Lymphography and abdominal computed tomography in the staging of non-Hodgkin lymphoma. With an analysis of discrepancies

Ninety-one patients with non-Hodgkin lymphoma (NHL) were subjected to computed tomography (CT) and lymphography. Both examinations agreed in 74 patients (81%) with regard to the infradiaphragmatic lymph nodes. In patients undergoing CT prior to lymphography, the concordance amounted to 75 per cent. When lymphography was the initial examination, the concordance amounted to 86 per cent. Lymphography was abnormal in 30 per cent of the patients with a normal CT scan and in 93 per cent of those with an abnormal CT scan as the first examination. CT was abnormal in 4 per cent of patients with a normal lymphogram and in 84 per cent of those with an abnormal lymphogram as the first examination. CT did not detect mesenteric or retrocrural lymph node enlargement in the absence of retroperitoneal lymph node involvement. Eleven patients had extranodal manifestations of the disease (excluding liver and spleen), and 3 were detected primarily with CT. Lymphography is the most complete examination for the infradiaphragmatic lymph nodes for staging purposes. Although CT outlined the disease better, it changed the lymphographic diagnosis in only 2 per cent of the patients. Lymphography modified the CT stage in 15 per cent of the patients. When abdominal CT is performed first, in staging patients with NHL, lymphography will only yield additional information when CT is normal or equivocal.     

Hodgkin disease: CT of the thymus

The computed tomography (CT) scans in two groups of patients with Hodgkin disease were reviewed to determine the frequency of thymic enlargement. In 50 CT scans from 50 patients with evidence of thoracic disease on CT scans who were examined for primary staging, the thymus was enlarged in 15 of 50 (30%). Fifty CT scans were obtained from 44 patients at the time of 50 separate episodes of known or suspected relapse. Relapse occurred in the mediastinum in 12 episodes, lung parenchyma in five, and both sites in one. Thymic enlargement thought to be due to involvement by disease was present in seven of 18 (38%). Mediastinal disease was associated with thymic enlargement in all but one patient in whom a thymic cyst developed after radiation therapy. Differentiation of thymic enlargement from enlarged superior mediastinal lymph nodes was easily made in all but two patients. Thymic enlargement in the absence of lymph node enlargement may indicate a different disease, since isolated Hodgkin disease of the thymus is uncommon. Primary thymic tumor should be considered initially, whereas after treatment, rebound hyperplasia of the thymus may be the cause of enlargement.     

Comparison of positron emission tomography and lymphangiography in the diagnosis of infradiaphragmatic Hodgkin's disease

Purpose: To evaluate the respective roles of positron emission tomography using ¹⁸F-fluorodeoxyglucose (FDG-PET) and lymphangiography (LAG) in staging Hodgkin's disease (HD) patients with negative contrast-enhanced infradiaphragmatic computed tomography (CT).

Material and Methods: 28 patients underwent FDG-PET and LAG at initial staging. Concordant positive findings on both tests were regarded as actual HD locations and concordant negative findings as true negative. In case of discrepancy, the reference was biopsy or magnetic resonance imaging (MRI).

Results: Concordant results were obtained in 26 patients (24 negative, two positive). In two of the 24 negative patients, PET showed additional lesions in the spleen and one celiac lymph node (one patient), and in the right kidney and the right iliac crest (one patient). Discordant results were obtained in two patients. Both methods indicated infradiaphragmatic involvement in different locations in one patient. In the other, PET was falsely positive (PET done within 24 hours after a negative LAG), which was confirmed by biopsy (benign inflammatory, probably due to LAG medium).

Conclusion: FDG-PET and LAG gave comparable results, making invasive LAG unnecessary. Furthermore, LAG, when performed before PET, can be responsible for false-positive PET results.     

