Ön mediasten lenfoması (lenfoblastik lenfoma/Hodgkin lenfoma)

Özet

Çocuk ve ergenlerde ön mediastinal lenfomalar arasında T-lenfoblastik lösemi/lenfoma ve klasik Hodgkin lenfoma öne çıkar; primer mediastinal (timik) büyük B-hücreli lenfoma daha seyrek, mediastinal gri zon lenfoma ise çocuklarda çok nadirdir. Kontrastlı BT, timus yatağındaki yumuşak doku kitlesini, diğer nodal istasyonları, hava yolu ve büyük damar basısını ve plevral-perikardiyal sıvıyı haritalar. Radyolojik dağılım histolojik alt tipi tek başına belirlemez; doku tanısı ve klinik evreleme ekip tarafından bütüncül yapılır. Trakeobronşiyal daralma veya SVC obstrüksiyonunu fark etmemek işlem öncesi yüksek riskli anatomiyi gözden kaçırabilir.

Faz ve pencere

Kontrastlı tanısal

Kontrastlı BT, ön mediastendeki yumuşak doku kitlesini, nodal zincirleri, damar ilişkilerini ve hava yolu basısını değerlendirmede en önemli görüntüleme yöntemi olarak kullanılır.

Önerilen pencereler: Mediasten (G 350 / M 50), Akciğer (G 1500 / M -600), Yumuşak doku (G 400 / M 40).

BT bulguları

• Timus yatağında lobüle yumuşak doku — üst ön mediastendeki normal bilobüle timus konturunun ötesine geçen nodüler kitleyi tanımlayın.
• Birden fazla nodal istasyon — paratrakeal, subkarinal, hiler ve alt servikal nodal zincirlerin birlikte tutulumu dağılımı gösterir.
• Trakea ve ana bronş basısı — kitle hava yolunu itebilir veya lümenini daraltabilir; en belirgin sıkışma düzeyini not edin.
• Vena kava superior ve büyük damarların çevrelenmesi — damarların kitle tarafından sarılmasını, lümen daralmasını veya tıkanmasını değerlendirin.
• Homojen veya heterojen kitle dokusu — tedavi öncesi yumuşak doku baskın olabilir; büyük kitlede nekroz veya tedavi sonrası değişiklikler görülebilir.
• Plevral veya perikardiyal efüzyon — eşlik eden sıvının tarafını ve kalp çevresindeki dağılımını tanımlayın.
• Kompartıman dışına uzanım — visceral mediastene, akciğer hilusuna, göğüs duvarına veya boyun alt kesimine devamlılığı belirleyin.

Ölçütler ve sınıflamalar

Çocukluk çağı mediastinal lenfoma alt tipleri

WHO torasik tümör sınıflamasında mediastinal hematolenfoid tümörler içinde T-lenfoblastik lösemi/lenfoma, klasik Hodgkin lenfoma, primer mediastinal büyük B-hücreli lenfoma ve mediastinal gri zon lenfoma yer alır. Pediatrik mediastinal serilerde lenfoblastik lenfoma, ardından Hodgkin lenfoma ve primer mediastinal büyük B-hücreli lenfoma öne çıkar; gri zon lenfoma çok seyrektir. Bu alt tipler histopatoloji ve immünfenotiple belirlenir; BT dağılımı ve komşu yapılara etkileri gösterir.

Normalde

Normal aynı düzeyde timus, lobları seçilebilen düzgün ve homojen yumuşak dokudur; sağ paratrakeal, subkarinal ve hiler nodal zincirler belirgin kitle halinde değildir. Lenfoma şüphesinde timus dışına uzanan konturu, nodal istasyonların sayısını, trakea-karina açıklığını ve SVC lümenini aynı anatomik kesitlerde karşılaştırın.

Ayırıcı tanı

Rebound timik hiperplazi

timus loblarında simetrik, homojen ve düzgün büyüme vardır; ayrı nodal istasyonlarda kitle beklenmez.

Mediastinal germ hücreli tümör

çoğunlukla tek merkezli kitlede yağ, sıvı ve kalsifikasyon birlikteliği lenfomadan ayrılır.

Substernal tiroid

kitle boyun tiroidiyle kesintisiz uzanır ve tiroid dokusuna benzer kuvvetli kontrastlanabilir.

Lenfatik malformasyon

sıvı yoğunluklu, çok odacıklı ve ince septalı görünüm solid lenfoid dokudan farklıdır.

Timik kist

düzgün sınırlı sıvı attenüasyonlu odak oluşturur; çoklu istasyon nodal hastalık yapmaz.

Tuzaklar

• Ön mediastendeki her yumuşak dokuyu lenfoma saymayın; yaşa uygun timus loblarını, şekil simetrisini ve damarların serbest geçişini kontrol edin.
• Tek başına kitlenin BT görünümünden T-LBL ile Hodgkin lenfomayı ayırmaya çalışmayın; istasyon dağılımını tarif edin ve histolojiyi açık bırakın.
• Çok büyük kitlede damar lümeni kitle kenarında incelip kontrastla zayıf dolabilir; tromboz demeden önce kesit boyunca damar devamlılığını ve kollateral yolları izleyin.
• Tedavi sonrası timus reboundu ve rezidüel lenfoma benzer yumuşak doku yoğunluğu verebilir; önceki inceleme, dağılım ve morfoloji değişimini karşılaştırın.

Kendini dene

1. Ergen hastada ön mediastende lobüle yumuşak doku kitlesi, paratrakeal ve hiler nodlar ile trakeal bası var. En olası tanı grubu hangisidir?

   • Mediastinal lenfoma
   • Olgun teratom
   • Timik kist
   • Substernal tiroid
   Cevabı göster

   Mediastinal lenfoma. Lobüle timus yatağı kitlesiyle çoklu nodal istasyonların tutulması lenfomayı destekler. Teratomda karışık yağ-sıvı-kalsiyum; kistte sıvı içeriği; tiroidde boyunla devamlılık beklenir.

2. Ön mediastinal kitlesi olan bir hastada yüz ve üst ekstremite ödemi ile boyun venlerinde belirginleşme ve yüzde siyanoz görülüyor. Bu bulgular hangi klinik tabloyla uyumludur?

   • Süperior vena kava (SVC) sendromu
   • Üst hava yolu obstrüksiyonu
   • Perikardiyal tamponad
   • Pulmoner emboli
   Cevabı göster

   Süperior vena kava (SVC) sendromu. Vena kava superior basısı yüz ve üst ekstremite ödemine, boyun venlerinde belirginleşmeye ve yüzde siyanoza yol açabilir; bu bulgular vena kava superior sendromuyla uyumludur.

İlgili konular

• Ön mediasten kitlesine yaklaşım

Kaynaklar

Bu sayfadaki 40 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 2 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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