Introduction
Background
Lymphoma is a descriptive term for malignancy of lymphoreticular cells of specific lineage (T cells, B cells, and histiocytes), in which the malignant lymphocytes crowd the normal, healthy cells in bone marrow and cause the lymph nodes to enlarge. This disease is divided into Hodgkin disease (HD) and non-Hodgkin lymphoma (NHL). The thorax is involved in 85% of all cases of HD and 45% of all cases of NHL. Unlike HD, NHL has many subtypes. The patient's prognosis and treatment vary according to the type of NHL.
A PA chest radiograph in a 28-year-old woman who presented with weight loss, showing a cavitating lesion (mimicking tuberculosis) in the left midzone adjacent to the left hilum. Histology confirmed a large-cell NHL.
Nonenhanced CT scan through the mediastinum at the level of the carina shows enlarged tracheobronchial and subcarinal nodes. Note the small bilateral pleural effusion.
T1-weighted coronal MRIs of the thorax in a 55-year-old woman with lower dorsal pain (same patient as in Image 18 in Multimedia). Note the signal-intensity changes in the body of D12; these are associated with a right-sided, large, paravertebral soft-tissue mass involving the psoas muscle. Biopsy confirmed non-Hodgkin lymphoma (NHL).
This 28-year-old man was being evaluated for fever of unknown origin. Gallium-67 study shows extensive uptake in the mediastinal lymph nodes due to non-Hodgkin lymphoma (NHL).
Pathophysiology
NHL is not a single entity but is instead a diverse group of cancers differentiated on the basis of cell type. Many classifications for NHL exist. The most common are the Rappaport classification and the working formulation by the National Cancer Institute. Other classifications include the Kiel classification, the Revised European American classification of Lymphoid Neoplasms (REAL), and the World Health Organization (WHO) classification. The working classification is a compromise between the histologic pattern and prognosis.
Molecular diagnostic assays have become routine in the evaluation of lymphomas. The Southern transfer and the polymerase chain reaction (PCR) assay are used to assess for B- and T-cell clonality and for rearrangements involving proto-oncogenes, such as bcl-1 and bcl-2; they are also used to monitor minimal residual disease. In B-cell lymphomas, clonality is often immunopathologically determined by demonstrating the presence of monoclonal surface immunoglobulin. T-cell lymphomas have no immunopathologic equivalent to monoclonal surface immunoglobulin, although aberrant loss of T-cell antigen expression is presumptive evidence of T-cell malignancy.1 Therefore, in T-cell lymphomas, studies to determine clonality are especially important.
Molecular studies are also useful in the determination of B- or T-cell lineage, as well as in the detection of chromosomal translocations, minimal residual disease, and viral DNA sequences (eg, those of the Epstein-Barr virus) involved in the pathogenesis of some lymphomas.2,3
Classification of NHL
NHL tumors include the following:
- Low-grade NHL tumors
- Small lymphocytic tumors (lymphocytic and well-differentiated in the Rappaport classification)
- Follicular predominantly small cleaved-cell (nodular, poorly differentiated lymphocytes) tumors
- Follicular mixed and large cleaved-cell (nodular, [mixed] lymphocytic and histiocytic) tumors
- Intermediate-grade NHL tumors
- Follicular predominantly large-cell (nodular, histiocytic) tumors
- Diffuse small cleaved cell (diffuse, poorly differentiated, lymphocytic) tumors
- Diffuse (mixed) large- and small-cell (diffuse, [mixed] lymphocytic and histiocytic) tumors
- Diffuse large-cell (diffuse, histiocytic) tumors
- High-grade NHL tumors
- Large-cell, immunoblastic (diffuse, histiocytic) tumors
- Lymphoblastic (lymphoblastic lymphoma) tumors
- Small noncleaved (undifferentiated Burkitt and non-Burkitt) tumors
- Miscellaneous NHL tumors
- Composite
- Mycosis fungoides
- Histiocytic
- Unclassified
Follicular tumors are less aggressive and more widespread than are other tumors. Follicular tumors have a higher relapse rate and may undergo transformation into a more aggressive histology, whereas diffuse tumors are more aggressive and localized and have lower relapse rate. Most mediastinal tumors are of the diffuse and poorly differentiated lymphocytic type. Although this type is localized at presentation, its presence implies disseminated disease.
Staging of lymphomas
Lymphomas are staged by using the Ann Arbor system, as follows:
- Stage I - The tumor involves only 1 lymph node region, organ, or other site.
