eMedicine Specialties > Radiology > Chest

Hodgkin Disease, Thoracic

Narainder Gupta, MBBS, MSc, FRCR, MD, Assistant Professor of Cardiothoracic Radiology, Division Director, Division of Cardiothoracic Radiology, Thomas Jefferson University Hospital
Jamshed B Bomanji, MBBS, MSc, PhD, Consulting Staff, Institute of Nuclear Medicine, Middlesex Hospital; Nuclear Medicine Consultant, University College Hospital

Updated: Jan 21, 2009

Introduction

A positron emission tomography (PET) scan obtained with fluorodeoxyglucose (FDG) that shows increased FDG uptake in a mediastinal lymph node.

A CT scan showing bulk disease.

A CT scan showing lung parenchyma involvement with Hodgkin disease.

Background

Hodgkin disease is a cancer of the lymph system (a lymphoma) that is characterized by the presence of large, abnormal Reed-Sternberg cells in a background of lymphocytes, macrophages, fibroblasts, and granulocytes. Dr Thomas Hodgkin first described Hodgkin disease in 1832.^1,2,3,4

The lymphatic system is composed of lymph nodes, lymphatic channels, the spleen, bone marrow, and the thymus. Because the lymphatic system is located throughout the body, Hodgkin disease can start almost anywhere; however, in this article, only thoracic involvement is addressed.

In the thorax, Hodgkin disease most commonly involves the mediastinum. The nodular sclerosing histologic subtype of Hodgkin disease is the most common form found in the thorax, and it has a predilection for the anterior mediastinum (especially the thymus). The diagnosis of Hodgkin disease must be based on tissue biopsy results, because treatment strategies are based on the histologic type, the stage of disease, and the age and performance status of the patient. Imaging is essential for tumor staging, for assessing the response to treatment, for diagnosing relapses, and for evaluating treatment-related disorders.^{2,5,6,7,8,9,10}

Related eMedicine topics:

Hodgkin Disease (Hematology)

Hodgkin Disease (Pediatrics)

Lymphomas, Endocrine, Mesenchymal, and Other Rare Tumors of the Mediastinum

Pathophysiology

The etiology of Hodgkin disease remains unknown. A strong association with the Epstein-Barr virus (EBV) exists; however, the presence of EBV is not specific for Hodgkin disease, and it can be found in other malignancies.¹¹

Measures to prevent Hodgkin disease have not been established because no definite cause has been identified.

Frequency

United States

According to the American Cancer Society, an estimated 8220 new cases of Hodgkin disease will be diagnosed in the United States in 2008.¹²

Patients with Hodgkin disease usually have an increased incidence of Hodgkin disease in their family history; however, the genetic nature of Hodgkin disease has not been established, and an increased family history may be caused by exposure of family members to identical environmental hazards. The incidence is increased in patients who are immunocompromised (eg, patients with AIDS and organ - transplant recipients).

Mortality/Morbidity

The aim of treatment is to cure Hodgkin disease. More than 75% of newly diagnosed cases of Hodgkin disease can be cured with chemotherapy and/or radiation therapy. The prognosis depends on various factors, including the presence of systemic symptoms, the stage of the disease at presentation, the presence of large masses, and the treatment administered. Effective treatment has led to high survival rates (ie, 1-year survival rate, 92%; 5-year survival rate, 85%; 10-year survival rate, 80%; and 15-year survival rate, 74%).^12,13,14

Sex

The male-to-female ratio is 1:1.5. In nodular sclerosing Hodgkin disease, females are affected twice as often as men; however, in patients with nodular sclerosing Hodgkin disease, thymic involvement is more common in men.⁶

Age

Hodgkin disease has a bimodal incidence, with peaks seen in adults aged 15-40 years and in adults older than 55 years.⁴

Anatomy

Knowledge of lymph node distribution and lymphatics in the thorax is important because mediastinal involvement of the lymph nodes is the most common manifestation of thoracic Hodgkin disease. A clear understanding of normal radiographic findings in chest radiography is pivotal to recognizing subtle enlargement of the lymph nodes.^2,10

(Click Image to enlarge.) A schematic diagram showing the location of the mediastinal lymph nodes.

