Thoracic Castleman disease: computed tomography and clinical findings

Human Oncoviruses and Thoracic Tumors: Understanding the Imaging Findings

Approximately 1.4 million virus-induced cancers occur annually, representing roughly 10% of the cancer burden worldwide. Seven oncogenic DNA and RNA viruses (ie, oncoviruses) are implicated in approximately 12%-25% of all human cancers owing to a variety of mechanisms as uncommon consequences of the normal viral life cycle. These seven well-recognized human oncoviruses are Epstein-Barr virus (EBV), human T-lymphotropic virus 1, hepatitis B virus, hepatitis C virus, HIV, human papilloma virus (HPV), and human herpesvirus 8 (HHV-8). Several viruses-namely, EBV, HPV, and Kaposi sarcoma herpesvirus or HHV-8-are increasingly being recognized as being related to HIV and/or AIDS, the growing number of transplant cases, and the use of immunosuppressive therapies. Infectious and inflammatory processes, and the accompanying lymphadenopathy, are great mimickers of human oncovirus-related tumors. Although it is often difficult to differentiate these entities, the associated clinical setting and radiologic findings may provide clues for an accurate diagnosis and appropriate management. Malignant lymphoid lesions are best evaluated with multidetector chest CT. The radiologic findings of these lesions are often nonspecific and are best interpreted in correlation with clinical data and histopathologic findings. ^©RSNA, 2022.

Clinical and Pathological Characteristics of Hyaline-Vascular Type Unicentric Castleman Disease: A 20-Year Retrospective Analysis

The first case of hyaline vascular type of unicentric Castleman disease (HV-UCD) was reported more than six decades ago. Since patients with HV-UCD are often asymptomatic and this condition is generally discovered incidentally on imaging tests, most of the previous reports were of mediastinal origin detected by chest radiography. In recent years, improved access to imaging modalities has provided new insights in the diagnosis of this condition. In this study, we reviewed the detailed clinical and pathological findings of 38 HV-UCD cases (20 males and 18 females, mean age: 42.8 years). The most common site involved was the abdominal cavity (34.2%), followed by mediastinum (23.7%) and retroperitoneum (15.8%). In the abdominal cavity, mesenteric origin was the most common. The mean size of masses was 4.8 cm. Pathologically, thick hyalinized collagen fibers surrounding large blood vessels and calcification were observed (81.6% and 23.7%, respectively). Multinucleated giant cells resembling Warthin–Finkeldey cell were also observed in occasional cases (23.7%). This is a unique paper that summarizes detailed clinical and pathological findings of a large series of a rare disease. The clinical information presented in this paper is more plausible than previous views and is useful for accurate diagnosis and understanding of the disease.

Unicentric Castleman disease: multidetector computed tomography classification with surgical and pathologic correlation

Background

This study aimed to correlate multidetector computed tomography (MDCT) classification of unicentric Castleman disease with the surgical and pathologic features.

Methods

The imaging manifestations of 63 cases of unicentric Castleman disease confirmed by pathology were retrospectively analyzed. Every patient underwent an MDCT examination. Classification based on imaging manifestations, surgical, histopathological, and imaging features were simultaneously reviewed and analyzed by two radiologists, with any disagreements resolved by consensus.

Results

Sixty-three patients with unicentric Castleman disease were divided into I-IV types by imaging manifestations: type I, single mass with smooth margin (n=5); type II, single mass with irregular or lobulated margin (n=33); type III, single invasive mass with blurred margin (n=20); and type IV, multiple fused masses (n=5). Thirty-eight cases of type I and type II were diagnosed as hyaline-vascular type by pathology after complete surgical resection; 20 cases were type III, in which eight cases were partially resected, 17 cases were pathologically diagnosed as hyaline-vascular type, and the remaining three cases were a mixed type. In five cases of type IV that could not be completely resected, four cases were hyaline-vascular type, and one case was plasma cell type.

Conclusions

MDCT is an excellent tool for the detection and diagnosis of unicentric Castleman disease. Classification by MDCT features is a reliable method for evaluating tumor infiltration and growth mode, which helps surgical optimization.

