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Neuroradiology Case of the Week
Case 329
Matthew Thrall, Ashwani Sharma, MD
and P-L Westesson, MD, PhD, DDS
Clinical
Presentation: A 17-year-old female with no significant past medical history presented with cervical lymphadenopathy and anemia.
Imaging Findings: CT findings often include lymph adenopathy of the thorax (85-99%) with lung parenchymal involvement in 12% of the cases. In intra-pulmonary disease, with the bronchovesicular form, one usually finds coarse reticulonodular patterns contiguous with the mediastinum, nodular parenchymal lesions, and/or miliary nodules. In the massive pneumonic form, diffuse non-segmental infiltrate, massive lobar infiltrates, homogeneous confluent infiltrates with shaggy borders, and/or air bronchograms are often seen.
Abdominal adenopathy is often found as well, but less often. The most common site of abdominal involvement is the spleen, which is found in 37% of the cases. The liver is less involved, at only 8%.
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| Figures 1A&B: Axial CT of chest showed confluent nodular densities in the right lung involving all three lobes, with most prominence in the lower lobe. Small cavitary areas within this nodular confluent airspace disease also are seen. There are central air bronchograms noted. |
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Figure 2: The thoracic inlet has multiple supraclavicular nodes (arrows) many of which are clumped together. The largest clump is on the left and measures 6.2 cm transversely by 2.8 cm. Adenopathy continues into the mediastinum |
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Figures 3A&B: Axial CT scan of the neck revealed multiple bilateral enlarged lymph nodes.
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| Figure 4: CT scan of upper abdomen revealed enlarged retroperitoneal lymph nodes with splenomegaly. |
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Figures 5A&B: After three months of treatment, the densities in both the left and right lungs have significantly diminished along with cervical lymphadenopathy. |
Diagnosis: Hodgkin's disease
Discussion: Hodgkin's lymphoma is a common (40% of all lymphomas) disease of the T-cells with a bimodal distribution at age 25-30 years and over 70 years. There were 7,400 cases in the U.S. in 2001. It usually presents with asymptomatic unilateral cervical lymphadenopathy. The nodular sclerosing histologic subtype is most common, which has an affinity for the anterior mediastinum. The treatment goal in Hodgkin's disease (HD) is to cure the disease, which differs from some other lymphomas. More than 75% of newly diagnosed cases can be cured with therapy (chemotherapy a/or radiation).
HD has a tendency to arise within lymph node areas and spread in a contiguous, orderly fashion, which differs from non-Hodgkin disease.
CT scanning is preferred for staging as it is more sensitive in detecting lymphadenopathy and extra-lymphatic involvement, and CT of the thorax, abdomen, and pelvis is usually performed for initial staging. MRI is performed in patients in whom chest wall involvement is suggested (since it offers better tissue contrast).
Differential diagnosis includes other neoplasms (lymphomas or leukemias), infectious causes (pneumonia, disseminated lung diseases), and sarcoidosis.
References:
- Dahnert WF. Radiology Review Manual. 2nd ed, Philadelphia: Lippincott Williams & Wilkins, 1993.
- Lister TA, Crowther D, Sutcliffe SB, et al. Report of a committee convened to discuss the evaluation and staging of patients with Hodgkin's disease: Cotswolds meeting. J Clin Oncol. 1989 Nov;7(11):1630-6. [Medline]
- Kennedy BJ, Loeb V Jr, Peterson V, et al. Survival in Hodgkin's disease by stage and age. Med Pediatr Oncol. 1992;20(2):100-4. [Medline]
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