Imaging of Lymphoma in the Chest William F. Auffermann, MD
Disclosures
Imaging of Lymphoma in the Chest
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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; 27:595615
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; 32:13691380
Lymphoma Staging Lymphoma Staging Abramson,
Ann Arbor - Cotswolds modification, from Townsend and Lynch, Lancet, 2012, v380, p83647
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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, p253264 Sharma, et. al., Patterns of Lymphadenopathy in Thoracic h i Malignancies, li i RadioGraphics, di hi 2004, v24, p419434 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]