Primary. Mediastinal. Large-B-Cell. Lymphoma: Radiologic. Findings at. Presentation. Kill Shaffer1. Darrell Smith2. David Kim3. William. Kaplan4'5. George.
Primary Mediastinal Large-B-Cell Lymphoma: Radiologic Findings at Presentation
OBJECTIVE.
Kill Shaffer1 Darrell Smith2 David Kim3 William Kaplan4’5 George Canellos6
a distinct
mediastinal
entity.
to review
for 43 patients
RESULTS.
All but one lesion the masses
within
were
seen by chest radiography patients who underwent all were
reported
on CT scans
findings.
Also,
Primary
rimary
mediastinal
Received January 16, 1996;accepted after revision March 6, 1996. Presented at the annual meeting of the American gen Ray Society, San Francisco, CA, April 1993.
mediastinal
of Radiology,
Dana-Farber
Cancer
MA 021 15. Address
RoentInstitute,
correspon-
non-Hodgkin’s includes cell of
types
this called
tal, 75 Francis St., Boston, MA 02115.
cell University
San Francisco,
of Nuclear
Medicine,
of Cal-
CA 94143.
Dana-Farber
Cancer
from
type
dence to K. Shaffer. 2Department of Radiology, Brigham and Women’s Hospiof Hematology-Oncology,
patients distinctive
ical
7Joint Center for Radiation Therapy, 40 Binney St., Boston, MA 02115.
in
AJR1996;167:425-430
gallium
pattern
large-cell several
reports than
for
Ray Society
AJR:167, August 1996
treatment. patients
localization
prior other with
of have
The with
also
has
studies types of female
behavior,
disdin-
presentation
of
been
[4-fl].
a younger a
a
at pre-
the majority lymphoma
mediastinal
suggested
phoma,
of large-
systemic [4]. A distinctive
lymphoma
were
were present in 32% gallium scintigraphy,
showed
evidence
of
of superior
noted age
large-cell lympredominance,
and poor
and did not
is seen
as a
focus
on the radiologic
[6]. We undertook a retrospective of cases of primary mediastinal large-
B-cell
lymphoma
to
determine
of the disease
radiologic
at presentation.
and Methods
Fifty-six patients with primary mediastinal large-B-cell lymphoma were identified by retrospective review of records from three institutions between 1976 and 1991. Details of clinical information, treatment, and outcome for these patients have been published elsewhere 151. Included in the study were patients who had tumor primarily in the mediastinum (documented clinically, by negative
laparotomy
or by staging
in more recent eases) and biopsy diffuse
large-cell
Pathologic
These
median
typically
findings review
Materials
5% show
disease or diffuse for
attenua-
effusions
Patients
or “diffuse Among all
features
contrast, large-cell
at presentation
aggressive
0361-803X/96/1672-425 Roentgen
to
large-B-
of fluid
Pleural
lymphoma
findings
sometimes
approximately
in with
sentation; patients
and
classification classifications, was
histologic
mediastinal
6Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115.
of Medi-
lymphoma
with
abdominal
Division, Department
the working In older
lymphoma,
ease
© American
as and
areas of necrosis.
patients
immunoblastic
“histiocytic lymphoma” lymphoma” [3].
5Deceased.
cine, Brigham and Women’s Hospital, Boston, MA 02115.
[1]
and
[2].
of
Institute, Boston, MA 02115.
tHematology-Oncology
large
lymphoma
Areas
of cases.
MR imaging
contains
large-B-
lymphoma
both
histiocytic
4Department
reclassified
mediastinal
mediastinum.
in 50%
large-B-cell
that often
mass
cell lymphoma is a recently reclassified distinct subtype of
ifornia, San Francisco,
primary
of patients. Pericardial effusions Of the 2 1 patients who underwent
positive
mediastinal
anterior
P
3Department
for
in one patient.