- Stage II - The tumor involves 2 or more lymph node regions on the same side of the diaphragm, an organ and lymph nodes in the same half of the body, or another site and lymph nodes in the same half.
- Stage III - The tumor involves lymph node regions and/or the spleen (and on both sides of the diaphragm).
- Stage III (1) - The tumors are above the renal vessels.
- Stage III (2) - The tumors are in the lower abdomen.
- Stage IV - The tumor is extranodal, with diffuse involvement of nonlymphatic organs or tissues (eg, bone, marrow, lung, liver).
- Stage IV A - Constitutional symptoms are absent.
- Stage IV B - Constitutional symptoms are present.
Frequency
United States
Lymphomas constitute 57% of all hematologic cancers, and NHL constitutes 3% of all newly diagnosed cancers. It is the fifth most commonly diagnosed cancer in United States. An increased incidence is seen in patients taking immunosuppressive drugs and in those with immunodeficiency syndromes, human immunodeficiency virus (HIV) infection, or collagen vascular disease, as well as in persons who have undergone an organ transplant.4 An increased incidence is also noted in rural farming communities; this finding is probably related to the use of pesticides and herbicides.
Burkitt lymphoma is a subtype of NHL in African people; this has a high association with previous infection with the Epstein-Barr virus.
The incidences of various types of NHL tumors are as follows:
- Low-grade NHL tumors
- Small lymphocytic type - 3.6%
- Follicular predominantly small cleaved-cell type - 22.5%
- Follicular mixed and large cleaved-cell type - 7.7%
- Intermediate-grade NHL tumors
- Follicular predominantly large-cell type - 3.8%
- Diffuse small cleaved-cell type - 6.9%
- Diffuse (mixed) large- and small-cell type - 6.7%
- Diffuse large-cell type - 19.7%
- High-grade NHL tumors
- Large-cell, immunoblastic type - 7.9%
- Lymphoblastic type - 4.2%
- Small noncleaved type - 5%
International
The incidence is increasing because of rising rates of HIV infection. In men, the incidence is 20 cases per 100,000, and in women, the rate is 12.5 cases per 100,000. The prevalence of NHL is believed to be 4.5 million, with at least 30,000 deaths occurring annually. The incidence is higher in Europe, North America, and Australia than it is elsewhere. NHL is the third fastest increasing cancer in the world.
Human T-cell lymphotropic virus (HTLV-1) – associated T-cell lymphoma is common in Japan and the Caribbean.
The incidence of Burkitt lymphoma is 5.7-7.6 cases per 100,000 population; this type is more common in African populations.
Mortality/Morbidity
Advances in chemotherapy and radiation therapy have prolonged the survival of patients with NHL.
- The 5-year survival rate for adults with NHL is approximately 56.1%, in comparison with 47.3% in the late 20th century.
- Children respond better to treatment than do adults, with a 5-year survival rate of 75.2%. This rate represents a marked improvement from the late 20th century, when no children survived for 5 years.
Race
- Before the age of 50 years, the incidence of lymphoma shows no race predilection.
- After the age of 50-55 years, the incidence is higher in whites than it is in African Americans.
- Hispanic women are the second most commonly affected group after white women.
Sex
- The incidence of NHL is higher in males than in females by a ratio of 1.4:1.
- Hispanic women are the second most commonly affected group after white women.
Age
NHL occurs in individuals of all ages, although the incidence progressively increases with age. The incidence in the 20- to 25-year-old group is 2.5 cases per 100,000 population. By 60 years of age, this rate has increased to 43.7 cases per 100,000, and by 75 years, it has risen to 100 cases per 100,000. The median age of presentation is 55 years. (See also Race.)
- In children, NHL accounts for 4.0% of cancers. NHL is the third most common cancer in children after leukemia and CNS tumors. It is unusual before age 5 years.
- Childhood NHL and adult NHL differ in many ways. Childhood lymphomas predominantly affect boys (70%); these tumors have a diffuse pathology and high grade and are usually extranodal. Adulthood lymphomas have no sex predilection; these include diffuse and follicular types, are of any grade, and have a nodal pattern.
Anatomy
Classically, the mediastinum is anatomically divided into the superior, anterior, middle, and posterior compartments. The superior mediastinum is located above the aortic arch, the anterior mediastinum lies behind the sternum and anterior to the pericardium, and the middle mediastinum includes the pericardial sac, distal trachea, and paratracheal tissues. The posterior mediastinum is defined anteriorly by the pericardium and posteriorly by the spine.