Location,size, and distribution of mediastinal lymph node enlargement in chronic congestive heart failure

PURPOSE: The purpose of this study is to identify the prevalence, location, and size of enlarged mediastinal lymph nodes in patients with chronic congestive heart failure and to correlate the presence of lymph node enlargement with cardiac ejection fraction. METHODS: Sixty-six consecutive, retrospectively identified patients underwent computer tomography (CT) imaging of the thorax as part of a routine work-up prior to cardiac transplantation from 1993 to 1996. CT images of 44 of these patients were independently examined by 3 radiologists for evidence of pulmonary edema, pleural effusions, and the presence, size, and location of lymph nodes >1 cm in short axis. Multigated acquisition (MUGA) scans were available for cardiac ejection fraction assessment in 38 of the 44 patients. RESULTS: Twenty-nine (66%) patients had at least 1 mediastinal lymph node >1 cm. The mean ejection fraction was significantly less for patients with lymph node enlargement when compared with patients without lymph node enlargement (20% versus 35%; P < 0.01). Adenopathy was observed in 81% of patients with a calculated ejection fraction of <35%. No patient with an ejection fraction of >35% had lymph node enlargement. There was no correlation between pulmonary edema and the frequency of lymph node appearance. Sixty-three percent of the enlarged nodes were pretracheal, with a mean short axis diameter for all the enlarged nodes of 1.3 cm. CONCLUSIONS: Enlarged mediastinal lymph nodes were observed in 81% of patients with a calculated ejection fraction of <35%, most commonly in the pretracheal group. The presence of the lymph nodes did not correlate with CT evidence of pulmonary edema.     

影像学技术在霍奇金淋巴瘤诊疗中的价值

在我国,霍奇金淋巴瘤（HL）占全部恶性淋巴瘤的10.9％,约90％起源于淋巴结,通常呈对称性淋巴结肿大,很少累及结外组织.HL对放疗、化疗很敏感,是可治愈的肿瘤之一.该文主要就CT成像、MRI、67Ga成像、PET或PET/CT在HL诊断及预后评估等方面的应用作一综述,以进一步提高对HL影像学表现及其临床应用的认识.     

Enlarged mediastinal lymph nodes in the fibrosing alveolitis of systemic sclerosis.

The aim of this study was to determine the prevalence of enlarged mediastinal lymph nodes in systemic sclerosis (SSc) and relate this to the extent of pulmonary disease and disease activity as judged by high resolution computed tomography (HRCT). The HRCT scans of 78 patients with SSc were reviewed. The extent of lung disease and HRCT pattern were analysed and CT scans examined on soft tissue window settings for evidence of mediastinal lymph node enlargement. Sixty six (85%) patients had evidence of lung involvement on CT. Enlarged mediastinal lymph nodes were present in 21 (32%) patients with lung involvement but in only 1 (8%) patient without. The prevalence of enlarged mediastinal nodes increased with more extensive lung involvement on CT (p < 0.025), but correlated poorly with the type of CT appearance and concurrent erythrocyte sedimentation rate. Mediastinal lymph node enlargement occurs frequently in patients with SSc, particularly if lung involvement is extensive.     

Mesenteric lymphadenopathy in patient with Yersinia enterocolitica infection: a differential diagnosis to abdominal lymphoma

Summary We report a case of previously undiagnosed Yersinia enterocolitica infection in a 46-year old woman. She consulted her physician because of continual weight loss and physical lassitude. A leucocytosis was found. Sonography revealed an excessive enlargement of abdominal lymph nodes. A malignant lymphoma was suspected and the patient underwent a staging by CT. There the disease was limited on mesenteric and retroperitoneal lymph nodes. Bone marrow biopsy and CT-guided lymph node biopsy did not confirm a systemic lymphatic disease. The patient did not undergo a special therapy. After six months, CT showed a clear regression of enlarged lymph nodes. Finally, a previous Yersinia enterocolitica infection of immunotype 03 could be proved serologically. At this time, the patient had no complaints. Diagnostic and differential diagnosis of benign abdominal lymph node enlargement are discussed based on literature.      