CONCLUSION. bulky
44 Binney St. Boston,
with
arose in the anterior
evident
in 33% CT scans.
to have
vena cava syndrome
Department
findings
cell lymphoma.
N. Shulman8 tion
1
imaging
recently
films,
and CT scans
the
was
compare the findings with those for other disorders with a similar appearance. MATERIALS AND METHODS. We retrospectively reviewed plain images,
wished
lymphoma
disease
MR
We
large-B-cell
this
scintigrams,
Peter Mauch7 Lawrence
Primary
clinical
or immunoblastic-cell
diagnoses by
review
from
were
experienced
CT scans
showing
either
histology.
confirmed
through
hematopathologists
[51.
These patients had not been previously treated for lymphoma. Forty-three patients whose chest films obtained
at the time
of presentation
response
to
for
largest previous review this disease included
of 60
patients (23 men [53%] and were 19-69 years old (median,
review
made
up
the
study
were
available
population.
20 women 34 years
The
[47%l) old).
425
Shaffer
Imaging
time
uated
Methods
Chest
radiographs
and CT scans obtained
of presentation
were
reviewed
at the
before
CT scanning
198 1 , when
widely available. variety
by one radiolo-
et al.
CT scans
of institutions
were
was
performed
slice thickness,
not at a
types of CT to lung windows, the lower half of the chest
on many
single
data
parameters
different
gist whose subspecialty is pulmonary disease. Three perpendicular measurements of tumor size were obtained from chest radiographs and CT
scanners. One study was limited
scans
radiograph. Most CT scans were performed without IV contrast agent administration. Section thick-
Results
nesses
the
whenever
possible.
Tumor
volume
was
cal-
culated with the formula for estimation of the volume of a prolate spheroid: (sagittal diameter x axial diameter x coronal diameter)/2 [7]. Pleural effusions
were
Pericardial their
classified
as small,
effusions
maximum
pericardial
were
measured
thickness,
surface.
Note
moderate,
or large.
at the point
perpendicular was
made
to
of the
for
41
patients
review. One case was missing
the frontal digital able
was
available. chest
available
For radiograph
one
view,
a localizing
review
visible
gallium
scintigrams radiologist
was confirmed.
physician,
and
Films were and
in all eases,
no gap
coronal
were as follows: data acquisition.
An anterior
and
sections,
12/5/10, with
from
a the
no gap
the initial
anterior
mediastinal
rically
to the right
for
marily
masses
One patient underwent MR imaging for evaluation of suspected superior vena eava syndrome. The study was performed on a Magnetom unit (Siemens, Iselin, NJ) at 1.0 T, with the following parameters for sagittal imaging: 32/10/5 (TRII’E/
primarily
subearinal only
marked
extended mass
to the
and (Fig.
CT the
symmet-
masses
masses.
One
subearinal
of these
it
patient
mediastinal
patients
mediastinal
pri-
(28%)
One
posterior Two
2).
In
extended
right.
anterior
had
and
both
subcarinal masses
was
detected on a chest radiograph for a patient who did not undergo CT, and the other was
man with large anterior mediastinal mass
1000 ml, as determined by CT. A, Frontal chest radiograph shows
24/25 (35%),
left of the midline.
the
(35%)
imaging
to the left, and in 12 patients
extended
reading
mass and
I) was
on initial
radiographs and In 15 patients
15 patients
medi-
(Fig.
mass
finding
(42/43 chest examinations).
seven
available a nuclear
mediastinal
predominant
had
Fig. 1-37-year-old
with
For
on the chest
8 to 10 mm.
by a chest
cine
a
from
of the mass
for any of the patients.
for
avail-
only most
Gallium scintigraphy was performed at various institutions. Twenty-one gallium scintigrams were reported as positive at presentation. No galhum scintigrams were reported as negative at pre-
but
patient was
varied
of these
at
study for a CT scan. Thoracic were available for 25 of the 43 patients Seven patients without CT scans were eval-
from
CT scans (58%).
view
anteroposterior
were
the lateral
but did include
sentation
of the attenua-
tion characteristics of the masses on CT scans. Frontal and lateral chest radiographs obtained presentation
and one included
and a single
in millimeters),
acquisition.
mediastinal
widening
with
estimated
volume
and small bilateral
of greater pleural
than
effusions.
