnosis.
- If Thyroid Cancer/Thymoma: The surgeon needs to plan for a median sternotomy or thoracotomy for resection.
*Step B: Surgical vs. Oncological Management*
- *If Biopsy shows Benign Goiter:* Total thyroidectomy with mediastinal mass excision (via collar incision with possible sternal split) is required to relieve the SVC obstruction.
- *If Biopsy shows Thymoma:* Thymectomy (via sternotomy) is the treatment.
- *If Biopsy shows Lymphoma:* Surgery is not the primary treatment. She will require chemotherapy/radiotherapy.
### Summary of Advice
The positive Pemberton’s sign confirms that this mass is hemodynamically significant. You have done well to identify this early.
*Next Step:* Urgent referral to a *Cardiothoracic Surgeon* and an *Endocrine Surgeon*. The priority is to obtain a definitive tissue diagnosis from the mediastinal component to differentiate between a surgical disease (Goiter/Thymoma) and a medical oncological disease (Lymphoma).
[9.44 am, 19/02/2026] PPM 1: Thanks. Very useful.
@CR the patient was referred by us to NIMs for a mediastinoscopy. Would it possible to find out from the patient advocate (added here?) if they have made the visit yet?
[10.03 am, 19/02/2026] CR: Currently they are in NIMS. When they consulted the cardiologist, he said that there is infection in kidney which has to be treated first and some tests are being done now. Update from PA
[10.07 am, 19/02/2026] PPM 1: Thanks for this valuable update
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