Posttransplantation lymphoproliferative disorder: manifestations in pediatric thoracic organ recipients

PURPOSE: To describe and correlate the clinical and imaging features of posttransplantation lymphoproliferative disorder (PTLD) in young thoracic organ transplant recipients. MATERIALS AND METHODS: The authors retrospectively reviewed the medical and imaging records of 31 PTLD episodes in 27 patients with PTLD out of 183 young patients who survived for at least 1 month after thoracic organ transplantation: 18 (14%) heart transplant recipients and nine (16%) lung or heart-lung transplant recipients. Four patients had two separate PTLD episodes. The distribution, timing, and imaging features of the disease were analyzed. RESULTS: Seventeen (55%) of 31 episodes involved intrathoracic PTLD manifesting as multiple pulmonary nodules (n = 10), a solitary nodule (n = 3), alveolar consolidation (n = 3), and/or mediastinal adenopathy (n = 8). Extrathoracic PTLD occurred in 21 (68%) of 31 episodes and involved the abdomen (n = 15), head and neck (n = 11), and/or central nervous system (n = 3). The imaging findings of these episodes included bowel wall thickening, lymphadenopathy, and focal masses. Intrathoracic PTLD occurred more commonly in lung transplant recipients (89%) than in heart transplant recipients (44%); no cases of lymphoma involved the thorax. The frequency of extrathoracic manifestations was higher in heart transplant recipients (83%) than in lung transplant recipients (33%). In lung transplant recipients, the prevalence of early-onset PTLD was significantly greater than that in heart transplant recipients (P <.05). Intrathoracic PTLD tended to manifest early. CONCLUSION: PTLD in young thoracic transplant recipients involves the lungs and extrathoracic organs, tends to have an early onset, and manifests predominantly in the thorax in lung transplant and heart-lung transplant recipients, as opposed to heart transplant recipients.     

Thoracic and abdominal manifestations of lymphoma occurring in the immunocompromised patient.

Organ transplant and AIDS patients are at a much higher risk for developing non-Hodgkin's lymphoma than is the general population. This increased risk is directly related to chronic immunosuppression and often is associated with viral infections. In contrast to lymphomas occurring in nonimmunocompromised patients, these tumors typically are of higher grade, are more aggressive, have a worse prognosis, and exhibit a higher frequency of extranodal disease. The most frequent organs involved are the head and neck, bowel, liver, and lungs. Thoracic manifestations of ARL and PTLD are similar, consisting of nodular, diffuse alveolar, and interstitial pulmonary disease, mild to moderate mediastinal adenopathy, and pleural effusions. Of these findings, pulmonary nodules are the most specific, although they can be difficult to differentiate from Kaposi's sarcoma and opportunistic infections. Abdominal findings are also similar for the two diseases, with the most common lesions appearing as low attenuation, hypoechoic masses in the solid abdominal organs; ulcerating nodular or diffusely infiltrating bowel lesions; and bulky retroperitoneal, mesenteric, or omental adenopathy. The identification of solid masses in the abdominal organs in AIDS and transplant patients is highly suspicious for ARL and PTLD. Due to the overlap of imaging characteristics of different pathologies, however, biopsy usually is necessary to confirm the diagnosis. Both ARL and PTLD respond to therapy; however, the prognosis for patients with ARL is uniformly poor, whereas the prognosis for treated PTLD is remarkably good. An awareness of the imaging characteristics of ARL and particularly PTLD can have significant impact on prognosis by allowing for timely diagnosis and therapy.     

