Mediastinal Hodgkin lymphoma
Introduction
Introduction to mediastinal Hodgkin's lymphoma The mediastinal Hodgkin's disease occurs in young adults, with superficial lymphadenopathy and histological features of typical Reed-Sternberg cells. basic knowledge The proportion of illness: 0.003% Susceptible people: no specific population Mode of infection: non-infectious complication:
Cause
The cause of mediastinal Hodgkin's lymphoma
The cause of Hodgkin's lymphoma is unknown, histologically unique, lacking dominant malignant cells with invasive features, and the morphological characteristics of tumors in structure and cell composition are based on the inherent properties of tumor cells and the reactivity of the body. It is this atypical asymmetry of histology that suggests that Hodgkin's lymphoma is a simple disease as a whole.
Hodgkin's disease is related to several factors:
1 Genetic abnormalities: Many studies have focused on histocompatibility antigens, and there are overexpression of human cell antigen components between sick siblings, and in many reports it has been found that the same family may be composed of 2 or more people. The members are sick and the onset time is very close. There is sufficient evidence to show that the genetics are related to Hodgkin's lymphoma. The incidence of the patients' siblings can be increased by 5 to 7 times. The patients may have chromosomal abnormalities.
2 virus infection: the current study is more infectious factors, because most patients with cervical lymphadenopathy as the first, followed by mediastinal lymph nodes; other parts of the lymph node enlargement is rare, consider Hodgkin's lymphoma and respiratory tract There is a certain relationship between infectious factors (viruses) invading the portal. Although the viral cause is an important research direction for lymphatic tumors, the virus is not the only cause of tumorigenesis, and the transformation mechanism of virus-infected cells in vivo is more than expected. important.
Prevention
Mediastinal Hodgkin's lymphoma prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Complications of mediastinal Hodgkin's lymphoma Complication
Generally no complications.
Symptom
Symptoms of mediastinal Hodgkin's lymphoma Common symptoms Cervical lymph nodes, atmospheric tube displacement, wheezing, night sweats, breathing difficulties
In general, the clinical manifestations of Hodgkin's lymphoma patients appear earlier, and may appear before the clinic a few months ago. The average age of the disease is 30 years old, but there are two peak ages of onset: the first is at 20 ~ 30 years old, equal for men and women; the second is around 50 years old, more men than women, children are rare, and mostly boys.
Symptom
Less than 10% of patients with primary mediastinal malignant lymphoma do not have any symptoms. There are no positive findings in routine physical examination and chest X-ray examination, 25% of patients have clinical symptoms, and 90% of patients with nodular sclerosis have mediastinal invasion. It can be accompanied by cervical lymphadenopathy, and the affected lymph nodes grow slowly. 50% of the patients have only mediastinal masses. Most of them are women, aged 20-35 years old. The patient has local symptoms and local symptoms. Symptoms such as chest pain (sternal, scapula, shoulders, sometimes unrelated to breathing), tightness, cough (usually innocent), difficulty breathing, hoarseness, caused by local compression, and sometimes some serious symptoms Vena cava syndrome, but very rare, mediastinal Hodgkin's disease such as invasion of the lungs, bronchus, pleura, pneumonia-like manifestations and pleural effusion, some patients also have some lymphoma-related systemic manifestations such as:
(1) Fever: It is one of the most common clinical manifestations, generally low fever, sometimes accompanied by hot flashes, body temperature up to 40 ° C, mostly in the night, and normal again in the morning, a few in the advanced period of the cycle heat, this The fever is generally uncommon and non-specific, accompanied by night sweats, which lasts for a night, to a lesser extent. The normal population also has general itching, mostly in cases of mediastinal or abdominal lesions.
(2) Ethanol pain: 17% to 20% of Hodgkin's disease patients have pain in the lesions 20 minutes after drinking. The symptoms may be earlier than other symptoms and X-ray findings, which have certain diagnostic significance when the lesions are relieved or disappear. After that, the pain of ethanol disappears, and it reappears when it recurs. The mechanism is unknown.
