AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Background

Hodgkin disease (HD) is a lymphoma, which is a cancer of the lymph system characterized by the presence of abnormal large Reed-Sternberg cells in a background of lymphocytes, macrophages, fibroblasts, and granulocytes. Dr Thomas Hodgkin first described HD in 1832.

The lymphatic system is composed of lymph nodes, lymphatic channels, spleen, bone marrow, and thymus. As a result of the widespread presence of the lymphatic system throughout the body, HD can start almost anywhere; however, in this article, only thoracic involvement is addressed.

In the thorax, mediastinal involvement is most common. The nodular sclerosing histologic subtype of HD is the most common, and it has a predilection for the anterior mediastinum, especially the thymus. The diagnosis of HD must be based on tissue biopsy results because treatment strategies are based on the histologic type, the stage of disease, and the age and performance status of the patient. Imaging is essential for staging, for assessing the response to treatment, for diagnosing relapse, and for evaluating treatment-related disorders.

Pathophysiology

Etiology of HD remains unknown, but a strong association with the Epstein-Barr virus (EBV) exists. However, the presence of EBV is not specific and can be found in other malignancies.

At present, HD is not preventable because no definite cause has been identified.

Frequency

United States

According to the American Cancer Society, 7400 new cases of HD were estimated to occur in 2001 in the United States.

The incidence of HD in families of patients is increased, but the genetic nature is not certain, and it may be the result of exposure of family members to identical environmental hazards. The incidence is increased in patients who are immunocompromised, for example, in patients with AIDS and in organ transplant recipients.

Mortality/Morbidity

The aim of the treatment of HD is to cure the disease. More than 75% of newly diagnosed cases of HD can be cured with chemotherapy and/or radiation therapy. The prognosis depends on various factors; a few of these important factors include the presence of systemic symptoms, the stage of disease at presentation, the presence of large masses, and the treatment administered. Effective treatment has led to 1-, 5-, 10-, and 15-year survival rates of 93%, 82%, 72%, and 63%, respectively.

Sex

The male-to-female ratio is 1:1.5. In nodular sclerosing HD, females are affected twice as often as men, but in patients with nodular sclerosing HD, thymic involvement is more common in men.

Age

HD has a bimodal incidence. It is seen in adults aged 15-40 years and in persons older than 55 years.

Anatomy

Because mediastinal involvement of the lymph nodes is the most common manifestation of thoracic HD, knowledge of lymph node distribution and lymphatics in the thorax is important. A clear understanding of normal findings in the radiographic anatomy by using chest radiography (CXR) is pivotal to recognizing subtle enlargement of the lymph nodes.

On CXR of the left side, the normal aortopulmonary window is slightly concave, straight, or invisible. Any departure from this should be viewed with suspicion, and further investigations are needed. In the prevascular area, adenopathy is the most common cause for convexity of the aortopulmonary bay toward left lung.

On CXR of the right side, the azygous node lies variably in relation to the azygous vein as the vein passes forward above the right bronchus to enter the superior vena cava (SVC). This node is the lowest member of the group of right paratracheal lymph nodes. Any convexity in this region that has a greater part of its curvature above the right main bronchus probably should be regarded as abnormal. Low right prevascular nodal enlargement also can distort this region.

Subcarinal lymph nodes are difficult to recognize until they are large. They can cause displacement of the azygoesophageal pleural reflection. Paravertebral adenopathy can be diagnosed by distortion of the paravertebral pleural reflections, which produces convexity toward the lungs.

Pericardiac and diaphragmatic lymph nodes can fill the cardiophrenic angle on posteroanterior (PA) CXR. On lateral views, these may lie retrosternally or at the level of the inferior vena cava or phrenic nerve. Smaller lymph nodes in these areas may simulate a pericardiac fat pad.

When sufficiently enlarged, internal mammary lymph nodes can produce ill-defined increased opacity lateral to the sternum on PA CXRs. On lateral views, these can appear as anterior extrapleural masses against the chest wall.

Clinical Details

• Patients most commonly present with enlarged painless lymph nodes. Cervical lymph nodes are most common.

• HD can appear as an incidental finding on routine CXRs.

