Transcript Chest lymphoma - Learning

Chest lymphoma
John-Henry Corbett
Diagnostic Radiology
University of Free Sate
04/2012
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 ReedSternberg cells
– 90% originate in lymph nodes
– 10% originate in extranodal lymphoid tissue
• Lung, GI tract, skin
Hodgkin disease : Classification
• Types of Hodgkin lymphoma
– Lymphocyte predominant
• <5% , young patients
– Nodular sclerosing
• 70%
– Mixed cellularity
• 25%
– Lymphocyte depleted
• <5%
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
Non-Hodgkin Lymphoma
Classification
WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 2008
Non-Hodgkin Lymphoma
Classification
WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 2008
Ann Arbor staging
Stage
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 imaging
1.
2.
3.
4.
Initial staging of lymphoma
Monitoring radiological response to therapy
Imaging complications of treatment
Detecting evidence of relapse
Lymphoma : Chest involvement
A.
B.
C.
D.
E.
Nodal disease
Pulmonary parenchymal involvement
Pleura
Heart & pericardium
Chest wall
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
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
B) Pulmonary parenchymal
involvement
• Associated with
– existing or previously treated intrathoracic nodal
disease
– widespread extrathoracic disease
• Primary pulmonary NHL
• Primary pulmonary HD
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
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
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 lymphangitis carcinomatosis
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)
B) Pulmonary parenchymal
involvement
• Primary pulmonary Hodgkin Disease is
extremely rare
– Single or multiple pulmonary nodules
• Upper lobe predominance
• High incidence of cavitation
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 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 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
References
• Mohammed TL & Yadav R. Hodgkin lymphoma and nonHodgkin 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.