In radiologic practice, some use a modified division based on radiographic landmarks. The anterior mediastinum is bounded anteriorly by the sternum and posteriorly by a line from the intersection of the trachea with the sternum drawn inferiorly to intersect the diaphragm. The line that follows the posterior border of the heart and inferior vena cava defines the posterior boundary of the middle mediastinum. A line placed 1 cm posterior to the anterior border of the vertebral bodies divides the middle and posterior mediastinum.
A variation includes the esophagus and all tissue posterior to it, in the posterior mediastinum. This division is extremely useful in the clinical differential diagnosis of specific masses or neoplasms.
For practical purposes, the anterior mediastinum extends from the posterior surface of the sternum to the anterior surface of the pericardium and great vessels. It is normally occupied by the thymus, fatty tissue, and lymph nodes.
Lymphomas commonly affect the mediastinum, particularly the anterior compartment.
Presentation
Clinical presentation
Lymphomas can cause constitutional symptoms, such as fever, night sweats, fatigue, abdominal pain, indigestion, anemia, infections, loss of appetite and/or weight, and bone pain. Patients can present with painless masses in lymph nodes of the neck, axillae, groin, or abdomen. Mediastinal lymphomas can compress the adjacent structures.
Other findings are cough, chest pain, dysphagia (esophagus), dyspnea, facial edema, cyanosis, ecchymosis (obstruction of the superior vena cava), congestive cardiac failure, pericarditis, and hypotension.
Differential diagnosis and other problems to consider
Cystic mediastinal lesions
Cystic mediastinal lesions are well-marginated, round, epithelium-lined masses that contain fluid. The relatively common anterior mediastinal cystic masses include congenital benign cysts, such as thymic cysts, mature cystic teratoma, and lymphangioma. Many solid anterior mediastinal tumors may undergo cystic degeneration; these include thymomas, HD lesions, germ cell tumors, mediastinal carcinomas, and lymph-node metastases. Cystic degeneration especially occurs after radiation therapy and chemotherapy. Unlike HD, NHL is relatively evenly distributed in all mediastinal compartments, and posterior mediastinal lymphadenopathy is relatively common.5 Thus, cystic change in NHL can affect any mediastinal compartment.
Occasionally, extensive degeneration occurs in solid tumors. This may be hard to distinguish from congenital cysts. Mediastinal abscess is a rare occurrence in the anterior mediastinum and may be indistinguishable from other cysts. However, when images are interpreted in the light of clinical presentation, a correct diagnosis may be achieved in many cases.
Most mediastinal cystic hygromas are extensions of cervical lesions. Cystic hygroma confined solely to the mediastinum is rare. The cyst may be unilocular or multilocular and of variable size. The cyst wall is of variable thickness; it can be fibromuscular and contain mural thrombi. These tumors are known to be associated with chromosomal and other congenital anomalies. Cystic hygromas grow with the child but may increase in size suddenly as a result of infection or hemorrhage. Spontaneous shrinkage may also occur. On clinical examination, these tumors appear as smooth soft-tissue masses that usually become apparent before age 2 years.
Pericardial tumors
Intrapericardial teratoma is a rare tumor that may mimic other mediastinal tumors. The tumor is generally benign and originates from the 3 germinal layers. About 60% of the cases present in the first 2 years of life. Severe cardiorespiratory distress due to mediastinal compression and pericardial effusion are the main clinical symptoms. Echocardiography and cine angiography confirm the diagnosis, and early surgical removal brings immediate and durable improvement.
Mediastinal carcinoids
Mediastinal carcinoid tumors are rare. They are frequently malignant and have a different course that of the more benign anterior mediastinal tumors. Images usually do not differentiate these tumors, and tissue diagnosis is usually required.
Hughes describes a case of a 70-year-old man with an anterior mediastinal mass that was initially diagnosed as a thymoma. However, the mass was subsequently shown to be a carcinoid tumor. Surgical resection was greatly enhanced by preoperative angiography and transcatheter arterial embolization of the tumor. Early and aggressive diagnostic attempts, pre-operative angiography with or without arterial embolization, and complete surgical excision offer the best likelihood of a cure for these malignant tumors.