• An important feature of HD is its tendency to arise within lymph node areas and to spread in an orderly fashion to contiguous areas of lymph nodes.

• Constitutional signs and symptoms include the following:
  • Fever

  • Fatigue

  • Decreased appetite

  • Coughing and breathlessness

  • Drenching night sweats

  • Itching

  • Weight loss

  • Bone pain

  • Pressure symptoms due to enlarged lymph nodes

  • SVC syndrome

  • Dysphagia

  • Paraneoplastic syndromes

  • Dermatologic manifestations

  • Renal and metabolic manifestations

  • Neurologic manifestations

Currently, HD is classified according to the World Health Organization/Revised European-American Lymphoma classification system. According to a number of characteristics—the appearance of cells, their genetic characteristics, chemistry, and clinical behavior—HD is classified into 2 types as follows:

• Nodular lymphocyte-predominant Hodgkin lymphoma (5% of cases of HD)

• Classic Hodgkin lymphoma (95% of cases of HD), which is subdivided further into 3 subtypes
  • Nodular sclerosis Hodgkin lymphoma

  • Mixed-cellularity Hodgkin lymphoma

  • Lymphocyte-depletion Hodgkin lymphoma

HD is staged according to the Ann Arbor, Michigan conference of 1971. Some modifications were made to this classification at the Cotswolds, United Kingdom, meeting. Staging of HD is important for planning the effective treatment, and for follow-up monitoring, and for comparing the trial treatment plans available in various centers.

Staging is as follows:

• Stage I - Involvement of a single lymph node region (I) or localized involvement of a single extralymphatic organ (IE)

• Stage II - Involvement of 2 or more lymph node regions on the same side of the diaphragm (II) or localized involvement of a single extralymphatic organ or site and its regional lymph node or nodes with or without involvement of the other lymph node region on the same side of the diaphragm (IIE)

• Stage III - Involvement of lymph node regions on both sides of the diaphragm (III) with or without localized involvement of an associated extralymphatic organ or site (IIIE) with or without involvement of the spleen (IIIS) or both (IIIE+S)

• Stage IV - Disseminated/multifocal involvement of 1 or more extralymphatic organs with or without associated lymph node involvement or isolated extralymphatic organ involvement with distal nodal involvement

Bulk disease or massive mediastinal disease is defined as a ratio of the maximum transverse diameter of mass to the internal transverse thoracic diameter of greater than or equal to 0.33, as measured on CXRs at the T5-T6 intervertebral disk level. Others have defined bulk disease as lymph node mass measuring 10 cm or more in its greatest dimension.

The presence of B symptoms (eg, fever, weight loss >10%, drenching night sweats) and bulk disease is associated with worse prognosis in clinical stage I or stage II HD.

Preferred Examination

A complete patient history should be elicited and a physical examination performed.

Procedures and laboratory studies

Lymph node biopsy is performed for pathologic analysis and classification.

Laboratory investigations are performed. The following are assessed: full blood count with erythrocyte sedimentation rate, liver function, biochemistry, and renal function biochemistry.

Radiologic examinations

CXRs are obtained at presentation, during therapy, and for follow-up monitoring. Mediastinal lymph node enlargement can be detected in 60-75% of patients.

CT scanning of the thorax, abdomen, and pelvis is performed for initial staging purposes. Compared with other methods, CT is more sensitive in detecting lymphadenopathy and extralymphatic involvement. CT scanning may be most useful in evaluating patients with lymphoma because it can depict the lymph nodes in the chest, abdomen, and pelvis.

MRI is performed in patients in whom chest wall involvement is suggested; MRI offers better tissue contrast.

Ultrasonography and echocardiography are useful in detecting pericardial effusion and for directing lymph node biopsy and pleural interventions.

Bone scan is useful in evaluating bone involvement in HD. Gallium-67 scans obtained at baseline, during therapy, and in the posttreatment period help in differentiating active HD from nonactive HD.

Positron emission tomography (PET) scanning with 2-[fluorine 18]-fluoro-2-deoxy-D-glucose (FDG) is most useful in detecting disease relapse.

