Lymphoma, Hodgkin (Spine)

Diagnosis Definition

• Hodgkin lymphoma/disease (HD) comprises 25% of all lymphomas; age of onset is bimodal, peaking first at 20 years and then at 55 years or older
• 5 – 32% of living patients with HD are diagnosed with bone marrow involvement (50% at autopsy); multiple osseous lesions (66%) are more common than single lesions
• The dorsolumbar spine is the commonest site of skeletal HD
• Patients usually present with pain localized to the site of involvement, or pathologic fracture

Imaging Findings

• On radiographs and CT scanning, osteolytic lesions are commonest but lesions may be mixed or sclerotic; lytic lesions may appear sclerotic after treatment
• Bone scintigraphy is abnormal in 98% of patients with skeletal HD
• MRI is highly sensitive for showing marrow replacement, seen as low intensity on T1-weighted sequences and high intensity on T2; low intensity on T2 indicates fibrosis; STIR sequences show enhancement
• An ivory vertebra represents diffuse sclerosis of a vertebral body; vertebra plana, a flattened vertebral body, is a less common finding but both may occur and are not limited to lymphoma

KEY IMAGES

Pearls

• Abnormalities can be seen on bone scintigraphy or MRI before radiographic changes are evident
• CT best shows cortical and trabecular destruction, periosteal reaction, and sequestra
• Differential considerations of an ivory vertebra in an adult include osteosarcoma, osteoblastic metastasis, myeloma, and Paget disease
• MRI can show findings of HD and guide biopsy when sampling error results in a negative bone marrow biopsy

References

1. O’Neill J, Finlay K, Friedman L. Radiological manifestations of skeletal lymphoma. Curr Probl Diagn Radiol 2009; 38:228–236
2. Hwang S. Imaging of lymphoma of the musculoskeletal system. Radiol Clin North Am 2008; 46:379–396
3. Graham TS. The ivory vertebra sign. Radiology 2005; 235:614–615