Calcification in lymphoma occurring before therapy: CT features and clinical correlation

Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes

The assessment of lymph node dimensions is a commonly used criterion in analyzing lymphatic involvement related to inflammatory or neoplastic diseases. However, it is important to understand that the interpretation of lymph nodes goes beyond simply considering their size. A pathologic lymph node can present with enlarged dimensions, a heterogeneous appearance, increased cortex thickness, irregular contours, or a lobulated shape. In this context, it is essential to consider not only the dimensions but also the morphology, attenuation, and enhancement of lymph nodes on imaging exams. This article aims to demonstrate how characteristics of lymph nodes, beyond their size, can provide crucial insights that assist in diagnostic reasoning, focusing on computed tomography. By emphasizing different enhancement patterns, attenuation, and the potential contents related to these patterns, the study seeks to show how these features can indicate possible differential diagnoses and guide more accurate clinical assessments.

[Lesions of the prevascular mediastinum]

CLINICAL/METHODOLOGICAL ISSUE

Mediastinal masses are a group of heterogenous lesions which may be a coincidental finding or present with symptoms. More than half of mediastinal lesions are located in the prevascular mediastinum. As these tumors are not often encountered in clinical routine, making a diagnosis with a high degree of confidence may seem challenging.

STANDARD RADIOLOGICAL METHODS

The latest computed tomography (CT)-based classification of the mediastinal compartments by the International Thymic Malignancy Interest Group (ITMIG) moves away from earlier radiograph-based classification systems and helps to reliably classify tumors based on location, although in some cases the lesion can occupy more than one compartment.

PERFORMANCE

Radiology plays an important role in the evaluation of anterior mediastinal lesions. Although in some cases imaging features alone allow a diagnosis to be made; in other cases knowledge of important radiological features and their analysis in the context of patient factors like age and duration of symptoms can help to narrow down the differential diagnosis, avoid unnecessary workup, and guide further steps.

PRACTICAL RECOMMENDATIONS

Computed tomography (CT) is central for the characterization of mediastinal masses in clinical routine. In some situations, like in the case of thymic cysts or thymic hyperplasia, magnetic resonance imaging (MRI) can be used as a noninvasive problem-solving tool.

A spectrum of findings on computed tomography in paediatric abdominal and pelvic tumours in a Ghanaian teaching hospital

Objectives

To review the Computed Tomography( CT )features of pediatric oncological patients with abdominal and pelvic tumours and correlate these findings with their histopathological diagnosis.

Design

This was a retrospective cross-sectional facility-based study.

Setting

This study was conducted in the Pediatric Oncology Unit and Radiology Department of the Korle Bu Teaching Hospital.

Participants

Fifty-six pediatric oncology patients with contrast-enhanced abdominal and pelvic CT scans.

Data Collection

The abdominal and pelvic CT scans findings, patient biodata, and histopathology reports of oncology patients over four years were reviewed.

Statistical analysis

Simple descriptive statistics using frequency distribution, percentages, means, and standard deviation were used to describe the various variables and presented tables.

Results

The four commonest tumours were nephroblastoma, neuroblastoma, lymphoma, and hepatoblastoma. The mean age at diagnosis was 4.8 years, with a slightly higher male predominance. The majority of the tumours were extremely large at presentation. Overall, the CT - histopathology concordance was 79.2%.

Conclusion

Abdominal and pelvic CT scans play an important role in the diagnostic workup of pediatric malignancies by ensuring early and accurate diagnosis of these tumours.

Funding

None declared.

Calcified Axillary Lesions on Mammography: Review and Management

When interpreting mammography, breast radiologists may identify radiopaque densities in the axilla on the mediolateral oblique or lateral projections. When such densities are encountered, true calcifications must be differentiated from pseudocalcifications (artifact). Using imaging, breast radiologists should be able to localize the finding as being dermal, within the soft tissues, within a lymph node, or intramuscular. By combining the anatomic location with the clinical presentation and any other imaging findings, breast radiologists will be able to determine the most appropriate management.

Case series of pediatric mediastinal granuloma related to histoplasmosis

INTRODUCTION

Mediastinal granuloma (MG) is a postinfectious complication of histoplasmosis that remains a rare diagnosis in the pediatric literature. This case series presents a well phenotyped population to further characterize this disease process.

METHODS

Thirty cases of MG in children under 21 years-of-age presenting over a 16-year period were retrospectively analyzed.