Bilateral bone marrow aspirations and biopsy are performed to assess in stage III or IV disease with B symptoms.

Other investigations are directed to a particular clinical problem. For example, a superior venacavogram is obtained if the patient has clinical findings of SVC syndrome. Immunoscintigraphy is used on an experimental basis only.

Limitations of Techniques

CXR is available everywhere and inexpensive; however, CXR is limited in evaluating soft tissue involvement of the chest wall. CXRs cannot be used to differentiate the various causes of lymph node enlargement. CT scanning is limited in its availability, especially in Third World countries. CT scans cannot be used to differentiate the various causes of lymph node enlargement or active tumor residue versus inactive tumor residue. MRI is limited in its availability because of its high cost. Some patients are claustrophobic and therefore cannot tolerate the MRI examination. Ultrasonography is limited in the thorax because the air contained in the lungs is not a suitable window through which the ultrasound waves can travel.

Nuclear medicine is limited because of its availability in expert centers only. At present, PET imaging is limited, and the studies are expensive.

DIFFERENTIALS

Section 3 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Other Problems to be Considered

Leukemia
Pneumoconiosis
Histiocytosis X
Castleman disease
Agammaglobulinemia
Parasitic disorders
Connective tissue disorder

RADIOGRAPH

Section 4 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

HD commonly appears as intrathoracic disease; therefore, PA and lateral CXRs are essential for clinical staging. Mediastinal adenopathy is the most common presentation, and direct extension of disease can be detected on chest radiographs. Chest images also allow evaluation of complications related to chemotherapy and radiation therapy. In follow-up studies for recurrent disease, along with history taking, physical examination, and laboratory investigations, CXR is the primary imaging modality.

• Among patients with HD, 67-74% have abnormal CXR findings at presentation.

• Of patients with abnormal CXR findings, 90% have bilateral asymmetric nodal disease.

• In HD, disease spreads contiguously along lymph node chains. Prevascular and paratracheal lymph nodes are most commonly affected.

• A single lymph node group is involved in only 15% of patients.

• Rarely, the posterior mediastinal or paracardiac lymph nodes are involved.

• The internal mammary chain of lymph nodes can be enlarged but not without other lymph node involvement.

• CXR can demonstrate either a single group with lymph node enlargement or a lobulated appearance resulting from multinodal involvement.

• Calcification is seen very rarely in untreated lymphoma.

• Direct invasion of the lungs can occur in 15-40% of patients and is associated nearly always with hilar adenopathy.

• Primary pulmonary involvement without hilar, mediastinal, or extrathoracic involvement is unusual; however, recurrent HD may appear in the absence of adenopathy, especially the nodular sclerosing type.

• Lung involvement can produce ill-defined or well-defined nodules, which can be unilateral or bilateral. These nodules may cavitate.

• Lung involvement can also appear as consolidation.

• Other findings in HD that can be detected on CXR include pleural effusions and skeletal lesions.

• In HD, two thirds of bone lesions are of the mixed lytic and sclerotic variety, few are lytic alone, and 10-15% are sclerotic alone. Sclerotic lesions tend to be confined to the vertebrae, demonstrating a typical appearance of ivory vertebrae.

• Anterior scalloping of vertebrae can be detected on lateral CXR, especially in the lower thoracic region.

• With CXR, HD can be quantified by calculating the mediastinal mass ratio (ratio of the maximum width of mediastinum to the maximum transverse thoracic diameter at the level of the diaphragm), by finding a mediastinal mass larger than one third of the transverse thoracic diameter at the T4-T5 level, or by determining an absolute transverse mediastinal diameter of 10 cm.

• In follow-up imaging of mediastinal bulk disease, 60% of CXRs demonstrate findings of residual adenopathy after treatment. This residual adenopathy may not contain active disease and may represent only residual scarring, but these can be seen at long-term follow-up.

Degree of Confidence

Most of the time, sufficiently enlarged lymph nodes in the thorax can be detected on CXR, but subtle enlargement can be missed; therefore, further imaging with CT is warranted.

