Primary Mediastinal Large-B-Cell Lymphoma ...

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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.

References at A revised of lymphoid

Euroneo-

plasms: a proposal from the lntemational Lymphoma Study Group. Blood 1994;84:1361-1392 study

National of classifications

phoma:

summary

formulation

for

Cancer Institute sponsored of non-Hodgkin’s lym-

and description clinical

usage.

of a working 1982;

Cancer

49:2112-2135 3. Rappaport In: Armed

H. Tumors of the hematopoietic system. Forces Institute ofPathology, ed. Atlas of

tumor pathology Washington, DC: Armed Forces Institute of Pathology, 1966:99-101 4. Jacobson JO, Aisenberg AC, Lamarre L, et al. Mediastinal large cell lymphoma: subset of adult lymphoma curable modality

therapy.

Cancer

an uncommon with combined

1988;62: 1893-1898

5. Kim D, Mauch P. Shaffer K, et al. Large cell and immunoblastic lymphoma of the mediastinum: prognostic features and treatment outcome in 57

430

sclerosis:

a elini-

Am J Surg

Pathol

Cancer

eava

1982;50:277-282 D, Bitran JD, et al. Diffuse

lymphoma

with

sclerosis:

a elinico-

entity frequently causing superior obstruction. Cancer 1981;47:748-756 G, Ambrosetti A, Meneghini V, Ct al. large-B-cell lymphoma with selero-

sis: a clinical

study

of 21 patients.

J Clin

mary

Oncol

to

AK, Levine

mediastinal

A, Taylor

lymphoma

Am

lymphoma

of B-type,

with

JK, Banks PM, for classification

1986;

Cleary ML, of lymphoid

lymphomas

neoplasms proposed phoma Study Group.

by the International A summary version.

Clin

1995;103:543-560 PG. Large

Pathol

15. Addis BJ, Isaacson

the mediastinum: a B-cell thymic origin. Histopathologv 16. Jones

SE, Fuks

lymphomas. 405 cases. 17. Mauch

Z, Bull

of

tumour 1986;

1973;3l

cancer

Kalish

LA,

thies.

Lym-

Ri, Butler

Hodgkin’s

picture. Cancer 19. Samuels

JJ, Hicks

disease, TH,

ED. Natural

as related

history

of of

to its pathologic

M, Hamilton

PA, et al.

LR. Primary an

in Hodgkin

dis-

T, et al. Residual tomography

in

non-Hodgkin’s 1989;40:244-247

lym-

mediastinal

Di,

lymphoblastie entity.

Pattengale

PK,

lymphoma

in adults:

Ann

Intern

Med

et al. a

1978;

F, Rodriquez

E, Caruncho

values

and enhancing

AJR

et al. CT

lymphomatous adenopaTomogr 1994;18:59-64

KD, Diehl of necrotic

in patients

MV,

characteristics

LF, Cole BA, et al. The signifmediastinal lymph nodes on

with newly diagnosed

Hodgkin

1990;155:267-270

28. Panicek DM, Harty MP, Scicutella Ci, Carsky EW. Calcification in untreated mediastinal lym-

in

1966;19:317-344

Margolis

Hopper icance disease.

29.

CN,

in

ther-

mediastinum:

computed

thoracoabdominal J ComputAssist

CT J

phoma.

Radiology

Lee

Im J-G, Han

KS,

mediastinum: 30.

M, Coleman

of the

1988;l66:735-736 CG, Han MC, Kim C-W, Kim

wS. Malignant

correlation

Osteen R, Hellman S. Patterns of presentation Hodgkin disease. Cancer 1993;7l :2062-2071 18. Lukes

27.

:806-823 Kadin

with

Pombo

of

of probable 10:379-390

EJ, Farber

on follow-up

attenuation

of

involvement

89:319-324

M, et al. Non-Hodgkin’s

IV. Clinieopathologic

PM,

cell

patients

lymphoid

cell lymphoma

pleural

initial mediastinal adenopathy ease. AiR 1982;138:229-235 24. Uematsu M, Kondo M, Tsutsui

26.

Am

Rev

Am

analysis of 20 eases. Semin Diagn Pathol 1985; 2:28 1-295 23. North LB. Fuller LM, Hagemeister FB, Rodgers RW, Butler JJ, Shullenberger CC. Importance of

et al. A proneoplasms.

classification

and

JA, Dohring

study

European-American

wall

large

Histopathologv

14. Chan

chest

clinicopathologic

1994;25:5l7-536 JK, Banks PM, Cleary ML, et al. A revised

vena

facts.

SE, Bergin CJ, Hoppe RT. MR imaging

Convoluted

10:589-600

N. Superior

myth-the

22. Waldron

sclerosis:

and immunohistochemieal

cases. Histopathology

the

phoma. C/in Radio! 25. Rosen PJ, Feinstein

J Med

Assoc

patients with lymphoma: effect on radiation apy planning.AJR 1993;160:1 191-1195

CR, et al. Pri-

in adults.

Can

1990;14l:l I 14-1118

detect

masses

1980;68:509-5l4 12. Menestrina F, Chilosi M, Bonetti F, et al. Mediasti-

13. Chan posal

syndrome,

21. Carlsen

1990;8:804-808 1 1 . Lichtenstein

lymphoma.

20. Yellin A, Rosen A, Reiehert

Boston: Little, Brown 1991:334 8. Trump DL Mann RB. Diffuse large cell and undifferentiated lymphomas with prominent mediasti-

pathologic vena caval 10. Todeschini Mediastinal

large-cell 1992;43:120-126

Radiolf

RespirDis

histopathological

2. Anonymous.

with

dif-

7. Sanders RC, Casey J. Prostate. In: Sanders RC, Miner NS, eds. Clinical sonographv: a practical

ofeight Ct

J. Mediastinal

1986; 10:176-191

nal large-eell

I. Hanis ML, Jaffe ES, Stein H, pean-Ameriean classification

Mediastinal

1:1336-1343

study of 60 eases.

histiocytie

are important

association

1993;1 G, Rosai

9. Miller JB, Variakojis

Patients typically have a large anterior mediastinal mass containing focal areas of necrocommon.

large-cell

copathologic

nal involvement.

with equal

study

fuse

T, Frizzera

guide.

large-B-cell type

in young

distribution

by cal-

and volumes

mediastinal

Primary

with

or CT, as shown

of dimensions

eulated with both methods phoma

of

performed

J Cliii Oncol

6. Perrone

Estimation

can be accurately

patients.

mainly

unsuspected

et al.

primary germ CT features.AJR

Suster

S. Moran

plasms

that may

Diagn

CA. mimic

cell tumors of the 1989; 153:947-951

Malignant benign

thymic

conditions.

neoSemin

Pat/to! 1995;12:98-l04

3 1 . Borg MF, Benjamin CS, Childs WJ. The value of routine computed tomography scanning of the chest

in patients

presenting

matic

Hodgkin’s

disease.

with Austra!as

supradiaphragRadio!

1993;

37:244-248

AJR:167, August

1996