Thymic tumors
Thymic neoplasms are a common cause of an anterior mediastinal mass and may be benign or malignant. Thymoma and thymic carcinoma are epithelial malignancies with distinct clinicopathologic features. True thymic hyperplasia and thymic lymphoid hyperplasia may enlarge the thymus and simulate a neoplasm. Thymic carcinoid is a rare, aggressive neuroendocrine malignancy associated with multiple endocrine neoplasias. Thymolipoma is a benign neoplasm. HD and NHL may primarily or secondarily involve the thymus.
Thyroid, parathyroid, and associated tumors
Thyroid-tissue masses in the anterior mediastinum can arise from either ectopic thyroid tissue or retrosternal extension of a cervical thyroid gland into the mediastinum. Although rare, goiter, adenoma, carcinomas, and lymphoma can arise in ectopic thyroid tissue.
Ectopic parathyroid tissue is occasionally found in the superior and/or anterior mediastinum adjacent to the thymus. This is the most common location for ectopic parathyroid adenomas. Radionuclide scans provide near–tissue–specific diagnosis, although cross-sectional imaging may be required for better anatomic definition.
Mediastinal lipomatosis
Mediastinal lipomatosis is the term applied to the accumulation of excess, unencapsulated fat in the mediastinum. This benign accumulation of fat, usually seen in adults, may be part of generalized obesity. It may also occur in patients with Cushing disease or in those treated with long-term steroid therapy.
The importance of recognizing this condition lies in differentiating the masslike accumulation of fat in the anterior mediastinum from other, more serious mediastinal pathology. Standard posteroanterior (PA) chest radiography usually reveals a smooth, sometimes lobulated widening of the anterior and superior mediastinum without tracheal deformity. Associated enlargement of the fat pad may be observed at the costophrenic angles. The paraspinal lines may be displaced laterally as a result of fat deposition in the paravertebral gutters.
Results from computed tomography (CT) scanning can aid in definitive diagnosis. On CT scans, fat is recognized as areas of low attenuation with values of -70 to -130 HU. MRI can similarly help in reliable diagnosis, because fat has high signal intensity on T1-weighted images. With fat-suppression techniques, the signal intensity of fat decreases, permitting its distinction from tissues that appear hyperintense on T1-weighted magnetic resonance imaging (MRI) scans. The distribution of fat in mediastinal lipomatosis is homogeneous and usually has little mass effect on the adjacent structures; this finding differentiates mediastinal lipomatosis from multiple thoracic lipomas.
Diaphragmatic hernias
Herniation of abdominal viscera into the thorax may occur through several potential openings in the diaphragm or in the foramina anterior and posterior to the diaphragm. One such opening lies anteriorly between the costal and sternal attachments of the diaphragm; this is termed the foramen of Morgagni. Morgagni herniation may result in a right-sided, cardiophrenic-angle mass.
The imaging findings depend on the hernial contents. These hernias most commonly contain omentum, liver, or colon; occasionally, they contain small bowel. CT scan or ultrasonographic results can confirm the presence of liver in the herniation. Omental fat in the hernia may be difficult to differentiate from a mediastinal lipoma on axial CT scans. However, multiplanar CT scanning or MRI may easily demonstrate a connection with abdominal fat. The diagnosis of herniated omental fat may be suggested by the identification of fine, linear densities, which represent omental vessels in the fat.
Neural tumors
Neural tumors are the most common cause of a posterior mediastinal mass. However, in rare cases, they occur in the anterior mediastinum, where they may be confused with other tumors. Most neural tumors are benign, with the malignant ones generally occurring in young patients.
The origin of the tissue can be used to classify neural tumors. Tumors that arise from the sympathetic chain can be further divided into the following types:
- Malignant neuroblastoma - This rarely occurring tumor is found in children younger than 10 years
- Ganglioneuroblastoma - A more common tumor, it has an intermediate prognosis.
- Ganglioneuroma - This benign tumor can occur in young adults.
Tumors arising from the peripheral nerve and nerve sheath can be further divided into the following types:
- Schwannoma (neurilemoma) - A benign growth that is the most common of all mediastinal neurogenic tumors
- Neurofibroma - A benign tumor that may be associated with von Recklinghausen disease
- Nerve-sheath tumor/schwannoma - A rare, malignant tumor.
Paragangliomas (chemodectomas) arise from paraganglial tissue in the paravertebral sympathetic chain, along the aorta, the aortopulmonary window, or the vagus nerve. These are rare, benign, nonfunctioning tumors. Approximately 10% of these lesions behave aggressively and are typically locally invasive.
