Accepted Manuscript Title: Multimodality Imaging of Cardiothoracic Lymphoma Author: Brett W. Carter PII: DOI: Reference:

S0720-048X(14)00255-1 http://dx.doi.org/doi:10.1016/j.ejrad.2014.05.018 EURR 6789

To appear in:

European Journal of Radiology

Received date: Revised date: Accepted date:

24-12-2013 2-4-2014 9-5-2014

Please cite this article as: Carter BW, Multimodality Imaging of Cardiothoracic Lymphoma, European Journal of Radiology (2014), http://dx.doi.org/10.1016/j.ejrad.2014.05.018 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Cover Letter ( Including complete author details for ALL authors)

Multimodality Imaging of Cardiothoracic Lymphoma

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Brett W. Carter, M.D.* The University of Texas MD Anderson Cancer Center Department of Diagnostic Radiology, Section of Thoracic Imaging 1515 Holcombe Blvd., Unit 1478 Houston, TX 77030 USA Tel: 713-745-8451 Fax: 713-794-4361 E-mail: [email protected] *Corresponding author

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Authors:

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Leila Khorashadi, M.D. Department of Radiology Mount Auburn Hospital Cambridge MA 02138 Tel: 617-499-5070 Email: [email protected]

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Carol C. Wu, M.D. Department of Radiology Massachusetts General Hospital 55 Fruit Street FND-202 Boston, MA 02114 Tel: 617-724-4254 Email: [email protected]

Myrna C.B. Godoy, M.D., Ph.D. The University of Texas MD Anderson Cancer Center Department of Diagnostic Radiology, Section of Thoracic Imaging 1515 Holcombe Blvd., Unit 1478 Houston, TX 77030 USA Tel: 713-792-5884 Fax: 713-794-4361 E-mail: [email protected] Patricia M. de Groot, M.D. The University of Texas MD Anderson Cancer Center Department of Diagnostic Radiology, Section of Thoracic Imaging 1515 Holcombe Blvd., Unit 1478 Houston, TX 77030 USA Tel: 713-792-5884 Fax: 713-794-4361 E-mail: [email protected]

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Gerald F. Abbott, M.D. Department of Radiology Massachusetts General Hospital 55 Fruit Street FND-202 Boston, MA 02114 Tel: 617-724-4254 Email: [email protected]

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John P. Lichtenberger III, M.D. Department of Radiology David Grant Medical Center Travis AFB, CA 94535 Tel: 707-423-7691 Email: [email protected]

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*Conflict of Interest

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The authors and affiliated institutions have no conflicts of interest.

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*Title Page (including paper title & Complete corresponding author details)

Multimodality Imaging of Cardiothoracic Lymphoma

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Brett W. Carter, M.D. The University of Texas MD Anderson Cancer Center Department of Diagnostic Radiology, Section of Thoracic Imaging 1515 Holcombe Blvd., Unit 1478 Houston, TX 77030 USA Tel: 713-745-8451 Fax: 713-794-4361 E-mail: [email protected]

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Corresponding Author:

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*Manuscript containing Abstract, Sections and References (Without corresponding author details)

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Multimodality Imaging of Cardiothoracic Lymphoma

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Abstract Lymphoma is the most common hematologic malignancy and represents approximately 5.3% of all

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cancers. The World Health Organization published a revised classification scheme in 2008 that groups

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lymphomas by cell type and molecular, cytogenetic, and phenotypic characteristics. Most lymphomas

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affect the thorax at some stage during the course of the disease. Affected structures within the chest

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may include the lungs, mediastinum, pleura, and chest wall, and lymphomas may originate from these

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sites as primary malignancies or secondarily involve these structures after arising from other

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intrathoracic or extrathoracic sources. Pulmonary lymphomas are classified into one of four types:

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primary pulmonary lymphoma, secondary pulmonary lymphoma, acquired immunodeficiency

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syndrome-related lymphoma, and post-transplantation lymphoproliferative disorders. Although

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pulmonary lymphomas may produce a myriad of diverse findings within the lungs, specific individual

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features or combinations of features can be used, in combination with secondary manifestations of the

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disease such as involvement of the mediastinum, pleura, and chest wall, to narrow the differential

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diagnosis. While findings of thoracic lymphoma may be evident on chest radiography, computed

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tomography has traditionally been the imaging modality used to evaluate the disease and effectively

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demonstrates the extent of intrathoracic involvement and the presence and extent of extrathoracic

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spread. However, additional modalities such as magnetic resonance imaging of the thorax and 18F-FDG

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PET/CT have emerged in recent years and are complementary to CT in the evaluation of patients with

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lymphoma. Thoracic MRI is useful in assessing vascular, cardiac, and chest wall involvement, and PET/CT

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is more accurate in the overall staging of lymphoma than CT and can be used to evaluate treatment

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response.

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Keywords: Lymphoma; thoracic; cardiac; CT; MRI; PET/CT

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Introduction Lymphoma is the most common hematologic malignancy (1), arising from white blood cells in the blood, bone marrow, spleen, or other solid organs. Intrathoracic involvement is much more

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common in Hodgkin lymphoma (HL) than non-Hodgkin lymphoma (NHL) (2). The most commonly

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involved sites within the chest include the lungs, mediastinum, pleura, and chest wall, and lymphomas

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may originate from these sites as primary malignancies or secondarily involve these structures after

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arising from other intrathoracic or extrathoracic sources. Recognition of the thoracic manifestations of

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lymphoma is necessary for accurate diagnosis of the disease, and key features can be identified on

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multiple modalities such as chest radiography, chest CT, thoracic MRI, and PET/CT.

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In this article, we review the current classification system of pulmonary lymphomas and

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describe key radiologic features of cardiothoracic lymphoma across multiple imaging modalities.