结节病肺部改变的CT征象分析

目的探讨结节病肺部改变的CT表现及特征。方法回顾性分析90例经手术病理证实的结节病的临床资料及CT表现。结果结节69例（76．7％），主要沿支气管血管束分布37例（41．1％），团块影31例（34．4％），磨玻璃影39例（43．3％），支气管血管束增粗30例（33．3％），小叶间隔线58例（64．4％），纤维化17例（18．9％），包括支气管变形8例（8．9％）、条索影5例（5．6％）、蜂窝影4例（4．4％），空气潴留3例（3．3％），支气管狭窄8例（8．9％），胸膜改变42例（46．7％），肺门纵隔淋巴结增大76例（84．4％）。2种及2种以上肺部病变并存83例（92．2％），肺部病变合并肺门纵隔淋巴结增大76例（84．4％）。结节、团块、磨玻璃影、支气管血管束增粗治疗后随访吸收好转例数分别为25例（25／30）、9例（9／15）、11例（11／16），10例（10／12）；小叶间隔线、支气管变形、条索影、蜂窝影吸收好转例数分别为10例（10／22）、0例（0／4）、1例（1／3），0例（0／2）。结论结节病肺部CT表现形式多样，具有一定特征性，同时结合肺门纵隔淋巴结增大改变，有助于提高诊断正确率。     

The CT appearance of pleural and extrapleural disease in lymphoma.

OBJECTIVE: Pleural effusions in patients with lymphoma that are assumed to be related to malignancy are attributed to either lymphatic obstruction by tumour with resultant decreased clearance of pleural fluid, or direct tumour involvement of the pleura. The purpose of our study was to determine how often pleural or extrapleural disease was detected by computed tomography (CT) of patients with pleural effusions and primary or recurrent lymphoma. METHODS AND MATERIALS: We reviewed CT examinations showing evidence of pleural effusion in 61 patients with a diagnosis of primary or recurrent lymphoma and no history of other systemic disorders, including infection. The study population consisted of patients with non-Hodgkin's lymphoma (n = 44) or Hodgkin's disease (n = 17); both primary disease (n = 11) and recurrent disease (n = 50) were represented. Each CT examination was evaluated for the presence of disease involving the visceral and parietal pleura and extrapleural space, mediastinal adenopathy, and pulmonary parenchymal disease. RESULTS: Fourteen patients (23%) (nine with non-Hodgkin's lymphoma and five with Hodgkin's disease) had parietal pleural disease (thickening or nodules). Eighteen patients (30%) (14 with non-Hodgkin's lymphoma, four with Hodgkin's disease) had tumour or enlarged lymph nodes in the extrapleural space. Forty-three patients (70%) had mediastinal lymphadenopathy. Patients who received intravenous contrast did not have evidence of visceral pleural abnormalities or underlying pulmonary parenchymal disease. CONCLUSION: Forty-one percent of the patients with lymphoma and pleural effusions had CT evidence of pleural and/or extrapleural disease. The majority of the patients with extrapleural disease had adjacent posterior mediastinal disease.     

Hilar and mediastinal lymph node metastases in malignant melanoma.

Of 65 patients with intrathoracic metastases from melanomon, 35 had metastasis to hilar or mediastinal nodes. In 28 of these 35, hilar and mediastinal lymph node enlargement was radiographically visible, hilar node enlargement was more commonly seen than mediastinal node enlargement. Pulmonary nodules were demonstrated radiographically in 25 of the 28 patients. Although lymph node enlargement was often asymmetric, symmetric hilar adenopathy mimicking sarcoidosis occurred in five of the 28 patients. Seven patients had unilateral involvement of lung and hilar and mediastinal nodes. In patients with melanoma, indirect metastatic spread via pulmonary nodules to hilar and mediastinal nodes may account for the frequent association of node metastases with lung nodules, the occurrence of intrathoracic adenopathy in the absence of extrathoracic node metastases, and the common finding of unilateral lung and nodal disease.     

Advanced prostatic carcinoma: pulmonary manifestations

To clarify the role of standard chest radiography in prostatic adenocarcinoma, the pulmonary manifestations of 198 patients with Stage D disease were evaluated. All patients were treated with chemotherapeutic protocols allowing for adequate clinical and radiographic correlation. Retrospective interpretation of serial chest radiographs revealed that 35% of our patients had visible intrathoracic abnormalities; however, only 24% of the patients had abnormalities attributable to intrathoracic metastases. Twenty-two percent of patients had pleural effusions, 16% reticular opacities, 3.5% reticulonodular opacities, 8% isolated or discrete pulmonary nodules, and 4.5% adenopathy. Etiologies of these opacities included metastatic disease in 93.5% of those with adenopathy and nodular or reticulonodular opacities, but 39% of pleural effusions and 52% of reticular opacities were best attributed to concomitant processes. Four patients had intrathoracic metastases without bone metastases. Standard chest radiography is a valuable screening procedure that should be correlated with clinical data to differentiate metastases from concomitant processes.     