False Positives/Negatives

A confluence of pulmonary veins, especially on the right, can be mistaken for subcarinal lymphadenopathy. Small pericardiac or diaphragmatic lymph nodes can mimic a fat pad. An enlarged azygous vein can mimic azygous adenopathy. When in doubt, repeat CXR by using the Valsalva maneuver. All of these false-positive CXR findings can be easily identified by performing CT.

Subtle enlargement of intrathoracic lymph nodes can be missed on CXR, and its detection greatly depends on the observer's experience as well as the type of CXR performed.

CT SCAN

Section 5 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

In conjunction with CXR, CT is the modality of choice for initial staging and follow-up monitoring of HD. Contrast-enhanced CT of the thorax, abdomen, and pelvis is performed in all patients. Any suggestion of lymph node enlargement, as demonstrated by CXR, is usually confirmed by using CT scanning.

CT has the additional advantage of depicting other areas of lymph node enlargement that are not obvious on CXR. Some areas of lymph node enlargement that are difficult to detect by using CXR include paracardiac, supradiaphragmatic, and internal mammary chain lymph nodes, but these can be detected easily by using CT scanning. CT scans also help in formulating treatment plans and radiation fields.

• Involvement of the lungs and pericardium can be detected occasionally on CT scans; these exclude treatment by using radiation therapy.

• CT size criteria for lymph node involvement in the mediastinum are well defined. According to the criteria, subcarinal, paracardiac, and retrocrural lymph nodes are enlarged if they are larger than 12, 8, and 6 mm in short-axis diameter, respectively. The remainder of the lymph nodes are enlarged if they are larger than 10 mm in short-axis diameter.

• On CT, lymph node enlargement can be seen as multiple, rounded soft-tissue masses or bulky soft-tissue masses due to nodal aggregation. Usually, a homogeneous soft-tissue mass is noted, but it may be heterogeneous when it is large, with areas of low attenuation representing necrosis, hemorrhage, or cyst formation.

• In rare cases, calcification can be seen in the lymph nodes on pretreatment scans.

• A discrete or infiltrating thymic mass can be seen.

• Associated findings that can be detected on CT scans include mediastinal displacement, compression, invasion of vascular structures, and pericardium, heart, pleural, lung, or chest wall invasion.

Degree of Confidence

CT scans can help in confidently differentiating the various causes of mediastinal or hilar enlargement seen on CXRs in most patients. However, CT is limited in detecting chest wall invasion, for which MRI is the modality of choice. CT is limited in the use of size criteria for lymph node involvement because nodes larger than those defined by the criteria can be reactive without tumor involvement. Lymph nodes smaller than those defined by the size criteria can harbor HD. Residual masses can persist during and after treatment without any viable tumor being present.

False Positives/Negatives

CT scans cannot help in differentiating between fibrosis and viable tumor. MRI, gallium scanning, or PET can be used to identify residual tumor and predict the response to therapy.

MRI

Section 6 of 12  

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• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

MRI is not the primary modality for use in evaluating HD, but it can be used in problem solving. The multiplanar capability, high tissue contrast, and flow sensitivity of MRI, as well as the use of gadolinium-based contrast agents, makes MRI an ideal tool for problem solving. Its soft-tissue contrast and multiplanar capability also make it useful in assessing chest wall invasion, pericardial involvement, pleural involvement, and brachial plexus involvement.

• In thoracic lymphomas, MRI is used to image suggestive spinal cord compression, involvement of spinal cord and meninges, involvement of the musculoskeletal system in the chest, cardiac involvement, and involvement of the brachial plexus.



• MRI is also helpful in posttreatment evaluation to differentiate between fibrosis and tumor.



• On MRI, lymph node involvement is defined by size criteria is similar to those of CT.



• MRIs are helpful in planning radiation therapy fields because of its multiplanar capabilities.



• On T1-weighted images, tumor involvement can be seen as relatively homogeneous masses with low signal intensity, similar to that of muscle.



• On T2-weighted images, high signal intensity equal to or slightly greater than that of fat can result from tumoral edema, inflammation, immature fibrosis, or granulomatous tissue.



• Follow-up T2-weighted images can show signal intensity increased from the baseline. This finding is correlated with disease recurrence.



• Low signal intensity on posttherapeutic T2-weighted images rules out relapse in most patients.



