{"id":47565,"date":"2026-08-21T15:08:29","date_gmt":"2026-08-21T07:08:29","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=47565"},"modified":"2026-08-28T21:09:37","modified_gmt":"2026-08-28T13:09:37","slug":"mediastinumfs-1","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/mediastinumfs-1\/","title":{"rendered":"Short cases &#8211; Mediastinum case 1 (FS)"},"content":{"rendered":"\r\n<h2>\r\n\t\t\tMediastinum case 1 (FS)\t<\/h2>\r\n\t<p><em>Case writer: A\/Prof Nga Min En<\/em><\/p>\r\n\t<p><strong>Clinical history:<\/strong><\/p>\r\n<ul>\r\n<li>\r\n18M, history of cough for 1 month\r\n<\/li>\r\n<li>\r\nAccompanied by face and neck &#8216;puffiness&#8217; and &#8216;feeling of pressure&#8217; when supine\r\n<\/li>\r\n<li>\r\nCT scan of the thorax shows a 16 x 15 x 9cm anterior mediastinal mass compression on the superior vena cava. No fat or calcification is noted.\r\n<\/li>\r\n<li>\r\nAn open incisional biopsy is performed, and sent for frozen section.\r\n<\/li>\r\n<li>\r\nWhat additional clinical information would you want at the time of the frozen section?\r\n<\/li>\r\n<li>\r\nHow would you handle this fresh specimen?\r\n<\/li>\r\n<li>What are the cytologic findings?<\/li>\r\n<li>What are your differential diagnoses?<\/li>\r\n<li>What ancillary tests would you do?<\/li>\r\n<\/ul>\r\n\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.1-1536x1150.png\" alt=\"thoracic.1\" height=\"479\" width=\"640\" title=\"thoracic.1\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.2-1024x765.jpg\" alt=\"thoracic.2\" height=\"478\" width=\"640\" title=\"thoracic.2\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.3-1024x778.jpg\" alt=\"thoracic.3\" height=\"486\" width=\"640\" title=\"thoracic.3\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.4-1024x769.png\" alt=\"thoracic.4\" height=\"481\" width=\"640\" title=\"thoracic.4\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.5-1024x765.png\" alt=\"thoracic.5\" height=\"478\" width=\"640\" title=\"thoracic.5\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n\t<p>Click picture to enlarge<\/p>\r\n\t<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-0\" aria-controls=\"fl-accordion--content-0\" aria-expanded=\"true\" type=\"button\">Frozen Section Findings<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Collapse<\/i><\/button><\/a><p>&nbsp;<\/p>\r\n<ul>\r\n<li>In anterior mediastinal masses that arrive fresh for frozen sections (FS), cytology samples are especially useful, in addition to the usual H+E-stained frozen sections<\/li>\r\n<li>The following cytology smears can be prepared:\r\n<ul>\r\n<li>Touch imprints (1 air-dried, 1 alc-fixed)<\/li>\r\n<li>Smears from scrapings (1 air-dried, 1 alc-fixed)<\/li>\r\n<li>The alcohol-fixed smears can be stained with H+E<\/li>\r\n<\/ul>\r\n<\/li>\r\n<li>Both air-dried and alcohol-fixed smears are useful\r\n<ul>\r\n<li>Air-dried &#8211; for cytoplasm (e.g. scant bluish cytoplasm in lymphoma); for background material (e.g. lymphoglandular bodies; tigroid background in seminoma)<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.6.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.6.png\" alt=\"\" width=\"2076\" height=\"1557\" \/>(opens in new tab)<\/a><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p>&nbsp;<\/p>\r\n<ul>\r\n<li>Touch imprint shows large, discohesive cells admixed with a few lymphocytes. Note how much larger the lesional cells are compared to lymphocytes.<\/li>\r\n<li>The background shows a characteristic lacy &#8220;tigroid&#8221; appearance\u00a0 &#8211; this is due to glycogen from the cytoplasm.<\/li>\r\n<li>This characteristic background is seen in air-dried smears and not alcohol-fixed smears.<\/li>\r\n<\/ul>\r\n<p>&nbsp;<\/p>\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.7.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.7.png\" alt=\"\" width=\"2401\" height=\"1790\" \/>(opens in new tab)<\/a><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p>&nbsp;<\/p>\r\n<ul>\r\n<li>Frozen sections show a somewhat nested appearance<\/li>\r\n<li>There are large polygonal cells with fairly abundant pale cytoplasm<\/li>\r\n<li>Some lymphocytes are seen between the nests<\/li>\r\n<\/ul>\r\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-1\" aria-controls=\"fl-accordion--content-1\" aria-expanded=\"false\" type=\"button\">Differential Diagnoses<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\r\n<p>In a young patient (teens or early adulthood) with an anterior mediastinal mass, the main differential diagnoses are:<\/p>\r\n<ul>\r\n<li>Lymphoma (e.g. Hodgkin lymphoma, primary mediastinal large B-cell lymphoma,\u00a0 T-lymphoblastic lymphoma)<\/li>\r\n<li>Germ cell tumour (e.g. seminoma, teratoma, non-seminomatous GCTs)<\/li>\r\n<\/ul>\r\n<p>Thymic tumours may be added to the DDx list in middle-aged to older\u00a0 patients.