This document contains 44 figures showing images from CT scans, MRI scans, ultrasound exams, radiographs and lymphograms depicting the lymph nodes and lymphatic system in patients. The images show normal lymph node anatomy as well as enlarged or involved lymph nodes in patients with conditions such as Hodgkin's lymphoma, non-Hodgkin lymphoma, testicular cancer and other malignancies. They demonstrate how different imaging modalities can be used to evaluate the lymph nodes and stage diseases affecting the lymphatic system.

1. 17
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 17.1 CT section through the upper abdomen
of a young male patient shows the cisterna chyli
as a small (0.5 cm) low-attenuation structure
lying between the aorta and IVC (arrow). The
cisterna chyli may be seen on CT examination in
almost all patients providing there is sufficient
retroperitoneal fat. A smaller lymphatic duct may
be seen behind the IVC (arrowhead).

4. • Fig. 17.2 Early phase lymphogram film with
contrast medium outlining the thoracic duct.

5. • Fig. 17.3 Early phase lymphogram film with
opacification of both lymph nodes and lymph vessels.
There are several afferent lymphatics feeding into each
lymph node. The single efferent lymphatic always
leaves the lymph node through the hilum.

6. • Fig. 17.4 Axial T1 -weighted MRI examination of
the neck. Bilateral retropharyngeal nodes may
be identified (arrows). On T 1 -weighted
sequences, lymph nodes appear darker than the
surrounding fat. Note the flow void
phenomenon-the great vessels of the neck
appear black.

7. • Fig. 17.5 T1 -weighted sagittal MRI scan'
demonstrating a malignant lymph node in the
deep cervical chain invading the jugular vein
(as shown by flow void).

8. • Fig. 17.6 T1 -weighted axial MRI examination of
a patient with Hodgkin's disease demonstrating
anterior and posterior triangle nodes as small
areas of low signal within the relatively bright
signal of fat.

9. • Fig. 17.7 CT examination showing
supraclavicular and superior mediastinal
lymph nodes.

10. • Fig. 17.8 CT scan showing enlargement and
almost certain involvement of a diaphragmatic
lymph node. The enlargement of a diaphragmatic
or paracardiac lymph node is of great importance
in patients with Hodgkin's disease considered for
mantle irradiation. Normal-sized lymph nodes in
this area are not seen on CT examination. A =
aorta.

11. • Fig. 17.9 Frontal view
of a lymphogram
showing opacification
of the pelvic and
retroperitoneal lymph
nodes

12. • Fig. 17.10 CT section through the pelvis
showing bilateral pelvic and groin lymph node
enlargement in a patient with non-Hodgkin
lymphoma.

13. • Fig. 17.11 Contrast-enhanced CT study showing
enlargement and involvement of an
interaorticocaval lymph node (arrow) in a
patient with a right-sided testicular malignancy.
Right-sided testicular tumours frequently spread
to the interaorticocaval lymph nodes. This is
extremely uncommon when the testicular
primary is on the left.

14. • Fig. 17.12 CT section showing mesenteric
lymph node involvement (arrowheads) in a
patient with non-Hodgkin's lymphoma. This is
common in non-Hodgkin's lymphoma, but
seen in fewer than 5% of patients with
Hodgkin's disease.

15. • Fig. 17.13 Contrast-enhanced CT scan
showing considerable enlargement of upper
abdominal, peripancreatic and portal lymph
nodes (arrows). The superior mesenteric
artery and the hepatic artery are outlined by
contrast.

16. • Fig. 17.14 Frontal chest radiograph. A large
mediastinal nodal mass in a patient
presenting with Hodgkin's disease is seen
compressing the major airways.

17. • Fig. 17.15 (A) The opacified ureters are seen
on intravenous urography to be displaced
around a large central abdominal mass. (B)
The presence of this mass is confirmed on the
CT section. The final diagnosis was testicular
teratoma.

18. • Fig 17.16
Lymphangioscintigram
demonstrating
lymphoedema with poor
lymph drainage in the left
leg. Letters a, b and c
correspond to groin nodes,
the knees and ankles,
respectively.

19. • Fig. 17.17 Gallium-67 radioisotope scan in a
patient with nodular sclerosing Hodgkin's
disease affecting supraclavicular and mediastinal
nodes. Note the normal uptake in the liver.

20. • Fig. 17.18 Early phase lymphogram film. The
limb is swollen, and when lymphography was
attempted, lymphatics filled poorly. This is an
example of secondary lymphoedema due to
filariasis.

21. • Fig. 17.19 (A) Staging CT on this patient with a
testicular primary shows no significant
adenopathy. Note the 0.25 cm node in the left
retroperitoneum (arrowhead). (B) Seven
months later this lymph node has enlarged
(arrowhead), indicating the presence of an
occult primary in the lymph node at the time
of original staging.

22. • Fig. 17.20 T 1 -weighted axial MRI showing
lymph node involvement from a supraglottic
SCC (arrows) pre contrast (A), and
demonstrating rim enhancement secondary to
central necrosis post contrast (B).

23. • Fig. 17.21 T 1 -weighted axial MRI showing
extra-capsular tumour spread from lymph
node demonstrated by ill defined lymph node
margins and abnormal signal in the
surrounding fat.

