What are the preferred modalities for thoracic non-Hodgkin lymphoma (NHL) imaging?

Updated: Mar 05, 2019
  • Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: Eugene C Lin, MD  more...
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The primary investigation of suspected lung and mediastinal pathology is standard chest radiography. After a mediastinal lesion is identified on a conventional radiograph, CT scanning is the preferred modality for further evaluation of the middle and anterior mediastinum. MRI is preferred when neural involvement is suspected, and then imaging is generally limited to the spine. [3, 4, 5, 6, 7]

Abdominal disease is demonstrable on ultrasonograms. However, CT scanning is commonly used to show the presence and extent of disease. Visceral involvement may be diffuse or focal, with multiple nodules or sometimes a large, solitary mass present. If symptoms indicate osseous involvement, conventional radiographs may depict areas of destruction, periosteal new-bone formation, and a sclerotic lesion (in some cases). Vertebral lesions are best evaluated with MRI, particularly when vertebral collapse has occurred. MRI provides elegant demonstration of surrounding soft tissue involvement and intraspinal disease if present. MRI has a role in select cases for follow-up and for differentiation of fibrosis from disease, but if the signal intensity remains high, differentiation may be impossible, and positron emission tomography (PET) is better. In cases of central nervous system (CNS) involvement, MRI is preferred and should be used for evaluation. MRI is a valuable tool in the setting of a residual mass after treatment, giving clinically useful information for prognosis. [8] Similarly, testicular ultrasonography (US) can be performed if it is clinically applicable. [3, 5]

Isotope studies with gallium are rarely used. Gallium-67 (67Ga) scintigraphy has a sensitivity of 85% for high-grade NHL. Its sensitivity for low-grade NHL is poor. Ga-67 scintigraphy can be used to monitor responses to treatment. Where available, fluorodeoxyglucose (FDG)-PET scanning is increasingly used to image and stage malignancy. Compared with cross-sectional morphologic imaging, FDG-PET has several advantages. FDG-PET depends on metabolic abnormalities in cancer tissue and not on size criteria, as CT scanning does. It also provides a complete body survey, which is important in evaluating a multifocal disease process such as NHL. FDG-PET provides superior lesion contrast, allowing for easy detection, and the tomograms enable good anatomic localization. Whole-body FDG-PET followed by conventional imaging techniques of areas of abnormal radionuclide uptake is more cost-effective than are conventional staging methods. PET/CT has increasingly been used in staging NHL, although its availability remains limited. [4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19]

T1-weighted coronal MRIs of the thorax in a 55-yea T1-weighted coronal MRIs of the thorax in a 55-year-old woman with lower dorsal pain (same patient as in the previous image). Note the signal-intensity changes in the body of D12; these are associated with a right-sided, large, paravertebral soft-tissue mass involving the psoas muscle. Biopsy confirmed non-Hodgkin lymphoma (NHL).
This 28-year-old man was being evaluated for fever This 28-year-old man was being evaluated for fever of unknown origin. Gallium-67 study shows extensive uptake in the mediastinal lymph nodes due to non-Hodgkin lymphoma (NHL).
Nonenhanced CT scan through the mediastinum at the Nonenhanced CT scan through the mediastinum at the level of the carina shows enlarged tracheobronchial and subcarinal nodes. Note the small bilateral pleural effusion.
Posteroanterior (PA) chest radiograph in a 16-year Posteroanterior (PA) chest radiograph in a 16-year-old male adolescent with thoracic non-Hodgkin lymphoma (NHL) shows subtle enlargement of the lower paratracheal lymph nodes.
Posteroanterior (PA) chest radiograph in a man wit Posteroanterior (PA) chest radiograph in a man with thoracic non-Hodgkin lymphoma (NHL) shows mediastinal widening due to grossly enlarged right paratracheal and left paratracheal nodes.
A PA chest radiograph in a 28-year-old woman who p A PA chest radiograph in a 28-year-old woman who presented with weight loss, showing a cavitating lesion (mimicking tuberculosis) in the left midzone adjacent to the left hilum. Histology confirmed a large-cell NHL.

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