International evidence-based consensus diagnostic and treatment guidelines for unicentric Castleman disease

Castleman disease (CD) includes a group of rare and heterogeneous disorders with characteristic lymph node histopathological abnormalities. CD can occur in a single lymph node station, which is referred to as unicentric CD (UCD). CD can also involve multicentric lymphadenopathy and inflammatory symptoms (multicentric CD [MCD]). MCD includes human herpesvirus-8 (HHV-8)-associated MCD, POEMS-associated MCD, and HHV-8-/idiopathic MCD (iMCD). The first-ever diagnostic and treatment guidelines were recently developed for iMCD by an international expert consortium convened by the Castleman Disease Collaborative Network (CDCN). The focus of this report is to establish similar guidelines for the management of UCD. To this purpose, an international working group of 42 experts from 10 countries was convened to establish consensus recommendations based on review of treatment in published cases of UCD, the CDCN ACCELERATE registry, and expert opinion. Complete surgical resection is often curative and is therefore the preferred first-line therapy, if possible. The management of unresectable UCD is more challenging. Existing evidence supports that asymptomatic unresectable UCD may be observed. The anti-interleukin-6 monoclonal antibody siltuximab should be considered for unresectable UCD patients with an inflammatory syndrome. Unresectable UCD that is symptomatic as a result of compression of vital neighboring structures may be rendered amenable to resection by medical therapy (eg, rituximab, steroids), radiotherapy, or embolization. Further research is needed in UCD patients with persisting constitutional symptoms despite complete excision and normal laboratory markers. We hope that these guidelines will improve outcomes in UCD and help treating physicians decide the best therapeutic approach for their patients.

Emerging role of 18F-FDG PET/CT in Castleman disease: a review

Castleman disease (CD) describes a group of rare hematologic conditions involving lymphadenopathy with characteristic histopathology and a spectrum of clinical abnormalities. CD is divided into localized or unicentric CD (UCD) and multicentric CD (MCD) by imaging. MCD is further divided based on etiological driver into human herpesvirus-8-associated MCD, POEMS-associated MCD, and idiopathic MCD. There is notable heterogeneity across MCD, but increased level of pro-inflammatory cytokines, particularly interleukin-6, is an established disease driver in a portion of patients. FDG-PET/CT can help determine UCD versus MCD, evaluate for neoplastic conditions that can mimic MCD clinico-pathologically, and monitor therapy responses. CD requires more robust characterization, earlier diagnosis, and an accurate tool for both monitoring and treatment response evaluation; FDG-PET/CT is particularly suited for this. Moving forward, future prospective studies should further characterize the use of FDG-PET/CT in CD and specifically explore the utility of global disease assessment and dual time point imaging.

Trial registration ClinicalTrials.gov, NCT02817997, Registered 29 June 2016, https://clinicaltrials.gov/ct2/show/NCT02817997

Spectrum of [18F]FDG-PET/CT Findings in Benign Lymph Node Pathology

Diffuse lymphadenopathy has a long differential diagnosis that includes both malignant and benign causes. As part of the lymphadenopathy work-up, many patients undergo [¹⁸F]FDG-PET/CT for purposes of ruling out malignancy. FDG-avid lymph nodes, however, are not specific for malignancy. This review will illustrate the spectrum of nodal findings on FDG-PET/CT with correlation to other cross-sectional imaging and clinical history in patients with representative infectious, inflammatory, and benign lymphoproliferative disorders. These findings are important for the nuclear medicine radiologist to understand, as they can represent common pitfalls in the work-up of lymphadenopathy. While FDG-PET/CT may be limited in ascertaining a definitive diagnosis in a disease process as the cause of lymphadenopathy, it can help to narrow this differential and rule out certain diseases in the correct clinical context.

Different Imaging Features of Retroperitoneal Unicentric Castleman's Disease: A Case Report

Castleman's disease is a rare disease which is difficult to diagnose early due to its lack of specific manifestations, and also is easily confused with lymphoma or other solid tumors. Castleman's disease can occur in any part of the body containing lymph nodes and is most common in the chest, followed by the neck, abdomen, and axillae. A 37-year-old woman was admitted to our hospital because of a tumor near the adrenal gland found by computed tomography. Positron emission tomography-computed tomography revealed that the retroperitoneal tumor may be a malignant disease. However, the pathological diagnosis after laparoscopic resection was retroperitoneal Castleman's disease, hyaline vascular type.