2. Signs
Common signs include sternal and chest wall deformation can be accompanied by venous dilatation (uncommon), can reach intracranial lymphadenopathy (uncommon), tracheal displacement, superior vena cava obstruction, wheezing, wheezing, atelectasis and consolidation, chest Signs of effusion and pericardial effusion, vocal cord paralysis, Horner syndrome and brachial plexus symptoms are not common, and should be examined for superficial lymph nodes.
Examine
Examination of mediastinal Hodgkin lymphoma
Often with mild or moderate anemia, 10% are small cell hypochromic anemia, most of the white blood cells are normal, a few mild or significant increase, with increased neutrophils, in addition to blood routine, red blood cell sedimentation rate is also the main indicator. Examination of serum immunoglobulin can assess the general condition.
X-ray inspection
Chest X-ray examination is an important routine examination. From the current data analysis, mediastinal lymphoma has no clear diagnostic radiological features, but more or less can assist diagnosis. The symmetry fusion of the mediastinum and hilar lymph nodes above Hodgkin's lymphoma is The wavy shape protrudes into the lung field, and the boundary between the lymph nodes is a typical change. The tracheal bifurcation and hilar lymph nodes are more than the paratracheal lymph nodes. Invasion of the anterior mediastinum and the retrosternal lymph nodes is another characteristic X-ray of Hodgkin's lymphoma. Performance (Figure 1). Hodgkin's lymphoma always has mediastinal and hilar lymph node lesions, and then there are intrapulmonary lesions. The characteristic features in the lungs are radiant radial cords, which may be related to the obstruction of lymphatic drainage to the hilar in the lungs. Chronic pleural effusion can occur in odd-gold lymphoma, but pleural effusion is rare as the only X-ray. If the tumor is huge, it will cause compression of surrounding organs and tissues, leading to superior vena cava obstruction, tracheal displacement, atelectasis, and invasion of the chest wall. The sternum and/or chest wall are simultaneously invaded. It may be caused by a direct invasion of the tumor or an invasion of the lymph nodes in the breast. For important radiological manifestations, the lymph node metastasis of the tumor may invade the intercostal lymph nodes and be in the spine. A lump is formed next to the chest wall lymph node metastasis or pericardial involvement, which may lead to paralysis of the pericardial lymph nodes, diaphragmatic lymph nodes and/or diaphragm muscles. Although the above performance is not specific for Hodgkin's lymphoma, it is very useful for diagnosis and treatment. Significant.
2. CT scan
Some scholars reviewed the CT specimens of Hodgkin's lymphoma with clear diagnosis. 70% of the patients had chest invasion. Generally, the irregular density of the edge of the tumor was uneven. Sometimes the tumor wrapped around the blood vessels and infiltrated into the periventricular septum. Centripetal manifestation, that is, from the lymph nodes of the anterior mediastinum or parasternal mediastinum to the peripheral lymph nodes, and then to the hilar region of the hilar region, the diaphragmatic group and the intramammary lymph nodes, rarely involving the posterior mediastinal lymph nodes, the lung metastasis is a follow-up performance and can invade the pleura Pericardium and chest wall, manifested as pleural effusion, pericardial effusion, chest wall invasion often anterior mediastinum and intra-abdominal lymph node lesions spread to the chest wall, no intrathoracic lymph node invasion and axillary lymph node invasion is rare.
3. Traumatic biopsy
(1) Percutaneous biopsy: Percutaneous biopsy is a diagnostic method with a long history. Puncture biopsy needles are divided into two categories:
1 aspiration needle: the needle is fine and flexible, with less damage to the tissue and less complications.