Thoracic manifestations of breast carcinoma: metastatic disease and complications of treatment.

Breast cancer, a common malignancy in women, is a major cause of cancer-related deaths. Metastases to the thorax are common in patients with breast cancer. Metastases can manifest radiographically as pulmonary nodules, lymphangitis carcinomatosa, endobronchial masses, intrathoracic adenopathy, pericardial or myocardial masses and pleural effusions. Additionally, pulmonary abnormalities occur after radiotherapy, chemotherapy and autologous bone marrow transplantation. Knowledge of the various intrathoracic manifestations of metastases and complications of therapy is important in staging and evaluating patients with breast cancer and deciding on the most appropriate treatment.     

Pulmonary sarcoidosis in the older patient: conventional radiographic features

The clinical and radiographic findings in 29 patients presenting with pulmonary sarcoidosis after the age of 50 years were reviewed. Fifty-nine percent (17 patients) had atypical findings at presentation. The atypical patterns at radiography included mediastinal adenopathy alone or in combination with unilateral hilar adenopathy (n = 8), solitary or multiple pulmonary masses (n = 3), and atelectasis (n = 3). Five patients had extrathoracic tumors at the time that the diagnosis of pulmonary sarcoidosis was made, which confused the diagnosis at radiography. An enhanced awareness of the atypical patterns of sarcoidosis in the older patient may facilitate the diagnostic process.     

The CT findings of pulmonary sarcoidosis: analysis of 25 patients

We analyzed the CT findings in 25 patients with biopsy-proved pulmonary sarcoidosis. In all 25 patients, 10-mm collimation scans were available. In 16 of the 25 patients, select 1.5-mm scans were obtained. These were retrospectively targeted by using a 20- to 25-cm field of view and a high-spatial-resolution algorithm. The CT and pathologic findings were compared in two patients in whom surgical specimens of the lung were available. CT findings included hilar and mediastinal adenopathy (n = 22), subpleural nodules (n = 19), and 1- to 10-mm-diameter nodules (n = 17) and irregular linear densities (n = 12), both mainly along the bronchovascular structures. High-resolution CT was superior to conventional CT in the assessment of subpleural nodules and irregular linear densities, but conventional CT was superior in the assessment of peribronchovascular nodules. The two gross pathologic specimens showed the sarcoid granulomas to be mostly along the lymphatics in the peribronchovascular sheath and, to a lesser extent, in subpleural and interlobar septal lymphatics. We conclude that the characteristic CT appearance of pulmonary sarcoidosis consists of small nodules and irregular linear densities along the bronchovascular bundles.     

CT of posttransplantation lymphoproliferative disorder in pediatric recipients of lung allograft

OBJECTIVE: The purpose of this study was to determine the CT and clinical findings of posttransplantation lymphoproliferative disorder in pediatric lung allograft recipients. MATERIALS AND METHODS: We reviewed the medical records and CT examinations of 260 lung transplantations in pediatric patients and found 26 recipients who had 29 episodes of histologically proven posttransplantation lymphoproliferative disorder. The clinical and CT features of the disease, the time to diagnosis, and the outcomes were assessed. RESULTS: The clinical presentation of posttransplantation lymphoproliferative disorder varied from asymptomatic pulmonary nodules (14/29 [48%]) detected on chest CT to specific (organ-related) and nonspecific symptoms (15/29 [52%]). Intrathoracic posttransplantation lymphoproliferative disorder occurred in 20 (69%) of 29 cases and manifested as multiple pulmonary nodules (n = 17), alveolar infiltrates (n = 2), and combined nodules and infiltrates (n = 1). In eight (28%) of 29 cases, there was extraparenchymal disease, including adenopathy, pleural effusion, and esophageal thickening and erosions. Extrathoracic posttransplantation lymphoproliferative disorder occurred in 13 cases and involved the abdomen (n = 10), paranasal sinuses (n = 2), and brain (n = 1). In the abdomen, extranodal disease was more common than nodal disease and presented as bowel wall thickening, focal mass lesions, and splenomegaly. In 18 of 29 episodes of posttransplantation lymphoproliferative disorder, the histologic diagnosis was lymphoma. The median time to diagnosis after transplantation for the 29 episodes of posttransplantation lymphoproliferative disorder was 10 months. Thirteen of the 26 patients died. The median time of survival after the diagnosis of posttransplantation lymphoproliferative disorder was 17 months. CONCLUSION: Posttransplantation lymphoproliferative disorder in pediatric lung transplant recipients occurs with relatively high frequency in both the chest and abdomen, tends to have lymphomatous features, and results in substantial mortality rates.     

