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Primary lymphoedema, axillary web syndrome (AWS) and yellow nail syndrome may be related. Mr B is a 66-year-old gentleman with genital lymphoedema and lymphoedema of all four extremities. In 2023, he was diagnosed with non-Hodgkin lymphoma and also underwent cardiac surgery. In November 2023, he completed an inpatient rehabilitation at the Földi clinic in Germany, where he received intensive treatment for his lymphoedema and was also diagnosed with bilateral AWS. The presence of AWS in a patient with primary lymphoedema and no history of axillary surgery is unique. Although AWS typically presents after axillary surgery, this case highlights that it can also occur in patients without lymph node surgery. While the precise cause of this presentation of AWS is not known, it may be connected to yellow nail syndrome or potentially the recent chemotherapy treatment. This article will describe the clinical case, highlighting the need for further research on AWS present in primary lymphoedema.

Lymphatic flow and anatomy can be challenging to study, owing to variable lymphatic anatomy in patients with diverse primary or secondary lymphatic pathologic conditions and the fact that lymphatic imaging is rarely performed in healthy individuals. The primary components of the lymphatic system outside the head and neck are the peripheral, retroperitoneal, mesenteric, hepatic, and pulmonary lymphatic systems and the thoracic duct. Multiple techniques have been developed for imaging components of the lymphatic system over the past century, with trade-offs in spatial, temporal, and contrast resolution; invasiveness; exposure to ionizing radiation; and the ability to obtain information on dynamic lymphatic flow. More recently, dynamic contrast-enhanced (DCE) MR lymphangiography (MRL) has emerged as a valuable tool for imaging both lymphatic flow and anatomy in a variety of congenital and acquired primary or secondary lymphatic disorders. The authors provide a brief overview of lymphatic physiology, anatomy, and imaging techniques. Next, an overview of DCE MRL and the development of an MRL practice and workflow in a hybrid interventional MRI suite incorporating cart-based in-room US is provided, with an emphasis on multidisciplinary collaboration. The spectrum of congenital and acquired lymphatic disorders encountered early in an MRL practice is provided, with emphasis on the diversity of imaging findings and how DCE MRL can aid in diagnosis and treatment of these patients. Methods such as DCE MRL for assessing the hepatic and mesenteric lymphatic systems and emerging technologies that may further expand DCE MRL use such as three-dimensional printing are introduced. © RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Silicone breast implants are frequently used for breast augmentation for cosmetic purposes, as well as for breast reconstruction after prophylactic or therapeutic mastectomy. Silicone lymphadenopathy is a well-known complication of silicone breast implants. Silicone droplets are present in the breast tissue through 'silicone bleeding' of the implant or because of implant rupture. These silicone particles can migrate from the breast to the regional lymph nodes. Silicone lymphadenopathy is caused by a substantial foreign body reaction against these silicone particles, and is frequently associated with asteroid body-containing multinucleated giant cells. Similar multinucleated giant cells are often observed in the capsule surrounding the silicone breast implant, and the number of associated asteroid bodies is highly variable. Here, we discuss a series of twelve women with breast implant-related asteroid bodies in their lymph nodes and/or breast tissue. This pictorial essay illustrates that the presence of asteroid bodies in a lymph node does not necessarily suggests a diagnosis of sarcoidosis. Clinical information about the patient having (or having had) silicone breast implants is often lacking. The encounter of asteroid body-containing giant cells in lymph node cytology, biopsies or resections should therefore lead to reflex clinical-pathological correlation, before establishing a final diagnosis.