2 cutting needle: the needle is thicker, the tissue damage is large, and the complications are more. Generally speaking, the 22nd needle puncture should be advocated, and the 20-22nd needle is called the safety needle, which belongs to the cytological examination, and the 18th needle can be obtained. More tissue cells, but more complications, high risk, 18 needle needle biopsy is a histopathological examination, according to different parts can be performed by suction or cutting method, the suction is when the needle tip reaches the lesion area The needle core is taken out and connected with the 30ml empty needle tube. The upward needle lifting facilitates the pressure to form a vacuum state, and makes several quick back and forth punctures: the needle tip movement range cannot be >0.5 to 1 cm, which is fan-shaped, so that the cell tissue sucked by the puncture area enters. In the needle tube, the tissue cells in the needle tube are smeared, placed in a container of absolute ethanol, and immediately stained to see the smear, to determine whether it is actually pumped to the cell tissue, otherwise it is necessary to redo suction, and then tighten the syringe needle The plug is removed together with the puncture needle and the syringe. The cutting method generally consists of a cannula, a cutting needle and a needle core. Under the guidance of CT and B-ultrasound, the needle is inserted into a suitable position, and the cutting needle and the needle core are advanced forward by 0.5 to 1. Cm, pull out the needle core, pull back and rotate the cutting needle, cut out part of the tissue and then pull out the needle and the cannula together, and then perform CT or B-ultrasound detection in the same part after puncture to observe whether there is abnormal change, after puncture Close observation for 2 to 4 hours.
(2) mediastinoscopy: divided into neck mediastinoscopy, anterior mediastinoscopy, posterior mediastinoscopy, general application of neck and anterior mediastinoscopy two standard methods of exploration, neck mediasoscopy indications are Paratracheal mass and mediastinal lymph node biopsy, the latter is more used, the potential risk is damage to the large blood vessels and left recurrent laryngeal nerve injury, anterior mediastinoscopy is mainly used for primary pulmonary artery window lymph node or mass biopsy, the more common complications are Pneumothorax, the specific method can be found in the relevant chapter of this book.
(3) cervical lymph node resection: cervical lymph nodes, subgingival lymph node group, submandibular lymph node group and cervical lymph node group, etc., for the unexplained lymph node enlargement, or suspected lymph node area must be histopathological examination To confirm the diagnosis, the incision should be selected according to the lesion site. During the operation, attention should be paid to the nerves, blood vessels and other important tissues around the lymph nodes. During the operation, detailed blunt separation should be done to avoid injury. When the supraclavicular lymph nodes are removed, care should be taken not to damage the brachial plexus. Nerve and subclavian veins, but also to avoid damage to the thoracic duct and right lymphatic duct, so as not to form a chylothorax.
Diagnosis
Diagnosis and differentiation of mediastinal Hodgkin's lymphoma
Cervical lymph node biopsy and mediastinal lymph node biopsy can help diagnose, the latter through the CT guided puncture or mediastinoscopy, in addition to pay special attention to the patient's various complaints, the location and size of the enlarged lymph nodes, primary mediastinal lymphoma The general clinical symptoms are rare. When chest compression symptoms occur, the body and chest X-ray can be found abnormal. The common X-ray of malignant lymphoma is mediastinal and hilar lymph node enlargement.
Differential diagnosis
1. The thymoma malignant lymphoma accounts for almost half of the young patients, while the thymic tumors are generally over 40 years old. The thymoma less than 40 years old is very rare. The thymoma is located in the anterior superior mediastinum, and Hodgkin's lymphoma is also common in the former. The mediastinum, the site is not a specific diagnosis basis, mainly based on clinical manifestations, thymoma has local and systemic myasthenia gravis, red blood cell dysplasia and hypogammaglobulinemia and other clinical specific manifestations, thymoma rarely appears Swelling lymph nodes, and malignant lymphoma often have enlarged lymph nodes in different parts of the body surface. Most of the malignant lymphomas are enlarged lymph nodes in the anterior mediastinum and enlarged lymph nodes fused into a mass. CT-enhanced scans are mostly Inhomogeneous enhancement, including nodular-like enhancement zone, thymoma mostly showed a uniform density of mediastinal mass, some with low-density cystic and necrotic areas, enhanced scanning thymoma generally showed uniform enhancement, and reported malignant lymphoma The enhancement value is more than 30HU, and the thymoma is less than 30HU, the thymoma calcification rate is about 25%, and the majority of malignant lymphoma is calcified. It is after radiotherapy. The calcification of the primary tumor is very rare. The untreated intratumoral calcification is almost a thymoma. The thymoma grows directly to the adjacent tissue and invades the mediastinal space.