On chest radiographs of the left side, the normal aortopulmonary window is slightly concave, straight, or invisible. Any departure should be viewed with suspicion, and further investigations are needed. In the prevascular area, adenopathy is the most common cause for convexity of the aortopulmonary bay toward the left lung.

On chest radiographs of the right side, the azygos node lies variably in relation to the azygos vein as the vein passes forward above the right bronchus to enter the superior vena cava (SVC). This node is the lowest member of the group of right paratracheal lymph nodes. Any convexity in this region that has a greater part of its curvature above the right main bronchus probably should be regarded as abnormal. Low right prevascular nodal enlargement also can distort this region.

Subcarinal lymph nodes are difficult to recognize until they are large. They can cause displacement of the azygoesophageal pleural reflection. Paravertebral adenopathy can be diagnosed by distortion of the paravertebral pleural reflections, which produces convexity toward the lungs.

Pericardiac and diaphragmatic lymph nodes can fill the cardiophrenic angle on posteroanterior (PA) chest radiographs. On lateral views, these may lie retrosternally or at the level of the inferior vena cava or phrenic nerve. Smaller lymph nodes in these areas may simulate a pericardiac fat pad.

On PA chest radiographs, internal mammary lymph nodes can produce ill-defined increased opacity lateral to the sternum when sufficiently enlarged. On lateral views, these can appear as anterior extrapleural masses against the chest wall.

Presentation

• Patients most commonly present with enlarged, painless lymph nodes. Cervical lymph nodes are the most common.¹⁵
• Hodgkin disease can appear as an incidental finding on routine chest radiographs.
• An important feature of Hodgkin disease is its tendency to arise within lymph node areas and spread in an orderly fashion to contiguous lymph nodes.
• The constitutional signs and symptoms include the following:
  • Fever
  • Fatigue
  • Decreased appetite
  • Coughing and breathlessness
  • Drenching night sweats
  • Itching
  • Weight loss
  • Bone pain
  • Pressure symptoms resulting from enlarged lymph nodes
  • SVC syndrome
  • Dysphagia
  • Paraneoplastic syndromes
  • Dermatologic manifestations
  • Renal and metabolic manifestations
  • Neurologic manifestations

Currently, Hodgkin disease is classified according to the World Health Organization/Revised European-American Lymphoma classification system. According to a number of characteristics, such as the appearance of cells, their genetic characteristics, chemistry, and clinical behavior, Hodgkin disease is classified into 2 types as follows:

• Classic Hodgkin lymphoma (95% of cases of Hodgkin disease), which is further subdivided into 3 subtypes:
  • Nodular sclerosis Hodgkin lymphoma
  • Mixed-cellularity Hodgkin lymphoma
  • Lymphocyte-depletion Hodgkin lymphoma
• Nodular lymphocyte-predominant Hodgkin lymphoma (5% of cases of Hodgkin disease)

Hodgkin disease is staged according to the guidelines set out by the Ann Arbor, Michigan, conference of 1971. Some modifications were made to this classification at the Cotswolds, United Kingdom, meeting.¹⁶ Staging of Hodgkin disease is important for planning effective treatment, for follow-up monitoring, and for comparing trial treatment plans available in various centers.

Staging is as follows:

• Stage I - Involvement of a single lymph node region (I) or localized involvement of a single extralymphatic organ (IE)
• Stage II - Involvement of 2 or more lymph node regions on the same side of the diaphragm (II) or localized involvement of a single extralymphatic organ or site and its regional lymph node or nodes, with or without involvement of the other lymph node region on the same side of the diaphragm (IIE)
• Stage III - Involvement of lymph node regions on both sides of the diaphragm (III) with or without localized involvement of an associated extralymphatic organ or site (IIIE), with or without involvement of the spleen (IIIS), or with or without involvement of both (IIIE+S)
• Stage IV - Disseminated/multifocal involvement of 1 or more extralymphatic organs, with or without associated lymph node involvement, or isolated extralymphatic organ involvement with distal nodal involvement

Bulk disease or massive mediastinal disease is defined as the ratio of the maximum transverse diameter of a mass to the internal transverse thoracic diameter being 0.33 or greater, as measured on chest radiographs at the T5-T6 vertebral disk level. Other authors have defined bulk disease as a lymph node mass measuring 10 cm or more in its greatest dimension.¹⁷

The presence of other symptoms (eg, fever, weight loss >10%, drenching night sweats) and bulk disease is associated with a worse prognosis for patients with clinical stage I or stage II Hodgkin disease.

