CASE 9057 Published on 17.02.2011

Hodgkin\'s lymphoma

Section

Chest imaging

Case Type

Clinical Cases

Authors

Patton, D.
Emergency Department, Ulster Hospital, Northern Ireland

Patient

11 years, male

Clinical History
A previously healthy 11 year old boy presented for the second time to the emergency department in a three week period complaining of sharp retrosternal chest pain.
Imaging Findings
An 11 year old previously healthy boy presented to the emergency department complaining of a three week history of intermittent sharp retrosternal chest pain. He did not report any other features on further questioning.
His initial observations were within normal limits; however, he had a low-grade pyrexia of 37.6. Cardiovascular examination was unremarkable and his electrocardiogram showed no acute changes. Abdominal examination revealed non-tender hepatosplenomegaly. Respiratory examination revealed no abnormality.
Chest radiograph revealed a large retrosternal mass in the mediastinum with some displacement of the trachea (Fig. 1).
CT imaging of the chest, abdomen and pelvis revealed enlarged lymph nodes in the neck and supraclavicular fossa bilaterally. There were multiple nodes in the mediastinum with the largest measuring 5.7 x 5.2 x 9.8 cm (Fig. 2). It also demonstrated enlargement of the liver and spleen (Fig. 3).
He was subsequently diagnosed with Hodgkin Lymphoma (HL) following a surgical biopsy of a superficial cervical lymph node.
Discussion
Hodgkin Lymphoma (HL) is a B-cell malignant disorder predominately affecting lymphatic tissue. It is a rare disease with a slight male predominance (1.3:1) and a peak incidence in the third decade. The presence of the Reed-Sternberg cell is pathognomonic, and is derived from germinal centre B cells. The aetiology of Hodgkin Lymphoma is thought to be multifactorial, but there is a well documented link between Hodgkin lymphoma and Epstein-Barr virus (EBV), accounting for approximately 50% of cases worldwide [1,2,3,4].

Hodgkin Lymphoma normally presents with lymphadenopathy, typically cervical nodes, which are usually painless and resistant to antibiotic therapy. There may be accompanying hepatosplenomegaly. Patients with mediastinal adenopathy may present with respiratory symptoms such as shortness of breath, chest pain or cough [3,5].

Imaging studies that should be undertaken when Hodgkin Lymphoma is suspected include chest radiography with AP and lateral views to assess the bulk of the mediastinum. CT/MRI of the neck, chest, abdomen and pelvis are also useful to assess the extent of the disease and look for extranodal involvement. Ultrasound scanning has a small role to play in the initial diagnosis but can be used for follow up and monitoring particularly of cervical nodes, as it is relatively simple and non-invasive. Fluorodeoxyglucose (FDG) positron emission tomography (PET) has a proved role for HD in adults but the role of this imaging technique is as yet uncertain in children. However, it may play a role in distinguishing between benign masses and active disease post treatment [5].

No single imaging technique can provide a definitive diagnosis and lymph node biopsy remains the gold standard for diagnosis as fine-needle aspiration is not recommended because of lack of stromal tissue obtained which leads to difficulty classifying the Hodgkin lymphoma [5].

Today, the majority of children and adolescents diagnosed with Hodgkin's lymphoma will be cured following treatment with chemotherapy alone or in combination with low-dose, involved-field radiation, with a recurrence rate of less than 10% [6]. This has lead to concerns that repeated doses of radiation delivered in the course of "routine" post therapy surveillance would be detrimental. Clinicians managing these cases should carefully consider the long term implications of serial scans and question the use of imaging studies in these patients beyond those performed for initial assessment and response to treatment, with good clinical follow up and examination yielding a 98% pick up rate for recurrence without the need for imaging [7].
Differential Diagnosis List
Hodgkin lymphoma
Non-Hodgkin lymphoma
Lymphadenopathy
Acute lymphoblastic leukaemia
Tuberculosis
Final Diagnosis
Hodgkin lymphoma
Case information
URL: https://www.eurorad.org/case/9057
DOI: 10.1594/EURORAD/CASE.9057
ISSN: 1563-4086