24. • Fig. 17.22 The lymph nodes are generally
enlarged and appear foamy in a patient with
lymphoma.

25. • Fig. 17.23 A single focal deposit is seen within
the enlarged and opacified lymph node
medial to the left ureter (arrow) in this patient
with an endometrial cancer.

26. • Fig. 17.24 (A) Staging CT scans in a patient with a
recently resected right-sided testicular tumour
showed prominent lymph nodes between the
aorta and inferior vena cava (arrow). (B) One
month later these have resolved without
treatment. Reactive enlargement of lymph nodes
is a possible source of error if patients are
scanned too close to the date of their surgery. It
is better to wait 3-4 weeks.

27. • Fig. 17.25 Small-volume (<2 cm)
retroperitoneal metastatic disease in a
patient with a left-sided teratoma. Left sided
testicular primary teratomas almost always
spread initially to a retroperitoneal lymph
node under the left renal vein (arrow).

28. • Fig. 17.26 Large retroperitoneal metastasis (
M) arising from an ipsilateral testicular
teratoma seen both on CT (A) and MRI (B).

29. • Fig. 17.27 (A) CT scan through the abdomen of this patient
with metastatic teratoma. (B) CT scan showing an increase
in tumour size, along with a decrease in attenuation
following treatment, for a testicular teratoma. This almost
always indicates differentiation of the tumour into a benign
variant. The residuum is excised to protect the patient in
the future. Note both the residual interaorticocaval lymph
node (arrow) and the liver metastasis (M), both of which
enlarge on treatment.

30. • Fig. 17.28 Long-term reassessment of a patient
who had previously had a parotid malignancy
resected, now with clinical suspicion of
recurrence, shows considerable distortion of the
architecture, but the low signal intensity on T2-
weighted MRI sequences suggested the scar
tissue (arrow) to be benign. This was confirmed
at subsequent re-exploration.

31. • Fig. 17.29 CT examination of the abdomen
demonstrating hulk retroperitoneal lymph
node disease (stage X).

32. • Fig. 17.30 CT scans through the abdomen of a
patient with gastric NHL showing thickening
of the gastric wall and prominence of the
rugal folds, with associated nodal disease, (A)
before (B) and after treatment.

33. • Fig. 17.31 T 1 -weighted contrast-enhanced
axial MRI of the brain showing periventricular
enhancing nodules in disseminated mantle
cell lymphoma.

34. • Fig. 17.32 CT scan showing normal fat and soft-tissue
densities in the left paravertebral area. On the right
the fat in the paravertebral area is obliterated by
lymphoma tissue (arrow), which is closely applied to
the nerve root exit foramen. The paravertebral tissues
should be systematically reviewed when CT scanning
any patient with malignant disease, so that lesions may
be detected and treated prior to the onset of cord
compression.

35. • Fig. 17.33 CT scan through the orbits of a
patient presenting with orbital NHL. Diffuse
thickening of the tissues is seen bilaterally.

36. • Fig. 17.34 Lateral soft-tissue radiograph of
the neck showing abnormal soft tissue from a
primary NHL of the neck arising in the
epiglottis and presenting with dysphagia.

37. • Fig. 17.35 CT scan showing pulmonary
involvement in a patient with NHL. A mass of
tumour tissue is seen around the right hilum.
In addition, a number of ill-defined
intrapulmonary nodules are seen on the right.

38. • Fig. 17.36 Abdominal CT examination of a
patient with NHL showing secondary
involvement of the iliac bone. Note also the
involvement of the terminal ileum
demonstrated by the use of oral contrast.

39. • Fig. 17.37 (A) Possible terminal ileal
lymphoma in a symptomatic patient with
previous abdominal radiation. (B) Adequate
bowel opacification shows this to be caecum.
(See also Fig. 17.38)

40. • Fig 17.38 Left-sided IVC (arrows) draining into
the left renal vein. This may be mistaken for
lymphadenopathy. Although intravenous contrast
was not used the correct diagnosis was made due
to knowledge of anatomy and its variants.

41. • Fig. 17.39 CT scan on a patient with NHL
shows enlargement of the retrucrural lymph
nodes (arrowhead). A= aorta.

42. • Fig. 17.40 (A,B) Adult T-cell lymphoma
presenting with liver and spleen disease.
Although in this case the use of intravenous
contrast demonstrated splenic involvement it
did not change patient management.

43. • Fig. 17.41 CT scans showing lymphoma in the
left paravertebral area (arrows) (A). On
follow-up (B) there has been progression
with destruction of the transverse process
and encroachment on the nerve root exit
foramen.

44. • Fig. 17.42 Lymphoma deposits in the kidney
as shown by echo-poor areas on ultrasound.
These rarely affect renal function but there is
early hydronephrosis due to retroperitoneal
lymph node disease. If bilateral this should be
treated by stents or nephrostomy prior to
chemotherapy.

45. • Fig. 17.43 CT examination showing interstitial
pulmonary shadowing in an
immunosuppressed patient on chemotherapy.
In this case the diagnosis was varicella
pneumonia.

46. • Fig. 17.44 CT examination showing midline
fibrosis with linear borders secondary to
mediastinal radiotherapy.