Also, cardiac silhouette appears to be enlarged. B, Contrast-enhanced CT image at level just below carina reveals large anterior mediastinal mass that contains
necrotic
areas
and displaces
mediastinal
structures
posteriorly.
Note small bilateral
effusions. C, Contrast-enhanced CT image at lung bases reveals pericardial effusion (small white arrows), eral pleural effusions, and anterior cardiophrenic adenopathy (large white arrow).
426
pleural
bilat-
AJR:167, August 1996
Primary
visible
only
presumed
on a CT
necrosis
scan.
Cystic
in masses
areas
were
visible
Mediastinal
of
mal
by
widened
in width
Large-BCeIl
(O.2
cm)
to 1 cm
Lymphoma
in 19 patients
in seven
patients
(44%),
small
(16%),
and large
in three
in one case.
cases,
moderate The
in one
CT for 1 1 patients (44%) (Fig. I). Calcifications within the tumor were evident on CT
widened to larger than I cm in 14 patients (33%; range, 1.5-5.5 cm), and obscured in
classified one case,
as small in two cases, and large in one case.
scans
three
effusions
were
for
shown
two
patients;
in Figure
nodules
identified
presentation. chest lar;
results
3. Three on CT
Tumor
radiographs
size and
CT
for
patients scans
one had
are lung at
seen
on
and
obtained
measurements scans
were
simi-
19 patients patients
(44%), (51%),
narrowing
bowed
and
posteriorly
bowed
in two patients
middle
and
lower
graphs,
the right
lobes.
with
radiowas
nor-
right. in
primarily
ally.
but
patients
had on
left,
was
and
pleural the
five
effusions
effusions
right
side,
occurred
were
four
bilater-
classified
as
the was
mediastinal
masses
were
lateral
pleural
In
patients,
located
at the
right
effusions,
and
one
large
of
the
left
14
of the maxi-
were
patients, and
located
at
the mediastinal midline
were
present
one moderate left
the
symmetric
also
effusions
case,
on
In three
bilaterally
In four
sion,
six
in three one
as the side of the
mass.
masses
small
in (large
the same
were
small
the side
mediastinal
the effusions
ease
right).
effusions,
mal effusion
the
the left hemidia-
on
and
were
moderate in The bilateral
moderate
in one
with
maximal
mass
the mass
small
the midline.
occurred
right
patients
in whom
five
on the
The
the same
and
and asymmetric
patients.
was
symmetric
symmetric
and
mediastinal
elevated.
The
on the left
cases,
was
other
was
occurred
was
diaphragm
diaphragm
right sided
Fourteen
radiographs,
eight
The
three
in all but one patient,
(33%);
chest
(23%),
of the elevated
markedly narof the right stripe
chest
as the side of the maximal
phragm
On
on the defined
On
of a hemidiaphragm
in 10 patients
poorly
In one case,
(5%).
intermedius was dense opacification paratracheal
in 22
posteriorly
the bronchus rowed, with
in
(7%).
elevation
two
side
details are given in Table 1. The trachea was positioned normally
patients
unilateral
case,
left effusions
effusion).
and
uni(two
left effuIn one
fl-
Fig. 2.-Unusual site of presentation of mediastinal large-B-cell lymphoma in 40-year-old man who had two large mediastinal masses-one in anterior mediastinum and ane (larger mass) in subcarinal space. A, Unenhanced CT image through level of left atrium reveals larger mass in subcarinal space (straight arrows). Minimal gas is present within esophagus, just posterior to mass (curved arrow), which abuts descending aorta (A). Also note large left pleural effusion. B, Unenhanced CT image in region of posterior costophrenic sulci reveals posterior mediastinal and paraspinal adenopathy (arrows) adjacent to descending aorta (A) and large left pleural effusion.