Abstract: Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations., Competing Interests: Conflicts of interest and sources of funding: none declared. Outside of the present work, the authors are members of the speakers bureau of Guerbet, Julius Zorn GmbH, and Philips Healthcare., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The lymphatic system has been poorly understood and its importance neglected for decades. Growing understanding of lymphatic flow pathophysiology through peripheral and central lymphatic flow imaging has improved diagnosis and treatment options in children with lymphatic diseases. Flow dynamics can now be visualized by different means including dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), the current standard technique to depict central lymphatics. Novel imaging modalities including intranodal, intrahepatic and intramesenteric DCMRL are quickly evolving and have shown important advances in the understanding and guidance of interventional procedures in children with intestinal lymphatic leaks. Lymphatic imaging is gaining importance in the radiologic and clinical fields and new techniques are emerging to overcome its limitations., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: The primary morbidities of inguinal and axillary systematic nodal dissection are lymphatic fistulas and seromas. Intraoperative fluorescence imaging-guided sealing of lymph vessels may prevent these postoperative complications., Methods: Indocyanine dye was injected intracutaneously into the distal limb before the beginning of the lymphadenectomy. Systematic nodal dissection was performed according to standard protocols. Near-infrared imaging was applied throughout the procedure and real-time fluorescence-guided lymph vessel sealing was performed., Results: Fluorescence-guided lymph vessel sealing was implemented in three patients undergoing axillary systematic lymph node dissection. No adverse events occurred following fluorescence dye injection. All patients could be discharged free of wound complications., Conclusion: Fluorescence-guided lymph vessel sealing might be a promising new technique for preventing lymphatic fistulas and lymphocele after systematic lymphadenectomy., Competing Interests: Ioannis Karampinis hat keinen Interessenkonflikt zu erklären. Andreas Gerken hat keinen Interessenkonflikt zu erklären. Christoph Reissfelder hat keinen Interessenkonflikt zu erklären. Kai Nowak ist als Berater im Bereich der intraoperativen Fluoreszenztechnologie für Stryker und Novadaq tätig. Jens Jakob hat keinen Interessenkonflikt zu erklären., (Thieme. All rights reserved.)

Lymphatic abnormalities encompass a wide range of disorders spanning solitary common cystic lymphatic malformations (LMs) to entities involving multiple organ systems such as lymphangioleiomyomatosis. Many of these disorders are rare, yet some, such as secondary lymphedema from the treatment of malignancy (radiation therapy and/or lymph node dissection), affect millions of patients worldwide. Owing to complex and variable anatomy, the lymphatics are not as well understood as other organ systems. Further complicating this is the variability in the description of lymphatic disease processes and their nomenclature in the medical literature. In recent years, medical imaging has begun to facilitate a deeper understanding of the physiology and pathologic processes that involve the lymphatic system. Radiology is playing an important and growing role in the diagnosis and treatment of many lymphatic conditions. The authors describe both normal and common variant lymphatic anatomy. Various imaging modalities including nuclear medicine lymphoscintigraphy, conventional lymphangiography, and MR lymphangiography used in the diagnosis and treatment of lymphatic disorders are highlighted. The authors discuss imaging many of the common and uncommon lymphatic disorders, including primary LMs described by the International Society for the Study of Vascular Anomalies 2018 classification system (microcystic, mixed, and macrocystic LMs; primary lymphedema). Secondary central lymphatic disorders are also detailed, including secondary lymphedema and chylous leaks, as well as lymphatic disorders not otherwise easily classified. The authors aim to provide the reader with an overview of the anatomy, pathology, imaging findings, and treatment of a wide variety of lymphatic conditions. © RSNA, 2022.

Context.—: Endosalpingiosis is a benign Müllerian inclusion that can mimic metastatic low-grade mammary carcinoma, particularly when encountered in axillary lymph nodes excised for breast cancer staging. Immunohistochemistry can be useful in histologically ambiguous cases, and a targeted immunopanel should include a marker of gynecologic tract origin and a marker of mammary origin. GATA3 is a sensitive immunomarker for breast carcinoma, but the immunoreactivity of GATA3 in endosalpingiosis has not been systematically evaluated., Objective.—: To evaluate whether GATA3 immunohistochemistry could be used to differentiate endosalpingiosis from metastatic mammary carcinoma., Design.—: Whole slide sections of 15 cases of endosalpingiosis involving nonneoplastic tissues were subjected to GATA3 immunohistochemistry. Nuclear GATA3 labeling was scored as percentage and intensity labeling, with any labeling considered positive; GATA3 labeling was recorded in all cells present in the sections., Results.—: Half (47%, n = 7 of 15) of the endosalpingiosis cases involved lymph nodes (2 axillary, 5 pelvic) and half (53%, n = 8 of 15) involved pelvic organs or soft tissue (3 myometrial, 2 paratubal, 2 periadnexal soft tissue, and 1 pelvic sidewall). GATA3 immunohistochemistry was negative in all cases of endosalpingiosis, with intact, positive control labeling in lymphocytes. The benign fallopian tube epithelium present on the sections of paratubal endosalpingiosis displayed focal (<5%), weak labeling for GATA3, specifically within the ciliated and secretory cells., Conclusions.—: These findings support the diagnostic utility of GATA3 immunohistochemistry and its use in a targeted immunopanel to resolve the differential diagnosis of metastatic low-grade mammary carcinoma (GATA3+) and nodal endosalpingiosis (GATA3-).