Preferred Examination

A complete patient history should be elicited and a physical examination performed.

Procedures and laboratory studies

A lymph node biopsy is performed for pathologic analysis and classification.

Laboratory investigations are performed to assess the full blood count with erythrocyte sedimentation rate, liver function,   biochemistry, and renal function biochemistry.

Radiologic examinations

Chest radiographs are obtained at presentation, during therapy, and for follow-up monitoring. Mediastinal lymph node enlargement can be detected in 60-75% of patients.

Computed tomography (CT) of the thorax, abdomen, and pelvis is performed for initial staging purposes. Compared with other methods, CT is more sensitive for detecting lymphadenopathy and extralymphatic involvement. CT scanning may be most useful for evaluating patients with lymphoma because it can depict the lymph nodes in the chest, abdomen, and pelvis.^18,19

Magnetic resonance imaging (MRI) is performed in patients with suggested chest wall involvement because it offers better tissue contrast.

Ultrasonography and echocardiography are useful for detecting pericardial effusion and for directing lymph node biopsies and pleural interventions.²⁰

Bone scanning is useful for evaluating bone involvement in Hodgkin disease. Gallium-67 scans obtained at baseline, during therapy, and in the posttreatment period can help in differentiating active Hodgkin disease from nonactive Hodgkin disease.¹⁵

Positron emission tomography (PET) scanning with fluorodeoxyglucose (FDG) is most useful for detecting disease relapse.^21,22

Bilateral bone marrow aspirations and biopsies are performed to assess stage III or IV disease with associated symptoms (eg, fever, weight loss >10%, drenching night sweats).²³

Other investigations are directed to a particular clinical problem. For example, a superior venacavogram is obtained if the patient has clinical findings of SVC syndrome. Immunoscintigraphy is used on an experimental basis only.

Limitations of Techniques

Radiography is available everywhere and is inexpensive; however, it is limited for evaluating soft - tissue involvement of the chest wall. Chest radiographs cannot be used to differentiate the various causes of lymph node enlargement.

CT scanning is limited in its availability, especially in developing countries. CT scans cannot be used to differentiate the various causes of lymph node enlargement or to determine whether tumor residue is active or inactive.²⁴

MRI is limited in its availability because of its high cost. Also, some patients are claustrophobic and cannot tolerate the MRI examination.

Ultrasonography is limited in the thorax because air contained in the lungs is not a suitable window through which the ultrasound waves can travel.

Nuclear medicine is limited because of its availability in expert centers only. At present, PET imaging is limited in availability and the studies are expensive.

Differential Diagnoses

Other Problems to Be Considered

Leukemia
Pneumoconiosis
Histiocytosis X
Castleman disease
Agammaglobulinemia
Parasitic disorders
Connective tissue disorder

Radiography

A posteroanterior (PA) chest radiograph demonstrating normal findings.

A lateral chest radiograph demonstrating normal findings.