Imaging and clinical features of Castleman Disease

BACKGROUND

Castleman disease (CD) is a group of uncommon lymphoproliferative disorders that is easily confused with lymphoma or other solid tumors. The purpose of our study was to evaluate the imaging and clinical findings of CD, and thus improve the understanding and diagnosis of CD.

METHODS

This retrospective study included 74 patients (37 men and 37 women, mean age ± standard deviation, 35 ± 15.2 years,) with histopathologically confirmed CD diagnosed based on CT or MRI between January 2010 and May 2017. The CT and MRI findings were analyzed by two radiologists in consensus, and clinical presentation and histopathologic characteristics were documented.

RESULTS

The CD subtypes included 61 hyaline vascular variant cases (82.4%) and 13 plasma cell variant cases (17.6%). Unicentric CD and multicentric CD were observed in 65 (87.8%) and 9 (12.2%) patients, respectively. On non-enhanced CT, enlarged nodes with hypodensity or isodensity were seen, whereas varying degrees of enhancement were observed in contrast-enhanced CT. Homogeneous and heterogeneous enhancements were observed in 43 (62.3%) and 26 (37.7%) patients, respectively. Hypertrophied vessels and calcification were detected in 38 (51.2%) and 18 (24.3%) patients, respectively. MRI revealed hypointense to isointense lesions on T1-weighted images, isointense to hyperintense lesions on T2-weighted images, and hyperintense lesions on diffusion-weighted imaging; 9 (75%) and 3 (25%) patients demonstrated homogeneous and heterogeneous enhancement, respectively.

CONCLUSION

CD often shows well-defined, mildly hypodense or isodense, homogeneous lymph nodules on non-enhanced CT/MRI, with intermediate and marked enhancement on contrast-enhanced CT/MRI. Calcification and hypertrophied vessels may be valuable diagnostic features.

Castleman Disease of the Thorax: Clinical, Radiologic, and Pathologic Correlation: From the Radiologic Pathology Archives

Castleman disease is a complex lymphoproliferative disease pathologically divided into two subtypes, the hyaline vascular variant (HVV) and the plasma cell variant (PCV). The HVV is the most common, is thought to represent a benign neoplasm of lymph node stromal cells, and is treated with surgical resection. It is most commonly found in the mediastinum, where it classically appears as a unicentric, avidly enhancing mass at computed tomography (CT) and magnetic resonance imaging. This appearance can mimic other avidly enhancing mediastinal masses, and location, clinical history, laboratory data, and nuclear medicine single photon emission CT (SPECT) and positron emission tomography (PET) studies can help narrow the differential diagnosis. Multicentric Castleman disease (MCD), which in the majority of cases is composed of the PCV, is an aggressive lymphoproliferative disorder associated with human herpesvirus infection, interleukin 6 dysregulation, and other systemic disorders. While it can be difficult to differentiate MCD from lymphoma, the presence of avidly enhancing lymph nodes can suggest the diagnosis. The purpose of this article is to review the clinical, immunologic, and pathologic findings associated with both unicentric Castleman disease and MCD and discuss how the imaging findings correlate with the pathophysiology of the disease.

Castleman disease-associated diffuse parenchymal lung disease: A STROBE-compliant retrospective observational analysis of 22 cases in a tertiary Chinese hospital

Intrathoracic involvement is common in Castleman disease (CD), but CD-associated diffuse parenchymal lung disease (DPLD) is rare and not well-reported.We conducted a retrospective analysis of 262 CD patients with a definite pathological diagnosis who were hospitalized between 1999 and 2015.Twenty-two CD patients had DPLD based on chest computed tomography (CT) scans. Among them, 9 were male and 13 were female, with a mean age of 45.3 years. Coughing (72.7%), fever (68.2%), and dyspnea (59.1%) were the common clinical manifestations. In high-resolution CT, obvious lymphadenopathy (81.8%) was the most frequent, followed by multiple nodules of different sizes (72.7%), cysts (59.1%), and patches of ground-glass opacity (54.5%). Six patients had lymphocytic interstitial pneumonia (LIP)-like CT images. Superficial lymph node biopsies (63.6%), video-assisted thoracic surgery lung biopsies (27.3%), CT-guided percutaneous lung biopsies (9.1%), and endoscopic lymph node biopsies (9.1%) were performed to make final diagnoses. The hyaline vascular variant (27.3%), the plasma cell variant (63.6%), and the mixed variant (9.1%) were the pathological subtypes. All but 2 were prescribed chemotherapy, and none was administered anti-interleukin-6 therapy. Among them, 14 patients improved, 3 died, 2 were stable, 2 were refractory, and 1 was lost to follow-up.Chinese CD-associated DPLD might be more prevalent in middle-aged female patients, with most cases being the plasma cell variant. Although a LIP-like pattern was reported, only one-quarter of the patients showed LIP-like CT images. Multiple nodules (especially solid nodules), cysts, and patchy areas were the common pulmonary radiological findings. More than half of the patients improved after chemotherapy. A well-designed prospective study should be performed to confirm these results.