Fig. 3.-Unenhanced CT image at level of carina in 37-year-old man before treatment reveals tiny focus of calcification in center of large, lobular anterior mediastinal mass (arrow). Mass is slightly heterogeneous in density but lacks discrete areas of necrosis. A = ascending aorta, P = main pulmonary artery. AJR:167, August 1996
427
Shaffer
patient,
a left-sided
small
bilateral
Pericardial (32%) were
mass
pleural fluid
of the available
25
was
was
in two
present
in
and
3.0
(two
By
we
identified
not seen including patients),
extension
additional
pericardial
of tumor
(one
disease
and
patient)
with
along
of tumor
extension
region
4),
(one patient),
of
Discussion
eardiophrenic of tumor
and a subearinal
mass
radiograph
hilar
into
(one
not visi-
patient).
CT
involvement
suspected
in two patients abnormality on chest
hilar
and
chest
wall
extension
chest
wall
extension
of tumor
scintigrams tracer uptake
the mediastinal
masses
who
MR examination
underwent
gradient-echo anterior
(Fig.
(Fig.
along
with
a dilated
return
from
6), the
was
signal on a located in the
extending
symmetri-
sequence, mediastinum,
rein
5). In the patient
cally to both sides of the midline. absence of flow in the superior
into the cardiophrenie
extension
gallium abnormal
tumor, which had an intermediate
the heart
region (two and left hilar
Mediastinal was
first
the
l980s
azygos
vein
the upper
body.
We saw an vena cava,
providing
venous
non-Hodgkin’s
recognized [8-I
tumors
nosed
as thymomas,
tie
had [
on the basis tumors are medullary the
Size
by Chest
Radiography
Value Determined Parameter
Coronal diameter (cm) Sagittal (cm) Axial
diameter diameter
Chest Radiography Mean
SD
10
2
(n
=
and CT
B cells
Range 6-15
Mean 10
cases
(ml)
aExciuding
of
the
SD
Range
3
4-15
8
2
4-13
9
2
5-12
11
2
4-18
10
2
5-16
primary
diagnostic
in
about
considfrom of the
I 8-24%
lymphoma,
482
248
448
258
of
mostly
type
of
I I , 161. When
[
large-B-cell
lymphoma
mediastinal
involvement
lymphoma
more
by noncommonly
in advanced disease, with tumors in sites throughout the body, rather than
as an initial site of disease. In contrast, nodular sclerosis variant of Hodgkin’s
100-1120
axial sections.
ease
occurs
from
59%
with
mediastinal
[17] to 78%
Differentiation
because
of superior distinguish up to 35%
complaint
and
studies vena
presentation in Only one documented cava
but
clinical
syndrome
scribed Hodgkin’s 49 patients
wall in
of
available
eava
bulky
mediastinal syndrome
is
Hodgkin’s disease case of superior in
our
series,
was
incomplete
also
has
in
cases.
invasion
both lymphomas with
this
Thirteen showed
of
occurred
information
of our older
Chest large-
many
with
studies
displacement
Superior
large-B-
[19].
imaging
at
vena
syndrome clinically,
presented
review
had
with
structures.
many
Hodgkin’s
of 20 mediastinal
in one
for review,
[20].
mediasti-
and
vena eava these entities
patients
patients
masses rare
in
primary
lymphoma
lymphoma
these
involvement
is not possible on the basis of imaging alone. It has been suggested that the
presence may help cell
the dis-
[18] of cases.
between
large-B-cell
disease findings
Fig. 4.-Unenhanced CT scan of 41 -year-old woman reveals chest wall invasion by primary mediastinal B-cell lymphoma located anteriorly and elevating medial portions of left pectoral muscles (arrow).
