Lymphadenopathy, Hilum



Lymphadenopathy, Hilum


Toms Franquet, MD, PhD



DIFFERENTIAL DIAGNOSIS


Common



  • Bronchogenic Carcinoma


  • Lymphoma



    • Non-Hodgkin Lymphoma


    • Hodgkin Lymphoma


  • Metastasis


  • Primary Tuberculosis


  • Fungal Infection


  • Sarcoidosis


  • Chronic Heart Failure


Less Common



  • Viral Infection


  • Nontuberculous Mycobacteria


  • Berylliosis


  • Silicosis


  • Amyloidosis


  • Castleman Disease


Rare but Important



  • Drug-Induced Lymphadenopathy


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Increased hilar density: Most common radiographic manifestation of hilar mass


  • Lymphadenopathy: Common cause of unilateral or bilateral hilar enlargement



    • Considerable overlap in differential diagnosis


    • Unilateral hilar enlargement: Bronchogenic carcinoma, metastases, lymphoma, and infections


    • Bilateral hilar enlargement: Sarcoidosis (symmetric), metastases, lymphoma


  • Enlarged pulmonary artery may mimic hilar mass


  • CECT is recommended to evaluate hilar enlargement



    • Low-attenuation/minimal enhancement lymphadenopathy: Tuberculosis, nontuberculous mycobacteria, metastases (testicular tumors), and Hodgkin lymphoma


Helpful Clues for Common Diagnoses



  • Bronchogenic Carcinoma



    • Invasive, spiculated, large, aggressive appearance


    • Associated pulmonary emphysema common


    • Associated mediastinal or contralateral lymphadenopathy


    • Usually solid, noncavitating, no avid contrast enhancement


    • Calcification rare


  • Lymphoma



    • Non-Hodgkin Lymphoma



      • Bulky, bilaterally asymmetrical, mediastinal-hilar adenopathy


      • Slight to moderate uniform enhancement


    • Hodgkin Lymphoma



      • Homogeneous rounded or bulky soft tissue masses


      • May present with asymmetric hilar adenopathy and minimal mediastinal involvement


      • Nodes calcifying following radiation therapy (20%)


  • Metastasis



    • Bronchogenic cancer: Hilar involvement (30%)


    • Distal primary tumors: Hilar metastases without mediastinal involvement are exceptional



      • Head & neck tumors, genitourinary track, breast, and malignant melanoma


  • Primary Tuberculosis



    • Unilateral hilar or mediastinal adenopathy (unilateral in 80-90% of cases)


    • CECT: Lymph nodes show low-attenuation center and peripheral rim enhancement


  • Fungal Infection



    • Histoplasmosis



      • Right middle lobe syndrome (encased bronchus)


      • Postobstructive pneumonia: Encased bronchus or broncholith


      • CECT: Enlarged lymph nodes show central low attenuation from caseous necrosis


    • Coccidioidomycosis



      • Bronchopneumonic infiltrates with hilar node enlargement (20%)


      • Rarely, bilateral hilar adenopathy occurs without parenchymal involvement


    • Paracoccidioidomycosis (P. brasiliensis)



      • More common in Latin American countries



      • Frequent enlargement of hilar and mediastinal lymph nodes


      • Complications: Suppuration and fistula formation, scarring and pulmonary fibrosis


  • Sarcoidosis



    • Most common cause of bilateral symmetric hilar adenopathy


    • Radiograph shows 1, 2, 3, nodes (right paratracheal, right and left hilar), also called Garland triad


    • Must exclude lymphoma


    • Can rarely develop eggshell pattern of calcification


  • Chronic Heart Failure



    • Mediastinal lymphadenopathy does not necessarily indicate malignancy or infectious process


    • Usually mild symmetric enlargement only


Helpful Clues for Less Common Diagnoses



  • Viral Infection



    • Epstein-Barr virus



      • Splenomegaly in 50% of cases


      • Generalized lymphadenopathy (hilar and mediastinal involvement included)


    • Rubeola (measles)



      • Pulmonary infiltrates (55%) and hilar lymphadenopathy (74%) early in course


  • Nontuberculous Mycobacteria



    • Extensive hilar (unilateral or bilateral) and paratracheal lymphadenopathy


    • ± parenchymal disease


    • Nodes undergo extensive necrosis


  • Berylliosis



    • Sarcoid pattern in patient with exposure to beryllium


    • Hilar or mediastinal adenopathy (40%), always associated with lung disease


    • Nodes: Diffuse or eggshell calcification


  • Silicosis



    • Silicosis and coal worker’s pneumoconiosis (CWP) similar, lung disease usually less severe in CWP


    • Hilar and mediastinal lymphadenopathy common


    • Eggshell calcification (5%)


  • Amyloidosis



    • Isolated finding or associated with interstitial involvement


    • May be massive


    • Adenopathy: Stippled, diffuse, or eggshell calcifications


  • Castleman Disease

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Aug 8, 2016 | Posted by in CARDIOLOGY | Comments Off on Lymphadenopathy, Hilum

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