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 Lymphoma Classification 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

7. Ann Arbor staging StageInvolvement ISingle node group or region IESingle extranodal site IITwo or more nodes on same side of diaphragm IIELocalized disease in an organ and node on same side of diaphragm IIINode groups on both sides of diaphragm IIIEAbove diaphragm + localized extralymphatic IIISAbove diaphragm + spleen IVExtension beyond above limit

8. Lymphoma : Goals of imaging 1.Initial staging of lymphoma 2.Monitoring radiological response to therapy 3.Imaging complications of treatment 4.Detecting evidence of relapse

9. Lymphoma : Chest involvement A.Nodal disease B.Pulmonary parenchymal involvement C.Pleura D.Heart & pericardium E.Chest wall

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 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

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 lymphangitis carcinomatosis

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 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

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.