2. Giant lymph node hyperplasia in the chest is a rare, benign lesion of unknown origin, which is also called Castleman's disease, mediastinal lymph node-like disorder or vascular follicular lymph node hyperplasia. Lymphatic chain occurs in any part, but 70% is found in the mediastinum, followed by pulmonary vascular level in the hilar region. The age of onset is 50-70 years old. According to the histological manifestations of massive lymph node hyperplasia in the chest, it is divided into 3 types:
1 transparent blood vessel type;
2 plasma cell type;
3 mixed type, the disease was once considered to be ectopic thymic hyperplasia and thymoma. At present, this view is denied. The patients are mostly young adults aged 40 to 50 years. There is no gender difference in the incidence. The disease is not invasive and does not occur. In distant metastases, 90% of patients were asymptomatic. After routine physical examination and compression symptoms of intrathoracic organ structure, some patients were found to have systemic symptoms such as anemia, fatigue, joint pain, night sweats and low fever after chest X-ray findings. Symptoms disappear after surgical resection of the lesion. X-ray examination of massive lymph node hyperplasia in the chest can occur in any area of the mediastinum and in the hilar and lung parenchyma. The mass can be located on one or both sides of the midline of the chest, and the X-ray findings are non-specific. CT scan and aortic angiography have certain diagnostic value. Angiography can show the nourishing blood vessels and the site of the tumor. The nourishing arteries show clearer, but the drainage vein development is unclear. The treatment is mainly caused by surgical treatment. Satisfied, not easy to relapse after surgery.
3. Patients with central lung cancer are generally older and may have a long-term smoking history. There are no causes of cough, hemoptysis and blood stasis, accompanied by clinical symptoms such as chest pain, chest tightness and shortness of breath. Radiological imaging reveals that the hilar and mediastinum are occupied. Positional lesions, hilar masses are considered to be the most direct and most important imaging manifestations of central type of lung cancer. The hilar masses are nodular, with irregular edges and lobulated appearances. Atelectasis, some malignant lung cancer tumors can rapidly invade the bronchial wall with hilar lymph node metastasis, and often occupy a significant space before the affected bronchus is obviously narrow. The central lung cancer has a burr at the edge of the hilar mass, and the lesion is based on the bronchi. The heart is infiltrated into the surrounding area. The central type of lung cancer is often accompanied by the hilar, mediastinal lymphadenopathy, lymph node enlargement and cancer tissue fusion, surrounding the surrounding blood vessels, nerves and compression of surrounding organs, most patients undergoing exfoliated cells And bronchoscopy was confirmed.
4. Sarcoidosis Primary idiopathic sarcoidosis is relatively rare, generally not easy to diagnose, sarcoidosis is a non-caseal granulomatous disease, temperate regions are more common in the tropics, black morbidity is higher, Can be found at any age, but more common in 20 to 40 years old, the symptoms of sarcoidosis are mostly mild, or asymptomatic, often found in the chest X-ray enlargement of the chest, the lymph nodes of the hilar enlargement are mostly bilateral Symmetrical, multinodular adhesions can be lobulated, smooth and sharp at the edges, often accompanied by paratracheal, main-pulmonary window, swollen lymph nodes and lungs, increased lung texture, thick cords, reticular Small nodular mass: sarcoidosis and intrathoracic lymphadenopathy is characterized by generally no compression of the superior vena cava and other large blood vessels, lymph nodes can be calcified, eggshell-like, surgical resection is good.
