•
•
Calcification in Pelvic Lymph Nodes Containing Hodgkin's Disease Following Radiotherapy 1
Diagnostic Radiology
Thomas W. McLennan, M.D. and Ronald A. Castelllno, M.D. The appearance of roentgenographically demonstrable calcification in intrathoracic lymph nodes containing Hodgkin's disease following radiotherapy is an unusual but recognized occurrence. This report describes two patients with Hodgkin's disease in whom similar lymph node calcifications developed in involved pelvic nodes following radiotherapy. Such calcification appears to be secondary to tumor degeneration which may result from a variety of postulated causes, including radiotherapy. INDEX TERMS: Calcification. Hodgkin's disease. Lymph nodes, calcification Radiology 115:87-89, April 1975
•
•
demonstrable calcification in lymphomatous tumors is rare, having been reported once as a spontaneous phenomenon (1) and following radiotherapy in scattered reports (2, 3, 6, 11-13). Reports of radiographically detectable calcification occurring in lymph nodes involved with Hodgkin's disease following radiotherapy in all but one instance (2) have been confined to the thorax (3, 6, 11-13). Calcification in areas of degeneration and necrosis of tumor might be expected to occur with appreciable frequency following therapy, but in published reports the incidence is remarkably low. In one series calcification of intrathoracic lymph nodes involved with Hodgkin's disease following radiotherapy developed in 2 of 158 patients (3). This paper reports a more unusual phenomenon-2 cases of calcification developing in pelvic lymph nodes involved with Hodgkin's disease following radiotherapy.
graphs revealed a progression of the stippled calcification to a conglomerate, denser mass (Fig. 1,8 and C) in the left pelvis. In November 1973, the patient died after gradual deterioration of renal function. At autopsy an 8 X 8 em firm calcified mass was found in the left pelvis, as well as hydronephrosis and persistent tumor in the liver. Microscopy of the pelvic mass revealed diffuse necrosis, focal areas of calcification, and absence of tumor cells (Fig. 1, D). CASE II: This 62-year-old man presented in February 1965 with hepatomegaly and a fist-sized right pelvic mass. Biopsy of the liver and pelvic mass revealed nodular sclerosing Hodgkin's disease. A lymphogram (Fig. 2, A) disclosed enlarged replaced right iliac and inguinal lymph nodes and scattered abnormalities of the left para-aortic lymph node group. Radiation therapy included 2,025 rads to the iliac and inguinal lymph nodes in 19 days; 3,000 rads to the spleen and para-aortic lymph nodes in 23 days; 60 mei of 198Au calculated to deliver 2,000 rads of beta radiation to the liver, and an additional 1,000 rads external radiation to the liver in 4 days. All lymph node-bearing areas became negative, the liver size markedly decreased, and all liver function studies returned to normal by June 1965. In December 1970, surveillance abdominal radiography demonstrated faint, stippled calcification in the region of the previous right iliac lymphadenopathy. Serial abdominal radiographs showed the progressive accumulation of mottled calcification at the site of these previously irradiated bulky nodes (Fig. 2, B). At present (April 1974) the patient remains free from disease 9 years after diagnosis and treatment of Stage IV Hodgkin's disease with histologically documented liver involvement.
