Imaging of Lymphoma in the Chest William F. Auffermann, MD

Disclosures

Imaging of Lymphoma in the Chest

• None

William F. Auffermann, MD/PhD TUESDAY

Department of Radiology and Imaging Sciences Emory University School of Medicine

Outline • • • •

Lymphoma basics Non /Hodgkin Lymphoma Non-/Hodgkin Organs specific imaging of Lymphoma S i Staging

Lymphoma • • • • •

A malignancy of the lymphocytes. Cell types: B-cell B cell, T T-cell cell, natural killer cell Typically presents as a solid tumor I Involves l the h lymph l h nodes d andd solid lid organs Greater than 30 types of lymphoma

Lymphoma Basics

Lymphoma, Leukemia, Myeloma Disease

Location of proliferating abnormal lymphocytes

Lymphoma

Solid tumor in lymph nodes or other organs

Leukemia

Cells infiltrating bone marrow and circulating in blood

Myeloma

Plasma cells in bone marrow

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General - Imaging Modalities • CT: high resolution imaging with limited soft tissue contrast. • MRI: Current clinical use is primarily for assessing vascular and cardiac invasion. invasion • PET : High sensitivity for active disease and useful in staging/re staging/re-staging. staging

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Imaging of HL and NHL

Hodgkin Lymphoma

HL Imaging Findings

• Accounts for 10-15% of lymphoma (30-40yo 40yo & >50yo) • Bimodal Age distribution (30 • ~60% have mediastinal lymphadenopathy (LAD) at presentation presentation. • Less than 10% have isolated subdiaphragmatic i involvement l • Usually spreads along contiguous lymph nodes until late in the course of the disease

Bulkyy anterior mediastinal lymphadenopathy y p p y which may coalesce into lobular masses

HL Imaging Findings

Non-Hodgkin Lymphoma (NHL)

• Often infiltrates the thymus • Hilar LAD without anterior mediastinal LAD is rare and should suggest another diagnosis • Lung involvement is often secondary (extending from hilar regions), regions) but rarely the site of primary disease.

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• • • •

Heterogeneous group of disorders Greater than 30 types of NHL Most (85-90%) are derived from B-cells M common types off NHL Most NHL: – diffuse large B-cell (~30%) – Follicular (~30%)

• Thoracic manifestations in 45% (usually mediastinal lymphadenopathy)

NHL Imaging Findings

Often presents with bulky anterior mediastinal/paratracheal lymphadenopathy

NHL (Compared to HL) • Staging more dependent on overall tumor burden and histological g type yp • More likely to involve noncontiguous sites. • Lymph nodes often larger at presentation • Primary pulmonary involvement is more common • More likely to invade mediastinal structures and involve other organs.

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NHL (Compared to HL) Imaging findings are more variable compared with HL

Organ Specific Imaging of Lymphoma

Thoracic Organs Involved • • • •

Mediastinal lymph nodes Lungs Pleura H Heart

Mediastinal Lymph Nodes

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Mediastinal Lymph Nodes

Mediastinal Lymph Nodes Peripheral p T-cell Lymphoma y p

• Most common lymph nodes involved are anterior mediastinal • Calcification uncommon prior to treatment • Lymphadenopathy may cause SVC syndrome (lymphoma 2rd most common cancer cause, cause after lung cancer) • Isolated hilar involvement uncommon

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• Lymph L h nodes d may fform conglomerate l masses • Mass usually homogeneous

Mediastinal Lymph Nodes

DDX - Metastases

BLBCL

Large g mass occasionallyy be necrotic/cystic y Metastases – primary malignancy elsewhere

DDX - Goiter • Contiguous with thyroid • Attenuation matchingg thyroid • May be using iodine uptake nuclear medicine scan

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DDX - Sarcoid • Lymph nodes usually in paratracheal and hilar regions • Partially calcified

DDX – Thymus (normal)

DDX - Thymoma

• Normal configuration: triangular in shape with concave or straight margins • Diameter i less l than h 15 mm (adults) • If iinvolved l d in i lymphoma l h is considered as a nodal site for staging purposes

• • • •

Age > 40 Anterior mediastinum 1/3 cystic 1/3 calcified : often thin an linear in capsule • If ppleura involved, usually unilateral.

Image(s): Courtesy of Dr. Travis Henry

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DDX - Thymoma Abnormal

Normal

Image(s): Courtesy of Dr. Travis Henry

DDX – Germ Cell Tumor • • • • •

Age < 40 Anterior mediastinum May contain fat y Mayy be cystic May rarely contain calcium

Image(s): Jeung M, et al. Radiographics 2002;22:S79-S93

DDX – Castleman Disease • Single enlarged node – matted LAD • Usually in middle and posterior mediastinum • Rare in anterior mediastinum • May demonstrate avid contrast enhancement

Lungs

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Lungs Pulmonary involvement seen in ~ 10-15% More common in HL than in NHL Usually secondary to lymphoma elsewhere Di Disease often f extends d iinto the h lung l from f adjacent lymph nodes • Perilymphatic lung involvement

