Case 18 - T Cell Lymphoma, lymphadenopathy
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Let's look at this patient.
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And there was bilateral
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neck mass thought to be represent lymph nodes.
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So we start from above in the brain.
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We look over the brain,
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parenchyma, look over the blood vessels.
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They look fine. Looking at the orbits,
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no abnormalities.
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We come into the parotid glands
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and no apparent abnormality
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in the parotid glands. We come to the nasopharynx.
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As I look through the aerodigestive system,
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usually I'm thinking in terms of the anatomy
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of the aerodigestive system.
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So I look at the nasopharynx,
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I look at the oropharynx, I look at the oral cavity,
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I look at the supraglottic larynx, the hypopharynx,
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the glottic larynx, the subglotic larynx,
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the thyroid gland,
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the esophagus, and the trachea.
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So those are the aerodigestive system
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sections of the anatomy, and
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they all look pretty good.
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The reason why this is important is because the
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next thing to look at are the spaces of the neck.
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And we immediately see that we have markedly
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enlarged lymph nodes bilaterally
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in the jugular chains.
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One of these lymph nodes that's necrotic appears
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to be in the level five chain behind
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the sternocleidomastoid muscle.
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And you see that also on the left side
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with a necrotic lymph node.
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Now,
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this is a bilateral process with
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enlarged lymph nodes.
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We do not see an aerodigestive system
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primary tumor. So again,
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we are going to be worried about inflammatory
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conditions such as tuberculosis or Kawasaki
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disease or Kimura's disease, or some of the
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more bizarre other lymph node lesions, including
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sinus histiocytosis with massive lymphadenopathy,
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Rosai-Dorfman syndrome, et cetera.
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In this case, we're going to continue
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on and look into the mediastinum.
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We want to see whether there's any
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lymphadenopathy in the mediastinum or in the hilar
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region that would suggest a possibility
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of something like sarcoidosis.
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Don't see that in this particular case.
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So here, when we have these big massive lymph nodes
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and they have areas with or without necrosis,
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we also want to consider the diagnosis of lymphoma.
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Lymphoma can lead to bilateral lymphadenopathy
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maybe in the supraclavicular region.
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But in this case, the final diagnosis
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was a T-cell lymphoma.
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I want to just make a quick comment about one
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other finding on this case and that is the presence
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of edema in the retropharyngeal space.
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Remember that the retropharyngeal
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is anterior to the longus colli,
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longus capitis muscle complex
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but posterior to the pharynx.
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So we see edema in this individual,
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not a collection
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but just low-density edema in the retropharyngeal
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space extending to the glottic level.
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This may be on the basis of some element of
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lymphoid obstruction secondary
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to the patient's lymphoma.
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We'll talk about the retropharyngeal space
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shortly and how to distinguish retropharyngeal
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edema from retropharyngeal phlegmon, from
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retropharyngeal abscess from retropharyngeal
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necrotizing lymphadenitis.
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In this case,
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necrotic lymph nodes, which we would normally ascribe
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to an infection being caused by T-cell lymphoma.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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