43 Hodgkin Lymphoma

Clinical Presentation

A 14-year-old presents with 2 weeks of intermittent fever and swollen neck nodes on the right.

Figure 43A

Radiologic Findings

Initial frontal (Fig. 43A1) and lateral (Fig. 43A2) chest radiographs demonstrate a large anterior mediastinal mass causing posterior tracheal compression and deviation. A moderate-sized left pleural effusion is present. Multiple axial CT postintravenous contrast enhancement scans (Figs. 43B1 to 43B4) demonstrate a large anterior mediastinal mass. This bulky, inhomogeneous, and nodular mass causes vascular deviation and significant superior vena cava (SVC) compression. Note that the left pleural effusion is located anterior, as the child was scanned in the prone position due to respiratory compromise when in the supine position. Images using lung windows (Fig. 43B5) demonstrate significant tracheal narrowing.

Figure 43B

Diagnosis

Hodgkin’s lymphoma

Differential Diagnosis

Mediastinal germ cell tumor
Thymic tumor
Leukemia, especially T cell
Other types of lymphoma
Langerhans’ cell histiocytosis

Figure 43C Axial slice at lung windows from a CT scan demonstrates a fine interstitial process of lymphatic dilatation, which could be secondary either to central lymphatic obstruction by the tumor or to interstitial spread of tumor into the lung through lymphatic channels. A nodule in the right middle lobe is in keeping with parenchymal involvement with lymphoma.

Discussion

Background

Lymphoma, the third most common malignancy in children behind leukemia (first) and CNS tumors (second), constitutes approximately one quarter of all pediatric mediastinal masses. The most common anterior mediastinal mass in children is the nodular sclerosing subtype of Hodgkin’s disease. Approximately 85% of children with Hodgkin’s disease have involvement of the intrathoracic lymph nodes, whereas 60% of children with non-Hodgkin’s have intrathoracic/mediastinal nodal involvement.