Micronodular thymic carcinoma with lymphoid hyperplasia (MNTCLH) is a rare form of thymic carcinoma. We present the experience of RYTHMIC, the French national network devoted to the treatment of thymic epithelial tumors through multidisciplinary tumor boards with a review of all tumors by pathologists for classification and staging. Six cases of MNTCLH were diagnosed during a review of 1007 thymic epithelial tumors. Histologically, epithelial cells with atypia and mitoses formed micronodules that were surrounded by an abundant lymphoid background with follicles. There was neither obvious fibro-inflammatory stroma nor necrosis. Spindle cells areas were common. Initial diagnosis was micronodular thymoma in two cases, cellular atypia being overlooked, eclipsed by the micronodular pattern. Immunohistochemistry with a panel of five antibodies showed that cytokeratins (AE1-AE3) and p63-positive epithelial cells also expressed CD5 and that there was no TdT-positive cells within the tumors. CD20 highlighted the lymphoid hyperplasia. Additionally epithelial cells also expressed CD117 and diffusely Glut 1. Twenty-seven micronodular thymomas with lymphoid stroma diagnosed during the same period did not show the CD5 and CD117 positivities seen in MNTCLH and contained TdT-positive lymphocytes. Three of the 6 patients with MNTCLH had adjuvant radiotherapy. Three patients with follow-up information were alive without recurrence at 38, 51, and 95 months. Our study shows that immunohistochemistry, such as that used in the RYTHMIC network with a small panel of antibodies, may easily help to confirm the correct diagnosis of MNTCLH, a rare and low-aggressive form of thymic carcinoma, and avoid the misdiagnosis of micronodular thymoma., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Here we describe various techniques for visualization of the lymphatic vasculature, particularly in the heart. Addressing macro-, microscopic, and molecular levels of lymphatic organization, we give examples of how to explore the roles of specific antigens/markers expressed in lymphatic vessels and their extracellular matrix as structural and functional elements involved in various biological functions of lymphatics. Some obstacles and technical challenges related to lymphatic visualization are also discussed., (Copyright © 2020. Published by Elsevier Inc.)

Background: Lymphatic abnormalities play a role in effusions in individuals with a Fontan circulation. Recent results using near-infrared fluorescence imaging disclosed an increased contraction frequency of lymphatic vessels in Fontan patients compared to healthy controls. It is proposed that the elevated lymphatic pumping seen in the Fontan patients is necessary to maintain habitual interstitial fluid balance. Hyperthermia has previously been used as a tool for lymphatic stress test. By increasing fluid filtration in the capillary bed, the lymphatic workload and contraction frequency are increased accordingly. Using near-infrared fluorescence imaging, the lymphatic functional reserve capacity in Fontan patients were explored with a lymphatic stress test., Methods: Fontan patients (n = 33) were compared to a group of 15 healthy individuals of equal age, weight, and gender. The function of the superficial lymphatic vessels in the lower leg during rest and after inducing hyperthermia was investigated, using near-infrared fluorescence imaging., Results: Baseline values in the Fontan patients showed a 57% higher contraction frequency compared to the healthy controls (0.4 ± 0.3 min -1 vs. 0.3 ± 0.2 min -1 , p = 0.0445). After inducing stress on the lymphatic vessels with hyperthermia the ability to increase contraction frequency was decreased in the Fontan patients compared to the controls (0.6 ± 0.5 min -1 vs. 1.2 ± 0.8 min -1 , p = 0.0102)., Conclusions: Fontan patients had a higher lymphatic contraction frequency during normal circumstances. In the Fontan patients, the hyperthermia response is dampened indicating that the functional lymphatic reserve capacity is depressed. This diminished reserve capacity could be part of the explanation as to why some Fontan patients develop late-onset lymphatic complications., (© 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