RESULTS

Seventy-five percent of patients presented with respiratory symptoms. Histoplasma antigen was negative in 90%. Histoplasma antibody was positive in 100%. Fine needle aspirates were positive for histoplasma in 31% whereas excisional biopsy was positive in 71%. Bronchoalveolar lavage (BAL) was negative for histoplasma in all cases where performed. Computed tomography revealed 53% of MGs were right paratracheal, 60% had internal calcifications, and 23% had splenic calcifications. Sixteen patients (53%) were managed with medical therapies only, with 7 (44%) treated with steroids and antifungals and 7 (44%) with antifungals alone. The remaining 14 patients (47%) underwent surgical excision and 9 were also treated with antifungals (64%). Bronchial compression was the most common comorbidity within the medically managed only group whereas vascular compression and fistulation were most common within the surgically managed group.

CONCLUSION

Respiratory symptoms should raise suspicion for MG. Diagnostic evidence of MG includes positive histoplasma serologies, right paratracheal location, internal calcifications, and splenic calcifications. Bronchoscopy, BAL and needle biopsies provide minimal diagnostic benefit. Antifungals are used in the majority of cases, whereas steroids are used most often in non-surgically managed patients with airway compression. Indications for surgical resection are less defined, but include vascular compression and fistulation unresponsive to medical treatment.

Imaging findings of lesions in the middle and posterior mediastinum

Lesions in the middle and posterior mediastinum are relatively rare, but there are some useful radiological clues that can be used to diagnose them precisely. It is useful to determine the affected mediastinal compartment and the locations of the main thoracic nerves on medical images for diagnosing such mediastinal lesions. Neurogenic tumors can occur in the middle mediastinum, although they generally arise as posterior mediastinal tumors. Based on the above considerations, we review various characteristic imaging findings of middle and posterior mediastinal lesions, and their differential diagnoses.

A 13th-century cystic echinococcosis from the cemetery of the monastery of Badia Pozzeveri (Lucca, Italy)

OBJECTIVE

To differentially diagnose a calcified formation recovered from a 13th century AD grave from the Tuscan monastery of Badia Pozzeveri, Lucca, Italy.

MATERIALS

A calcified formation from the thoraco-abdominal region of a skeleton buried in the monastery cemetery.

METHODS

Cone Beam Computed Tomography, Scanning Electron Microscope and Energy Dispersive X-Ray Spectroscopy.

RESULTS

A hollow, calcified ovoid formation was identified as typical of a hydatid cyst, permitting the diagnosis of cystic echinococcosis in a 35-45year-old female.

CONCLUSIONS

The study reveals the circulation of the parasite Echinococcus granulosus in the region of Lucca in late medieval Tuscany.

SIGNIFICANCE

This finding is the fourth case of cystic echinococcosis from an archaeological context in Italy and provides insight into environmental conditions that appear to have affected members of a community, irrespective of social status.

LIMITATIONS

Caution and the application of multiple analyses must be exercised in the differential diagnosis to discriminate among calcified formations.

SUGGESTIONS FOR FURTHER RESEARCH

Analysis of stable isotopes of the calcified formation, such as ¹⁵N and ¹³C, in order to compare them with isotopic values of the host individual and to further confirm the parasitic origin of the find.

Feline lymphoma in the nervous system: pathological, immunohistochemical, and etiological aspects in 16 cats

ABSTRACT: The pathological, immunohistochemical (IHC), and etiological features of lymphoma involving the nervous system (NS) in cats were analyzed through a retrospective study (2004-2017) in Rio Grande do Sul State, Brazil. The NS involvement was observed in 16 (12.2%) of 125 felines with lymphoma. Young cats were mainly affected, with a median of 24 months old. Most cases were secondary central NS lymphoma, whereas in three cats, the NS involvement was primary. IHC revealed 14 (87.5%) FeLV-positive, six FIV-positive, and one FeLV/FIV-negative cats. Distribution of feline lymphoma in the NS was 8/16 in the spinal cord, 7/16 in the brain, and 1/16 in the paravertebral nerves and ganglia (neurolymphomatosis). The lymphoma pattern in the spinal cord was exclusively extradural, often focal (6/8), and located in the lumbar (3/6), sacral (1/6), thoracic (1/6), and cervical segments (1/6). Brain neuroanatomical patterns were: leptomeningeal lymphomatosis (4/7), lymphomatous choroiditis (2/7), and intradural lymphoma (1/7). The feline with primary neurolymphomatosis presented a marked thickening of paravertebral nerves and ganglia from the sacral region. B-cell lymphoma (75%) was often diagnosed, and diffuse large B-cell lymphoma (DLBCL) (11/16) was the main subtype. T-cell lymphoma (25%) was less commonly observed and was classified as peripheral T-cell lymphoma (PTCL) (3/16) and T-cell lymphoblastic lymphoma (T-LBL) (1/16).