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Epidemiologic and Clinical Features

Lymphoma is the most common hematologic malignancy, representing approximately 5.3% of

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all cancers and 55.6% of all blood cancers (1). The incidence of lymphoma in the United States is

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approximately 22.5 per 100,000 individuals (1).

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Most lymphomas affect the thorax at some stage during the course of the disease, and thoracic

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involvement is much more common in HL than NHL (2). One of the most important risk factors is

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immunosuppression resulting from medications such as chemotherapeutic agents or infections such as

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the human immunodeficiency virus (HIV) (3). For all lymphomas, lymphadenopathy is the most common

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abnormality reported at the time of presentation. “B symptoms” such as fever, night sweats, and

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weight loss, as well as additional nonspecific symptoms such as fatigue, may be present (3). However, in

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the setting of pulmonary lymphoma, it should be noted that patients may be asymptomatic or present

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with different symptoms or combinations of symptoms depending on the specific histologic type of

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pulmonary lymphoma and the extent of disease.

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Classification The World Health Organization (WHO) published its first classification scheme for lymphoma in 2001 (4), and subsequently released an updated edition in 2008 (5). The WHO classification system

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groups lymphomas into categories based on cell type and additional characteristics such as molecular,

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cytogenetic, and phenotypic features (5). In summary, lymphomas are grouped into 5 different

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categories: mature B-cell neoplasms, mature T-cell and NK neoplasms, HL, histiocytic and dendritic cell

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neoplasms, and post-transplantation lymphoproliferative disorder (5).

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Pulmonary Lymphoma

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Pulmonary lymphoproliferative disorders may be classified into reactive/non-neoplastic

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lymphoid lesions and malignant pulmonary lymphoproliferative disorders. This article focuses on the

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latter, which have been divided into primary pulmonary lymphoma, secondary pulmonary lymphoma,

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and lymphomas affecting immunocompromised patients, specifically AIDS-related lymphoma (ARL) and

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post-transplantation lymphoproliferative disorder (PTLD).

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Primary Pulmonary Lymphoma

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Primary pulmonary lymphoma is rare, representing less than 1% of malignant pulmonary

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neoplasms (6), less than 1% of all malignant lymphomas (7), and 3.6% of extranodal lymphomas (8). The

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diagnostic criteria for primary pulmonary lymphoma include involvement of the lung, lobar, or primary

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bronchus, with or without mediastinal lymphadenopathy, but without evidence of extrathoracic

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lymphoma for at least 3 months following the initial diagnosis (9). NHL represents 80% of primary

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pulmonary lymphomas, and the most common type is mucosa-associated lymphoid tissue (MALT)

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lymphoma. Patients with MALT lymphoma are typically asymptomatic and the prognosis is good.

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Diffuse large B-cell lymphoma (DLBCL) is the other major histology of primary pulmonary lymphoma,

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and is frequently seen in immunocompromised patients. In contrast to MALT lymphoma, these patients

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are usually symptomatic and may present with dyspnea, fever, and/or weight loss, and the prognosis is

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poor (10).

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MALT lymphomas demonstrate a wide variety of findings on CT. Single or multiple pulmonary nodules (Figure 1) or foci of consolidation are present in 70% of cases (10) (Figure 2). These findings

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tend to be multiple and bilateral, as well as peribronchovascular in distribution, which can result in

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airway dilatation (10). Hilar and/or mediastinal lymphadenoapthy is present in 30% of cases (10).

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DLBCL usually manifests as solitary or multiple pulmonary nodules or masses, frequently with cavitation

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(10) (Figure 3).

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When primary pulmonary lymphoma manifests as pulmonary nodules, the differential diagnosis

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should include benign entities such as non-calcified granulomas, pulmonary infection such as fungal

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pneumonia and septic emboli, and vasculitides such as granulomatosis with polyangiitis. Malignant

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etiologies such as metastatic disease should be suspected in the setting of a known malignancy and

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multiple pulmonary nodules. In the setting of a solitary pulmonary nodule or mass, primary lung cancer

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must be included in the differential diagnosis. When consolidation is the predominant feature of

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primary pulmonary lymphoma, the differential diagnosis should include benign etiologies such as

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pneumonia, organizing pneumonia, and pulmonary hemorrhage. In the setting of non-resolving

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consolidation, low-grade pulmonary adenocarcinoma should be considered.

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Secondary Pulmonary Lymphoma

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Secondary pulmonary lymphoma is much more common than primary pulmonary lymphoma.

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NHL represents 80-90% of all cases of secondary pulmonary lymphoma with nearly 50% of patients

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presenting with thoracic involvement and 24% with pulmonary parenchymal disease (11). HL represents

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10-15% of all cases of secondary pulmonary lymphoma with nearly 85% of patients presenting with

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thoracic involvement and 38% with pulmonary parenchymal disease (11).

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The imaging findings in secondary pulmonary lymphoma are extremely variable, as a wide variety of primary lymphomas may secondarily involve the lung parenchyma. Three distinct patterns of

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pulmonary disease have been described: lymphangitic, nodular, and alveolar (12). Overall,

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lymphadenopathy is the most frequent intrathoracic manifestation of secondary pulmonary lymphoma.

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Mass-like consolidation (Figure 4) and interstitial thickening (Figure 5) are the most common pulmonary

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manifestations of NHL and HL, respectively (13). Pulmonary nodules measuring less than 1 cm, alveolar

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opacities, and pleural abnormalities such as nodules and effusions are seen in equal frequency in NHL

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and HL (13). Air bronchograms are somewhat more prevalent in NHL (61%) than HL (47%) (10).

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Pulmonary parenchymal disease in HL is almost always associated with hilar and/or mediastinal

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lymphadenopathy, whereas isolated pulmonary involvement in NHL may occur (10).