CT联合超声诊断POEMS综合征

目的探讨POEMS综合征CT和超声影像学表现特点,提高认识能力。方法选取4例经CT和超声诊断的POEMS综合征患者临床资料,分析影像学表现。结果 4例均为男性,CT表现4例腋窝、腹股沟淋巴结多发肿大,3例纵隔淋巴结肿大,增强扫描呈明显均匀强化,超声显示淋巴结内部及周围血流丰富;4例多浆膜腔积液;3例脊柱、骨盆、胸骨多发局限性骨质硬化;3例乳腺发育;3例肺动脉高压。结论骨质硬化性改变、多中心富血供淋巴结肿大、肺动脉高压在POEMS综合征有一定影像学特点,密切结合临床可做出正确诊断。     

Computed tomography of abdominal paraaortic lymph node disease: preliminary observations with a 6 second scanner.

Eleven patients suspected of having tumor involving para-aortic lymph nodes were studied with the Varian 6 second whole body CT scanner. All patients had a pedal lymphangiogram; six were abnormal. In three of these six, CT provided clinically important information on the extent of disease which was not detectable by other radiographic studies. CT scanning improved on lymphangiographic interpretation when large bulky nodes were only partially filled and when whole chains of nodes failed to fill. In both situations, the enlarged paraaortic nodes were well delineated on CT. The internal architecture and morphological abnormalities of small well filled nodes were better portrayed by lymphangiography. In the four cases in which lymphangiograms were normal and the one case in which the lymphangiogram showed reactive hyperplasia, the CT scans were normal.     

Upper abdominal lymph nodes: criteria for normal size determined with CT

Reports of the upper limits of normal for lymph node size at abdominal computed tomography have varied from 6 to 20 mm. Establishment of an upper limit for node size by specific location, analogous to that which has been reported for mediastinal lymph nodes, was sought. Short-axis diameters of the lymph nodes were measured in 130 patients who were not likely to have enlarged abdominal lymph nodes. Seven locations were defined, and the largest nodal measurement for each was recorded. Histographic analysis and nonparametric statistical methods were used to determine threshold values for the maximum node size in each region. The upper limits of normal by location were as follows: retrocrural space, 6 mm; paracardiac, 8 mm; gastrohepatic ligament, 8 mm; upper paraaortic region, 9 mm; portacaval space, 10 mm; porta hepatis, 7 mm; and lower paraaortic region, 11 mm. Lower paraaortic lymph nodes larger than 11 mm by short-axis measurement are abnormal. In other locations, nodes smaller than 1 cm may be abnormal if the determined thresholds are exceeded.     

Planning mantle radiation therapy in patients with Hodgkin disease: role of gallium-67 scintigraphy

Detection of all sites of lymphoma is imperative for accurate planning of radiation therapy. In patients with Hodgkin disease, mantle radiation is used to treat the thoracic lymph nodes; in those with early-stage or nonbulky disease, mantle and paraaortic radiation may be the only treatment given. CT scanning of the chest adds important information to that obtained from chest radiographs. Gallium-67 scintigraphy has also been used to provide additional information on sites of active tumor. To determine the usefulness of 67Ga-citrate scintigraphy in planning the portals for radiation therapy, we analyzed the radiation treatment plans in 26 consecutive patients with Hodgkin disease; in all 26 patients, the disease had been staged by chest radiographs, chest CT scans, and gallium-67 images. Gallium-67 imaging alone provided unique information that affected the treatment plans in three patients (12%). The combined results of gallium-67 imaging and CT scans influenced the planning of radiation therapy in eight patients (31%). Gallium-67 imaging was found to be an important adjunctive study for optimal planning of radiation therapy in patients with Hodgkin disease.     

Abdominal lymphoma staging: is MR imaging with T2-weighted turbo-spin-echo sequence a diagnostic alternative to contrast-enhanced spiral CT?