Clinical spectrum of intrathoracic Castleman disease: a retrospective analysis of 48 cases in a single Chinese hospital

Background

Thorax is the common place to develop Castleman disease (CD), but there is no systemic clinical analysis for intrathoracic CD.

Methods

We conducted a retrospective analysis of 48 intrathoracic CD patients with definite pathological diagnosis who were hospitalized between 1992 and 2012 in a Chinese tertiary referral hospital.

Results

The study included 16 cases with unicentric CD (UCD) and 32 cases with multicentric CD (MCD). UCD were younger than MCD (30.5y vs 41.6ys, P < 0.05). MCD were more symptomatic (50% vs 96.9%, P < 0.001) and sicker than UCD, including more fever, hepatomegaly and/or splenomegaly and hypoalbuminemia. All of UCD showed solitary mass in various sites and two of them were complicated by small pleural effusion. In the MCD group, their chest CT showed obvious lymphadenopathy in the hilum and/or mediastinum (100%), diffuse parenchymal lung shadows (43.75%), pleural effusion (40.6%), mass in the mediastinum (6.25%) or hilum (3.12%) and bronchiolitis obliterans (BO) (3.12%). Besides LIP-like images, multiple nodules of different size and sites, patchy, ground-glass opacities and consolidation were showed in their chest CT. Surgery were arranged for all UCD for diagnosis and treatment and all were alive. In MCD group, superficial lymph nodes biopsies (21 cases), surgery biopsy (9 cases) and CT-guided percutaneous lung biopsy (2 cases) were performed. Hyaline vascular (HV) variant were more common in the UCD group (75% vs 37.5%, P < 0.05). In MCD group, 28 cases were prescribed with chemotherapy, one refused to receive therapy and the rest three were arranged for regular follow-up. Among MCD, 18 cases was improved, 7 cases was stable, 4 cases lost follow-up and 3 cases died.

Conclusions

Intrathoracic MCD was more common than UCD in our hospital. MCD was older, more symptomic and sicker than UCD. HV variant were more common in UCD. All of UCD showed mass in various intrathoracic locations and surgery resection was performed for all and all were alive. Mass, pleural effusion, BO and diffuse pulmonary shadows, including LIP-like images, multiple nodules of different size and sites, patchy, GGO and consolidations were showed in our MCD. Most of MCD cases were arranged with chemotherapy and their prognosis were worse than UCD’s.

Multimodality imaging and clinical features in Castleman disease: single institute experience in 30 patients

OBJECTIVE

To analyse imaging features of subtypes of Castleman disease (CD), emphasizing differentiating features from lymphoma.

METHODS

Institutional review board-approved, Health Insurance Portability and Accountability Act compliant, retrospective study examined 30 patients with CD. 30 patients (females, 20; mean age, 46 years; range, 22-87 years) with histopathologically confirmed CD and pre-treatment imaging formed the analytic cohort. Imaging at presentation in all patients [CT, 30; positron emission tomography (PET)/CT, 5; MR, 4; ultrasound, 3] and subsequent imaging in three cases that developed lymphoma was reviewed by two radiologists in consensus.