• • • •

Consolidation with air bronchograms Pulmonary nodules Ground glass opacities L Lymphangetic h i spread d off tumor

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Lungs - Findings

Pulmonary Consolidation

Pulmonary Consolidation

malt

Nodular Sclerosing Hodgkin lymphoma

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MALT Lymphoma

Pulmonary Consolidation

Pulmonary Nodules

HL

HL

Ground Glass Opacities

HL

MALT Lymphoma

DDX - Pneumonia

DDX - Pneumonia

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Pulmonary Nodules

• Tree-in-bud opacities and/or centrilobular nodules • Lymphangitic pattern not seen

C Consolidation lid i with i h less l marked k d lymphadenopathy l h d h

DDX - Metastases

DDX - Metastases

M Metastatic i endometrial d i l leiomyosarcoma l i

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DDX - Bronchogenic Carcinoma

• Often unilateral mass or consolidation • Asymmetric lymphadenopathy • Middle mediastinal and hilar > anterior

• Often unilateral mass or consolidation • Asymmetric lymphadenopathy • Middle mediastinal and hilar > anterior

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DDX - Bronchogenic Carcinoma

DDX - Sarcoid

• Architectural distortion and superior p hilar retraction • Partially calcified lymph nodes

DDX - Eosinophilic Pneumonia • Peripheral consolidation. • Often increased blood: eosinophil count, count IgE, ESR • Similar to organizing pneumonia but often in upper lung zones.

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DDX – Organizing Pneumonia • Consolidation often in peripheral or peribronchovascular distribution. • Lower lung l zone predominance. • Usually U ll no LAD Mueller-Mang, et al; RadioGraphics 2007; 27:595–615

Lymphangitic Spread

DDX - Lymphangitic • • • • •

Pulmonary edema – usually smooth Interstitial Lung Disease – usually peripheral Sarcoidosis B Bronchogenic h i Carcinoma C i Metastases – gastric cancer, breast cancer

Pleura

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Pleura

Pleura

• Pleural effusions are common (seen in 80% in HL,, 50% overall)) • Pleural effusions usually not associated with pleural malignancy unless pleural masses are seen

HL

DDX - Pleura • Reactive – secondary to infection or inflammation,, often uniform thickness • Asbestos – mild thickening, partially calcified • Pleurodesis – high attenuation material • Drop-metastases (Thymoma) – oval/lobular anterior i mediastinal di i l mass, mediastinal di i l lesions l i in other node groups less common, unilateral • Mesothelioma – LAD less common

Heart and Pericardium

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Heart and Pericardium

Heart and Pericardium

• Pericardium involved more frequently than the y myocardium • Pericardial effusions are usually associated with pericardial involvement of lymphoma • Valves lack lymphatic vessels and are usually spared • Central necrosis less common Will often extend over epicardial surface encasing the coronary arteries.

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Image(s): Courtesy of Dr. Travis Henry

Heart and Pericardium- Imaging

DDX - Heart and Pericardium • Metastases to the heart: – Most common – Lesions elsewhere

• Cardiac Sarcomas:

If cardiac chambers are involved, involved the most frequent chamber involved is the right atrium

– More likely to involve valves and great vessels – Central C t l necrosis i more common. – Avid contrast enhancement

Jeudy, et. al.; RadioGraphics 2012; 32:1369–1380

Lymphoma Staging Lymphoma Staging Abramson,

Ann Arbor - Cotswolds modification, from Townsend and Lynch, Lancet, 2012, v380, p836–47

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Lymphoma Staging – Summary • I: Single lymph node region or lymphoid structure • II: Two or more lymph y p node regions g or lymphoid y p structures on one side of diaphragm • III: Lymph nodes on both sides of diaphragm • IV: Extranodal involvement (other than *E)

Treatment Related Findings

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Treatment Related Findings

Treatment Related Findings

• Lymph nodes and other areas of involved y p decrease in size,, often to with lymphoma within normal limits • Residual foci of scar tissue may occur and may calcify • PET is a sensitive method for assessing treatment response Treated lymph nodes may calcify

Treatment Related Findings Summary

Radiation may cause scarring and volume loss

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Summary Thoracic Lymphoma

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• Most common manifestation of lymphoma in the chest is an anterior mediastinal and paratracheal lymphadenopathy • Lymphadenopathy may coalesce into a homogeneous mass (large masses may show central necrosis) • Imaging findings are variable, and other organs may be involved involved. • Calcification is rare in untreated disease

Helpful References • Bae, et. al., Cross-Sectional Evaluation of Thoracic Lymphoma, Radiol Clin N Am, 2008, v46, p253–264 • Sharma, et. al., Patterns of Lymphadenopathy in Thoracic h i Malignancies, li i RadioGraphics, di hi 2004, v24, p419–434 • Mukherjee M kh j S, S Th The Emperor E off All Maladies: M l di A Biography of Cancer, 2011, Scribner, New York.

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Questions? William F. Auffermann [email protected]