Clinical Conference on Management Dilemmas Robert M. Smith, MD, CM, FCCP, Steven M. Dubinett, MD, Kenneth Grudko, MD, Edward C. Rosenow III, MD, FCCP, Daniel R. Budman, MD, Jeff Schnader, MD, CM, FCCP  CHEST  Volume 114, Issue 1, Pages 295-306 (July 1998) DOI: 10.1378/chest.114.1.295 Copyright © 1998 The American College of Chest Physicians Terms and Conditions

FIGURE 1 Top: chest x-ray film obtained at the time of initial diagnosis, after a failed attempt at resection, showed a 8.5×9×10-cm mass in the right mid-chest. Bottom: a CT study of the chest at the level of the lesion confirmed a large homogeneous mass lateral to the right pulmonary artery. CHEST 1998 114, 295-306DOI: (10.1378/chest.114.1.295) Copyright © 1998 The American College of Chest Physicians Terms and Conditions

FIGURE 2 Chest x-ray film obtained on referral approximately 2 years after radiation therapy to the mass showed a persistent mass which was 1 to 3 cm smaller in each dimension than the size at initial presentation. CHEST 1998 114, 295-306DOI: (10.1378/chest.114.1.295) Copyright © 1998 The American College of Chest Physicians Terms and Conditions

FIGURE 3 Histologic findings from the resected mass of lymphoid tissue. Top: germinal center with concentrically arranged mantle cells with an “onion skin layer” appearance; a central vessel and vascular hyalinization are present. Center: germinal center exhibiting concentric cuffs of small lymphocytes. One vessel enters the germinal center at a 90° angle giving the so-called lollypop lesion appearance one sees in Castleman's disease.19 Bottom: multiple germinal centers exhibiting hyalinization of vessels, hypervascularity, and an interfollicular dense plasma cell infiltrate. Histologically, the lesion was encapsulated, indicating it was a lymph node. Hematoxylin-eosin, original magnification ×200. CHEST 1998 114, 295-306DOI: (10.1378/chest.114.1.295) Copyright © 1998 The American College of Chest Physicians Terms and Conditions

FIGURE 4 Chest x-ray film obtained immediately postoperatively. CHEST 1998 114, 295-306DOI: (10.1378/chest.114.1.295) Copyright © 1998 The American College of Chest Physicians Terms and Conditions

FIGURE 5 Top: chest x-ray films. Center and bottom: CT scan sections of the chest obtained at readmission on day 24 after resection of the mass on the right side of the chest. CHEST 1998 114, 295-306DOI: (10.1378/chest.114.1.295) Copyright © 1998 The American College of Chest Physicians Terms and Conditions

FIGURE 6 Communication between the right superior segment bronchus and a large cavernous space with a loose surgical clip visible from the opening. CHEST 1998 114, 295-306DOI: (10.1378/chest.114.1.295) Copyright © 1998 The American College of Chest Physicians Terms and Conditions

FIGURE 7 Histologic findings from a second case of Castleman's disease diagnosed independently at the Dayton VA Medical Center in 1992. Top: compact germinal center exhibiting concentric cuffs of small lymphocytes and hyalinized central vessels. One vessel enters the germinal center at an almost 90° angle giving the so-called lollypop lesion appearance one sees in Castleman's disease.19 Bottom: a cluster of germinal centers demonstrating interfollicular vascularity, a finding which favors the “hyaline-vascular” type of Castleman's disease over other entities including HIV-related lymphoid hyperplasia. Hematoxylin-eosin, original magnification ×200. (Pathological interpretation courtesy of Dr. Seetha Suryaprasad.) CHEST 1998 114, 295-306DOI: (10.1378/chest.114.1.295) Copyright © 1998 The American College of Chest Physicians Terms and Conditions