cell
mediastinal
is excluded,
nal
428
for
mediastinal
is distinction Involvement
occurs
lymphoblastic
occurs many
two cases without lateral views.
bExcluding one case with incomplete
accounting
anterior
of non-Hodgkin’s
Hodgkin’s
48-1287
15], likely
[
=
(cm) Volume
is
large-cell lymmade up of dif-
[1, 13, 14]. These arise from thymic
differential
mediastinum
CT (n
large-
lymphoma
in this disease types of lymphoma.
other
by:
41 )
In a new
in our series.
eration ofTumor
exist.
neoplasms,
of histology thought to
The primary fi:1IM..surements
of ante-
and immunoblasts, which to consistently distinguish
preponderance
location
does
mediastinal
fuse large cells can be difficult
medi-
types
a subtype of includes tumors
and
considerable between
other
masses
primary
phoma
and
of lymphoid
considered
misdiagor anaplas-
findings and
rior mediastinal B-cell
been
12],
lymphomas
classification
reviews,
seminomas,
of imaging
in
entity
early
initially
carcinomas
overlap
lymphoma
as a clinical
I 1. In these
some
astinal
Of the seven viewed, all showed
in I 6 only
effusions
inferiorly
patient), (Fig.
sites
on chest radiographs pericardial effusions
border into the cardiophrenic patients), pericardial effusions (one
the
extension
radiographs. CT,
(five
patients),
excluded
in two
patients. disease patients,
into
patients),
ble on the chest
patient,
cm
border
(two
the left hilum and adjacent left eardiophrenie region (one patient), paraspinal adenopathy
eight
1.5 cm in one patient,
patients,
cardiac
region
0.5 cm in one
1.0 cm in two patients, 2.0 cm
the
with
patients whose CT scans for review. The maximal
of fluid
thickness
was associated
effusions.
et al.
been
de-
Hodgkin’s and nonand occurred in 19 of
Hodgkin’s
disease
AJR:167,
and three
August
1996
Primary
Mediastinal
Large.
p
:
Fig. 5.-Gallium
Fig. 6.-Primary
matic uptake in anterior mediastinum.
obstruction. A, Coronal
scintigraphy of primary mediastinal large-B-cell lymphoma in 37-year-old man shows dra-
of other abnormal
Note absence
patients with non-Hodgkin’s in one series [21]. Chest wall
phoma sion
was demonstrated
only
two
mation ing;
of our
been
without
Large-cell occur
show
a
missed,
in
infordisease in older
imaging. elsewhere in the age of 52 years and
male-to-female
predominance
[8, 101, as in our series,
the median
dominance
of
described
age
was
35 years.
a female-to-male
the coronal
approximately
[4, 8, 15]. Other
65%
[l9J
to 70%
our patients
there
distribution
between
maximum
ease
alone
as a discriminator
disease
and Hodgkin’s
equal
60%
is suggested
of the largest
6, 8, 10, 15, 19]. Tumors in our
when
series
are combined
series
AJR:167,
diameters
August
1996
were
shows
large, lobular
were
typically masses, on
the
10 cm or greater
disease
tumor
from
[26]
10%
necrosis
was
vena cava
mass with homoge-
mediastinum.
Note portion
mary
mediastinal
Hodgkin’s
was
of necrosis
cations
were
untreated
lymphomas
large
the differential
often
cell tumors
masses or thymic
be large and areas
studies.
vated
and
local
infiltration
[ 15, 19, 24],
faces
or lymphatic
Lympho-
during
a review fluid
mediastinal
phrenic
and
as a large
ral fluid
[20,
effusions
can be large
thickness associated
in
cystic
incidences Thus,
areas ranging
whereas
as common
in pri-
lymphoma
described [28].
as in
the presence
Minimal
within
25].
these
calcifiin two in other
tumors,
include
anterior
which
proof pleu-
prognosis.
