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CT of thoracic lymph nodes. Part II: diseases and pitfalls

¹ Department of Radiology, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, 270 Rama VI Road, Rajathevi, Bangkok 10400, Thailand, ² Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd., Campus Box 8131, Saint Louis, Missouri 63110, USA

View larger version (112K): [in this window] [in a new window]   Figure 1. Enhanced CT scan in a 37-year-old woman with lymphoma demonstrating enlarged pre-vascular (arrowheads) and left upper paratracheal (arrow) nodes, encasing the patent left carotid (C) and left subclavian (S) arteries. Lack of vessel invasion or constriction is a feature that may be helpful for distinguishing lymphoma from metastatic carcinoma. (From Glazer HS, Semenkovich JW, Gutierrez FR. Mediastinum. In: Lee JKT, Sagel SS, Stanley RJ, Heiken JP, editors. Computed body tomography with MRI correlation, 3rd edn. Philadelphia, PA: Lippincott-Raven Publishers, 1998:261–349 [13]. Reprinted with permission).

View larger version (68K): [in this window] [in a new window]   Figure 2. A 37-year-old woman with sarcoidosis. (a) Enhanced CT scan at level of aortic arch reveals enlarged para-aortic nodes (straight arrows) lying anterior and lateral to the aortic arch at the levels below the superior margin of the aortic arch (A); enlarged right lower paratracheal nodes (open arrows); and enlarged retrotracheal node (wavy arrow). Note mild contrast enhancement of these enlarged lymph nodes. V = left brachiocephalic vein, Oe = oesophagus. (b) Enhanced CT scan at the subcarinal level reveals enlarged bilateral interlobar nodes (open arrows) and subcarinal nodes (closed arrow). As with lymphoma, obstruction of mediastinal or hilar vessels or bronchi is rare, even with marked lymph node enlargement. A = ascending aorta, D = descending aorta.

View larger version (119K): [in this window] [in a new window]   Figure 3. Enhanced CT scan in a 58-year-old man with histoplasmosis revealing enlarged subaortic (arrow) and left lower paratracheal (arrowhead) nodes, secondary to left upper lobe histoplasmosis pneumonia (open arrows).

View larger version (121K): [in this window] [in a new window]   Figure 4. Enhanced CT scan with lung-window setting in a 48-year-old woman with haemoptysis showing calcified left hilar node (arrow) eroded into the left main bronchus, consistent with broncholithiasis. Multiple calcified subcarinal and left hilar nodes (arrowheads) are seen, characteristic of prior granulomatous infection.

View larger version (111K): [in this window] [in a new window]   Figure 5. Enhanced CT scan in a 43-year-old man with AIDS and Mycobacterium Avium-Complex infection revealing slightly low attenuation subcarinal (black arrowheads) and right hilar (white arrow) lymphadenopathy. There was no visible lung disease.

View larger version (87K): [in this window] [in a new window]   Figure 6. (a, b) Enhanced CT scans in a 64-year-old woman with hyaline-vascular type of Castleman's disease demonstrating (a) enhancing para-aortic (arrows), (b) subaortic (arrowhead), (a,b) right paratracheal (curved arrow), and (b) left hilar (open arrow) nodes, separated from subaortic nodes by the first branch of the left pulmonary artery (wavy arrow). The hyaline-vascular type is most common, and usually presents as an asymptomatic, solitary lymph node mass in the middle or posterior mediastinum or hilum. The less common plasma-cell type is usually associated with systemic symptoms and disseminated disease.

View larger version (69K): [in this window] [in a new window]   Figure 7. A 64-year-old man with idiopathic pulmonary fibrosis (a) Enhanced CT scan shows mild para-aortic (arrow), subaortic (arrowheads) and right hilar (open arrow) lymphadenopathy. (b) Lung-window setting at the corresponding level shows peripheral, subpleural reticular opacities, characteristic of idiopathic pulmonary fibrosis. (From Sagel SS, Slone RM. Lung. In Lee JKT, Sagel SS, Stanley RJ, Heiken JP, editors. Computed body tomography with MRI correlation, 3rd edn. Philadelphia, PA: Lippincott-Raven Publishers, 1998:351–454 [15]. Reprinted with permission).

