'Management of Hodgkin's Lymphoma with Mediastinal Involvement'

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'Management of Hodgkin's Lymphoma with
Mediastinal Involvement' Imaging
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Staging HD
Stage I one LN region. Stage II two or more
node regions on the same side of the diaphragm,
with or without localized disease in one
extra-lymphatic organ. Stage III LNs on both
sides of the diaphragm, with or without splenic
involvement and with or without localized disease
in another organ. Stage IV diffuse
disseminated disease of multiple organs LNs.
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Conventional Radiography

• CXR retains a major role in the Dx of mediastinal
  masses lung parenchymal and/or pleural disease.
  
• It guides the clinician in what to evaluate next
  in the patient with a mediastinal mass and lung
  and/or pleural disease.
• The CXR is universally available, noninvasive,
  and inexpensive. It also has a low radiation
  dose.

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CXR

• CXR shows mediastinal hilar lymphadenopathy in
  60 patients with HD.
• Lung lesions (round lesions) do not occur without
  hilar node enlargement.
• Septal lines may be seen with lymphatic
  obstruction.
• Pleural effusions do not necessarily imply
  infiltration of the pleura.
• Pericardial effusions always indicate invasion of
  the pericardium by tumour.

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CXR Specificity Sensitivity

• Wide differential of anterior mediastinal mass
• Differentiation between benign malignant
  lesions may not be possible.
• CT is superior to radiography for depicting
  calcification and obliteration of fat planes,
  mediastinal lymphadenopathy, and bone erosions.

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Ultrasound

• Abdominal US rapidly establishes involvement of
  kidneys and spleen.
• The renal findings are those of enlarged kidneys
  which are mildly hypoechoic, and loss of the
  normal architecture.
• Splenic deposits are seen as foci of low
  echogenicity .
• US echocardiography useful in detecting
  pericardial effusion for directing lymph node
  biopsy and pleural interventions.

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Computed Tomography is the Imaging of Choice
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Computed Tomography

• Exact location of the mediastinal tumour, its
  relationship to adjacent structures.
• Differentiates mediastinal masses from those
  encroaching from the lung or other structures.
• Differentiates fluid, fat, calcification, cysts
  from solid tumours.
• Assesses the vascularity.
• Reveals local invasion of adjacent structures

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CT Specificity Sensitivity

• Specificity low in terms of differentiating
  benign Vs malignant.
• Lung involvement in HD has a nonspecific
  appearance.
• Osseous involvement must be focal associated
  with bone destruction. Patients with infiltrative
  marrow involvement have no bone destruction tend
  to be asymptomatic difficult to detect on CT.
• CT cannot be used to monitor response to
  treatment, as residual nonviable fibrotic tissue
  is frequently seen.

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MRI
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MRI

• Vascular images superior to CT can better
  delineate the relationship of an identified
  mediastinal mass to adjacent vessels.
• MRI can be used to differentiate a suspected
  vascular masses such as an aortic aneurysm.
• MRI contrast agents can be used when iodinated
  contrast is contraindicated.
• It provides increased detail in the subcarinal
  and aortopulmonary window areas, as well as in
  the inferior aspects of the mediastinum at the
  level of the diaphragm.

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MRI

• MRI is preferred to CT scanning in the evaluation
  of invasion or extension of tumours, especially
  tumours closely associated with the heart.
• MRI superior to CT for defining masses impinging
  on the thoracic inlet or at the thoracoabdominal
  level.
• MRI better depicts recurrences in the chest wall
  in both HD and NHL.

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SVC occlusion due to mediastinal lymphoma
GAD
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Radionuclides
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Galium-67

• Ga-67 avidity is proportionate to its
  histopathologic grade.
• High grade lymphomas, such as diffuse large cells
  NHL, most Hodgkin's, typically demonstrate
  intense Ga-67 uptake
• Low grade lymphomas, such as nodular, poorly
  differentiated lymphocytic NHL, typically do not.

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• 67Ga scanning distinguishes residual disease from
  post-treatment fibrosis in bulky mediastinal HD.
• Post-treatment 67Ga uptake is a poor prognostic
  factor in HD NHL, it is an accurate predictor
  of both response to therapy and the overall
  outcome.
• The sensitivity and specificity of GS in HD
  ranges from 85-97 and from 90-100,
  respectively.
• Use of high-dose GS ECAT has increased the
  sensitivity of 67Ga, especially in evaluating the
  mediastinum and abdomen.

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Gallium-67 uptake in NHL in a patient being
evaluated for PUO
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FDG-PET

• Depends on metabolic abnormalities in cancer
  tissue and not size criteria, as does CT.
• Provides a complete body survey, which is
  important in evaluating a multifocal disease.
• Provides superior lesion contrast allowing for
  easy detection.
• Good anatomic localization because of the
  tomographic nature of the images.

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FDG-PET shows fibrosis
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FDG-PET active disease
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PET CT in diffuse large B-cell NHL of skin and
subcutaneous tissues, recently transformed from
prior low-grade NHL. CT scan of the lower neck
shows several subcutaneous nodules of varying
size that show variable uptake on PET.
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PET CT in an 80-year-old female with diffuse
large B-cell NHL of skin and subcutaneous
tissues, recently transformed from prior
low-grade NHL. In this image, an anterior
subcutaneous nodule in the chest shows a high
level of uptake on PET. Several similar nodules
in the anterior left chest on CT do not show
uptake and may represent regions of lower grade
NHL