On CT scans, paragangliomas appear as well-marginated, homogeneous soft-tissue masses that are intensely enhancing after the administration of iodinated contrast material. These tumors are commonly para-aortic or paraspinous. However they may occur in the aortopulmonary window, along the recurrent laryngeal nerve, and near the proximal aspect of the subclavian arteries. The tumor may undergo extensive cystic degeneration or hemorrhage internally, which can result in areas of low attenuation.
On T1-weighted MRI scans, the lesions have heterogeneous signal intensity, with areas of signal void occurring as a result of flowing blood. On T2-weighted images, the tumors have high signal intensity.
Sternal tumors
Sternal tumors may mimic other mediastinal tumors. Most sternal tumors represent metastases from the breast, lung, kidney, or thyroid gland. Primary sternal tumors are rare. Most common primary, malignant sternal tumors are chondrosarcomas, whereas osteosarcomas are rare. Chondrosarcomas typically arise near the costochondral junction.
CT scanning is superior to MRI in the demonstration of foci of calcification in chondrosarcomas and osteosarcomas. However, because of its great ability to distinguish tumor from normal soft tissue, MRI is the modality of choice for assessing the extent of chest-wall tumors and their relationship to adjacent structures.
Leukemia
Lymphomas and acute lymphoblastic leukemia are the most common causes of anterior mediastinal lymphadenopathy. In general, those neoplasms that predominantly affect lymph nodes or tissues are referred to as lymphomas, and those affecting the bone marrow and peripheral blood are termed leukemia. Many lymphomas, however, also affect the marrow and blood, and many leukemias are capable of tissue infiltration.
Other causes of lymphadenopathy
Causes of lymphadenopathy also include infectious, immunologic, malignant, endocrine, and storage diseases, as well as a variety of miscellaneous disorders.5
Infectious diseases include those due to viruses (Epstein-Barr virus, cytomegalovirus, hepatitis, HIV, herpes simplex, herpesvirus-6, varicella-zoster virus, rubella, measles, adenovirus), bacteria (streptococci, staphylococci, atypical Mycobacteria species, and species causing cat-scratch disease, syphilis, tularemia, brucellosis, chancroid, melioidosis, tuberculosis, diphtheria, leprosy), fungi (species causing histoplasmosis, coccidioidomycosis, paracoccidioidomycosis), protozoa (those causing toxoplasmosis, leishmaniasis, trypanosomiasis), and Rickettsia species (scrub typhus, rickettsialpox).
Immunologic diseases include rheumatoid arthritis (eg, adult Still disease), systemic lupus erythematosus, mixed connective tissue disease, dermatomyositis, Sjögren syndrome, serum sickness, angio-immunoblastic lymphadenopathy, silicosis, graft-versus-host disease, primary biliary cirrhosis, and drug hypersensitivity reactions to diphenylhydantoin, hydralazine, atenolol, allopurinol, gold, carbamazepine, primidone, and cephalosporins.
Malignant conditions include HD and primary neoplastic diseases of the nodes. Secondary neoplastic processes in the nodes include acute and chronic lymphocytic leukemia, acute and chronic myeloid leukemia, idiopathic myelofibrosis with extramedullary hematopoiesis, and malignant, metastatic diseases from various primary sites.
Miscellaneous diseases include sarcoidosis, amyloidosis, dermatopathic lymphadenitis, Castleman disease (giant lymph-node hyperplasia), Kikuchi disease (histiocytic necrotizing lymphadenitis), Kawasaki disease (mucocutaneous lymph-node syndrome), familial Mediterranean fever, severe hypertriglyceridemia, inflammatory pseudotumor of the lymph node, and histiocytosis X.
Preferred Examination
The primary investigation of suspected lung and mediastinal pathology is standard chest radiography.
After a mediastinal lesion is identified on a conventional radiograph, CT scanning is the preferred modality for further evaluation of the middle and anterior mediastinum. MRI is preferred when neural involvement is suspected, and then imaging is generally limited to the spine.
Abdominal disease is demonstrable on ultrasonograms. However, CT scanning is commonly used to show the presence and extent of disease. Visceral involvement may be diffuse or focal, with multiple nodules or sometimes a large, solitary mass present. If symptoms indicate osseous involvement, conventional radiographs may depict areas of destruction, periosteal new-bone formation, and a sclerotic lesion (in some cases). Vertebral lesions are best evaluated with MRI, particularly when vertebral collapse has occurred. MRI provides elegant demonstration of surrounding soft tissue involvement and intraspinal disease if present.