Imaging of Extranodal Genitourinary Lymphoma

The genitourinary (GU) system is commonly affected by disseminated lymphoma. Rarely, lymphoma can originate from and remain localized to one of the GU organs and thus presents as primary extranodal disease. Up to 40% of lymphomas present as extranodal disease, with only 3% having the GU system as the primary site of involvement. This article describes and correlates the radiologic and pathologic features of extranodal lymphomatous disease affecting the GU system with specific focus on the kidneys, adrenal glands, testicles, and ovaries. Lymphoma of the uterine body and cervix, external female genitalia, urinary bladder, and prostate gland is briefly discussed.

Unusual childhood presentations of abdominal non-Hodgkin's lymphoma

Non-Hodgkin's lymphoma (NHL) is a relatively common childhood cancer that can present in a myriad of ways. It is essential that NHL is included in the differential diagnosis of children presenting with an abdominal complaint, especially those with unexplained or prolonged symptoms. We describe three acute pediatric presentations of abdominal NHL, two of which presented as acute abdomen (the first mimicking intussusception and the second appendicitis), and the third involving lower limb edema. This case series illustrates the array of presentations of abdominal NHL and the diagnostic challenges that they can provide.

Beyond PET/CT in Hodgkin lymphoma: a comprehensive review of the role of imaging at initial presentation, during follow-up and for assessment of treatment-related complications

Objective

The purpose of this article is to provide a comprehensive review of the role of imaging modalities other than PET/CT in the management of Hodgkin lymphoma (HL). PET/CT is the imaging modality of choice in the management of Hodgkin’s lymphoma (HL). However, imaging modalities other than PET/CT such as plain radiographs, ultrasound, CT, MRI and nuclear imaging can help in various stages of clinical management of HL, including the initial workup and post-treatment surveillance. Both CT and MRI help in detecting recurrences, treatment-related pulmonary, cardiovascular and abdominal complications as well as second malignancies. Familiarity with expected post-treatment changes and complications on surveillance images can help radiologists guide patient management. The purpose of this article is to provide a comprehensive review of the role of imaging modalities other than PET/CT in the management of Hodgkin lymphoma (HL).

Main Messages

• Surveillance of HL patients is usually performed with plain radiographs and CT.

• Follow-up imaging can depict normal post-treatment changes or treatment-related complications.

• Imaging is important for the timely detection of second malignancies in HL patients.

Malignant abdominal rocks: where do they come from?

For the radiologist, calcifications in an abdominal malignancy raise questions of both diagnostic and prognostic significance. Although certain cancers are well known to calcify, such as colorectal and ovarian, malignant abdominal calcifications actually arise from a wide variety of epithelial, mesenchymal, lymphoid, or germ cell neoplasms. The pathophysiology of calcification in abdominal malignancies is heterogeneous and incompletely understood. Calcifications may present primarily, in untreated tumors, or develop during treatment; the latter can occur in variable clinical settings. A basic understanding of the varied pathogenic etiology can assist the radiologist in assessing disease status. By presenting an assortment of calcified abdominal malignancies on computed tomography in varied clinical settings, we aim not only to inform the differential diagnosis, but also to clarify the prognosis of calcifications in abdominal malignancies.

Role of Structural Imaging in Lymphoma

The lymphomas, Hodgkin lymphoma and non-Hodgkin lymphoma, are among the most common types of cancer in the United States. Imaging plays an important role in the evaluation of patients with lymphoma, because it aids in treatment planning and in the determination of prognosis. Structural imaging entails the assessment of morphologic features of normal tissues and organs of the body and of malignant lesions within these structures, and plays a major role in the noninvasive assessment of lymphoma. This article reviews cross-sectional structural imaging modalities with an emphasis on computed tomography and magnetic resonance imaging, with some mention of ultrasonography.

Cross-sectional evaluation of thoracic lymphoma

Thoracic lymphomas most frequently involve mediastinal lymph nodes in the anterior mediastinum and paratracheal areas. The lymphomas may also involve lung, thymus, pleura, pericardium, chest wall, and the breast and their radiologic manifestations are diverse. Lymphomas (mostly BALT lymphoma and large B-cell lymphoma) may arise primarily from the lung with various imaging features including single or multiple nodule(s) and area(s) of consolidation. CT is currently the most important imaging modality for the evaluation of thoracic lymphoma but FDG PET also plays a crucial role in the clinical management of these cases.