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The most common pulmonary manifestations of secondary pulmonary lymphoma, specifically

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mass-like consolidation in HL and interstitial thickening in NHL, are nonspecific and can be seen in a wide

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variety of disease processes other than pulmonary lymphoma. When consolidation is the predominant

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feature of secondary pulmonary lymphoma, the differential diagnosis should include benign etiologies

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such as pneumonia, organizing pneumonia, and pulmonary hemorrhage. In the setting of non-resolving

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consolidation, low-grade pulmonary adenocarcinoma should be considered. When the primary feature

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is interstitial thickening, benign processes such as pulmonary edema, sarcoidosis, and other interstitial

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lung diseases should be included in the differential diagnosis. Additionally, malignant conditions such as

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lymphangitic carcinomatosis should be considered.

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AIDS-Related Lymphoma

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Following Kaposi sarcoma, lymphoma is the second most common malignancy affecting AIDS

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patients, and the proposed mechanism is a disorder of B lymphocyte proliferation resulting from long-

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term stimulation by HIV and Epstein-Barr virus (EBV) infections. ARL almost always represents NHL,

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typically an aggressive B-cell lymphoma (14). Lymphoma is 40-100 times more common in AIDS patients

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than the general population, and affects individuals with median CD4 counts less than 55 dl-1 (15). The

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incidence of ARL is estimated at 5-20%, and ARL is responsible for the death of up to 20% of patients

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with HIV. Multiple well-circumscribed pulmonary nodules and/or masses, most measuring greater than 1

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cm and with a size range of 0.5-5 cm, are typical (16). These nodules tend to be located within the lung

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periphery and may demonstrate cavitation. Alternatively, a solitary large pulmonary nodule or mass

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measuring 2-5 cm may be present. In two studies, pleural effusion was the most common intrathoracic

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manifestation of ARL, and was found in association with parenchymal abnormalities such as air-space

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opacities, consolidation, and nodules (17,18) (Figure 6). The presence of mediastinal lymphadenopathy

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is highly variable, and ranges from 3-54% (17). A combination of pulmonary nodules, pleural effusion,

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and lymphadenopathy in a patient with HIV should suggest the diagnosis of ARL.

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In patients with HIV/AIDS and pulmonary nodules, the differential diagnosis includes infectious

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etiologies such as fungal pneumonia and septic emboli. In this population, multiple pulmonary nodules

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secondary to metastatic disease or vasculitides should be considered much less likely. In the setting of a

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solitary pulmonary nodule or mass, primary lung cancer must be included in the differential diagnosis.

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Post-Transplantation Lymphoproliferative Disorder

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Post-transplantation lymphoproliferative disorder (PTLD) represents a spectrum of diseases that

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includes benign/non-neoplastic proliferations and aggressive lymphomas. PTLD is characterized by a

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disorder of B or T cells in the setting of immunosuppression, typically following solid organ or stem cell

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transplantation. EBV seropositivity is the most important risk factor for the development of PTLD, and

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most cases are B-cell lymphomas resulting from unopposed B-cell proliferation (19). Lung

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transplantation carries the highest incidence of disease following solid organ transplantation (6-9%)

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(20). Most cases occur within 2 years following transplantation, and thoracic involvement occurs in 70%

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of cases. Although symptomatology is variable, the most commonly reported symptoms include fever,

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lymphadenopathy, upper respiratory tract infections, a mononucleosis-type illness, and weight loss.

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The combination of such symptoms and the very rapid progression of PTLD may mimic infectious and

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inflammatory processes. Aggressive forms of PTLD carry a mortality rate of 60-100% (19). However,

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recognition of PTLD is important because resolution or improvement has been documented in

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approximately 60-70% of cases following reduction in immunosuppression. This phenomenon has also

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been observed in patients with autoimmune diseases such as rheumatoid arthritis treated with

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methotrexate that develop lymphoproliferative disorders and lymphoma. Spontaneous remission of

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disease in some of these patients following the withdrawal of methotrexate has been reported (21).

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The most common pulmonary abnormalities of PTLD include well-circumscribed pulmonary

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nodules and/or masses measuring 0.3-5 cm, air-space opacities and consolidation, and mediastinal and

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hilar lymphadenopathy (22). Pulmonary nodules tend to be located in the peripheral and basilar aspects

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of the lungs, and may be surrounded by ground-glass opacity in a halo configuration. Less common

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findings include interlobular septal thickening and focal ground-glass opacity (Figure 7) (23).

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Intrathoracic lymphadenopathy is present in 30-60% of cases (10).

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The differential diagnosis for PTLD includes infectious etiologies such as fungal pneumonia that

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may manifest as pulmonary nodules. However, in contrast to PTLD, these nodules are less well defined

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and more commonly demonstrate cavitation. When PTLD manifests as a soft tissue nodule or mass,

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primary lung cancer must be considered. When PTLD manifests as airspace opacities and consolidation,

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organizing pneumonia and pulmonary hemorrhage should be included in the differential diagnosis. In

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organizing pneumonia, these findings are usually peripheral, peribronchovascular, subpleural, and

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basilar in distribution, and respond well to treatment with steroids.

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Tracheobronchial Lymphoma

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Primary lymphoma of the airway is an uncommon malignancy, and may represent various histologic subtypes, including both HL and NHL (24). Several case reports describe MALT lymphoma of

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the trachea, which typically is localized, has an indolent course and carries a good prognosis (25).

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Patients may be asymptomatic, or may present with non-specific symptoms such as wheezing or

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hemoptysis. Tracheobronchial lymphoma may manifest as a solitary soft tissue mass or polypoid,

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lobulated thickening of the airway wall caused by submucosal infiltration (26). Intraluminal tumors may

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result in airway obstruction and varying degrees of atelectasis (Figure 8).

The differential diagnosis for tracheobronchial lymphoma includes tracheobronchial tumors that

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manifest as intraluminal soft tissue masses or thickening of the airways, including the most common

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primary airway malignancies such as squamous cell carcinoma, adenoid cystic carcinoma,

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mucoepidermoid carcinoma, and carcinoid. Metastatic disease should also be included.

