Chest lymphomaChest lymphoma

John-Henry CorbettDiagnostic Radiology

University of Free Sate04/2012

Hodgkin diseaseHodgkin disease

– Bimodal age distribution with peaks at 30 & 70 yrs– Origin in paracortical regions of lymph nodes• Not T- or B-cells

– Diagnosis is based on the presence of Reed-Sternberg cells

– 90% originate in lymph nodes– 10% originate in extranodal lymphoid tissue• Lung, GI tract, skin

Hodgkin disease : ClassificationHodgkin disease : Classification

• Types of Hodgkin lymphoma– Lymphocyte predominant• <5% , young patients

– Nodular sclerosing• 70%

– Mixed cellularity• 25%

– Lymphocyte depleted• <5%

Non-Hodgkin LymphomaNon-Hodgkin Lymphoma

• 4 x more common than Hodgkin disease• Heterogenous group of lymphoproliferative

malignancies• Intrathoracic involvement in 50% of newly diagnosed

cases ( vs 80% in HD )• 60% originate in lymph nodes & 40% in extranodal

sites– 85% arise from B-cells and 15% from T-cells

• Increased incidence in patients with altered immune status– Transplant patients, AIDS, Collagen vascular diseases

Non-Hodgkin LymphomaNon-Hodgkin LymphomaClassificationClassification

WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 2008

Non-Hodgkin Lymphoma Non-Hodgkin Lymphoma ClassificationClassification

WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 2008

Ann Arbor stagingStage Involvement

I Single node group or region

IE Single extranodal site

II Two or more nodes on same side of diaphragm

IIE Localized disease in an organ and node on same side of diaphragm

III Node groups on both sides of diaphragm

IIIE Above diaphragm + localized extralymphatic

IIIS Above diaphragm + spleen

IV Extension beyond above limit

Lymphoma : Goals of imagingLymphoma : Goals of imaging

1. Initial staging of lymphoma2. Monitoring radiological response to therapy3. Imaging complications of treatment4. Detecting evidence of relapse

Lymphoma : Chest involvementLymphoma : Chest involvement

A. Nodal diseaseB. Pulmonary parenchymal involvementC. PleuraD. Heart & pericardiumE. Chest wall

A) Nodal chest involvementA) Nodal chest involvement• Hodgkin disease– Thoracic involvement in 85% of newly diagnosed

cases– Best diagnostic clue for intrathoracic disease is

mediastinal lymphadenopathy• Predilection for the anterior mediastinum, especially

thymus• 65-75% abnormal CXR at presentation

– Prevascular and paratracheal lymph nodes most commonly involved

– Contiguous progression from one lymph node group to the next

– Nodes rarely calcify before treated

A) Nodal chest involvementA) Nodal chest involvement• Non-Hodgkin Lymphoma– Best diagnostic clue : • bulky mediastinal, bilateral, asymmetrical hilar

lymphadenopathy• Lobulated lymph node masses

– Superior mediastinal + paratracheal nodes– Lymph node masses will encase and displace

structures rather than infiltrate and obstruct

B) Pulmonary parenchymal B) Pulmonary parenchymal involvementinvolvement

• Associated with – existing or previously treated intrathoracic nodal

disease– widespread extrathoracic disease

• Primary pulmonary NHL• Primary pulmonary HD

B) Pulmonary parenchymal B) Pulmonary parenchymal involvementinvolvement

• 3x more frequent in HD than in NHL• Relatively rare – 10% of cases at initial presentation• Becomes more common as the disease progresses• Particularly frequent in pt who relapse after treatment• In Hodgkin disease– Lung disease almost invariably accompanied by visible

intrathoracic adenopathy– If mediastinal nodes have been previously irradiated,

recurrence may be confined to the lungs• NHL– Lung disease can be seen in absence of mediastinal

lymphadenopathy

B) Pulmonary parenchymal B) Pulmonary parenchymal involvementinvolvement

• Various radiographic appearances• Most common patterns are– One or more areas of pulmonary consolidation

• May contain air bronchograms• May be segmental or lobar in shape• Often radiate from hila or mediastinum

– Without conforming to segmental anatomy– In keeping with concept that extension into lungs is by direct

invasion from involved mediastinal nodes

– Peripheral subpleural masses or areas of consolidation• With no connection to mediastinal nodes

– Appearance of lymphangitis carcinomatosis

B) Pulmonary parenchymal B) Pulmonary parenchymal involvementinvolvement

B) Pulmonary parenchymal B) Pulmonary parenchymal involvementinvolvement

• Primary pulmonary Hodgkin Disease is extremely rare– Single or multiple pulmonary nodules• Upper lobe predominance• High incidence of cavitation

C) Pleura C) Pleura

• Pleural effusion – Usually in presence of mediastinal lymphadenopathy– At presentation

• In 10% of NHL• In 7% of HD

– Most often due to central lymphatic /venous obstruction rather than direct malignant involvement• Clear after treatment of mediastinal disease

• Focal pleural masses + effusion is seen in recurrent disease

D) Heart and pericardiumD) Heart and pericardium

• Rarely involved• Direct involvement can occur in high grade

peripheral T-cell and large B-cell lymphomas– More often (but still rare) in • AIDS related lymphoma• Post-transplant lymphoproliferative disorders

• Pericardial effusion• Acute onset heart block, congestive cardiac

failure or cardiac tamponade

E) Chest wallE) Chest wall• Hodgkin disease– Spread into chest wall from anterior mediastinal mass

• In Hodgkin and Non-Hodgkin lymphoma– Chest wall masses can also spread from axillary or

supraclavicular nodes– Can arise de novo in chest wall– Bony destruction is rare

• Consider infection or carcinoma

ReferencesReferences

• Mohammed TL & Yadav R. Hodgkin lymphoma and non-Hodgkin lymphoma, mediastinum. In: Diagnostic Imaging: Chest. First Edition. Amirsys; 2006.

• Padley S & MacDonald SLS. Pulmonary neoplasms. In: Grainger & Allison’s Diagnostic Radiology. Fifth Edition. Churchill Livingstone; 2008.

• Vinnicombe SJ & Reznek RH. Reticuloendothelial disorders: lymphoma. In: Grainger & Allison’s Diagnostic Radiology. Fifth Edition. Churchill Livingstone; 2008.

• World Health Organisation classification of tumours of haematopoietic and lymphoid tissues 2008.