PURPOSE: To evaluate the diagnostic value of MR imaging in abdominal lymphoma staging, in comparison with that of the established spiral CT, within the context of a prospective study. METHODS: 50 patients with non-Hodgkin (n = 27) and Hodgkin lymphoma (n = 23) were examined with a plain T2-weighted TSE sequence (parameters: TE 90 ms, TR >2.500 ms, slice thickness 8 mm, slice interval 0.8 mm, ETL 20, NEX 4), and with spiral CT following oral and intravenous administration of contrast agent. RESULTS: Both CT and MR imaging agreed in showing abdominal lymphomas in 34/50 cases. The size of the detected lymphomas was between 1.5-9 cm (mean: 4.3 +/-2.2 cm). In the analysis of the individual lymph node sites, CT showed involvement of the paraaortic lymph nodes in 29/50 patients, compared with 28/50 in MRI, and involvement of the portal lymph nodes in 15/50, compared with 12/50. Both techniques showed the iliac lymph nodes in 21/50 patients, the inguinal lymph nodes in 10/50, and the mesenteric lymph nodes in 11/50. Both techniques also showed focal organ lesions in 12/50 cases. CONCLUSIONS: In the staging of abdominal lymphomas, MR imaging with a T2-weighted TSE sequence can be regarded as equal to spiral CT in the detection of lymph adenopathy and the demonstration of focal organ lesions. In addition to the absence of ionizing radiation, the advantage of MR imaging is that there is no necessity for oral or intravenous administration of contrast agent.     

Thymic involvement in Hodgkin disease: CT and sonographic findings

To evaluate the morphologic characteristics and frequency of thymic enlargement in Hodgkin disease, the initial and follow-up computed tomographic (CT) scans of 43 patients with newly diagnosed Hodgkin lymphoma were retrospectively analyzed. Sonograms of the thymic region in 21 patients were also available and were compared with the CT scans. Initial CT scans showed thymic enlargement in 17 of the 43 patients, no evidence of thymic enlargement in 15 patients, and equivocal findings in 11 patients. Analysis of follow-up CT scans indicated that seven of the 11 patients with initially equivocal findings had had thymic enlargement. In all seven patients, the anterior mediastinal tumor shrank with therapy and adopted a typical tongue-shaped thymic configuration. In nine of the 24 patients with thymic enlargement, the thymus remained enlarged after therapy and full clinical remission. The comparison of sonograms and CT scans showed that sonography could not help differentiate the normal-size thymus from surrounding fatty tissue. All thymic glands that were considered diseased because of enlargement at CT were sonographically visible due to an abnormal, hypoechoic structure. The results of the study show that thymic enlargement presumed to be due to involvement by Hodgkin disease seems to occur more frequently than previously reported.     

Tuberculosis versus lymphomas in the abdominal lymph nodes: evaluation with contrast-enhanced CT

OBJECTIVE: Tuberculosis in the abdominal lymph nodes may be difficult to distinguish from lymphomas. This study evaluated specific CT imaging criteria for differentiating these entities. MATERIALS AND METHODS: We retrospectively reviewed the anatomic distribution and CT enhancement patterns of disease in 69 patients, 26 (38%) with tuberculosis and 43 (62%) with untreated lymphomas involving abdominal lymph nodes. Of the patients with tuberculosis, five (19%) had disseminated disease and 21 (81%) had nondisseminated disease. Of the patients with lymphomas, 16 (37%) had Hodgkin's disease and 27 (63%) had non-Hodgkin's lymphoma. RESULTS: Disseminated and nondisseminated tuberculosis involved predominantly lesser omental, mesenteric, anterior pararenal, and upper paraaortic lymph nodes. Lower paraaortic lymph nodes were involved more often in Hodgkin's disease (15 patients [94%]), non-Hodgkin's lymphoma (24 patients [89%]), and disseminated tuberculosis (five patients [100%]) than in nondisseminated tuberculosis (one patient [5%]). Mesenteric lymph nodes were involved more often in disseminated tuberculosis (four patients [80%]) and nondisseminated tuberculosis (11 patients [52%]) than in Hodgkin's disease (one patient [6%]) (p < .01). Anatomic distribution was not different between disseminated tuberculosis and non-Hodgkin's lymphoma. Tuberculous lymphadenopathy commonly showed peripheral enhancement, frequently with a multilocular appearance, whereas lymphomatous adenopathy characteristically showed homogeneous attenuation (14 patients [87.5%] with Hodgkin's disease and 19 patients [70%] with non-Hodgkin's lymphoma [p < .01]). CONCLUSION: Our findings indicate that the anatomic distribution and specific enhancement patterns of lymphadenopathy seen on contrast-enhanced CT can be useful in differentiating between tuberculosis and untreated lymphomas of the abdominal lymph nodes.     