• Increased signal intensity on T2-weighted images obtained within 6 months of therapy is nonspecific. However, after 6 months, this finding suggests recurrent disease.



• Overall, the accuracy of MRI in the prediction of disease recurrence is similar to that of gallium scintigraphy.



• An enlarging or new mass may represent recurrent disease, a posttherapeutic thymic cyst, or thymic hyperplasia.



• Dense fibrosis may demonstrate low signal intensity on T2-weighted images.



• MRI also has a role in identifying the areas of bone marrow abnormalities for targeting bone marrow biopsy, but MRI is not a replacement for bone marrow biopsy in pathologic staging.

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble movingor straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Degree of Confidence

As with the criteria used in CT, a lymph node larger than 10 mm can be reactive without tumor involvement. Lymph nodes smaller than those in the size criteria can harbor the disease.

MRI is more sensitive in detecting bone marrow involvement associated with lymphoma.

False Positives/Negatives

False-positive findings can result from residual lymph node masses that may not harbor any disease. To evaluate this possibility further, ⁶⁷Ga and PET scanning can help.

Radiation-induced inflammatory changes can result in increased signal intensity on T2-weighted images. These changes can mimic active disease.

ULTRASOUND

Section 7 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
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• Intervention
• Multimedia
• References

Findings

Sonography can help in performing mediastinal biopsy, but it primarily is used for the evaluation and biopsy of lesions involving the chest wall. Rubens et al used prebiopsy CT to identify the window for real-time sonographic biopsy. Echocardiography is useful in the detection of clinically undetectable pericardial disease.

Degree of Confidence

Ultrasonography cannot help in differentiating the causes of pericardial effusion, eg, malignant, radiation-induced, drug-induced, or idiopathic effusion.

NUCLEAR MEDICINE

Section 8 of 12  

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Findings

⁶⁷Ga citrate scintigraphy

⁶⁷Ga citrate scintigraphy (GS) has been shown to provide important diagnostic and prognostic information in patients with lymphoma. In HD, GS provides information additional to CT for planning radiation therapy. GS is helpful in distinguishing residual disease from posttreatment fibrosis in bulky mediastinal HD.

Posttreatment ⁶⁷Ga uptake is a poor prognostic factor in HD and non–Hodgkin lymphoma, and it is an accurate predictor of both response to therapy and the overall outcome. In patients with aggressive lesions, advanced stage or with difficult-to-treat cases, sequential gallium scintigraphy can be performed before, during, or after therapy. These studies help in understanding the gallium avidity of the tumor, the response of tumor to therapy, and the timing of the therapeutic response.

Gallium uptake in tumor cells is mediated by transferrin receptors, and binding to cell-surface transferrin receptors allows this complex to be taken by actively growing tumor cells. Radiation therapy results in transient or permanent loss of ⁶⁷Ga uptake, although recurrent HD is invariably associated with the return of increased uptake.

The sensitivity and specificity of GS in HD ranges from 85-97% and from 90-100%, respectively. Use of high-dose GS and single-photon emission computed tomography techniques has increased the sensitivity of GS, especially in evaluating the mediastinum and abdomen.

FDG PET evaluation

Uptake of FDG is increased in malignant cells compared with normal tissues because of the altered metabolism during malignancy in which glycolysis becomes the major metabolic pathway. Several studies have suggested that FDG scintigraphy is as good as CT for staging the lymphoma. Moog et al showed that FDG PET is superior to CT in staging nodal lymphoma. Bangerter et al found that the sensitivity and specificity of FDG PET are 98% and 90%, respectively, while positive predictive value and negative predictive value were 92 and 97%, respectively, for detecting hilar and mediastinal sites of disease before treatment.

FDG PET studies may cause upstaging of the disease because of bone marrow involvement. These studies can be used to guide targeted MRI and bone marrow biopsy. FDG PET can also help in characterizing residual masses after therapy when morphologic imaging modalities are of limited value. PET can be used in the detection of relapse, and Bangerter et al found a sensitivity and specificity of 86% and 96%, respectively, for detection of recurrent disease in mediastinal and hilar nodes in patients with lymphoma.

