Hodgkin lymphoma is the most common tumoral cause of mediastinal mass and typically presents as large, lobulated, confluent lymphadenopathy in the anterior (prevascular) mediastinum. Mediastinal involvement is found in 60-70% of all Hodgkin lymphoma cases, with nodular sclerosis being the most common subtype. It shows a bimodal distribution between ages 15-35 and over 50; there is slight male predominance. B symptoms (fever, night sweats, weight loss) are present in 30-40% of cases. CT is the primary imaging modality and PET-CT is the gold standard for staging and treatment response assessment. Reed-Sternberg cells are diagnostically important.
Age Range
15-35
Peak Age
25
Gender
Male predominant
Prevalence
Uncommon
Hodgkin lymphoma is characterized by neoplastic proliferation of Reed-Sternberg (RS) cells of B-lymphocyte origin. RS cells are found within a mixed inflammatory background of reactive lymphocytes, eosinophils, histiocytes, and plasma cells. In the nodular sclerosis subtype, collagen bands (sclerosis) divide the tumor into nodules — this fibrosis contributes to heterogeneous appearance on imaging. The tumor typically spreads along contiguous lymph node stations — this feature differentiates it from non-Hodgkin lymphoma which shows skip metastases. The frequency of mediastinal involvement reflects the lymphoid tissue richness of thymus and mediastinal lymph nodes. High FDG uptake on PET-CT reflects increased glycolysis of RS cells and surrounding inflammatory cells. Post-treatment residual mass is common and consists of fibrosis — PET-CT is critical in differentiating from active disease.
FDG-avid bulky (>10 cm) lymphadenopathy in the anterior mediastinum + B symptoms (fever, night sweats, weight loss) in a young patient aged 15-35 is the classic presentation of Hodgkin lymphoma and strongly supports the diagnosis.
Large (usually >5 cm, bulky >10 cm), lobulated, confluent lymphadenopathy mass in the anterior mediastinum. Shows homogeneous or mildly heterogeneous soft tissue density. Encases great vessels (SVC, aorta) but usually does not invade the lumen ('vascular encasement without invasion'). Pericardial and pleural extension may occur. Enhancement is typically homogeneous and moderate.
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A bulky lymphadenopathy mass with lobulated contours and homogeneous soft tissue density encasing great vessels is seen in the anterior mediastinum, suggesting Hodgkin lymphoma.
Lymph node involvement in Hodgkin lymphoma progresses along contiguous stations: cervical → supraclavicular → mediastinal → para-aortic. Skip metastases are rare. Bilateral hilar lymphadenopathy may occur but unilateral or asymmetric is more common. Involvement typically begins above the diaphragm (80% of cases).
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Lymphadenopathy distribution along contiguous stations is observed, with the contiguous spread pattern consistent with Hodgkin lymphoma.
Hodgkin lymphoma is one of the most FDG-avid tumors on PET-CT (SUVmax typically >10, often 15-25). All involved lymph nodes and extranodal sites show intense FDG uptake. PET-CT is the gold standard for Ann Arbor staging, treatment response assessment (Deauville criteria — Lugano classification), and recurrence detection. Interim PET-CT (after 2 cycles) is critical for prognostic determination.
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The anterior mediastinal mass and accompanying lymphadenopathy show markedly high FDG uptake on PET-CT (SUVmax: ...), consistent with Hodgkin lymphoma.
Active lymphomatous tissue shows hyperintense signal on T2-weighted images. In nodular sclerosis subtype, fibrous bands are seen as low-signal lines revealing the septated architecture. Post-treatment fibrosis shows low signal on T2 — this finding is important in differentiation from active disease. Necrotic areas appear markedly hyperintense.
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The mass shows hyperintense signal on T2-weighted sequences with low-signal fibrous bands creating a septated architecture, consistent with nodular sclerosis Hodgkin lymphoma.
Shows marked diffusion restriction on DWI — ADC values are low due to high cellular density. DWI is used in whole-body MRI staging (as an alternative to PET-CT to reduce radiation burden in children and young adults). ADC values may correlate with treatment response — post-treatment ADC increase indicates response.
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The mass shows marked diffusion restriction with low ADC values on DWI; the high cellularity finding is consistent with lymphoma.
Post-treatment residual fibrotic mass is common on CT (60-80% of cases). Mass size reduction without complete resolution is seen. Residual mass density is generally non-solid with heterogeneous texture. PET-negative residual mass (Deauville score 1-3) indicates absence of active disease and does not require additional treatment. PET-positive residual mass (Deauville score 4-5) indicates relapse or refractory disease.
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A residual mass in the anterior mediastinum showing significant size reduction compared to pre-treatment is seen; PET-CT for active disease assessment is recommended.
Criteria
Most common subtype (70%). Collagen bands divide tumor into nodules. Lacunar RS cells. Mediastinal involvement very common.
Distinct Features
Fibrous bands seen as septation on CT, bulky mass in anterior mediastinum, common in young women
Criteria
Second most common subtype (20-25%). Mixed inflammatory cells and classic RS cells. EBV association frequent (70%). More common in males and HIV-positive patients.
Distinct Features
Peripheral LAP more common, mediastinal involvement less bulky, B symptoms frequent
Criteria
Rare subtype (5%). 'Popcorn' cells (LP cells). CD20 positive, CD30 negative. Common in young males, good prognosis.
Distinct Features
Mediastinal involvement rare, peripheral LAP dominant, slow course, relapse common but prognosis good
Distinguishing Feature
Non-Hodgkin lymphoma may show skip metastases (non-contiguous), extranodal involvement is more frequent. Hodgkin lymphoma shows contiguous spread. Histopathology and immunophenotyping are definitive.
Distinguishing Feature
Thymoma is well-defined, presents as a single mass without lymphadenopathy. Hodgkin lymphoma appears as confluent lymphadenopathy and has no myasthenia gravis association.
Distinguishing Feature
Seminoma occurs in young males, presenting as a large homogeneously enhancing mass. β-hCG may be mildly elevated. Lymphoma shows B symptoms and widespread lymphadenopathy.
Distinguishing Feature
Thymic carcinoma presents as irregularly marginated, invasive, necrotic solid mass. Lymphoma shows more homogeneous, lobulated, encasing pattern. Biopsy is definitive.
Urgency
urgentManagement
medicalBiopsy
NeededFollow-up
3-monthHodgkin lymphoma is treated with ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) chemotherapy plus radiotherapy. Early stage (I-II) has >90% cure rate. Advanced stage (III-IV) is treated with BEACOPP or escalated BEACOPP. Interim PET-CT (after 2 cycles) is critical for treatment response and prognosis (Deauville score). Salvage chemotherapy plus autologous stem cell transplant is the standard approach for relapse.
Hodgkin lymphoma is highly responsive to chemotherapy and radiotherapy. Cure rates exceed 90% in early stages. PET-CT plays a critical role in treatment response assessment. The Deauville score determines treatment efficacy.