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Differentiation of lymphoma from these entities is typically not possible based on imaging

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manifestations and tissue sampling is necessary to establish the diagnosis.

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Mediastinal Involvement

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Lymphadenopathy and Mediastinal Masses

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NHL may affect the mediastinum in the setting of systemic DLBCL or as a primary mediastinal

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NHL. Lymphadenopathy is the most common feature, which may manifest on chest radiography as loss

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of the normal mediastinal contours, lines, and stripes, or as a mediastinal mass (Figure 9). On CT,

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mediastinal lymphadenopathy is typically defined as lymph nodes measuring greater than 1 cm in short-

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axis dimension (Figure 9). The prevascular, paratracheal, subcarinal, hilar, and posterior mediastinal

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nodal stations are most commonly affected (27). Although most nodes are homogeneous, the presence

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of hypoattenuation suggests necrosis or cystic change. Mediastinal lymphadenopathy can coalesce to

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form large mediastinal masses, and may invade the pulmonary parenchyma or the chest wall.

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Calcification is rare in untreated disease, but is relatively common following therapy. Large B-cell

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lymphoma and T-cell lymphoblastic lymphoma are the most common histologies of primary mediastinal

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NHL, and typically manifest as bulky and heterogeneous anterior mediastinal masses (28). Because of

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the large size, mediastinal structures such as the trachea and esophagus and vessels such as the superior

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vena cava (Figure 10) may be invaded or become compressed. Large B-cell lymphoma is strongly

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associated with vascular involvement (28). Middle and posterior mediastinal masses are much less

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common, and the latter may invade the spinal canal and result in cord compression. Pleural and

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pericardial effusions may be present, and T-cell lymphoblastic lymphoma is more strongly associated

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with pericardial effusions (28). The presence and type of clinical symptoms in NHL depend on the

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aggressiveness of the tumor and the size and extent of mediastinal involvement. For instance, indolent

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NHLs may be asymptomatic or demonstrate only slow-growing lymphadenopathy. More aggressive

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NHLs may result in “B symptoms.” Dyspnea or cough may be present in the setting of airway

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compromise.

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HL typically results in lymphadenopathy, with multiple nodal groups affected in 85% of cases.

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The most commonly affected nodes include the prevascular, paratracheal, and aortopulmonary stations,

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and to a lesser extent the hilar and subcarinal stations. CT is effective at demonstrating the full extent

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of intrathoracic disease, which may be underestimated on chest radiography alone (29). Lymph nodes

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are typically homogeneous in appearance, although regions of hypoattenuation may indicate necrosis or

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cystic change. Calcification may be present in treated disease (Figure 11).

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Thoracic MRI is beneficial in determining the presence and extent of vascular, cardiac, and chest

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wall invasion. Several different imaging patterns have been identified on MRI. Lymphoma is usually

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hypointense on T1-weighted imaging, hyperintense or isointense to fat on T2-weighted imaging, and

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enhances following the administration of intravenous gadolinium contrast material (Figure 12).

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Enhancement is homogeneous, although areas of necrosis may result in heterogeneous enhancement.

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Following treatment, enhancement decreases markedly in patients with complete response (30).

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Inactive fibrosis typically manifests as low signal intensity on both T1- and T2-weighted imaging (31). In

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contrast, recurrent lymphoma usually manifests as regions of high signal intensity on T2-weighted

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imaging (31). Diffusion-weighted imaging (DWI) has demonstrated the ability to distinguish between

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benign and malignant lesions, as the former typically has low restricted diffusion and high apparent

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diffusion coefficient (ADC) values and the latter usually has high restricted diffusion and low ADC values

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(32,33). Additionally, DW-MRI has shown some ability to demonstrate early response to therapy as

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characterized by progressive increase in ADC values and decrease in restricted diffusion (34).

FDG PET/CT effectively demonstrates the metabolic activity of lymph nodes and has become the

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modality of choice for staging the disease (Figure 13). PET/CT is more accurate than CT at detecting

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lymph node involvement, with a sensitivity of 94% and a specificity of 100%, respectively, compared

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with 88% and 86% for CT (35). Additionally, PET/CT is effective at identifying intranodal and extranodal

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disease within the remainder of the body. The sensitivity and specificity of PET/CT in detecting organ

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involvement are 88% and 100%, respectively, compared with 50% and 90% for CT (35). PET/CT can also

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be used to evaluate treatment response. Following therapy, abnormalities in the mediastinum such as

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lymphadenopathy and soft tissue masses commonly persist, and PET/CT can differentiate between

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benign fibrosis (which may demonstrate low-grade or absent FDG uptake) and residual, metabolically

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active lymphoma (which typically demonstrates increased FDG uptake) (36) (Figure 14).

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The differential diagnosis of thoracic lymphadenopathy and mediastinal masses includes other

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primary and secondary malignancies of the mediastinum. Germ cell tumors may be difficult to

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differentiate from lymphoma, but are typically found in the anterior mediastinum and patients may

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have elevated levels of serum markers. For example, seminomas may demonstrate elevated levels of β-

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human chorionic gonadotropin (β-hCG) and nonseminomatous germ cell tumors can exhibit elevated

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levels of α-fetoprotein (αFP) or β-hCG depending on the tumor type. Teratomas often manifest as cystic

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lesions or heterogeneous masses with varying amounts of fat and calcification. Similarly, it may be

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difficult to distinguish lymphoma from thymic malignancies such as invasive thymoma and thymic

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carcinoma.

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Thymic Lymphoma Involvement of the thymus by lymphoma usually results from systemic disease, but may arise from the thymus as a primary malignancy. The most common primary thymic lymphomas include T-

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lymphoblastic lymphoma, mediastinal large B-cell lymphoma, and HL (37). Mediastinal large B-cell

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lymphoma, a subtype of DLBCL that arises from thymic medullary B-cells, affects young individuals and is

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more common in women than men (38). Mediastinal large B-cell lymphoma manifests as a soft tissue

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mass within the anterior mediastinum. Pleural and/or pericardial effusions may be present (39).