Findings

Hodgkin disease commonly appears as intrathoracic disease. PA and lateral chest radiographs are essential for clinical staging. Mediastinal adenopathy is the most common presentation, and direct extension of the disease can be detected on chest radiographs. Chest images also allow for the evaluation of complications related to chemotherapy and radiation therapy. In follow-up studies for recurrent disease, chest radiography is the primary imaging modality (along with history taking, physical examination, and laboratory investigations).¹⁰

• Of patients with Hodgkin disease, 67-74% have abnormal radiographic findings at presentation.
• Of patients with abnormal radiographic findings on chest images, 90% have bilateral asymmetric nodal disease.
• In Hodgkin disease, disease spreads contiguously along lymph node chains. Prevascular and paratracheal lymph nodes are most commonly affected.
• A single lymph node group is involved in only 15% of patients.
• Rarely, the posterior mediastinal or paracardiac lymph nodes are involved.
• The internal mammary chain of lymph nodes can be enlarged, but not without involvement of other lymph nodes.
• Chest radiographs can demonstrate either a single group with lymph node enlargement or a lobulated appearance resulting from multinodal involvement.
• Calcification is very rarely seen in untreated lymphoma.²⁵
• Direct invasion of the lungs can occur in 15-40% of patients and is nearly always associated with hilar adenopathy.²⁶
• Primary pulmonary involvement without hilar, mediastinal, or extrathoracic involvement is unusual; however, recurrent Hodgkin disease may appear in the absence of adenopathy (especially in nodular sclerosing Hodgkin disease).
• Lung involvement can produce either ill-defined or well-defined nodules, which can be unilateral or bilateral. These nodules may cavitate.
• Lung involvement can also appear as consolidation.
• Other findings in Hodgkin disease that can be detected on radiographs of the chest include pleural effusions and skeletal lesions.¹⁵
• In Hodgkin disease, two thirds of bone lesions are of the mixed lytic and sclerotic variety,  10-15% are sclerotic alone, and a small percentage are lytic alone. Sclerotic lesions tend to be confined to the vertebrae, demonstrating the typical appearance of ivory vertebrae.
• Anterior scalloping of vertebrae can be detected on lateral chest radiographs, especially in the lower thoracic region.
• With chest radiographs, Hodgkin disease can be quantified by calculating the mediastinal mass ratio (the ratio of the maximum width of the mediastinum to the maximum transverse thoracic diameter at the level of the diaphragm), by finding a mediastinal mass larger than one third of the transverse thoracic diameter at the T4-T5 level, or by determining an absolute transverse mediastinal diameter of 10 cm.¹⁷
• In follow-up imaging of mediastinal bulk disease, 60% of chest radiographs demonstrate findings of residual adenopathy after treatment. This residual adenopathy may not contain active disease and may represent only residual scarring, but these can be seen at long-term follow-up.

Degree of Confidence

Most of the time, sufficiently enlarged lymph nodes in the thorax can be detected on chest radiographs, but subtle enlargement can be missed; therefore, further imaging with CT is warranted.

False Positives/Negatives

A confluence of pulmonary veins, especially on the right side, can be mistaken for subcarinal lymphadenopathy. Small pericardiac or diaphragmatic lymph nodes can mimic a fat pad. An enlarged azygos vein can mimic azygous adenopathy. When in doubt, repeat chest radiographs and use the Valsalva maneuver. All of these false-positive findings on chest radiography can be easily identified by performing CT.

Subtle enlargement of intrathoracic lymph nodes can be missed on chest radiographs, and its detection greatly depends on the observer's experience, as well as the type of radiograph performed.

Computed Tomography

A CT scan showing bulk disease.

A CT scan showing lung parenchyma involvement with Hodgkin disease.

Findings

In conjunction with chest radiographs, CT is the modality of choice for initial staging and follow-up monitoring of Hodgkin disease. Contrast-enhanced CT scanning of the thorax, abdomen, and pelvis isperformed in all patients. Any suggestion of lymph node enlargement, as demonstrated on chest radiographs, is usually confirmed with CT scanning.^27,28,19

• Involvement of the lungs and pericardium can be occasionally detected on CT scans; these exclude treatment by radiation therapy.
• CT size criteria for lymph node involvement in the mediastinum are well defined. According to the criteria, subcarinal, paracardiac, and retrocrural lymph nodes are considered enlarged if they are larger than 12, 8, and 6 mm in their short-axis diameter, respectively. The remaining lymph nodes in the body are considered enlarged if they are larger than 10 cm in their short-axis diameter.^17,29,30,31
• On CT, lymph node enlargement can be seen as multiple, rounded soft-tissue masses or bulky soft-tissue masses caused by nodal aggregation. Usually, a homogeneous soft-tissue mass is noted; it may be heterogeneous when it is large, with areas of low attenuation representing necrosis, hemorrhage, or cyst formation.³²
• In rare cases, calcification can be seen in the lymph nodes on pretreatment scans.
• A discrete or infiltrating thymic mass can be seen.
• Associated findings that can be detected on CT scans include mediastinal displacement, compression, and invasion of the vascular structures,  pericardium, heart, pleura, lungs, and chest wall.

