Hodgkin’s Disease

 

l         Half of patients with Hodgkin’s have mediastinal lymph node enlargement visible on chest x-ray.

l         About 5-10% of patients may have mediastinal adenopathy without any other nodes involved

l         Clinically, over 90% of patients with Hodgkin’s have enlarged nodes, the disease behaving most benignly when restricted to the neck

l         Most have nodular sclerosing type

Imaging Findings

l         Parenchymal involvement occurs in 1/3 of patients with Hodgkin’s

o       Almost all have associated hilar or mediastinal adenopathy

o       Bronchovascular form (most common type of involvement)

§         Coarse reticulonodular pattern contiguous with mediastinum = direct extension from mediastinal nodes along lymphatics

§         Nodular parenchymal lesions

§         Miliary nodules

§         Endobronchial involvement

·         Lobar atelectasis secondary to endobronchial obstruction (rare)

§         Cavitation secondary to necrosis (rare)

o       Subpleural form

§         Circumscribed subpleural masses

§         Pleural effusion from lymphatic obstruction  (20-50%)

o       Pneumonic form

§         Diffuse nonsegmental infiltrate (pneumonic type)

§         Massive lobar infiltrates (30%)

§         Homogeneous confluent infiltrates with shaggy borders

·         Contain air bronchogram

o       Nodular form

§         Multiple nodules <1 cm in diameter

l         Extraparenchymal manifestations in the chest

l         Hilar adenopathy is usually bilateral but asymmetric

 

 

Frontal and lateral radiograph of the chest shows mediastinal adenopathy
(red arrows) producing lobulated soft tissue masses

 

 

l         Anterior mediastinal nodes commonly involved

o       They may calcify after radiation therapy

l         Mediastinal and hilar lymphadenopathy

o       Most common manifestation

§         Present in 90-99%

§         Commonly multiple lymph node groups involved

o       Location

§         Anterior mediastinal and retrosternal nodes commonly involved (DDx: sarcoidosis)

§         Confined to anterior mediastinum in 40%

§         20% with mediastinal nodes have hilar lymphadenopathy also

§          Hilar lymph nodes involved bilaterally in 50%

o       Spread from anterior mediastinum to

§         Pleura

§         Pericardium

§         Chest wall

o       On initial chest film adenopathy identified in 50%

§         Lymph nodes may calcify following radiation / chemotherapy

l         About 1/3 have pleural effusions

o       Effusion usually does not contain malignant cells

l         Atelectasis is very uncommon and almost always due to an endobronchial lesion

l         Prognostically, mediastinal node enlargement worsens prognosis but only minimally.

o       Diffuse lung involvement, on the other hand, carries a grave prognosis

l         Thoracic XRT portal is called a “mantel” because of its T shape to cover supraclavicular and mediastinal nodes

o       Lymphoma is radiosensitive – tumors frequently beginning to show reduction in size almost at once

Staging
 

l         Stage I is adenopathy limited to one lymph node bearing group

l         Stage II is adenopathy involving two or more non-contiguous groups on the same side of the diaphragm

l         Stage III is adenopathy involving lymph node groups on both sides of the diaphragm

l         Stage IV is extranodal involvement-such as lung or brain

l         “A” signifies absence of symptoms

l         “B” signifies   presence of fever, night sweats or pruritis