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Secondary involvement of the thymus is much more common in HL than in NHL. A review of 43 patients with HL revealed thymic enlargement in 24 (56%), 6 of which (14%) showed isolated thymic

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enlargement and 18 of which (42%) demonstrated thymic and nodal enlargement (40). HL may also

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manifest as an anterior mediastinal mass with or without cystic changes. On MRI, thymic lymphoma

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demonstrates T1 hypointensity and variable intensity on T2-weighted imaging. Following treatment,

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lymphomas are typically hypointense on T1- and T2-weighted imaging.

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Differentiating between primary thymic lymphoma and secondary involvement of the thymus by

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mediastinal and other lymphomas may be difficult on imaging studies as both processes result in an

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abnormal appearance of the thymus and may produce mediastinal lymphadenopathy. However,

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distinguishing thymic lymphoma from other thymic neoplasms such as thymoma on imaging may be

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possible. Lymphoma tends to occur in younger patients relative to thymoma and behave in a more

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aggressive manner. Additionally, the presence of thymic enlargement and hilar and mediastinal

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lymphadenopathy suggests the diagnosis of lymphoma (41). Differentiating thymic lymphoma from

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thymic hyperplasia, especially in those patients who have been treated with chemotherapy, may be

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difficult as hyperplasia may result in diffuse thickening and enlargement of the thymus. However, the

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utilization of in- and out-of-phase gradient echo sequences may be useful to differentiate thymic

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hyperplasia from lymphoma, as the former demonstrate loss of signal on out-of-phase images secondary

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to the suppression of microscopic fat interspersed between non-neoplastic thymic tissue (42,43).

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Thymic malignancies and lymphoma do not suppress on out-of-phase images.

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Cardiac Lymphoma Lymphomatous involvement of the heart and pericardium occurs most commonly in the setting

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of invasive local or systemic disease, termed secondary cardiac lymphoma. In pathologic series,

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approximately one-third of patients with NHL have cardiac involvement at autopsy (44). Primary cardiac

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lymphoma (PCL) is defined as lymphoma confined to the heart and pericardium without extra-cardiac

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disease. PCL is rare, comprising less than 1% of extranodal lymphomas at autopsy (45). It is usually a

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non-Hodgkin B-cell lymphoma and occurs most commonly in patients with HIV infection, although

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immunocompetent patients may be affected (46). Finally, cardiac lymphoma may present as a

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pericardial effusion composed of lymphomatous growth in a liquid phase, a manifestation of primary

275

effusion lymphoma (PEL) discussed below (47).

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Although cardiac lymphoma may occur anywhere in the heart, the right atrium and right

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ventricle are most commonly involved (48). Extension along the epicardial surface of the heart is

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characteristic, as is encasement of the coronary vessels and the aortic root (49). Pericardial thickening

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and effusion are often associated findings in primary and secondary cardiac lymphoma (Figure 15), and

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PEL typically manifests as an effusion without an associated mass (50). Lymphadenopathy is a

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characteristic feature of secondary cardiac lymphoma.

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Primary and secondary cardiac lymphomas have a similar imaging appearance.

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Echocardiography is often the initial imaging test in patients with suspected cardiac lymphoma. These

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infiltrative masses are often hypoechoic relative to myocardium, partially intra-cavitary, and associated

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with a pericardial effusion (51). Transesophageal echocardiography is reported to identify cardiac

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lymphoma in 100% of cases (52). Chest radiographs are frequently abnormal, showing enlargement of

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the cardiac silhouette, pericardial effusion, or pulmonary edema (53). On CT, cardiac lymphoma

Page 17 of 64

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commonly presents as multiple iso- to hypoattenuating masses that infiltrate the myocardium and have

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a predilection for the right atrioventricular groove (54) (Figure 16). These masses enhance

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heterogeneously, extend along the epicardium and encase the coronary arteries. MRI is superior to other imaging modalities in demonstrating the extent of myocardial and

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pericardial involvement with cardiac lymphoma (Figure 17). On T1-weighted imaging, cardiac lymphoma

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is hypointense and enhances with contrast. On T2-weighted images, these masses are iso- to

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hyperintense. Cine balanced SSFP imaging may show intra-chamber components of the mass, valvular

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involvement and resulting physiologic impairment.

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The differential diagnosis of cardiac lymphoma includes other primary and secondary neoplasms

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of the heart and pericardium. Cardiac metastases from primary malignancies such as lung, breast, and

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esophageal cancers and malignant melanoma are 20-40 times more common than primary cardiac

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neoplasms. Metastatic disease should be considered in patients with the appropriate clinical history and

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findings such as a pericardial effusion, pericardial thickening, or a cardiac mass on imaging studies.

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Primary cardiac sarcomas, of which the most common is angiosarcoma, should also be included in the

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differential diagnosis. These tumors manifest as discrete masses that involve the cardiac wall and

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chambers and are more common in the left atrium than the right atrium. Angiosarcomas are typically

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highly vascular, demonstrate regions of enhancement, and are more common in the right atrium than

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the left atrium.

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Pleural Lymphoma

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Primary pleural lymphoma is rare, representing only 7% of all cases of primary lymphoma, and

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typically affects patients with HIV infection or long-standing diseases of the pleura such as chronic

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tuberculous pyothorax (55,56). The majority of primary pleural lymphomas are B-cell lymphomas, and

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the proposed mechanism for the development of the disease is chronic stimulation of B-cells by

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longstanding pleural disease (57). Primary effusion lymphoma (PEL) is a rare form of lymphoma found in

Page 18 of 64

immunocompromised patients, primarily HIV-infected males and patients who have undergone solid

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organ transplantation. PEL manifests as a lymphomatous effusion that affects one body cavity in the

314

absence of a solid tumor mass. The pleural space is the most common space involved, followed by the

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pericardial and peritoneal spaces. The prognosis is typically poor with median survival less than 6

316

months. PEL is strongly associated with human herpes virus 8 (HHV-8) and to a lesser extent with EBV

317

infection (58). Pyothorax-associated lymphoma (PAL) may develop in patients with chronic pyothorax or

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longstanding pleural inflammation secondary to prior artificial pneumothorax used to treat tuberculosis.