OENTGENOGRAPHICALL Y
R
CASE REPORTS CASE I: This 29-year-old man presented in May 1968 with bilateral Inguinal adenopathy and a left-sided pelvic mass extending to the level of the umbilicus. Biopsy of the left inguinal mass revealed nodular sclerosing Hodgkin's disease. Metastatic work-up was negative for tumor. A lymphogram disclosed enlarged, partially replaced iliac nodes with obstruction to lymph flow on the left (Fig. 1, A). The patient received 4,400 rads to the mantle in 27 days and 4,000 rads to the para-aortic and iliac nodes and spleen in 43 days with marked reduction in size of the left pelvic mass by August 1968. In March 1970, an abdominal radiograph showed faint stippled calcification in the left pelvis at the site of the previous left pelvic mass. In July 1972, jaundice and hepatomegaly developed, and exploratory laparotomy revealed tumor involving the liver. A 10 X 10 em fibrotic mass was palpated in the left pelvis. Serial abdominal radio-
DISCUSSION
The two cases exhibited the progressive accumulation of stippled calcification at sites of previously irradiated lymphadenopathy due to Hodgkin's disease. The stippled calcification became more mottled and dense with age. The radiographic appearance seen in these two cases is similar to that of the stippled calcification developing in previously irradiated intrathoracic lymph
1 From the Division of Diagnostic Radiology, Stanford University School of Medicine, Palo Alto, Calif. Accepted for publication in September 1974. Supported in part by Grant CA-05838 of the National Cancer Institute, NIH. dk
87
88
THOMAS
W. McLENNAN
AND RONALD
A. CASTELLINO
April 1975
Fig. 1. Case I. Coned anteroposterior views of left pelvis. A. Twenty-four hour lymphogram obtained in May 1968 shows enlarged, partially replaced left iliac lymph nodes consistent with involvement by Hodgkin's disease. B. Surveillance abdominal radiograph taken in July 1972 shows an irregularly calcified left pelvic mass in the region of the previously irradiated iliac lymphadenopathy. C. Tomogram of B. D. Photomicrograph (X45) of the left pelvic mass shows focal areas of calcification (dark areas), diffuse necrosis , and absence of tumor cells.
Fig. 2. Case II. Coned anteroposterior views of pelvis. A. Twenty-four hour lymphogram obtained in February 1965 shows enlarged, partially replaced right iliac lymph nodes consistent with involvement by Hodgkin's disease. S. Surveillance abdominal radiograph (magnified) taken in December 1970 shows a collection of mottled calcification at the site of the previously irradiated right iliac lymphadenopathy.
nodes containing Hodgkin's disease (3, 6, 11-13). The onset of radiographically detectable calcification following radiotherapy of lymph nodes containing Hodgkin's disease has ranged from 7 months to 14 years (2, 11). No relationship between the type or amount of radiotherapy and subsequent appearance of calcification have been identified in any of these cases.
Calcification in lymph nodes containing various tumors has been presumed to follow degeneration, hemorrhage and necrosis of the neoplasm. The appearance of calcification in intrathoracic lymph nodes containing Hodgkin's disease following radiotherapy has been considered to represent dystrophic calcification (2, 11). This has been explained by cellular necrosis resulting from
Vol. 115
CALCIFICATION IN PELVIC LYMPH NODES CONTAINING HODGKIN'S DISEASE
radiant energy, as well as compromise of vascular supply by endothelial damage, particularly at the capillary level. Necrotic tumors may have an extraordinary capacity to accumulate calcium, although no adequate explanation of this phenomenon has been offered (8). Other investigators regard this calcification as evidence of healing of the lymphoma, rather than any late radiation damage (6). In one patient with metastatic cervical carcinoma to lymph nodes, calcification occurred in pelvic nodes that had been irradiated and in para-aortic nodes that had not been irradiated (7). This most likely represents dystrophic calcification as a nonspecific response to local tissue damage in degenerating tumor. The differential diagnosis of radiographically demonstrable localized calcification within the abdomen is extensive (8). Roentgenographically visualized calcification within malignant tumors which are primary or metastatic to lymph nodes has been noted in many instances, including non-Hodgkin's lymphoma, hypernephroma, neuroblastoma, uterine cervical carcinoma, testicular embryonal carcinoma, ovarian dysgerminoma and papillary cystadenoma, and adenocarcinoma of the stomach, gallbladder, pancreas, and colon (2, 4, 5, 7, 10). To this list must be added the unusual occurrence of radiographically demonstrable calcification developing within previously irradiated pelvic lymph nodes containing Hodgkin's disease.
