대한흉부영상의학회 Weekly Chest Cases

Case No : 1403 Date 2024-09-09

Courtesy of Bo Da Nam, Jung Hwa Hwang / Soonchunhyang University Seoul Hospital
Age/Sex 66 / F
Chief ComplaintAbnormal chest radiography

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Diagnosis With Brief Discussion

Diagnosis: Posterior mediastinal lymphoma�� (biopsy proven low-grade B cell lymphoma)
Radiologic Findings: Fig 1. Chest PA reveals a bulging opacity in the right paratracheal stripe.
Fig 2. Axial and coronal non-enhanced chest CT images with mediastinal window settings show an ovoid or lentiform shape soft tissue mass at the right paravertebral area of T2-4 levels, with no evidence of adjacent bony erosion.
Fig 3. PET-CT image displays a hypermetabolic lesion (SUVmax = 4.7), corresponding to the abnormal soft tissue lesion seen on CT.
Fig 4. Sagittal and axial T2WI, and enhanced T1WI images demonstrate a flat-shaped lobulating contoured space-occupying lesion measuring approximately 7x4x1cm in the right paravertebral area of T2-4 levels. The lesion shows T1 iso and T2 high SI with heterogenous enhancement. There is no definite evidence of combined destructive changes in the adjacent bony structures of T-spine and right-side rib cages. Additionally, there is no evidence of neural foraminal widening.
Brief Review: The posterior mediastinum, encompassing the spine and paravertebral soft tissue, hosts a variety of neoplastic entities, with neurogenic tumors standing out as the most prevalent. This category includes neurofibromas and schwannomas, frequently encountered within the paravertebral region. Beyond neurogenic tumors, the posterior mediastinum can also be home to lymphomas, primary osseous tumors, and metastases.

Moving to the realm of primary mediastinal lymphomas, they predominantly manifest in the anterior and middle mediastinum. Among them, Diffuse Large B-cell Lymphoma (DLBCL) emerges as the most frequent histological type. Primary mediastinal lymphomas pose a unique challenge due to their location, often requiring a comprehensive diagnostic approach.

Exploring the radiologic features specific to paravertebral lymphomas, these tumors exhibit distinctive characteristics that differentiate them from neurogenic tumors. Notably, on coronal images, paravertebral lymphomas present as spindle-shaped masses along the vertebral column, a feature uncommon in neurogenic tumors. Additionally, they may manifest as a draping paraspinal soft-tissue mass, demonstrating extensive involvement of a vertebral body but with limited cortical bone destruction or height loss. The CT attenuation and MR signal intensity of these lymphomas can vary, providing a spectrum of imaging appearances.

Noteworthy nuances in radiologic features emerge when considering specific types of lymphomas. For instance, Hodgkin's lymphoma, especially of the nodular sclerosing type, tends to exhibit large amounts of fibrous tissue. On the other hand, diffuse infiltrating malignant lymphomas often display almost the entire malignant cell population with scant connective tissue, creating a distinct imaging profile. This nuanced understanding of radiologic features aids in the accurate identification and differentiation of paravertebral lymphomas from other entities within the posterior mediastinum, contributing to enhanced diagnostic precision and patient management.
References: RadioGraphics 2017; 37:413
Keywords

No. of Applicants : 59

▶ Correct Answer : 17/59, 28.8%

- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
- Other , Korea (South) SEONGSU KANG
- Seoul Medical Center , Korea (South) HYUK GI HONG
- University of Yamanashi , Japan TAKAAKI HASHIMOTO
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- , Japan YOSHIKI ISHII
- Nankai medical center , Japan NORITAKA KAMEI
- , Japan KENTARO KOTANI
- Other , Korea (South) CHAEHUN LIM
- Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
- GHICL , France MANUEL TOLEDANO
- TB centre kasaragod. , India rikhy krishnan
- Paras hospital, Panchkula , India SHALEEN RANA
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 24/59, 40.7%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- , Japan SUZUNE TSUKAMOTO
- ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
- , India ABHISHEK SONI
- Kyoto University , Japan AKIHIKO SAKATA
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- IRSA LA ROCHELLE , France JEAN LUC BIGOT
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Osaka University , Japan AKINORI HATA
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Shiga General Hospital , Japan YUSAKU MORIBATA
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- Mie university , Japan SHIKO OKABE
- Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
- Kyoto University , Japan SHO KOYASU
- Hyogo Prefectural Kobe Children , Japan SHUHEI NORIMOTO
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Kantou Rousai Hospital , Japan KAORU SUMIDA
- Toyota Kosei Hospital , Japan YUKI HAYASHI
- The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
- University of Yamanashi , Japan KOJIRO ONOHARA
- Juntendo University , Japan YUTAKA IKENOUCHI

▶ Semi-Correct Answer : 1/59, 1.7%

- The University of Tokyo Hospital , Japan JUN KANZAWA

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1403 Date 2024-09-09

Discussion

No. of Applicants : 59