Pericardial
(>2 cm in maximum
of our a poor
cases) but are not outcome [5]. The
association fluid with
of pleural but not pericardial a poor prognosis is not well
understood
and could
of these
patients
of disease
be attributable
to rela-
germ also can
The detection hila,
it often
of extension
eardiophrenic
mediastinum Hon
because
that are not visible
reveals
on chest
sites radio-
and that can alter stage and prognosis.
graphs in
cystic or necrotic [29, 30].
of the
pathologic
small numbers of patients. The use of CT is crucial in the evaluation
rarely Other
four
sur-
and possible
the association
a poor
with
reflected
pleural
involvement
of these
explain
with
have
of the
tively
tumors
also can be considered
could
Any
were
bulk
into
obstruction
or direct nerve.
cesses
may
of tumor
an ele-
present,
to the largest
tumor
compression
of initial
and
when
ipsilateral
were Pleu-
to be associated and is therefore
Pleural
hemidiaphragm,
as had
mass
[27].
can contain as well as calcifications
to note
imaging
fluids
[5]
presenting
twice
diagnosis;
important
of
veins
of our eases.
shown
large-B-
not specific.
[4, 5,
been prognosis
tumors,
can show
present
has
a poor
mediastinal
in our series,
as had been
this
with
appearance
large-B-cell
disease
but
the use
pericardial one third
an
with
to 20%
at least
and in about
clinically cases.
have
also
masses,
patients,
in
of our
Pleural present
generally
mediastinal
from
trachea.
in neck and upper
ral fluid in
[23], between
series
typically
anterior
of
cm
7.5
preclude
within
other
in half
mediastinal
lobular anterior mediastinal producing a mass effect
Average
data
vessels
size
disease.
lymphoma can to that of primary
within
than
described in
present
Hodgkin’s
and all series have been small, a predominance in women of approxi-
mately
previously
mdi-
the dis-
would
of fluid density
Areas been
This
at presentation
of size
been
Since
less
overlap
necrotic
is rare
slight seven
the sexes.
dimensions.
were
diameter
has
was an approximately
and many collateral
reported in one review in which approximately
considerable
cell lymphoma,
of in
axial
than that disease,
For
in this disease, [19, 22]. However,
vein (arrow)
of the masses
have
3:2 reports
and
is larger Hodgkin’s
pre-
cated a male predominance from
mediastinum
of superior
examination.
blastic similar
this type of lymphoma,
in plane of anterior
with symptoms
throughout
were
in which
azygos
pathologically
the median age of patients mediastinal large-B-cell lym-
is in the 30s
MR image
woman
mass (M) to left of midline. Also note pulmonary veins. No flow was seen in brachiocephalic
[16]. Conversely, phomas
gradient-echo
dilated
with
primary
mediastinal large-B-cell lymphoma in 33-year-old
mediastinal
half
was lackwall
particularly
cross-sectional
2: 1
studies
cases
of chest
lymphomas at a median
body
lyminva-
but clinical
of our
instances
may have cases
on imaging
patients,
about many
other
Lymphoma
neous signal intensity slightly higher than that of muscle and resembling that of liver parenchyma (arrows). B, Coronal MR image taken during same examination as that shown in A but in more posterior imaging plane
collections.
shows
of eight
B-Cell
fields.
treatment
is important The planning
of a tumor
region, impact
and in planning
of CT
also has been
into the posterior
on
radia-
radiation
emphasized
429
Shaffer
for patients
with
through
detection
the
areas
of
tumor
bulk
Hodgkin’s
tumor
disease,
of small
spread
[31].
either chest radiography the similarity
is an unusual
lymphoma sex
seen
in our series.
in
lym-
of non-Hodgkin’s patients,
our
sis.
Pleural
and
population.
note because
outcome. other
pericardial
Pleural
of their
Distinction
anterior
larly those
effusions
effusions between
mediastinal
of Hodgkin’s
ble on the basis
are
poor
tumor
masses, disease,
of imaging
to
with this
and
particu-
is not
findings
lymphoma
possi-
alone.
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