REFERENCES 1. Case Records of the Massachusetts General Hospital (Case 42242). N Engl J Med 254: 1139-1141, 1956
89
Dlagno,tic Radiology
2. Dolan PA: Tumor calcification following therapy. Am J Roentgenol 89: 166-174, Jan 1963 3. Fisher AMH, Kendall B, Van Leuven BD: Hodgkins's disease: a radiological survey. Clin Radiol 13: 115-127, Apr 1962 4. Fred HL, Eiband JM, Collins LC: Calcifications in intra-abdominal and retroperitoneal metastases. Review of the roentgenographic features. Am J Roentgenol 91: 138-148, Jan 1964 5. Ghahremani GG, Straus FH II: Calcification of distant lymph node metastases from carcinoma of colon. Radiology 99:65-66, Apr 1971 6. Grebbell FS, Lyons AR: A further case of lymph node calcification in Hodgkin's disease following radiotherapy. Br J Radiol 44:720-723, Sep 1971 7. Hutcheson J, Page DL, Oldham RR: Calcified lymph node metastases from carcinoma of the cervix. Cancer 32:266-269, Jul 1973 8. McAfee JG, Donner MW: Differential diagnosis of calcifications encountered in abdominal radiographs. Am J Med Sci 243: 609-650, May 1962 9. Papavasiliou CG: Calcification in secondary tumors of the spleen. Acta RadioI51:278-282, Apr 1959 10. Steidl RA: Extensive calcified retroperitoneal lymph node metastases from a primary carcinoma of the cecum. Radiology 89: 263-264, Aug 1967 11. Strickland B: Intra-thoracic Hodgkin's disease. Part II. Peripheral manifestations of Hodgkin's disease in the chest. Br J Radiol 40:930-938, Dec 1967 12. Whitfield AGW, Jones EL: Lymph node calcification in Hodgkin's disease. Clin RadioI21:259-260, Jul1970 13. Wyman SM, Weber AL: Calcification in intrathoracic nodes in Hodgkin's disease. Radiology 93:1021-1024, Nov 1969
Ronald A. Castellino, M.D. Division of Diagnostic Radiology Stanford University School of Medicine Palo Alto, Calif. 94305
•
Calcification in Pelvic Lymph Nodes Containing Hodgkin's Disease Following Radiotherapy 1
Diagnostic Radiology
Thomas W. McLennan, M.D. and Ronald A. Castelllno, M.D. The appearance of roentgenographically demonstrable calcification in intrathoracic lymph nodes containing Hodgkin's disease following radiotherapy is an unusual but recognized occurrence. This report describes two patients with Hodgkin's disease in whom similar lymph node calcifications developed in involved pelvic nodes following radiotherapy. Such calcification appears to be secondary to tumor degeneration which may result from a variety of postulated causes, including radiotherapy. INDEX TERMS: Calcification. Hodgkin's disease. Lymph nodes, calcification Radiology 115:87-89, April 1975
•
•
demonstrable calcification in lymphomatous tumors is rare, having been reported once as a spontaneous phenomenon (1) and following radiotherapy in scattered reports (2, 3, 6, 11-13). Reports of radiographically detectable calcification occurring in lymph nodes involved with Hodgkin's disease following radiotherapy in all but one instance (2) have been confined to the thorax (3, 6, 11-13). Calcification in areas of degeneration and necrosis of tumor might be expected to occur with appreciable frequency following therapy, but in published reports the incidence is remarkably low. In one series calcification of intrathoracic lymph nodes involved with Hodgkin's disease following radiotherapy developed in 2 of 158 patients (3). This paper reports a more unusual phenomenon-2 cases of calcification developing in pelvic lymph nodes involved with Hodgkin's disease following radiotherapy.
