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Weekly Chest CasesArchive of Old Cases

Case No : 622 Date 2009-09-27

  • Courtesy of Dong Won Kim, Ki-Nam Lee / Dong-A University Hospital, Busan, Korea
  • Age/Sex 70 / M
  • Chief ComplaintCoughing for 1 month, palpable neck mass, weight loss
  • Figure 1
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Diagnosis With Brief Discussion

Diagnosis
Angioimmunoblastic T-cell lymphoma
Radiologic Findings
Chest radiograph shows multiple nodules in both middle lung zones, right hilar enlargement, and hyperlucency and reticulation in both lungs.
CT scan demonstrates multiple lymph node enlargements with central low attenuation and peripheral well enhancement in paratracheal, subcarinal, hilar space. Well defined nodules and small area of consolidation are visible in RLL, LUL and LLL.

PET shows multiple hypermetabolic nodes in the left neck, mediastinum and inguinal region.

Brief Review
Angioimmunoblastic T-cell lymphoma is clinically characterized by a high fever, generalized lymphadenopathy, a skin rash, and hepatosplenomegaly. This is a relatively rare disorder but one that is clinically distinctive. It accounts for less than 1% of all non-Hodgkin lymphomas in Asia and Europe. Although this disorder has been regarded as an abnormal immune reaction (angioimmunoblastic lymphadenopathy with dysproteinemia or immunoblastic lymphadenopathy), it is now accepted as a subtype of PTCL. Because patients most commonly present with disseminated conditions, the imaging features are not distinguished from those in other lymphoma.
Primary pulmonary lymphoma cannot be distinguished from secondary pulmonary lymphoma solely on the basis of pathologic examination of pulmonary tissue only, because a variety of gross patterns of disease (solitary or multiple nodules, solitary infiltrate, or multiple infiltrates with or without hilar or mediastinal adenopathy) may be seen in either setting.
On chest radiographs, recurrent or secondary pulmonary lymphoma may present with various patterns: bronchovascuhar or lymphangitic with thickening of bronchovascular bundles and interlobular septae (41%), discrete pulmonary nodular (39%), pneumonic or alveolar with areas of consolidation (14%), and miliary or hematogenous with disseminated micronodules (6%). Lymphomatous infiltration of the alveoli can result in granuhomatous consolidation that may mimic the appearance of pneumonia or miliaiy tuberculosis. Lymphadenopathy and pleural effusions are also commonly present. Prevascular or pretracheal node involvement is seen most often. Other sites of lymph node involvement include the subcarinal, hilar,paraaortic, paravertebral, retrocrural nodes. Enlarged lymph nodes or mediastinal masses may appear low in attenuation due to necrosis.Other manifestations include cavitated masses and endobronchial masses.
Diagnosis is difficult because infection, granulomatous disease, primary or secondary carcinomas, or drug reactions may cause similar abnormal radiologic findings. Careful correlation of clinical, microbiologic, and histologic findings is necessary.
References
1. Lee HJ, Im J-G, Goo JM, et al. Peripheral T-Cell Lymphoma: Spectrum of Imaging Findings with Clinical and Pathologic Features RadioGraphics 2003; 23:7?8
2. Lee KS, Kim YK, Primack SL. Imaging of Pulmonary Lymphomas . AJR 1997;168:339-345.
3. Au V. Leung AN. Radiologic manifestation of lymphoma in thorax. AJR 1997;168:93-98.
Keywords
Mediastinum, Lung, Lymphproliferative disorder, Lymphoma,

No. of Applicants : 76

▶ Correct Answer : 23/76,  30.3%
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - CH Sud Rnion , Reunion jean-baptiste Noel
  • - SMG-SNUH boramae medical center , Korea (South) Kwang Nam Jin
  • - Toyama University Hospital, Laboratory of Pathology , Japan TANAKA TOMONORI
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OKUBO
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - MD SKNMC & GH,Pune,Maharashtra, INDIA , India Sushant Bhadane
  • - Samsung Medical Center , Korea (South) Eun Kim
  • - , Korea (South) Gil Sun Hong
  • - Assam Medical college , India samudra borah
  • - Seoul National University Hospital , Korea (South) Hye Jin Yoo
  • - kims,narkatpally , India k bhaskar
  • - Seoul Nationial University Bundang Hospital , Korea (South) Kyoung Jin Oh
  • - chp st martin , France Mariotte benoit
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - IRSA , France jean-luc BIGOT
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - CHU Grenoble , France Fabrice Bing
  • - Soonchunhyang University Cheonan Hospital , Korea (South) Park Sang Hyun
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - PITTWATER RADIOLOGY , Australia Saurabh Khandelwal
  • - PITTWATER RADIOLOGY , Australia Julie Arora
  • - Seoul Nationial University Bundang Hospital , Korea (South) Hee Seok Choi
▶ Correct Answer as Differential Diagnosis : 33/76,  43.4%
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun JunYeh
  • - Aba Prefecture People Hospital竊ŒSichuan Maerkang竊Œchina , China pu peng
  • - HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
  • - CHRU Lille , France Benjamin Damarey
  • - McGill University Health Centre , Canada Amr Ajlan
  • - severance hospital , Korea (South) lee kyung jong
  • - POPOVO HOSPITAL , Bulgaria VLADISLAV RUSINOV
  • - Paramount Diagnostic & Research Centre , India Mahavir Swami
  • - hospital Sao Paulo , Brazil israel missrie
  • - Trakya University School of Medicine, Turkey , Turkey Ahmet POLAT
  • - SMC , Korea (South) Jihoon Cha
  • - Uzunkopru Devlet Hastanesi , Turkey Armagan Sarac
  • - Assam medical college , India Karunakaran M
  • - Trakya University School of Medicine , Turkey Umut Ugur
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - Kashan University of Medical Sciences, kashan , Iran Ebrahim Razi
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - clinique de rochefort , France viviane pages
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - EKH-Berlin , Germany Michael Weber
  • - NOUR EL-ISLAM RADIOLOGY CENTER , Egypt ELSAYED MOUSA
  • - All India Institute of medical sciences , India Justin Moses
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Hopital du SacrCoeur , Canada Abraham Bohadana
  • - KMC,Manipal , India satish maddukuri
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - NASA SCANS , India RAKESH BHATIA
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - CHU caen , France nicolas gautier
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