The characteristics and significance of thoracic lymphadenopathy in parapneumonic effusion and empyema

The occurrence of significant mediastinal lymphadenopathy together with pleural effusion or empyema inevitably raises concern about the presence of intrathoracic malignancy or granulomatous disease. Lymph node enlargement may also occur when pneumonia is accompanied by a parapneumonic effusion or empyema. Features that allow "benign" lymph node enlargement to be distinguished from malignant causes have not previously been determined. The present study aims to establish the CT characteristics of enlarged nodes in parapneumonic effusion. The appearances of mediastinal lymph nodes were recorded in 50 consecutive patients with parapneumonic effusion/empyema. 18 (36%) had mediastinal lymphadenopathy (node size greater than 1 cm). The mean number of enlarged nodes was 1.9 (range 1-3) and the mean size was 1.4 cm (2 cm maximum). Seven patients had a single involved site, nine patients two sites and two patients three sites. The right paratracheal area was most commonly involved and the subcarinal area contained the largest nodes. The presence of enlarged nodes did not correlate with biochemical and microbiological stage of pleural infection, length of history, or extent of consolidation. This study shows that mediastinal lymphadenopathy is commonly associated with parapneumonic effusion and that multiple sites may be involved. The degree of enlargement is moderate although lymphadenopathy of greater than 2 cm size should raise the possibility of other pathology.     

STIR turbo SE MR imaging vs. coregistered FDG-PET/CT: quantitative and qualitative assessment of N-stage in non-small-cell lung cancer patients

PURPOSE: To conduct a prospective comparison of the accuracy of short inversion time (TI) inversion-recovery (STIR) turbo spin-echo (SE) imaging and coregistered 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) with computed tomography (CT) (coregistered FDG-PET/CT) to assess the N-stage in non-small-cell lung cancer (NSCLC) patients. MATERIALS AND METHODS: A total of 115 consecutive NSCLC patients prospectively underwent CT, STIR turbo SE imaging, and FDG-PET, as well as surgical and pathological examinations. All STIR turbo SE images were obtained with a 0.9% saline phantom, which was placed alongside the chest wall of each patient, and coregistered FDG-PET/CTs were reconstructed using commercially available software. For quantitative assessments, the ratio of signal intensity (SI) of each lymph node to that of 0.9% saline phantom (lymph node-saline ratio [LSR]) and maximal standardized uptake value (SUV(max)) of each lymph node were calculated. Feasible threshold values were determined by using the receiver operating characteristic (ROC) curve-based positive test, and diagnostic capabilities of N-stage were compared by McNemar's test on a per patient basis. RESULTS: When feasible, threshold values were adopted, quantitative sensitivity (90.1%) and accuracy (92.2%) of STIR turbo SE imaging were significantly higher than those of quantitative and qualitative sensitivities (76.7% and 74.4%) and accuracies (83.5% and 82.6%) of coregistered FDG-PET/CT on a per patient basis (P < 0.05). CONCLUSION: STIR turbo SE imaging is at least as valid as coregistered FDG-PET/CT for quantitative and qualitative assessment of the N-stage for NSCLC patients.     