Degree of Confidence

CT scans can help differentiate the various causes of mediastinal or hilar enlargement seen on chest radiographs in most patients; however, CT is limited in detecting chest wall invasion (in which case, MRI is the modality of choice). CT is limited in the use of size criteria for lymph node involvement because nodes larger than those defined by the criteria can be reactive without tumor involvement. Also, lymph nodes smaller than those defined by the size criteria can harbor Hodgkin disease. Residual masses can persist during and after treatment without any viable tumor being present.^27,18

False Positives/Negatives

CT scans cannot help in differentiating between fibrosis and viable tumor. MRI, gallium scanning, or PET scanning can be used to identify residual tumor and predict the patient’s response to therapy.^{33,34,35,36,37}

Magnetic Resonance Imaging

Findings

MRI is not the primary modality for evaluating Hodgkin disease, but it can be used in problem solving. Multiplanar capability, high tissue contrast, flow sensitivity, and the use of gadolinium-based contrast agents all make MRI an ideal tool for problem solving. Its soft-tissue contrast and multiplanar capability also make it useful for assessing chest wall invasion, pericardial involvement, pleural involvement, and brachial plexus involvement.⁴

• In thoracic lymphomas, MRI is used to image suggestive spinal cord compression, involvement of the spinal cord and the meninges, involvement of the musculoskeletal system in the chest, cardiac involvement, and involvement of the brachial plexus.
• MRI is also helpful in posttreatment evaluation to differentiate between fibrosis and tumor.²⁴
• On MRI, lymph node involvement is defined by size criteria similar to those of CT.
• MRI is helpful for planning radiation therapy fields because of its multiplanar capabilities.³³
• On T1-weighted images, tumor involvement can be seen as relatively homogeneous masses with low signal intensity (similar to that of muscle).
• On T2-weighted images, high signal intensity equal to or slightly greater than that of fat can result from tumoral edema, inflammation, immature fibrosis, or granulomatous tissue.
• Follow-up T2-weighted images can show signal intensity increased from the baseline. This finding is correlated with disease recurrence.
• Low signal intensity on post-therapeutic T2-weighted images rules out the possibility of relapse in most patients.
• Increased signal intensity on T2-weighted images obtained within 6 months of therapy is nonspecific; however, after 6 months, this finding suggests recurrent disease.³⁷
• Overall, the accuracy of MRI for predicting disease recurrence is similar to that of gallium scintigraphy.³⁵
• An enlarging or new mass may represent recurrent disease, a post-therapeutic thymic cyst, or thymic hyperplasia.⁵
• Dense fibrosis may demonstrate low signal intensity on T2-weighted images.
• MRI also has a role in identifying areas of bone marrow abnormality for targeting bone marrow biopsies; however, MRI is not a replacement for bone marrow biopsy in pathologic staging.³⁸

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. 

NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Degree of Confidence

As with the criteria used in CT, a lymph node larger than 10 cm can be reactive without tumor involvement. Lymph nodes smaller than those that fall within the size criteria can also harbor disease.¹⁷

MRI is more sensitive for detecting bone marrow involvement associated with lymphoma.³⁸

False Positives/Negatives

False-positive findings can result from residual lymph node masses that may not harbor any disease. To evaluate this possibility further, gallium scanning and PET scanning can help.

Radiation-induced inflammatory changes can result in increased signal intensity on T2-weighted images. These changes can mimic active disease.