graphs revealed a progression of the stippled calcification to a conglomerate, denser mass (Fig. 1,8 and C) in the left pelvis. In November 1973, the patient died after gradual deterioration of renal function. At autopsy an 8 X 8 em firm calcified mass was found in the left pelvis, as well as hydronephrosis and persistent tumor in the liver. Microscopy of the pelvic mass revealed diffuse necrosis, focal areas of calcification, and absence of tumor cells (Fig. 1, D). CASE II: This 62-year-old man presented in February 1965 with hepatomegaly and a fist-sized right pelvic mass. Biopsy of the liver and pelvic mass revealed nodular sclerosing Hodgkin's disease. A lymphogram (Fig. 2, A) disclosed enlarged replaced right iliac and inguinal lymph nodes and scattered abnormalities of the left para-aortic lymph node group. Radiation therapy included 2,025 rads to the iliac and inguinal lymph nodes in 19 days; 3,000 rads to the spleen and para-aortic lymph nodes in 23 days; 60 mei of 198Au calculated to deliver 2,000 rads of beta radiation to the liver, and an additional 1,000 rads external radiation to the liver in 4 days. All lymph node-bearing areas became negative, the liver size markedly decreased, and all liver function studies returned to normal by June 1965. In December 1970, surveillance abdominal radiography demonstrated faint, stippled calcification in the region of the previous right iliac lymphadenopathy. Serial abdominal radiographs showed the progressive accumulation of mottled calcification at the site of these previously irradiated bulky nodes (Fig. 2, B). At present (April 1974) the patient remains free from disease 9 years after diagnosis and treatment of Stage IV Hodgkin's disease with histologically documented liver involvement.
OENTGENOGRAPHICALL Y
R
CASE REPORTS CASE I: This 29-year-old man presented in May 1968 with bilateral Inguinal adenopathy and a left-sided pelvic mass extending to the level of the umbilicus. Biopsy of the left inguinal mass revealed nodular sclerosing Hodgkin's disease. Metastatic work-up was negative for tumor. A lymphogram disclosed enlarged, partially replaced iliac nodes with obstruction to lymph flow on the left (Fig. 1, A). The patient received 4,400 rads to the mantle in 27 days and 4,000 rads to the para-aortic and iliac nodes and spleen in 43 days with marked reduction in size of the left pelvic mass by August 1968. In March 1970, an abdominal radiograph showed faint stippled calcification in the left pelvis at the site of the previous left pelvic mass. In July 1972, jaundice and hepatomegaly developed, and exploratory laparotomy revealed tumor involving the liver. A 10 X 10 em fibrotic mass was palpated in the left pelvis. Serial abdominal radio-
DISCUSSION
The two cases exhibited the progressive accumulation of stippled calcification at sites of previously irradiated lymphadenopathy due to Hodgkin's disease. The stippled calcification became more mottled and dense with age. The radiographic appearance seen in these two cases is similar to that of the stippled calcification developing in previously irradiated intrathoracic lymph
1 From the Division of Diagnostic Radiology, Stanford University School of Medicine, Palo Alto, Calif. Accepted for publication in September 1974. Supported in part by Grant CA-05838 of the National Cancer Institute, NIH. dk
87
88
THOMAS
W. McLENNAN
AND RONALD
A. CASTELLINO
April 1975
Fig. 1. Case I. Coned anteroposterior views of left pelvis. A. Twenty-four hour lymphogram obtained in May 1968 shows enlarged, partially replaced left iliac lymph nodes consistent with involvement by Hodgkin's disease. B. Surveillance abdominal radiograph taken in July 1972 shows an irregularly calcified left pelvic mass in the region of the previously irradiated iliac lymphadenopathy. C. Tomogram of B. D. Photomicrograph (X45) of the left pelvic mass shows focal areas of calcification (dark areas), diffuse necrosis , and absence of tumor cells.
Fig. 2. Case II. Coned anteroposterior views of pelvis. A. Twenty-four hour lymphogram obtained in February 1965 shows enlarged, partially replaced right iliac lymph nodes consistent with involvement by Hodgkin's disease. S. Surveillance abdominal radiograph (magnified) taken in December 1970 shows a collection of mottled calcification at the site of the previously irradiated right iliac lymphadenopathy.
nodes containing Hodgkin's disease (3, 6, 11-13). The onset of radiographically detectable calcification following radiotherapy of lymph nodes containing Hodgkin's disease has ranged from 7 months to 14 years (2, 11). No relationship between the type or amount of radiotherapy and subsequent appearance of calcification have been identified in any of these cases.