Intrathoracic complications following allogeneic bone marrow transplantation: CT findings

The authors retrospectively reviewed computed tomographic (CT) scans of 18 patients who developed 21 episodes of intrathoracic complications after allogeneic bone marrow transplantation (BMT). Pathologic and/or microbiologic diagnoses were available for all patients. All patients were immunocompromised due to either graft-versus-host disease (GVHD), neutropenia, or recurrent malignancy after BMT. CT demonstrated diagnostically relevant findings that were not apparent at radiography in 12 of the 21 cases (57%). These included a ground-glass pattern in early pneumonia (n = 5); a peripheral distribution in GVHD, bronchiolitis obliterans organizing pneumonia, and eosinophilic drug reaction (n = 4); cavitating lesions in Pneumocystis carinii pneumonia (n = 1); hemorrhagic infarcts in aspergillosis (n = 1); and mediastinal adenopathy in recurrent Hodgkin disease (n = 1). The authors conclude that chest CT is superior to radiography in demonstrating the presence, distribution, and extent of intrathoracic complications developing in patients after allogeneic BMT. CT is useful in guiding procedures for tissue diagnosis.     

Intrathoracic Kaposi sarcoma in AIDS patients: radiographic-pathologic correlation

The chest radiographs and postmortem pathologic findings in 24 patients with acquired immunodeficiency syndrome (AIDS) and autopsy-proved intrathoracic Kaposi sarcoma were reviewed. Premortem radiographic visualization of pulmonary lesions of Kaposi sarcoma depended on the extent of involvement and the presence of concomitant disease. In three patients (13%) the radiographs showed nodular opacities that corresponded in size and configuration to nodules seen at autopsy. In 21 patients (87%) the lesions were not radiographically identifiable, in some cases because they were obscured by infection. The positive and negative predictive values of four radiographic findings for intrathoracic Kaposi sarcoma were evaluated, using a control group of 14 AIDS patients without intrathoracic Kaposi sarcoma at autopsy. Findings with a high positive predictive value were parenchymal nodular and reticular opacities (100%), pleural effusions (89%), and hilar and/or mediastinal lymphadenopathy (92%). None of these findings is specific, but the presence of any one in a patient with AIDS should increase the possibility of intrathoracic involvement by Kaposi sarcoma.     

Intrathoracic manifestations of metastatic testicular seminoma: a comparison of chest radiographic and CT findings

The chest radiographs and CT scans of 200 patients with pure testicular seminoma were reviewed. The radiographs showed evidence of intrathoracic metastatic disease in 25 patients (12.5%). Of these, 17 had an abnormal mediastinal contour, seven had pulmonary metastases, five had pleural effusions, and two had discrete pleural masses. CT showed evidence of intrathoracic metastatic disease in 30 patients (15%). This included mediastinal nodal enlargement in 21, pulmonary metastases in 12, pleural effusions in six, and pleural masses in two. CT not only showed disease in five patients with normal chest radiographs, but also showed additional sites of disease in four other patients with abnormal chest radiographs. The results suggest that mediastinal nodal enlargement is the most common intrathoracic manifestation of metastatic testicular seminoma. CT is more accurate than chest radiography in the detection of metastatic seminoma in the chest and defines the extent of metastatic disease more precisely.     