Ultrasonography

Findings

Ultrasonography can help in performing mediastinal biopsies, but it is primarily used for the evaluation and biopsy of lesions involving the chest wall. Rubens et al used prebiopsy CT to identify the window for real-time ultrasonographic biopsy. Echocardiography is useful for the detection of clinically undetectable pericardial disease.^{39,20,40,41,4}

Degree of Confidence

Ultrasonography cannot help in differentiating the causes of pericardial effusion (eg, malignant, radiation-induced, drug-induced, or idiopathic effusion).

Nuclear Imaging

Findings

Gallium-67 citrate scintigraphy (gallium scanning)

Gallium-67 citrate scintigraphy (GS) has been shown to provide important diagnostic and prognostic information in patients with lymphoma. In Hodgkin disease, GS provides additional information in conjunction with CT for planning radiation therapy. GS is helpful for distinguishing residual disease from posttreatment fibrosis in bulky mediastinal Hodgkin disease.^35,42,43,44

Posttreatment⁶⁷ Ga uptake is a poor prognostic factor in Hodgkin disease and non–Hodgkin lymphoma, and it is an accurate predictor of both the patient’s response to therapy and the overall outcome. In patients with aggressive lesions, advanced - stage tumors, or difficult-to-treat cases, sequential gallium scintigraphy can be performed before, during, or after therapy. These studies help in understanding the gallium avidity of the tumor, the response of tumor to therapy, and the timing of the therapeutic response.^{35,36,42,43,44,45}

Gallium uptake in tumor cells is mediated by transferrin receptors, and binding to cell-surface transferrin receptors allows this complex to be taken by actively growing tumor cells. Radiation therapy results in transient or permanent loss of⁶⁷ Ga uptake, although recurrent Hodgkin disease is invariably associated with the return of increased uptake.^43,44,45,46

In Hodgkin disease, the sensitivity of GS is 85-97% and the specificity is 90-100%. Use of high-dose GS and single-photon emission computed tomography (SPECT) techniques has increased the sensitivity of GS, especially for evaluating the mediastinum and abdomen.^45,47

FDG PET evaluation

Uptake of FDG is increased in malignant cells compared with normal tissues because of a patient’s altered metabolism during malignancy (in which glycolysis becomes the major metabolic pathway). Several studies have suggested that FDG scintigraphy is as good as CT for staging lymphomas. Moog et al showed that FDG PET is superior to CT in staging nodal lymphoma.⁴⁸ Bangerter et al found that for detecting hilar and mediastinal sites of disease before treatment, the sensitivity of FDG PET is 98% and the specificity is 90%, while the positive predictive value is 92% and the negative predictive value is 97%.^{22,34,36,49,50,51}

FDG PET studies may cause upstaging of the disease because of bone marrow involvement. These studies can be used to guide targeted MRI scans and bone marrow biopsies. FDG PET can also help in characterizing residual masses after therapy, when morphologic imaging modalities are of limited value. PET can be used in the detection of relapse, and Bangerter et al found a sensitivity of 86% and a specificity of 96% for the detection of recurrent disease in mediastinal and hilar nodes in patients with lymphoma.^{22,34,36,48,49,50,51}

A positron emission tomography (PET) scan obtained with fluorodeoxyglucose (FDG) that shows increased FDG uptake in a mediastinal lymph node.

Degree of Confidence

For GS, a posttreatment FDG PET scan with negative findings has a negative predictive value of 100%, but positive scans have a positive predictive value of only 61%.

False Positives/Negatives

Gallium uptake is nonspecific, and uptake can be seen in various tumors, inflammation, and infection; however, in a known setting of Hodgkin disease, any abnormal uptake should be viewed as active disease, residual disease, or recurrence.

Angiography

Findings

Angiography does not have much of a role in the diagnosis and management of Hodgkin disease, but superior venacavography is performed in patients believed to have SVC syndrome.

Intervention

Interventional radiology is primarily used to help perform transthoracic needle biopsies (TNB). The indications for TNB are isolated mediastinal or hilar adenopathy, pleural or chest wall involvement, diffuse pleural thickening, and distinction of lymphoma from primary mediastinal masses. TNB is usually CT guided, but other techniques such as fluoroscopy, continuous CT fluoroscopy, and ultrasonography can also be used. The complications of TNB include pneumothorax, bleeding, stroke, pericarditis, vasovagal reaction, and systemic air embolization.