RESULTS

Subtypes: hyaline-vascular (n = 18); multicentric not otherwise specified (NOS) (n = 6); human herpesvirus 8 associated (n = 2); mixed unicentric (n = 2); pure plasma-cell variant (n = 1); and unicentric NOS (n = 1). Distribution: unicentric (n = 17); and multicentric (n = 13). Nodal sites-unicentric: 13 thoracic, 3 abdominal and 1 cervical; multicentric: 9 abdominal, 8 thoracic, 6 cervical, 5 inguinal, 4 axillary and 4 supraclavicular. On CT, differentiating features from lymphoma were calcification (n = 8; 26.7%) and heterogeneous enhancement (n = 5; 19.2%). No association between CD subtype, degree or enhancement pattern, or calcification was noted. On PET/CT (n = 5), nodes were typically fluorine-18 fludeoxyglucose avid (n = 4). On ultrasound (n = 3), nodes were hypoechoic, homogeneous with posterior acoustic enhancement. On MR (n = 4), nodes were hypointense (n = 2) to isointense (n = 2) on T1 weighted images and isointense (n = 1) to hyperintense (n = 3) on T2 weighted images. All (n = 4) demonstrated homogeneous enhancement. Three cases developed non-Hodgkin's lymphoma, two of the three had larger spleens, and these cases had effusions/ascites.

CONCLUSION

CD can be unicentric or multicentric and involve nodes above and below the diaphragm. Patients with CD can develop lymphoma.

ADVANCES IN KNOWLEDGE

Assessing individual risk of developing lymphoma in patients with CD is difficult, although the findings of splenomegaly, pleural effusion and ascites may be suggestive.

Intrapulmonary unicentric Castleman disease mimicking peripheral pulmonary malignancy

Castleman disease, also known as angiofollicular lymph node hyperplasia, can manifest as a unicentric or multicentric disorder. Intrapulmonary Castleman disease is very rare. Here, we present a patient with intrapulmonary Castleman disease who underwent left upper pulmonary lobectomy for suspected early lung cancer. The histopathologic diagnosis of the lobar mass was hyaline-type Castleman disease. The patient has remained well after surgery, showing no local recurrence or distant disease during a two-year follow-up period. Although unicentric Castleman disease originating in the lung is rare, it should be considered in the differential diagnosis of primary pulmonary malignant tumors.

Castleman disease of the neck: CT and MR imaging findings

OBJECTIVE

To characterize the computed tomography (CT) and magnetic resonance imaging (MRI) findings of Castleman disease of the neck.

METHODS

The imaging findings of 21 patients with Castleman disease of the neck were reviewed retrospectively. Of the 21 patients, 16 underwent unenhanced and contrast-enhanced CT scans; 5 underwent unenhanced and contrast-enhanced MRI scans.

RESULTS

The unenhanced CT images showed isolated or multiple well-defined homogenous mild hypodensity lesions in fifteen cases, and a heterogeneous nodule with central areas of mild hypodensity in one case. Calcification was not observed in any of the patients. In five patients, MR T1-weighted images revealed well-defined, homogeneous isointense or mild hyperintense lesions to the muscle; T2-weighted images showed these as intermediate hyperintense. Sixteen cases showed intermediate to marked homogeneous enhancement on contrast-enhanced CT or MR T1-weighted images. Of the other five cases that underwent double-phase CT scans, four showed mild or intermediate heterogeneous enhancement at the arterial phase, and homogeneous intermediate or marked enhancement at the venous phase; the remaining case showed mild and intermediate ring-enhancement with a central non-enhanced area at the arterial and venous phases, respectively.

CONCLUSION

Castleman disease of the neck can be characterized as solitary or multiple well-defined, mild hypodensity or homogeneous intense lesions on plain CT/MR scans, and demonstrates intermediate and marked enhancement on contrast-enhanced CT/MR scans. On double-phase CT scans, Castleman disease often demonstrates mild enhancement at the arterial phase, and gradually uniform enhancement at venous phase. Double-phase enhanced CT or MRI may help to differentiate Castleman disease from other diseases.

Successful Treatment of Mediastinal Unicentric Castleman's Disease Using Video-Assisted Thoracoscopic Surgery with Preoperative Embolization

Unicentric Castleman's disease is a rare, benign lymphoproliferative disorder that is curable with surgical resection. However, significant bleeding often occurs during surgery because of tumor hypervascularity. We herein present a case of hyaline-vascular-type mediastinal unicentric Castleman's disease, successfully resected using video-assisted thoracoscopic surgery with preoperative embolization. In the present case, tumor hypervascularity and feeding vessels were revealed by computed tomography (CT), which led us to perform preoperative angiography and embolization to the tumor feeding arteries to reduce intraoperative bleeding. Castleman's disease should be considered in the differential diagnosis of hypervascular mediastinal tumors. Tumor vascularity should be assessed prior to surgery, and preoperative embolization should be considered.