Castleman disease (CD), also known as angiofollicular lymph node hyperplasia or giant lymph node hyperplasia, is an uncommon benign B-cell lymphoproliferative condition. It can affect several regions of the body although commonly described as a solitary mediastinal mass.
There are two distinct subtypes of CD
- unicentric disease (UCD): more common, localised, associated with minimal symptoms, and locally treated
- multicentric disease (MCD): usually in the context of HIV infection, being a systemic disease characterised by diffuse lymphadenopathy, anemia, splenomegaly, and systemic inflammatory symptoms
UCD typically occurs in children and young adults (3rd and 4th decades), with a slight female predominance (1.4:1) 15.
MCD, on the other hand, occurs in an older population (5th and 6th decades), with a slight male predominance 15. HIV is a relevant risk factor for this condition, and it has been demonstrated that all the HIV patients with MCD are coinfected with the human herpesvirus 8 (HHV-8).
UCD is usually asymptomatic and incidentally found on routine exams for other reasons. Depending on the anatomical site, a painless lymphadenopathy may be noted.
MCD has an exuberant clinical presentation due the systemic inflammation, with symptoms such as fevers, night sweats, fatigue, and weight loss, and clinical signs of generalised lymphadenopathy, hepatosplenomegaly, and fluid retention.
Haematological abnormalities such as anemia, elevated inflammatory markers, hypergammaglobulinemia, and hypoalbuminemia are commonly found in patients with the MCD 15.
The disease is of unknown aetiology, but the most widely accepted theory is that Castleman disease is a chronic low-grade inflammatory process. The interleukin 6 in the UCD and both interleukin-6 and HHV-8 in the MCD were demonstrated to play a critical role in pathogenesis and symptomatology of the disease 15.
The disease is characterised by hypervascular lymphoid hyperplasia. There are also several recognised subtypes based on histopathology 1-2:
- most common ~90%, corresponding to most cases of the UCD
- increased numbers of small hyalinized blood vessels within and between the lymphoid follicles, which show obliteration of the medullary sinuses
- “onion-skinning” arrangement of the small lymphocytes of the mantle zones, forming concentric rings around the germinal center
- often multicentric
- hyperplastic follicles of varying sizes, which show patent medullary sinuses
- less enhancing
- may be more symptomatic 5
- HHV-8–associated Castleman disease 8
- multicentric Castleman disease not otherwise specified
CD is an exclusion diagnosis usually made by excisional biopsy of an affected lymph node. Alternatively, core needle biopsy can be performed when the excision is not possible 15.
The distribution is as follows:
- thorax: ~70%
- abdomen/pelvis and retroperitoneum: 10-15%
- neck: 10-15%
MCD may involve all of the above, and is associated with a more complex clinical course with systemic symptoms including fever and organomegaly.
- POEMS syndrome
- osteosclerotic myeloma
- Kaposi sarcoma
- AIDS: especially multicentric 9
- amyloidosis 10
- chordoid meningioma 16
Thoracic lesions may present as mediastinal masses.
Both hyaline-vascular and plasma cell types present as hypoechoic masses and nodules 17. The ultrasonographic findings are not specific and can be indistinguishable from lymphoma and other lymphadenopathy. Doppler examination of hyaline-vascular type may reveal exuberant vascularity with predominantly peripheral flow, prominent penetrating feeding vessels entering the hilum, and low-resistance arterial wave pattern 18.
For mediastinal lesions: CT chest
- commonly seen as a solitary mediastinal mass, infiltrative mass, multiple lymph nodes or rarely as matted lymphadenopathy (with or without a dominant mass) in a single mediastinal compartment
- typical arborising calcification may be seen within the mass in 15% of cases
- hyalin vascular type typically shows intense homogeneous enhancement following contrast
- dynamic CT demonstrates early rapid enhancement with washout in the delayed phase
- plasma cell type are multicentric and are less enhancing 8
For abdominal lesions: CT abdomen
- most commonly, a single well-defined abdominal mass
- location is variable, and includes retroperitoneum, mesentery and porta hepatis 3
- enhancement is homogeneous, or in larger lesions (> 5 cm) may demonstrate central hypoattenuation consistent with necrosis.
- variable pattern of calcification, including arborising calcification.
For multicentric disease: multi-region CT
- bilateral hilar and mediastinal lymphadenopathy
- centrilobular nodules
- diffuse abdominal lymphadenopathy
General signal characteristics include:
- T1: iso to hyperintense relative to skeletal muscle
- T1 C+ (Gd): shows enhancement
- T2: arborising calcification may be seen as low signal
- low values on ADC may be encountered 13-14
There is growing evidence that active Castleman disease is FDG avid, why 18F-FDG PET(/CT) is more sensitive than CT alone and may be an effective diagnostic tool, especially if performed with hybrid imaging part SOA contrast-enhanced CT 12. Discrimination between uni- and multicentric disease, mapping of the extent of disease and monitoring disease progression seems possible, especially if confirmed in larger series 7,12.