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The artificial pneumothorax was generally abandoned in the 1950s as chemotherapeutic agents for the

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treatment of Mycobacterium tuberculosis became widely accessible. Therefore, PAL is rapidly becoming

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a rare disease as the majority of potential patients who underwent the procedure have aged. In

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contrast to PEL, PAL manifests as a homogeneous or heterogeneous soft tissue mass involving the

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pleura that usually does not enhance and is associated with an empyema cavity on CT. Pleural

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calcification is typically present. Complications such as fistula formation, as evidenced by an air-fluid

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level or a focus of air in the empyema cavity, invasion of the chest wall, and osseous destruction, may be

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identified (59).

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Secondary involvement of the pleura in systemic lymphoma is more common than primary

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pleural lymphoma. Approximately 16% of NHL cases present with pleural involvement at the time of

329

diagnosis or develop pleural disease at some point during the course of the disease (60). DLBCL is the

330

most common lymphoma to secondarily involve the pleura, followed by follicular lymphoma (61).

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Involvement of the pleura may be unilateral or bilateral, and the left hemithorax is more commonly

332

affected than the right (60). Most patients with pleural involvement are symptomatic, presenting with

333

dyspnea, cough, or chest pain (62). Typical imaging findings include pleural effusion, pleural thickening,

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which is typically nodular although plaque-like pleural thickening has been reported, and pleural nodules

335

and/or masses (Figure 18). The presence of an effusion in the setting of pleural involvement is a poor

Page 19 of 64

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prognostic factor (63). FDG PET/CT may be beneficial in identifying and localizing FDG-avid sites of

337

pleural involvement and evaluating response to therapy. The differential diagnosis of pleural lymphoma includes other disease processes such as pleural

339

metastatic disease and malignant pleural mesothelioma, which typically result in abnormalities such as

340

effusions, pleural thickening, nodules and masses. Metastatic disease is the most common overall

341

malignancy of the pleura and may be seen in the setting of lung cancer, breast cancer, thymoma, and

342

other primary malignancies. It may be difficult to differentiate pleural lymphoma from metastatic

343

disease, although the history of a non-lymphomatous primary malignancy elsewhere should raise

344

suspicion for metastatic disease. Malignant pleural mesothelioma (MPM) is the most common primary

345

malignancy of the pleura and the second most common overall malignancy of the pleura after

346

metastatic disease. Similarly, it may be difficult to differentiate pleural lymphoma from MPM, although

347

the presence of calcified pleural plaques, representing asbestos-related pleural disease and present in

348

approximately 20% of cases, should suggest MPM.

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Chest Wall Involvement

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Chest wall lymphoma is typically the result of direct invasion of HL or large B-cell lymphoma

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originating in the mediastinum, axilla or bone. Direct invasion occurs in 6.4% of patients with HL (26).

352

Primary chest wall neoplasms are rare, representing only 5% of chest wall tumors (64), and primary

353

malignant lymphoma comprises only 2.4% of primary chest wall tumors (65). Overall, chest wall

354

involvement occurs in 9.6% of patients during the course of their disease (66).

355

Radiographically, chest wall disease is suggested by discrepant size or margins of a soft tissue

356

mass on orthogonal views, which may cross anatomic boundaries of the lung or mediastinum. Bone

357

destruction may be evident. On cross-sectional imaging, HL typically presents as an infiltrative mass in

358

the parasternal soft tissues as a result of direct extension of disease from anterior mediastinal lymph

359

nodes (67) (Figure 19). Extension from posterior mediastinal lymph nodes may involve the thoracic

Page 20 of 64

spine. MRI is useful in evaluating chest wall masses due to its superior soft-tissue contrast resolution

361

and is more sensitive than CT for detecting chest wall involvement by lymphoma, as well as providing a

362

better evaluation of bone marrow, spine and cord involvement (68). Lymphoma is usually isointense to

363

mildy increased in signal intensity on T1-weighted imaging and hyperintense on T2-weighted imaging

364

(69).

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The imaging appearance of chest wall lymphoma is nonspecific, mimicking many infectious and

366

malignant diseases. Among infectious diseases of the chest wall, polymicrobial bacterial disease, fungal

367

disease such as aspergillosis, and atypical organisms such as tuberculosis should be considered.

368

Metastatic disease should be the primary consideration of malignant diseases of the chest wall. Primary

369

malignancies of the chest wall include chondrosarcoma, Ewing sarcoma (Askin tumor), osteosarcoma

370

and plasmacytoma.

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Histologic Sampling and Biopsy Considerations

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Although the combination of clinical presentation and findings on imaging studies may suggest

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the possibility of cardiothoracic lymphoma, histologic sampling is necessary in order to make a definitive

374

diagnosis, determine specific characteristics of the tumor, and guide patient management. In general,

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multiple core needle specimens (in most cases 3-5) are typically needed for architectural evaluation and

376

immunohistochemistry, and fine needle aspiration is required for flow cytometry.

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In a study of patients with primary pulmonary NHL, approximately 66.7% required surgical

378

procedures such as open thoracotomy or video-assisted thoracoscopic surgery (VATS) to establish the

379

diagnosis (70). Although bronchoscopy was performed in 83% of patients, diagnostic yield by direct

380

biopsy or transbronchial biopsy was only 30% (70). The utilization of cell marker studies or molecular

381

techniques such as flow cytometry using fluid obtained from bronchoalveoar lavage may be helpful in

382

identifying primary pulmonary lymphomas. Additional studies have demonstrated that only surgical

383

biopsy and resection specimens consistently produce high diagnostic yields of 64-90% (71,72).