Isotope studies with gallium are rarely used now. Gallium-67 (67 Ga) scintigraphy has a sensitivity of 85% for high-grade NHL. Its sensitivity for low-grade NHL is poor.67 Ga scintigraphy can be used to monitor responses to treatment.
Where available, fluorodeoxyglucose (FDG) positron emission tomography (PET) scanning is increasingly used to image and stage malignancy. Compared with cross-sectional morphologic imaging, FDG-PET has several advantages. FDG-PET depends on metabolic abnormalities in cancer tissue and not on size criteria, as CT scanning does. It also provides a complete body survey, which is important in evaluating a multifocal disease process such as NHL. FDG-PET provides superior lesion contrast, allowing for easy detection, and the tomograms enable good anatomic localization.
Whole-body FDG-PET followed by conventional imaging techniques of areas of abnormal radionuclide uptake is more cost-effective than are conventional staging methods. PET/CT has increasingly been used in staging NHL, although its availability remains limited.
MRI has a role in select cases for follow-up and for differentiation of fibrosis from disease, but if the signal intensity remains high, differentiation may be impossible, and PET is better. In cases of central nervous system (CNS) involvement, MRI is preferred and should be used for evaluation. MRI is a valuable tool in the setting of a residual mass after treatment, giving clinically useful information for prognosis.
Similarly, testicular ultrasonography (US) can be performed if it is clinically applicable.
Limitations of Techniques
The appearances of a mediastinal mass on chest radiographs are nonspecific, with a wide differential diagnosis, and the differentiation of benign and malignant lesions may not be possible. Subtle bone erosions can be missed on conventional radiographs. Underlying masses with pleural and pericardial effusions may not be detected. Fat attenuation in benign lesions may be obscured with tumor hemorrhage or rupture, and a false diagnosis of malignant lesion can be made. A standard PA chest radiograph may be difficult to obtain in ill patients and in young children with mediastinal magnification obscuring anterior mediastinal masses, as shown on anteroposterior (AP) radiographs.
Although CT scanning is the examination of choice in the assessment of mediastinal masses, at best, the findings only suggest the diagnosis of NHL. A tissue diagnosis is required. CT scanning can be invasive, and young patients may require sedation or a general anesthetic. In addition, CT scanning is expensive and exposes the patient to radiation. Moreover, patients may be allergic to iodinated contrast medium, which must be used with caution in persons with renal failure.
MRI provides better contrast resolution than do other studies, but biopsy is often required for a definite diagnosis.6 MRI is expensive and not universally available, and patients with claustrophobia and young children may need sedation or general anesthesia. MRI cannot be used with certain types of metallic implants or clips, with cardiac pacemakers, or with ferromagnetic foreign bodies. Image-guided biopsy may require more expensive, MRI-compatible equipment.
US is operator dependent, and access to the anterior mediastinum may be difficult because of the thoracic bony cage and lungs. US cannot be used to evaluate the lungs.
Although radionuclide scans are more tissue specific than are other studies, it has a potential for false-positive results, and uptake may occur in a variety of normal, inflammatory, and neoplastic tissues.
FDG-PET is expensive, currently has limited availability, and requires prolonged acquisition times. Sites with normal physiologic activity may contribute to false results, although this appears to be less of a problem than it is with67 Ga imaging. Persistent FDG uptake in a residual mass should prompt strong consideration of additional therapy, although occasionally, uptake may be related to thymic hyperplasia or a histiocytic reaction.
Differential Diagnoses
Other Problems to Be Considered
Cystic mediastinal lesions
Pericardial tumors
Mediastinal carcinoids
Thymic tumors
Extralobar sequestration
Mediastinal lipomatosis
Diaphragmatic hernias
Neural tumors
Sternal tumors
Leukemia
Other causes of lymphadenopathy
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Further Reading
Keywords
non-Hodgkin lymphoma, NHL, Hodgkin disease, HD, Hodgkin lymphoma, Hodgkin's lymphoma, Hodgkin's disease, non-Hodgkin's lymphoma, lymphoma, lymphosarcoma, reticulum cell sarcoma, histiocytic lymphoma, lymphocytic lymphoma, Burkitt lymphoma, Burkitt's lymphoma