Atypical aspects of intrathoracic posttransplantation lymphoproliferative disorders

Posttransplant lymphoproliferative disorders (PTLD), developing after immunosuppressive therapy in human organ-graft recipients, are, for the most part, Epstein-Barr virus-induced. The earlier the diagnosis is made, the greater the potential for reversibility. The chest radiographs and CT scans of 10 patients with thoracic locations of PTLD were reviewed. Mediastinal (n = 3) and hilar adenopathy (n = 2), pulmonary nodules (n = 8), and pleural thickening or effusion (n = 4) were encountered. The incidence of partial resolution with clinical remission (n = 4) appears to be noteworthy, and in all likelihood is related to the extensive necrosis (n = 5) that is frequently seen. Slow regression, transitory deterioration in one case, and localization only on the graft side in two cases, were observed. These morphological and evolutionary peculiarities must be known in order to optimize the diagnosis, and thus the prognosis, of these very original disorders. Correspondence to: C. Beigelman     

Pulmonary blastomycosis: findings on chest radiographs in 63 patients

Posteroanterior and lateral chest radiographs of 63 patients with proved pulmonary blastomycosis were evaluated to determine the most common findings. Included in the analysis were the location of the pulmonary infiltrates, the distribution and parenchymal patterns of disease, and the prevalence of adenopathy, pleural effusions, and/or cavity formation. Blastomycosis pneumonitis involved more than one pulmonary lobe in 21 patients and a single upper lobe in 27 of 63 patients. Forty-eight of the 63 patients had air-space consolidation. In nine of the 63 patients, a pulmonary mass was the major abnormality seen on radiographs. Approximately one fifth of the patients had associated pleural effusions and/or mediastinal or hilar adenopathy. Twenty-three patients (37%) had cavitation within the area of pulmonary consolidation. These findings suggest that blastomycosis should be considered when chest radiographs show air-space infiltrate in the upper lobes or in more than one lobe of the lung, especially when the infiltrate is associated with pleural effusions, cavitation, lymphadenopathy, and/or a paramediastinal mass.     

Lung cancer in patients seropositive for human immunodeficiency virus

The authors describe the clinical and radiographic findings of lung carcinoma in six patients infected with the human immunodeficiency virus (HIV). These patients were in a younger age group than is commonly associated with lung cancer. The radiographic findings included mediastinal adenopathy (n = 5), hilar masses with distal atelectasis (n = 3), parenchymal masses (n = 3), pleural effusions (n = 2), and pleural thickening (n = 1). Recognition of any of these findings should raise the diagnostic possibility of lung cancer in this group of younger patients.     

Pulmonary MALT lymphoma: imaging findings in 24 cases

The aim of this study was to describe the imaging features of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma. The chest radiographs (n = 18) and CT scans (n = 17) of 24 patients (18 men and 6 women) aged 27–78 years (mean = 56 years), with a known diagnosis of pulmonary MALT lymphoma, were retrospectively reviewed by two radiologists and the imaging findings are described. Six of the 24 patients had a history of an autoimmune disorder and 1 patient had acquired immune deficiency syndrome. Multiple pulmonary lesions were identified in 19 of 24 patients (79 %) and solitary lesions in 4 of 24 patients (17 %). Diffuse pulmonary infiltration was present in 1 patient. Lesions included masses or mass-like areas of consolidation (n = 21) and pulmonary nodules (n = 18). Associated findings were air bronchograms, airway dilatation, a positive angiogram sign and a halo of ground-glass shadowing at lesion margins. Peribronchovascular thickening was also observed, as were hilar or mediastinal lymph node enlargement and pleural effusions or thickening. Although rare, the diagnosis of pulmonary MALT lymphoma should be considered in patients with the imaging features described, particularly when in association with an indolent clinical course or a history of autoimmune disease. Received: 4 October 1999; Revised: 24 February 2000; Accepted: 18 April 2000     