Page 21 of 64

Data regarding the success rate of transthoracic needle biopsy when evaluating mediastinal

385

masses and lymphadenopathy is variable. Studies often consist of mixed patient populations (newly

386

diagnosed as well as recurrent disease), assess only one biopsy technique (fine needle aspiration or core

387

biopsy), and do not specify how many specimens were obtained. In these reports, the success rate

388

varies from 13% to 92% (73-80). In one study evaluating anterior mediastinal masses in 15 patients that

389

were diagnosed with HL by core biopsy alone, using light microscopy without immunohistochemical

390

stains or flow cytometry, only 20% of patients were diagnosed correctly (81). In this same study, 4 cases

391

of HL and 1 case of NHL were misdiagnosed as thymoma, whereas two cases of lymphocyte-rich

392

thymoma were misdiagnosed as lymphoma (81). Therefore, many surgeons advocate mediastinoscopy

393

and surgical biopsy.

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For cases of cardiac lymphoma, the type of biopsy is often determined by the location and

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nature of disease detected. For instance, in the setting of pericardial effusion, fluid sampling may be

396

performed. However, one study demonstrated that cytology of pericardial effusions was diagnostic in

397

only 67% of cases (82). In this same report, thoracotomy and biopsy was diagnostic in all cases. Several

398

modalities may be used for tissue sampling. For instance, TEE can be used to guide transvenous biopsy,

399

combined fluoroscopic imaging and TEE may assist in percutaneous intracardiac biopsy, and intracardiac

400

echocardiography-guided biopsy may be performed (82,83,84).

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Primary or secondary lymphoma of the pleura may be evaluated with cytological examination

402

and/or pleural biopsy. However, in one study, pleural fluid cytology had a high false-negative rate of

403

nearly 50% (85). The authors of the report proposed that the tendency to seed fluid in the pleural space

404

may be limited in some types of lymphoma. Therefore, it is recommended that a combination of both

405

cytologic and histologic examination be performed to evaluate cases of suspected pleural lymphoma.

406 407

The utilization of fine needle aspiration and non-excisional biopsy of chest wall tumors, including lymphoma, is controversial (86). The yield from these specimens may be unsatisfactory and lead to

Page 22 of 64

incorrect diagnosis and inappropriate management (87,88), and there is concern about the possibility of

409

needle track seeding (89). It has been suggested that all patients with chest wall tumors undergo

410

excisional biopsy as a minimum and that those in whom there is a strong suspicion of malignancy

411

undergo wide radical resection or resection or subsequent resection for safe margins (64). Non-

412

excisional biopsy is typically reserved for cases in which chest wall lesions are suspected metastases or

413

hematologic disease, as aggressive surgical resection is less beneficial in these patients (64).

414

Conclusion

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Lymphomatous involvement of the thorax may affect the lungs, mediastinum, pleura, and chest wall. Pulmonary lymphomas, which may be classified into one of four types, produce a myriad of

417

diverse findings within the lungs. However, imaging features common to the type of lymphoma can be

418

used, in combination with secondary manifestations of the disease such as involvement of the

419

mediastinum, pleura, and chest wall, to narrow the differential diagnosis. Although the diagnosis of

420

lymphoma may first be suggested on chest radiography, CT has traditionally been the primary imaging

421

modality used to evaluate the disease and typically demonstrates the extent of intrathoracic

422

involvement and the presence and extent of extrathoracic spread. Additional modalities such as MRI of

423

the thorax and 18F-FDG PET/CT are complementary to CT in the evaluation of patients with lymphoma.

424

Specifically, thoracic MRI is useful in assessing vascular, cardiac, and chest wall involvement, and PET/CT

425

is more accurate in the overall staging of lymphoma than CT and can be used to evaluate treatment

426

response.

427

References

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56. Hsu NY, Chen CY, Pan ST, et al. Pleural non-Hodgkin's lymphoma arising in a patient with a chronic

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pyothorax. Thorax 1996;51:103–4.

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thickening of the pleura. Jpn J Radiol 2010;28:62–5.

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findings. Radiology 1997;203(1):237-44.

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75. Stewart CJ, Duncan JA, Farquharson M, Richmond J. Fine needle aspiration

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Lister TA, Rohatiner AZ. Role of image-guided core-needle biopsy in the

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78. Assaad MW, Pantanowitz L, Otis CN. Diagnostic accuracy of image-guided

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81. Herman SJ, Holub RV, Weisbrod GL, Chamberlain DW. Anterior mediastinal masses:

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87. Gleeson F, Lomas DJ, Flower DR, Stewart S. Powered cutting needle biopsy of the pleura and chest

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wall. Clin Radiol 1990;41:199–200.

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88. Mrnkin HJ, Lange TA, Spanier S. The hazards of biopsy in patients with malignant primary bone and

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89. Anderson BO, Burt ME. Chest wall neoplasms and their management. Ann Thorac Surg

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1994;58(6):1774-81.

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Figure Legends

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Figure 1. Axial contrast-material enhanced CT image of a 37-year-old man demonstrates a solitary solid

625

nodule with central cavitation (arrow) in the left upper lobe. CT-guided biopsy revealed MALT

626

lymphoma.

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Figure 2. PA chest radiograph (A) of a 40-year-old man demonstrates a lobular opacity (black arrow) in

628

the paramediastinal left lung. Axial contrast-material enhanced coned-down CT image (B) of the same

629

patient shows a focus of consolidation (arrows) in the left upper lobe and left lower lobe adjacent to the

630

mediastinum. CT-guided biopsy revealed mucosa-associated lymphoid tissue (MALT) lymphoma.