Treatment and prognosis
For unicentric Castleman disease treatment is surgical, with good prognosis (can be curative).
Multicentric Castleman disease may be treated with any combination of surgery, chemotherapy and prednisolone 6. Available treatments include also antiviral strategies (targeting HHV-8), and monoclonal antibody therapies targeting CD20 or IL-6 15. Prognosis is relatively poorer.
History and etymology
The condition was first published by Benjamin Castleman in 1954 4.
For thoracic lesions consider
- if anterosuperior, consider: differential for an anterosuperior mediastinal mass
- if posterior, consider: differential for a posterior mediastinal mass
- 1. Shin JH, Lee HK, Kim SY et-al. Castleman's disease in the retropharyngeal space: CT and MR imaging findings. AJNR Am J Neuroradiol. 2000;21 (7): 1337-9. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 2. Ko SF, Hsieh MJ, Ng SH et-al. Imaging spectrum of Castleman's disease. AJR Am J Roentgenol. 2004;182 (3): 769-75. AJR Am J Roentgenol (full text) - Pubmed citation
- 3. Meador TL, Mclarney JK. CT features of Castleman disease of the abdomen and pelvis. AJR Am J Roentgenol. 2000;175 (1): 115-8. AJR Am J Roentgenol (full text) - Pubmed citation
- 4. Castleman B, Towne VW. Case records of the Massachusetts General Hospital: case 40011. N Engl J Med 1954;250:26 -30
- 5. Keller AR, Hochholzer L, Castleman B. Hyaline-vascular and plasma-cell types of giant lymph node hyperplasia of the mediastinum and other locations. Cancer. 1972;29 (3): 670-83. - Pubmed citation
- 6. Herrada J, Cabanillas F, Rice L et-al. The clinical behavior of localized and multicentric Castleman disease. Ann. Intern. Med. 1998;128 (8): 657-62. doi:10.1059/0003-4819-128-8-199804150-00010 - Pubmed citation
- 7. Enomoto K, Nakamichi I, Hamada K et-al. Unicentric and multicentric Castleman's disease. Br J Radiol. 2007;80 (949): e24-6. doi:10.1259/bjr/93847196 - Pubmed citation
- 8. Bonekamp D, Horton KM, Hruban RH et-al. Castleman disease: the great mimic. Radiographics. 2011;31 (6): 1793-807. doi:10.1148/rg.316115502 - Pubmed citation
- 9. Barker R, Kazmi F, Bower M. Imaging in multicentric Castleman's disease. J HIV Ther. 2008;13 (3): 72-4. - Pubmed citation
- 10. Haaga JR, Boll D. CT and MRI of the whole body. Mosby. (2009) ISBN:0323053750. Read it at Google Books - Find it at Amazon
- 11. Cronin DM, Warnke RA. Castleman disease: an update on classification and the spectrum of associated lesions. Adv Anat Pathol. 2009;16 (4): 236-46. doi:10.1097/PAP.0b013e3181a9d4d3 - Pubmed citation
- 12. Lee ES, Paeng JC, Park CM et-al. Metabolic characteristics of Castleman disease on 18F-FDG PET in relation to clinical implication. Clin Nucl Med. 2013;38 (5): 339-42. doi:10.1097/RLU.0b013e3182816730 - Pubmed citation
- 13. Oida Y, Shimizu K, Mukai M et-al. FDG-PET and diffusion-weighted MR imaging appearance in retroperitoneal Castleman's disease: a case report. Clin Imaging. 2008;32 (2): 144-6. doi:10.1016/j.clinimag.2007.08.020 - Pubmed citation
- 14. Nakayama T, Yoshimitsu K, Irie H et-al. Usefulness of the calculated apparent diffusion coefficient value in the differential diagnosis of retroperitoneal masses. J Magn Reson Imaging. 2004;20 (4): 735-42. doi:10.1002/jmri.20149 - Pubmed citation
- 15. Soumerai JD, Sohani AR, Abramson JS. Diagnosis and management of Castleman disease. Cancer Control. 2015;21 (4): 266-78. Pubmed citation
- 16. Kepes JJ, Chen WY, Connors MH et-al. "Chordoid" meningeal tumors in young individuals with peritumoral lymphoplasmacellular infiltrates causing systemic manifestations of the Castleman syndrome. A report of seven cases. Cancer. 1988;62 (2): 391-406. Pubmed citation
- 17. Moon W, Kim W, Kim I et-al. Castleman disease in the child: CT and ultrasound findings. Pediatr Radiol. 1994;24 (3): 182-184. Read relevant article. Accessed on 23/04/2016
- 18. Mahmood N, Suresh HB, Swethadri GK et-al. Ultrasound and Doppler findings in a rare case of Castleman's disease of the parotid. Dentomaxillofac Radiol. 2010;39 (1): 54-6. doi:10.1259/dmfr/77931198 - Free text at pubmed - Pubmed citation