Presentation
Past history of lymphoma.
Patient Data
Multiple bilateral pulmonary nodules, at least two demonstrating air bronchograms, but no clear cavitation. The larger demonstrate a subtle halo of ground glass. No consolidation. Pleural spaces clear. Bulky left axillary, mediastinal and hilar lymphadenopathy. No pericardial effusion.
Hepatosplenomegaly. At least two round low attenuation lesions are seen within the spleen, the largest in the inferior pole and bulging from the capsule. No liver lesions.
The pancreas, adrenal glands and kidneys are normal.
Retroperitoneal, mesenteric and pelvic lymphadenopathy.
No skeletal abnormality.
There are numerous FDG avid enlarged lymph nodes above and below the diaphragm, splenomegaly and numerous lung nodules consistent with high-grade lymphoma.
Above the diaphragm, metabolically active nodes are evident in Waldyers ring, bilateral cervical chain, left axillary and subpectoral, extensively throughout the mediastinum and right internal mammary stations.
Below the diaphragm, disease is present in the left crural, portahepatic, portacaval, celiac axis, mesenteric root, para-aortic, bilateral iliac chains and right inguinal nodes.
The spleen is enlarged and intensely metabolically active in keeping with splenic involvement.
The extensive extranodal disease is present throughout the lungs bilaterally.
Osseous deposits are present in the left sacrum, left iliac bone, L1 spinous process, and T2 and L3 vertebral bodies.
Patchy marrow uptake is noted but non-specific. It does not have the same metabolic signature as the nodal and solid organ disease possible reflecting separate marrow infiltrative process, likely AML in this case.
Normal uptake in the testes. Physiological uptake is present elsewhere.
The axillary nodes have been biopsied:
Microscopy: The core biopsies show a loose, relatively monotonous population of small lymphoid cells admixed with histiocytes with some intervening dense fibrous connective tissue. Immunoperoxidase shows the cells to be uniformly small T cells immunoreactive with CD 3 with very occasional CD20 immunoreactive cells. There is no CD10 immunoreactivity. Some of the T cells, show cytoplasmic BCL-2. The cells are also CD2 immunoreactive and predominantly CD4 and CD5, with scattered CD8 positive cells. There is no immunoreaction with BCL 6. There is no immunoreaction with EBV.
Conclusion: Lymph core - the morphology and immunophenotype, favors normal paracortical T lymphocytes rather than AILT given the CD10-, BCL6-, EBV - phenotype.
Case Discussion
The imaging findings are in keeping with stage 4 high-grade lymphoma with extensive supra and subdiaphragmatic nodal disease, splenic involvement and bilateral lung, and osseous disease.
The multiple bilateral solid pulmonary nodules have the main differentials made between lymphoma deposits or infection (e.g. invasive Aspergillus). Given the fact that the nodules were circumscribed and were not surrounded by a halo of ground-glass attenuation, lymphoma was favored 1. Further imaging follow-up after chemotherapy (not shown) has demonstrated shrinkage of all infra and supradiaphragmatic lesions evenly.