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Figure 3. Axial contrast-material enhanced CT image of a 56-year-old man shows numerous cavitary

632

nodules in the bilateral lungs. Biopsy revealed diffuse large B-cell lymphoma (DLBCL).

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Figure 4. PA chest radiograph (A) and axial contrast-material enhanced CT image (B) of a 70-year-old

634

man with a remote history of gastrointestinal lymphoma. PA chest radiograph (A) shows foci of

635

consolidation in the lungs bilaterally, greater on the left than the right. Axial contrast-material

636

enhanced CT image (B) demonstrates foci of consolidation bilaterally, as well as ground-glass opacity

637

with interlobular septal thickening in a “crazy paving” pattern (white arrows) and a small left pleural

638

effusion (black arrow). Biopsy confirmed secondary lymphomatous involvement of the lungs.

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Figure 5. Axial contrast-material enhanced coned-down CT image of a 61-year-old man with

640

extrathoracic NHL demonstrates interstitial and peribronchovascular thickening (arrow) in the right

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lower lobe. Bronchoalveolar lavage revealed secondary involvement of the lungs.

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Figure 6. Axial contrast-material enhanced CT image of a 29-year-old man with acquired

643

immunodeficiency syndrome (AIDS) demonstrates multiple pulmonary nodules in the lungs bilaterally,

644

as well as small left greater than right pleural effusions. Biopsy confirmed AIDS-related lymphoma (ARL.

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Figure 7. Axial contrast-material enhanced coned-down CT image of a 36-year-old man with PTLD shows

646

multiple foci of ground-glass opacity (arrows) in the lungs bilaterally, greater on the left than the right,

647

with subtle interlobular septal thickening.

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Figure 8. PA chest radiograph (A) of a 47-year-old woman demonstrates abrupt cutoff of the left main

649

bronchus (white arrow) and atelectasis of the left lung. Axial contrast-material enhanced coned-down

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CT images on lung (B) and soft tissue windows (C) show a lobulated, soft tissue mass in the distal left

651

main bronchus (black arrows) resulting in atelectasis of the left lung. Biopsy revealed primary

652

lymphoma of the airway.

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Figure 9. PA chest radiograph (A) of a 37-year-old man presenting with shortness of breath and chest

654

pain shows loss of the normal mediastinal contours and the presence of a large mediastinal mass. Axial

655

contrast-material enhanced coned-down CT image of the same patient demonstrates extensive

656

lymphadenopathy in the anterior mediastinum. Biopsy revealed NHL.

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Figure 10. Axial contrast-material enhanced coned-down CT image of a 39-year-old man with primary

658

mediastinal large B-cell lymphoma shows a large, heterogeneous anterior mediastinal mass that invades

659

and obliterates the superior vena cava. Because of the large size of these tumors, mediastinal structures

660

such as the esophagus and trachea and vessels such as the superior vena cava may be invaded.

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Figure 11. Axial contrast-material enhanced coned-down CT images of a 39-year-old woman with HL

662

before (A) and after (B) treatment. Baseline axial CT (A) demonstrates a large, homogeneous anterior

663

mediastinal mass. Axial CT image following chemotherapy (B) shows interval decrease in size of the

664

anterior mediastinal mass and development of multiple foci of internal calcification.

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Figure 12. Axial non-contrast T1-weighted (A), contrast-material enhanced T1-weighted (B), and T2-

666

weighted (C) MR images of a 53-year-old woman with an anterior mediastinal mass. Axial non-contrast

667

T1-weighted MR image (A) demonstrates the mass to be hypointense, but isointense relative to muscle.

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Axial contrast-material enhanced T1-weighted MR image (B) shows enhancement of the mediastinal

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mass. Axial T2-weighted MR image (C) demonstrates the mass to be isointense relative to fat. Biopsy

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revealed HL.

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Figure 13. Axial fused coned-down PET/CT image of a 34-year-old woman with biopsy-proven HL

672

demonstrates intense FDG uptake in multiple enlarged mediastinal lymph nodes.

673

Figure 14. Axial fused coned-down PET/CT images of a 49-year-old woman with NHL before (A) and

674

after (B) treatment. Baseline PET/CT (A) demonstrates extensive FDG-avid lymphadenopathy in the

675

mediastinum that has coalesced into a large mediastinal mass. PET/CT following one cycle of

676

chemotherapy (B) shows marked interval decrease in FDG uptake with an associated decrease in overall

677

size of the mass.

678

Figure 15. Axial contrast-material enhanced coned-down CT image (A) of a 42-year-old man with DLBCL

679

demonstrates a small pericardial effusion and thickening and enhancement of the pericardium (arrows).

680

Axial fused coned-down PET/CT image (B) demonstrates increased FDG uptake (arrows) in portions of

681

the abnormal pericardium, consistent with lymphomatous involvement.

682

Figure 16. Axial contrast-material enhanced coned-down CT image shows an infiltrating mass involving

683

the right atrioventricular groove (arrows) that extends into the interatrial septum and involves the

684

tricuspid valve. Biopsy revealed primary cardiac lymphoma is this HIV-positive patient, specifically non-

685

Hodgkin B-cell lymphoma.

686

Figure 17. Axial double inversion recovery (IR) coned-down cardiac MR image of a 54-year-old man

687

demonstrates a mass (arrow) centered in the right atrioventricular groove that surrounds the right

688

coronary artery. Biopsy revealed secondary cardiac lymphoma.

689

Figure 18. Axial contrast-material enhanced coned-down CT image of a 41-year-old man demonstrates a

690

large right pleural effusion and nodular thickening of the pleura in the right hemithorax (arrow).

691

Diagnostic thoracentesis and pleural biopsy revealed follicular lymphoma.

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Figure 19. Axial contrast-material enhanced coned-down CT image of a 58-year-old man shows a large

693

anterior mediastinal mass invading the chest wall with associated cortical destruction of the sternum.

694

Loculated fluid is present in the left pleural space. Biopsy of the mass revealed HL.

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