Childhood Burkitt lymphoma: abdominal and pelvic imaging findings

OBJECTIVE

Burkitt lymphoma in children can be localized or disseminated and can involve various sites. Our objective is to review the clinical presentation and abdominopelvic imaging findings of Burkitt lymphoma in the pediatric population.

CONCLUSION

Numerous abdominal and pelvic imaging findings are seen in Burkitt lymphoma affecting the gastrointestinal tract and solid organs. Recognition of the common and uncommon imaging findings is essential in the diagnosis and treatment of patients with Burkitt lymphoma because prompt therapy is critical.

[Calcification in metastatic cervical adenopathies from squamous cell carcinoma]

We report a case of hypopharyngeal squamous cell carcinoma with multiple calcified metastatic cervical adenopathies, and we review the relevant literature. The finding of calcified metastatic adenopathies from squamous cell carcinoma in the head and neck is very uncommon; only three cases have been reported to date.

Cross-sectional evaluation of thoracic lymphoma

In patients who have lymphoma, the presence and distribution of thoracic involvement is important in both tumor staging and treatment. Thoracic involvement in Hodgkin lymphoma (HL) is more common than in non-Hodgkin lymphoma (NHL). In HL, mediastinal lymphadenopathy with contiguous spread is a hallmark, and lung parenchymal involvement at the initial presentation is almost always associated with mediastinal lymphadenopathy. NHL is more heterogeneous and generally presents at a more advanced stage than HL. Most often, mediastinal involvement occurs as a disseminated or recurrent form of extrathoracic lymphoma. Bulky mediastinal disease with compression of adjacent structures can occur, particularly with high-grade subtypes of NHL and isolated lung disease without mediastinal lymphadenopathy can occur in contrast to HL.

Hodgkin's and Non-Hodgkin's Lymphomas

The diagnosis and management of lymphoma have undergone significant changes in the past 20 years. For example, new immunophenotypic and molecular methods have replaced traditional histology-based classification schemes for lymphoma. Fluorine-18-deoxyglucose (FDG) positron emission tomography (PET) has evolved into a potent staging tool and prognostic indicator in many kinds of lymphoma. The role of radiation therapy, especially in patients who have early-stage Hodgkin's disease, has changed substantially. The introduction of anti-CD 20 antibody therapy (Rituximab) has improved the treatment of B-cell lymphoma. These changes are linked with higher expectations for imaging, such as detection of more subtle lymphoma manifestations, evaluation of residual changes, and better assessment of early response. This article reviews clinical and radiologic features of both Hodgkin's disease and non-Hodgkin's lymphoma. It also describes the radiologic staging of lymphoma and the emerging role of FDG-PET for assessing lymphoma.

CT diagnosis of 52 patients with lymphoma in abdominal lymph nodes

AIM: To assess CT manifestations and its diagnostic value for lymphoma in the abdominal lymph nodes (LALN).

METHODS: CT findings in 52 cases of LALN proved by surgery or biopsy, including Hodgkin’s disease (HD) in 16 cases and non-Hodgkin’s lymphoma (NHL) in 36 cases, were retrospectively analyzed.

RESULTS: (1) CT manifestations based on distribution of the lesions of LALN: Solitary mass type was found in 10 cases, including solitary, round, uniform-density, enlarged lymph nodes in 3 cases; and multiple, enlarged lymph nodes fusing into singular lobular mass in 7 cases. Thirty-four cases of multiple-nodular type showed multiple, round, enlarged lymph nodes with uniform density and clear margins. Vessels-embedded signs, including mesenteric vessels, renal vessels, abdominal aorta or inferior vena cava, were seen in 6 cases, and duodenum-embedded signs were seen in 2 cases. Eight cases of diffuse type showed characteristic “cobblestone signs”. (2) CT manifestations correlated with pathological type: CT manifestations of 12 cases of HD were different from those of 40 cases of NHL in distribution, size, quantity and fused lesion of enlarged lymph nodes. (3) Twenty-eight cases of 52 patients were accompanied with extra-nodal lymphoma in the abdomen, especially gastrointestinal lymphoma, which had characteristic CT findings. (4) In follow-up examinations, CT images showed uniform, heterogeneous or rim enhancement in 15 cases, and occasional calcifications accompanied with reduction of the lesion size and quantity in 12 cases, whereas the lesions disappeared in 3 cases after treatment.

