PMC2815821_01
Serial follow up images of chest CT scans. A. Enlargement of multiple lymph nodes at the paratracheal and aortopulmonary window was noted at the time of initial diagnosis. B. The enlarged lymph nodes, noted on the initial CT scan, were found to be markedly improved on the 21st day of hospitalization. C. A CT scan performed nine months after initial diagnosis showed no abnormalities. D. No abnormalities in the lung parenchyma were found at the time of diagnosis. E. A CT scan performed at 21th day of hospitalization showed ground glass opacities in the peripheral areas of both lung parenchyma. F. Although minimal honey combing and reticular patterns remained, the ground glass opacities, noted at D, were not found with CT nine months after initial diagnosis.
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F1
The largest lymph node was measured at 3.5x2 cm in the right cardiophrenic area (Fig. 1A). The lungs were clear, without evidence of abnormal nodules (Fig. 1D). On the 21st hospital day, a chest CT scan, performed to evaluate the abnormal chest radiographic findings, showed ground glass opacities on the periphery of both lungs with smooth bronchovascular bundle thickening and interlobular septal thickening; however, the enlarged lymph nodes in mediastinum and right supraclavicular fossa were markedly improved (Fig. 1B, 1E). Interestingly, follow-up CT scans of the neck, chest and abdomen-pelvis showed no definite evidence of lymphadenopathy in the neck, intrathoracic mediastinum, markedly decreased lymphadenopathy in the paraaortic area and the left iliac chain, as well as improved hepatosplenomegaly with resolution of the previous low attenuating nodules (Fig. 1C).
Serial follow up images of 18FDG-PET scans. A. The initial 18FDG-PET scan showed massive areas of hot uptake in the mediastinum, intra-abdominal lymph nodes, spleen, possibly liver, near the entire vertebrae, bilateral shoulder, rib, and left femur. B. A follow-up 18FDG-PET scan, performed 3 months after the initial chemotherapy, showed markedly decreased hot uptakes in the liver, spleen, vertebral bodies and iliac lymph nodes. C. Nine months after initial chemotherapy, there was no definite abnormal uptake noted on the 18FDG-PET scan.
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F2
Whole body 18-fluorodeoxyglucose positron emission tomography (18FDG-PET) showed massive areas of hot uptake in the mediastinum, intra-abdominal lymph nodes, liver, and spleen; it showed multiple areas of hot uptake near the entire vertebra, bilateral shoulder, rib, left femur, and pelvic bones, as well as an abnormal lesion on the lungs (Fig. 2A). On 18FDG-PET images there was no evidence of lymphomatous involvement of the liver, spleen, iliac, inguinal area or spine, except for a residual lesion in the upper abdominal lymph node chain along the inferior vena cava and aorta (Fig. 2B). Nine months following the initial chemotherapy, whole body CT (neck, chest, abdomen and pelvis) scans, 18FDG-PET, and a whole body bone scan, performed for restaging, did not show any definite evidence of lymphomatous lesions, and thus were compatible with complete remission status (Fig. 2C).
Pathologic features. A. Left iliac lymph node biopsy. Microscopic examination of the specimen showed mixed cellularity type Hodgkin's disease with high contents of epitheloid histiocytes and a few Reed-Sternberg cells. (H-E stain, x400). B. Liver biopsy. Reed-Sternberg cells with background reactive cells infiltrated and replaced the liver parenchyma (H-E stain, x40).
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F3
A laparoscopic biopsy of the left iliac lymph node and liver, performed on the 7th hospital day, showed mixed celluarity with high contents of epitheloid histiocytes and a few Reed-Sternberg giant cells, compatible with Hodgkin's disease (Fig. 3).