Calcification in lymph nodes containing various tumors has been presumed to follow degeneration, hemorrhage and necrosis of the neoplasm. The appearance of calcification in intrathoracic lymph nodes containing Hodgkin's disease following radiotherapy has been considered to represent dystrophic calcification (2, 11). This has been explained by cellular necrosis resulting from
Vol. 115
CALCIFICATION IN PELVIC LYMPH NODES CONTAINING HODGKIN'S DISEASE
radiant energy, as well as compromise of vascular supply by endothelial damage, particularly at the capillary level. Necrotic tumors may have an extraordinary capacity to accumulate calcium, although no adequate explanation of this phenomenon has been offered (8). Other investigators regard this calcification as evidence of healing of the lymphoma, rather than any late radiation damage (6). In one patient with metastatic cervical carcinoma to lymph nodes, calcification occurred in pelvic nodes that had been irradiated and in para-aortic nodes that had not been irradiated (7). This most likely represents dystrophic calcification as a nonspecific response to local tissue damage in degenerating tumor. The differential diagnosis of radiographically demonstrable localized calcification within the abdomen is extensive (8). Roentgenographically visualized calcification within malignant tumors which are primary or metastatic to lymph nodes has been noted in many instances, including non-Hodgkin's lymphoma, hypernephroma, neuroblastoma, uterine cervical carcinoma, testicular embryonal carcinoma, ovarian dysgerminoma and papillary cystadenoma, and adenocarcinoma of the stomach, gallbladder, pancreas, and colon (2, 4, 5, 7, 10). To this list must be added the unusual occurrence of radiographically demonstrable calcification developing within previously irradiated pelvic lymph nodes containing Hodgkin's disease.
REFERENCES 1. Case Records of the Massachusetts General Hospital (Case 42242). N Engl J Med 254: 1139-1141, 1956
89
Dlagno,tic Radiology
2. Dolan PA: Tumor calcification following therapy. Am J Roentgenol 89: 166-174, Jan 1963 3. Fisher AMH, Kendall B, Van Leuven BD: Hodgkins's disease: a radiological survey. Clin Radiol 13: 115-127, Apr 1962 4. Fred HL, Eiband JM, Collins LC: Calcifications in intra-abdominal and retroperitoneal metastases. Review of the roentgenographic features. Am J Roentgenol 91: 138-148, Jan 1964 5. Ghahremani GG, Straus FH II: Calcification of distant lymph node metastases from carcinoma of colon. Radiology 99:65-66, Apr 1971 6. Grebbell FS, Lyons AR: A further case of lymph node calcification in Hodgkin's disease following radiotherapy. Br J Radiol 44:720-723, Sep 1971 7. Hutcheson J, Page DL, Oldham RR: Calcified lymph node metastases from carcinoma of the cervix. Cancer 32:266-269, Jul 1973 8. McAfee JG, Donner MW: Differential diagnosis of calcifications encountered in abdominal radiographs. Am J Med Sci 243: 609-650, May 1962 9. Papavasiliou CG: Calcification in secondary tumors of the spleen. Acta RadioI51:278-282, Apr 1959 10. Steidl RA: Extensive calcified retroperitoneal lymph node metastases from a primary carcinoma of the cecum. Radiology 89: 263-264, Aug 1967 11. Strickland B: Intra-thoracic Hodgkin's disease. Part II. Peripheral manifestations of Hodgkin's disease in the chest. Br J Radiol 40:930-938, Dec 1967 12. Whitfield AGW, Jones EL: Lymph node calcification in Hodgkin's disease. Clin RadioI21:259-260, Jul1970 13. Wyman SM, Weber AL: Calcification in intrathoracic nodes in Hodgkin's disease. Radiology 93:1021-1024, Nov 1969
Ronald A. Castellino, M.D. Division of Diagnostic Radiology Stanford University School of Medicine Palo Alto, Calif. 94305
![[The calcification of mediastinal lymph nodes following the radiotherapy of a lymphogranulomatosis].](/assets/img/hold.png)