View larger version (102K): [in this window] [in a new window]   Figure 8. Enhanced CT scan in a 38-year-old man with silicosis showing enlarged right and left lower paratracheal (arrows), subaortic (open arrows), and para-aortic (thin arrow) nodes with eggshell calcification. Note calcified bilateral intrapulmonary nodes (arrowheads). A = ascending aorta, D = descending aorta, V = superior vena cava.

View larger version (128K): [in this window] [in a new window]   Figure 9. Non-enhanced CT scan in a 41-year-old man with amyloidosis demonstrating calcified bilateral hilar, subcarinal, subaortic, and para-aortic nodes. Although an unusual cause of mediastinal lymphadenopathy, 75% of patients with thoracic amyloidosis have mediastinal lymph node enlargement, which may contain punctate calcification (as in this case), often associated with pulmonary parenchymal disease or pleural effusion. A = ascending aorta, D = descending aorta, S = superior vena cava (From Glazer HS, Molina PL, Siegel MJ, Sagel SS. High-attenuation mediastinal masses on unenhanced CT. AJR Am J Roentgenol 1991;156:45–50 [16]. Reprinted with permission).

View larger version (60K): [in this window] [in a new window]   Figure 10. Aberrant right subclavian artery in a 75 year-old woman with gastric cancer. (a) Non-enhanced CT scan at the level of the left brachiocephalic vein (V) shows a well-defined, soft tissue nodule (arrow) lying to the right of the oesophagus (*), mimicking an enlarged lymph node. Note relatively smaller brachiocephalic artery (a) than usual. T = trachea. (b) Non-enhanced CT scan at the lower level shows that the nodule is seen to represent an aberrant right subclavian artery (arrows) arising from the aortic arch (AA). It crosses the mediastinum from left to right behind the oesophagus (*) and trachea (T). S = superior vena cava.

View larger version (77K): [in this window] [in a new window]   Figure 11. Arterial phase CT scan(a) in a 50-year-old man with liver cirrhosis demonstrating soft tissue density (arrows, a and b) surrounding the oesophagus (Oe), seen to represent enhancing tubular structures during the portal venous phase (b), characteristic of oesophageal varices. A = descending aorta, V = inferior vena cava, L = liver, S = stomach.

View larger version (114K): [in this window] [in a new window]   Figure 12. Enhanced CT scan in a 54-year-old woman with sickle cell disease showing bilateral paravertebral soft tissue masses (arrows), consistent with extramedullary haematopoiesis. (From Slone RM, Gierada DS. Pleura, chest wall, and diaphragm. In Lee JKT, Sagel SS, Stanley RJ, Heiken JP, editors. Computed body tomography with MRI correlation (3rd edn). Philadelphia, USA: Lippincott-Raven Publishers, 1998:351–454 [17]. Reprinted with permission).

View larger version (52K): [in this window] [in a new window]   Figure 13. (a, b) Non-enhanced and enhanced CT scans in a 52-year-old woman showing normal superior pericardial recesses seen as small, non-enhanced near-water density structures (arrows) posterior to the ascending aorta (AA) and in the groove between the ascending aorta and pulmonary artery (P). The typical location and CT appearance allow pericardial recesses to be distinguished from mediastinal lymphadenopathy. Note a normal right lower paratracheal node containing a fat hilum (arrowhead). DA = descending aorta.

View larger version (130K): [in this window] [in a new window]   Figure 14. Enhanced CT scan in a 71-year-old man with aortic dissection showing slightly lobulated retrocrural structure of water attenuation (arrows), consistent with cisterna chyli.

View larger version (99K): [in this window] [in a new window]   Figure 15. (a–c) Enhanced CT scans in a 70-year-old man with intrathoracic goitre showing a large, inhomogeneously enhancing left paratracheal mass (arrowheads), displacing the trachea (T) to the right side. The mass is contiguous with the left lobe of the thyroid gland (th, c) on cephalad scan. Contiguity with the thyroid gland helps to distinguish intrathoracic goiter from lymphadenopathy.

View larger version (97K): [in this window] [in a new window]   Figure 16. Enhanced CT scan in a 54-year-old woman with ectopic parathyroid adenoma demonstrating an intensely enhancing soft tissue mass (arrow) in the aortopulmonary window region. A = ascending aorta, D = descending aorta, P = pulmonary artery.