艾滋病相关淋巴瘤的CT表现

目的探讨艾滋病(AIDS)相关淋巴瘤(ARL)的CT表现。资料与方法回顾性分析5例AIDS合并非霍奇金淋巴瘤(NHL)患者的CT表现,并复习文献总结ARL的影像学表现。结果5例AIDS合并NHLCT示:淋巴结肿大4例,其中腋窝淋巴结肿大2例,腹股沟淋巴结肿大1例,纵隔淋巴结肿大2例,腹腔淋巴结肿大3例。5例均有淋巴结外病变,肝脾肿大2例,肝内多发低密度结节2例,胰腺内多发低密度结节1例,肾上腺病变1例,十二指肠病变2例,胆管扩张2例,骨骼病变1例,软组织肿块2例。结论ARL以NHL为主,广泛累及淋巴结及淋巴结以外器官,淋巴结外病变发生率高、且常多脏器受累是其影像学特点。     

The prevalence of enlarged mediastinal lymph nodes in asbestos-exposed individuals: a CT study.

Patients with cryptogenic fibrosing alveolitis have a higher prevalence of enlarged mediastinal lymph nodes compared with the normal population. To determine whether or not this observation applies to individuals with asbestos-induced pulmonary fibrosis the high resolution computed tomography (CT) scans of 14 patients with definite asbestosis and 11 age-matched cases with benign asbestos-induced pleural disease, but no lung disease, were re-imaged on soft tissue settings. The site, size and number of mediastinal lymph nodes equal to, or greater than, 1.2 cm were recorded. In the asbestosis group 14 out of 14 patients had at least one enlarged lymph node with an average number per individual of four (range 1-10). In the control group two out of 11 patients each had one minimally enlarged lymph node. We conclude that mediastinal lymph node enlargement occurs frequently in asbestosis: awareness of this is important in the investigation of malignant disease in patients with asbestosis.     

Psoas lymph node metastasis in patients with carcinoma of the uterine cervix

Enlargement of lymph nodes between the psoas muscle and lumbar spine was demonstrated on CT in three of 14 cases having Stage IIb and III uterine cervical carcinoma with iliac or paraaortic lymphadenopathy. In two of these, the adjacent lumbar vertebral body was destroyed. We define psoas lymph nodes to include all lymph nodes located between the psoas muscle and the spine. Psoas lymph nodes may be divided into upper and lower groups: the upper group distributed along the lumbar arteries above in level of L4-L5 and the lower group distributed along the lumbar branches of the iliolumbar arteries below L5. There appears to be paravertebral communication between these two groups. The region of the psoas lymph nodes should be scrutinized in interpretating CT in patients with malignant pelvic tumors which have already spread to iliac or paraaortic lymph nodes. Obliteration of fat plane between psoas muscle and lumbar vertebra is a clue to the presence of enlargement of the psoas lymph nodes on CT. Massive enlargement of psoas lymph nodes may be difficult to distinguish from metastasis to psoas muscle. In such cases, MR imaging would be of help to differentiate these two conditions.     

胸部结节病的影像学诊断

目的回顾性分析胸部结节病的影像学表现,进一步提高对此病的认识,减少误诊。方法分析36例符合诊断标准的胸部结节病的胸片及CT表现。结果胸部淋巴结增大34例,其中两侧肺门及纵隔淋巴结增大22例,两侧肺门淋巴结增大而无纵隔淋巴结增大2例,一侧肺门及纵隔淋巴结增大7例,一侧肺门淋巴结增大而无纵隔淋巴结增大1例,仅有纵隔淋巴结增大2例。肺部病变25例,其中多发结节18例,条索状影13例,磨玻璃样影11例,支气管血管束增厚5例,空气潴留4例,实变2例。支气管改变8例,胸膜病变3例。CT对纵隔内较小淋巴结及肺内病灶的检出率明显高于胸片。结论有典型影像学表现的胸部结节病诊断容易;不典型者诊断困难,需密切结合临床及治疗后随访。