CONCLUSION: CT images show many characteristic manifestations valuable for qualitative diagnosis of LALN, and it is also helpful for pathological classification of LALN and therapeutic evaluation in follow-up of patients.

Patterns of lymphadenopathy in thoracic malignancies

There are different lymphatic drainage pathways in the thorax that are relevant in the staging of lung cancer, breast cancer, lymphoma, esophageal cancer, and malignant mesothelioma. To properly search for metastatic spread, it is important to carefully evaluate the specific nodal stations that drain the thoracic structures from which a primary tumor originates. Because size criteria have limitations in the prediction of nodal status, pathologic confirmation is essential for accurate staging. Computed tomography (CT) is useful in helping the surgeon or interventional radiologist determine the most appropriate approach for nodal sampling. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has an increasing role in detection of diseased lymph nodes that appear normal at CT alone, particularly when FDG PET images are fused with CT images. However, the role of radiologic imaging extends beyond initial staging and the guidance of interventions to include posttreatment assessment and the detection of recurrent disease. Therefore, at all levels of cancer imaging, it is essential to identify the relevant lymph node regions and their relations to the primary tumor.

Primary calcified T-cell lymphoma of the urinary bladder: a case report

Primary malignant lymphoma of the urinary bladder is extremely rare, and to our knowledge, no case described in the radiologic literature has been accompanied by calcification. We report a case in which the condition was associated with calcification, and describe the pelvic CT and MR imaging findings.

Appearance and distinguishing features of retroperitoneal calcifications at computed tomography

OBJECTIVES

To describe the appearance of retroperitoneal calcifications seen at computed tomography (CT) and to investigate which CT features distinguish benign from malignant retroperitoneal calcifications.

METHODS

We identified 25 patients with retroperitoneal calcifications by retrospective review of 39,931 abdominopelvic CT scans. Etiology of retroperitoneal calcifications was determined by examination of medical and histopathological records. By consensus, 2 abdominal radiologists recorded calcification number (solitary or multiple), location (suprarenal or infrarenal), morphology (globular or nonglobular), and the presence of soft-tissue components. The association between CT findings and etiology was assessed using the Fisher exact test.

RESULTS

Retroperitoneal calcifications were malignant in 15 patients and benign in 10. Solitary calcifications were seen more commonly in patients with benign disease (6 of 10 vs. 1 of 15, P < 0.01). Suprarenal calcifications were seen only in patients with malignancy (13 of 15 patients, P < 0.01). Nonglobular calcifications were seen only in patients with benign disease (6 of 10, P < 0.01). Soft-tissue components were seen more commonly in patients with malignancy (14 of 15 vs. 4 of 10; P < 0.01).

CONCLUSIONS

Retroperitoneal calcifications are rarely seen at CT and may be benign or malignant in etiology. Solitary or nonglobular retroperitoneal calcifications are likely to be benign while calcifications that are multiple, globular, suprarenal, or associated with noncalcified soft-tissue components are likely to be malignant.

Assessment of response to therapy using conventional imaging

The response of lymphoma to treatment is usually documented using cross-sectional imaging. The definitions of response and the changes seen on CT and MRI in the chest and abdomen are well recognised. However, the appearances of residual masses are more variable and features that may help in diagnosis will be included in this review.

Computerised tomography in the staging of Hodgkin's disease and non-Hodgkin's lymphoma

The last 25 years have seen major changes in the imaging investigation and subsequent management of patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL); accurate staging is vital for prognostication and treatment in both, and particularly in HD. The choice of imaging modality for staging depends on its accuracy, impact on clinical decision-making, and availability. Modern CT scanners fulfil most of the desired criteria. The advent of CT scanning, along with the development of ever more effective chemotherapeutic regimens, has resulted in the virtual demise of bipedal lymphangiography (LAG) as a staging tool in patients with lymphoma. It has rendered superfluous a battery of other tests that were in routine use. This contribution reviews the evidence for the use of CT in preference to LAG. CT accurately depicts nodal enlargement above and below the diaphragm, has variable sensitivity for intra-abdominal visceral involvement and is generally outstanding in depicting the extent of disease, especially extranodal extension. Despite the advances in CT technology, there are still areas where CT performs less well (e.g. disease in normal-sized lymph nodes, splenic and bone marrow infiltration). The influence of technical factors, such as the use of intravenous contrast medium, is discussed. In some instances, CT is not the imaging modality of choice and the place of newer techniques such as MRI and endoscopic ultrasound will be reviewed.