Pulmonary cryptococcosis: CT findings in immunocompetent patients

PURPOSE: To evaluate retrospectively the computed tomographic (CT) findings in immunocompetent patients with pulmonary cryptococcosis. MATERIALS AND METHODS: Institutional review board approval was obtained with a waiver of informed consent, and the study complied with requirements of the Health Insurance Portability and Accountability Act. Chest CT scans of 10 immunocompetent patients with clinically proved pulmonary cryptococcosis were retrospectively reviewed by four reviewers in consensus. Criterion for diagnosis of pulmonary cryptococcosis was (a) the histopathologic presence of the organism at lung biopsy or (b) a positive culture of a respiratory specimen or positive serum cryptococcal antigen test with clinical or radiographic evidence of active pulmonary infection. Patients included six women and four men ranging in age from 46 to 73 years (mean, 59 years). Scans were evaluated for nodules, masses, areas of ground-glass attenuation or of hazy increased attenuation, areas of consolidation, areas of cavitation, pleural effusions, linear opacities, septal thickening, lymphadenopathy, extent of parenchymal involvement, and distribution. RESULTS: The most common CT finding was pulmonary nodules (n = 9). Multiple nodules (n = 7) were more common than solitary nodules (n = 2). Nodules most commonly occupied less than 10% of the pulmonary parenchyma (n = 7), measured less than 10 mm in diameter (n = 7), and had middle and upper lung predominance (n = 6). The majority of the nodules were well defined with smooth margins (n = 7). Multiple nodules were usually bilaterally distributed (n = 5). Masses (n = 2), lymphadenopathy (n = 2), areas of consolidation (n = 2), areas of hazy increased attenuation (n = 1), pleural effusion (n = 1), and areas of cavitation (n = 1) were uncommon. CONCLUSION: CT most commonly demonstrated pulmonary nodules in immunocompetent patients with pulmonary cryptococcosis. The nodules were most often multiple, small, well defined, and smoothly marginated with middle and upper lung predominance.     

Mediastinal adenopathy and endobronchial involvement in metastatic renal cell carcinoma

Mediastinal adenopathy and endobronchial metastases are sometimes the only radiological manifestation of metastatic disease from extrathoracic neoplasms. We report on four patients in whom hilar and paratracheal adenopathy (n = 3) and endobrochial involvement (n = 1) were the only intrathoracic manifestations of metastatic renal cell carcinoma. Three of the patients had nephrectomies 9 months to 4 years before the appearance of intrathoracic disease; another patient presented with medastinal disease as the initial manifestation of renal cell carcinoma. If a patient with a history of renal cell carcinoma develops pulmonary hilar adenopathy, metastatic disease should be suspected and appropriate diagnostic measures should be taken.     

Pulmonary nontuberculous mycobacterial infection: radiologic manifestations.

The nontuberculous mycobacteria (NTMB) are a group of bacteria that can infect the cervical lymph nodes, skin, soft tissues, and lung. Pulmonary NTMB disease is increasing in prevalence and is most commonly caused by Mycobacterium avium-intracellulare or M kansasii. Occasionally, M xenopi, M fortuitum, or M chelonae also causes pulmonary disease. Diagnosis of pulmonary NTMB infection is often difficult because isolation of the organism from sputum or bronchoalveolar lavage fluid can represent airway colonization. The radiologic manifestations of pulmonary NTMB infection are protean and include consolidation, cavitation, fibrosis, nodules, bronchiectasis, and adenopathy. Pulmonary NTMB infection has five distinct clinicoradiologic manifestations: (a) classic infection, (b) nonclassic infection, (c) nodules in asymptomatic patients, (d) infection in patients with achalasia, and (e) infection in immunocompromised patients. Although classic NTMB infection may be indistinguishable from active tuberculosis, it is usually more indolent. The radiologic features of nonclassic NTMB infection are characteristic: bronchiectasis and centrilobular nodules isolated to or most severe in the lingula and middle lobe. In patients with acquired immunodeficiency syndrome, mediastinal or hilar adenopathy is the most common radiographic finding. Knowledge of the full spectrum of clinical and radiologic features of pulmonary NTMB infection is important to facilitate diagnosis and treatment.