Degree of Confidence

For GS, a posttreatment FDG scan with negative findings has a negative predictive value of 100%, but positive scans have a positive predictive value of only 61%.

False Positives/Negatives

Gallium uptake is nonspecific, and uptake can be seen in various tumors, inflammation, and infection. However, with a known setting of HD, any abnormal uptake should be viewed as active disease, residual disease, or recurrence.

ANGIOGRAPHY

Section 9 of 12  

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• Multimedia
• References

Findings

Angiography does not have much of a role in the diagnosis and management of HD, but superior venacavography is performed in patients believed to have SVC syndrome.

INTERVENTION

Section 10 of 12  

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• Ultrasound
• Nuclear Medicine
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• Intervention
• Multimedia
• References

Interventional radiology is primarily used to help perform transthoracic needle biopsy (TNB). The indications for TNB are isolated mediastinal or hilar adenopathy, pleural or chest wall involvement, diffuse pleural thickening, and distinction of lymphoma from primary mediastinal masses. TNB is usually CT guided, but other techniques such as fluoroscopy, continuous CT fluoroscopy, and ultrasonography can also be used. Complications of TNB include pneumothorax, bleeding, stroke, pericarditis, vasovagal reaction, and systemic air embolization.

Other possible interventions in thoracic HD include pleural drainage under ultrasonography guidance and drainage of postbiopsy pneumothorax under either fluoroscopy or CT guidance. For relief of the symptoms of SVC syndrome, SVC stenting is occasionally performed under fluoroscopic guidance.

Medical/Legal Pitfalls

• Subtle adenopathy can be missed by using CXR.
• When using CXR alone, the diagnosis can be missed altogether, or an accurate diagnosis can be delayed.

Special Concerns

• The incidence of HD is increased in patients with HIV infection. HD in these patients usually appears as advanced extranodal disease, with aggressive behavior of the tumor and with short survival rates in patients. Almost two thirds of patients present with extranodal disease, and almost 50% present with bone marrow involvement. The frequency of the mixed-cellularity and lymphocytic-depletion types is increased compared with the frequency in patients without HIV infection.
• Because of the successful therapies available for the treatment of patients with early-stage HD, patients live longer and have a higher risk of developing a second malignancy. Second malignancies are related to the extent of treatment for HD. There are no studies or consensus concerning how best to conduct the ongoing surveillance for second malignancies. Proper history taking, examination, and appropriate study (including radiologic studies) should be conducted on the basis of the patient's symptoms or any abnormal findings on physical examination.

MULTIMEDIA

Section 11 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Media file 1:  Hodgkin disease, thoracic. Positron emission tomogram obtained with 2-[fluorine 18]-fluoro-2-deoxy-D-glucose (FDG) shows increased FDG uptake in a mediastinal lymph node.
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Media file 2:  Hodgkin disease, thoracic. Schematic diagram showing mediastinal lymph nodes.
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Media file 3:  Hodgkin disease, thoracic. CT scan showing bulk disease.
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Media type:  CT

Media file 4:  Hodgkin disease, thoracic. Lung parenchyma involvement with Hodgkin disease.
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Media type:  CT

Media file 5:  Hodgkin disease, thoracic. Posteroanterior chest radiograph demonstrating normal findings.
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Media type:  X-RAY

Media file 6:  Hodgkin disease, thoracic. Lateral chest radiograph demonstrating normal findings.
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Media type:  X-RAY

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

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• Front D, Ben-Haim S, Israel O, et al. Lymphoma: predictive value of Ga-67 scintigraphy after treatment. Radiology. Feb 1992;182(2):359-63. [Medline].
• Glazer GM, Gross BH, Quint LE, et al. Normal mediastinal lymph nodes: number and size according to American Thoracic Society mapping. AJR Am J Roentgenol. Feb 1985;144(2):261-5. [Medline].
• Hill M, Cunningham D, MacVicar D, et al. Role of magnetic resonance imaging in predicting relapse in residual masses after treatment of lymphoma. J Clin Oncol. Nov 1993;11(11):2273-8. [Medline].
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Article Last Updated: Apr 9, 2007