Other possible interventions in thoracic Hodgkin disease include pleural drainage under ultrasonography guidance and drainage of postbiopsy pneumothorax under either fluoroscopy or CT guidance. For relief of the symptoms of SVC syndrome, SVC stenting is occasionally performed under fluoroscopic guidance.

Medicolegal Pitfalls

• Subtle adenopathy can be missed on chest radiographs.
• When using chest radiographs alone, the diagnosis can be missed altogether, or an accurate diagnosis can be delayed.

Special Concerns

• The incidence of Hodgkin disease is increased in patients with HIV infection. Hodgkin disease in these patients usually appears as advanced extranodal disease, with aggressive tumoral behavior and short survival rates in most patients. Almost 67%of patients present with extranodal disease , and almost 50% present with bone marrow involvement. The frequency of mixed-cellularity and lymphocytic-depletion types is increased compared with the frequency in patients without HIV infection.
• Because of the successful therapies available for the treatment of patients with early-stage Hodgkin disease, patients live longer and have a higher risk of developing a second malignancy. Second malignancies are related to the extent of treatment for Hodgkin disease. There are no studies or consensus concerning how to best conduct the ongoing surveillance for second malignancies. Proper history taking, examinations, and appropriate studies (including radiologic studies) should be conducted on the basis of the patient's symptoms or any abnormal findings on physical examination.

Multimedia

Media file 1: A positron emission tomography (PET) scan obtained with fluorodeoxyglucose (FDG) that shows increased FDG uptake in a mediastinal lymph node.

Media file 2: (Click Image to enlarge.) A schematic diagram showing the location of the mediastinal lymph nodes.

Media file 3: A CT scan showing bulk disease.

Media file 4: A CT scan showing lung parenchyma involvement with Hodgkin disease.

Media file 5: A posteroanterior (PA) chest radiograph demonstrating normal findings.

Media file 6: A lateral chest radiograph demonstrating normal findings.

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Keywords

Hodgkins disease, Hodgkin's disease, Hodgkin disease, Hodgkins, Hodgkin's, lymphoma, Hodgkin lymphoma, Hodgkin's lymphoma, Epstein-Barr virus

Contributor Information and Disclosures

Author

Narainder Gupta, MBBS, MSc, FRCR, MD, Assistant Professor of Cardiothoracic Radiology, Division Director, Division of Cardiothoracic Radiology, Thomas Jefferson University Hospital
Narainder Gupta, MBBS, MSc, FRCR, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, Royal College of Radiologists, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

Coauthor(s)

Jamshed B Bomanji, MBBS, MSc, PhD, Consulting Staff, Institute of Nuclear Medicine, Middlesex Hospital; Nuclear Medicine Consultant, University College Hospital
Jamshed B Bomanji, MBBS, MSc, PhD is a member of the following medical societies: British Medical Association, Medical Protection Society, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Medical Editor

Kitt Shaffer, MD, PhD, Director of Undergraduate Medical Education, Associate Professor, Department of Radiology, Cambridge Health Alliance
Kitt Shaffer, MD, PhD is a member of the following medical societies: American Roentgen Ray Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

John D Newell, Jr, MD, FACR, FCCP, FASER, Co-Director of Thoracic Imaging, UCDHSC; Director of Lung Imaging Center, Professor of Radiology and Professor of Medicine, Department of Radiology, University of Colorado Health Sciences Center, National Jewish Medical and Research Center; Univ. Colorado Hospital
John D Newell, Jr, MD, FACR, FCCP, FASER is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, American Thoracic Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Siemens Medical Grant/research funds Consulting; Forevision Technologies Ownership interest Consulting; Vida Corporation Ownership interest Board membership; TeraRecon Grant/research funds Consulting; eMedicine Honoraria Consulting

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Special thanks are extended to Dr. Jeremy Lawrance for his contributions to this topic.

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