Chest lymphoma

1. Chest lymphoma John-Henry Corbett Diagnostic Radiology University of Free Sate 04/2012

2. Hodgkin 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

3. Hodgkin disease : Classification • Types of Hodgkin lymphoma • Lymphocyte predominant • <5% , young patients • Nodular sclerosing • 70% • Mixed cellularity • 25% • Lymphocyte depleted • <5%

4. Non-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

5. Non-Hodgkin LymphomaClassification WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 2008

6. Non-Hodgkin Lymphoma Classification WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 2008

8. Lymphoma : Goals of imaging • Initial staging of lymphoma • Monitoring radiological response to therapy • Imaging complications of treatment • Detecting evidence of relapse

9. Lymphoma : Chest involvement • Nodal disease • Pulmonaryparenchymal involvement • Pleura • Heart & pericardium • Chestwall

10. A) 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

12. A) 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

14. B) Pulmonary parenchymal involvement • Associated with • existing or previously treated intrathoracic nodal disease • widespread extrathoracic disease • Primary pulmonary NHL • Primary pulmonary HD

15. B) Pulmonary parenchymal involvement • 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 intrathoracicadenopathy • If mediastinal nodes have been previously irradiated, recurrence may be confined to the lungs • NHL • Lung disease can be seen in absence of mediastinallymphadenopathy

16. B) Pulmonary parenchymal involvement • 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 lymphangitiscarcinomatosis

20. B) Pulmonary parenchymal involvement • Primary pulmonary lymphoma • Rare ; <1% of all lymphomas • Usually low grade B-cell NHL • Arises from mucosa associated lymphoid tissue (MALT) or Bronchus associated lymphoid tissue (BALT) • BALT lymphomas • 40-60 yrs • Tend to remain extranodal ; lymph nodes involved in advanced disease • Patients may have history of inflammatory or autoimmune disease • Imaging • Non-specific • Most commonly single pulmonary nodule • Multiple nodules or area of consolidation ca also be seen • Can remain for long period of time (non-resolving pneumonia)

21. B) Pulmonary parenchymal involvement • Primary pulmonary Hodgkin Disease is extremely rare • Single or multiple pulmonary nodules • Upper lobe predominance • High incidence of cavitation

22. C) Pleura • Pleural effusion • Usually in presence of mediastinallymphadenopathy • 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

23. D) 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

24. E) 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

25. References • 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.