<\/p>\r\n<p>Important information that is diagnostically relevant would be:<\/p>\r\n<ul>\r\n<li>Tumour markers e.g. b-HCG (may be mildly raised in seminoma), AFP levels<\/li>\r\n<li>LDH &#8211; not specific; this can be raised in lymphomas as well as germ cell tumours<\/li>\r\n<li>Radiological findings &#8211; e.g. teratomas tend to have distinctive features, with recognisable fatty, bony or calcific elements<\/li>\r\n<\/ul>\r\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-2\" aria-controls=\"fl-accordion--content-2\" aria-expanded=\"false\" type=\"button\">Paraffin Sections and Ancillary Tests <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.8.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.8.png\" alt=\"\" width=\"1436\" height=\"1077\" \/>(opens in new tab)<\/a><\/td>\r\n\r\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.9.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.9.png\" alt=\"\" width=\"1428\" height=\"1067\" \/>(opens in new tab)<\/a><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n\r\n<ul>\r\n<li>Sections show nests of large polygonal cells with pale cytoplasm<\/li>\r\n<li>Delicate fibrovascular septa are present between the nests<\/li>\r\n<li>Some aggregates of small lymphocytes are seen in association with the septa<\/li>\r\n<\/ul>\r\n<p>&nbsp;<\/p>\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.10.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/thoracic.10.png\" alt=\"\" width=\"1984\" height=\"1480\" \/>(opens in new tab)<\/a><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<ul>\r\n<li>The malignant cells are positive for OCT4 (shown here)<\/li>\r\n<li>They were also positive for CD117 and SALL4.<\/li>\r\n<li>Other germ cell tumour antibodies showed no reactivity (CD30, glypican 3).<\/li>\r\n<\/ul>\r\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-3\" aria-controls=\"fl-accordion--content-3\" aria-expanded=\"false\" type=\"button\">Diagnosis and Learning Points<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\r\n<p><u><b>Diagnosis<\/b><\/u><\/p>\r\n<ul>\r\n<li>Seminoma<\/li>\r\n<\/ul>\r\n<p>Find this in our Virtual Pathology Museum: <a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/virtual-pathology-museum\/00384-2\/\">https:\/\/medicine.nus.edu.sg\/pathweb\/virtual-pathology-museum\/00384-2\/<\/a><\/p>\r\n<p>&nbsp;<\/p>\r\n<p><u><b>Learning Points<\/b><\/u><\/p>\r\n<ul>\r\n<li>Differential diagnoses in anterior mediastinal masses depends on the <b>age<\/b> of the patient. Many tumours occur in young adults.<\/li>\r\n<li>Correlation with radiologic findings and tumour markers can be very helpful.<\/li>\r\n<li>Intra-operative cytology touch imprints and smears are very useful in evaluating frozen sections in mediastinal masses. Both air-dried and alcohol-fixed preparations should be performed, as they provide complementary information.<\/li>\r\n<\/ul>\r\n\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-updates-journal-clubs\" target=\"_blank\" rel=\"noopener\">Pathology Updates &#038; Journal Clubs(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/\" target=\"_blank\" rel=\"noopener\">Short Cases(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pg-patho\/\" target=\"_blank\" rel=\"noopener\">Postgrad Pathology Home(opens in new tab)<\/a>\r\n\r\n","protected":false},"excerpt":{"rendered":"<p>Mediastinum case 1 (FS) Case writer: A\/Prof Nga Min En Clinical history: 18M, history of cough for 1 month Accompanied by face and neck &#8216;puffiness&#8217; and &#8216;feeling of pressure&#8217; when supine CT scan of the thorax shows a 16 x 15 x 9cm anterior mediastinal mass compression on the superior vena cava. No fat or [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":47288,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-47565","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/mediastinumfs-1\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"Mediastinum case 1 (FS) Case writer: A\/Prof Nga Min En Clinical history: 18M, history of cough for 1 month Accompanied by face and neck &#8216;puffiness&#8217; and &#8216;feeling of pressure&#8217; when supine CT scan of the thorax shows a 16 x 15 x 9cm anterior mediastinal mass compression on the superior vena cava. 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and &#8216;feeling of pressure&#8217; when supine CT scan of the thorax shows a 16 x 15 x 9cm anterior mediastinal mass compression on the superior vena cava. 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