The thymus is a vital organ of the immune system that plays an essential role in thymocyte development and maturation. Thymic atrophy occurs with age (physiological thymic atrophy) or as a result of viral, bacterial, parasitic or fungal infection (pathological thymic atrophy). Thymic atrophy directly results in loss of thymocytes and/or destruction of the thymic architecture, and indirectly leads to a decrease in naïve T cells and limited T cell receptor diversity. Thus, it is important to recognize the causes and mechanisms that induce thymic atrophy. In this review, we highlight current progress in infection-associated pathogenic thymic atrophy and discuss its possible mechanisms. In addition, we discuss whether extracellular vesicles/exosomes could be potential carriers of pathogenic substances to the thymus, and potential drugs for the treatment of thymic atrophy. Having acknowledged that most current research is limited to serological aspects, we look forward to the possibility of extending future work regarding the impact of neural modulation on thymic atrophy., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Luo, Xu, Qian and Sun.)

Aim: Endometriosis is an inflammatory condition that shares a number of similarities with malignant diseases, such as an abnormal morphology, migration along the nerve bundles and metastatic spread to lymph nodes and distant organs. Endometriotic lesions are associated with oestrogen and progesterone imbalance which seems to play a key role in the pathogenesis of endometriosis. The aim of this study was to compare the status of both oestrogen and progesterone receptors in tissue of deep infiltrating endometriosis, lymph node endometriosis and atypical ovarian endometriosis using immunohistochemical methods, as well as to investigate the relationship between endometriosis and protein p53., Methods: A total of 40 cases with deep infiltrating endometriosis were included in our study. Based on histopathological analysis of resected specimens, the cases were divided into 2 groups: group 1 - lymph node endometriosis (cases with lymph node involvement; n=12) and group 2 - deep infiltrating endometriosis (cases without lymph node involvement; n=28). As a control group, eutopic endometrium of adenomyosis- and endometriosis-free women were used (n=16). Five cases of atypical ovarian endometriosis as well as descriptions of the nerve involvement in endometriosis were also included. Immunohistochemical staining with a total of 4 markers was performed - oestrogen and progesterone receptors (ER, PR), p53 and Ki-67 (proliferation index)., Results: The immunophenotype of the cases in groups 1 and 2 and in the control group was virtually identical in the proliferative phase - strong nuclear ER and PR expression in more than 90% of endometrial glandular and stromal cells. In the early and mid secretory phase, ER expression only slightly decreased (80%) in endometrial glandular cells in group 2 and the control group, whereas in the late secretory phase, significant decrease of ER expression only in the control group was observed (15-50%; P<0.001). In group 2 and the control group, significant decrease of PR expression only in endometrial glandular cells was observed in the mid and late secretory phase (less than 15%; P<0.001). Differences in receptor content were found only in isolated cases in group 2. In group 1, no secretory changes were found. In all three groups, sporadic and weak nuclear p53 expression in less than 3% in both endometrial glandular and stromal cells was detected (regardless of the phase of the menstrual cycle). In atypical ovarian endometriosis, higher and strong p53 expression (on average 26%) and decrease in ER (on average 56%) and PR (less than 1%) expression was observed; compared to the control group and groups 1 and 2, the differences for all 3 markers were highly significant (P<0.001). In all groups, the proliferation index (Ki-67) reached the highest values in the proliferation phase and decreased during the cycle. However, in endometriotic tissue, it was widely variable in the individual phases of the cycle. Perineural spread of endometriosis with significant neural hypertrophy, hyperplasia and involvement of the ganglia of the autonomic nervous system was detected in 5 cases (12.5%). Conlusion. From a histological and immunohistochemical point of view, deep infiltrating endometriosis and lymph node endometriosis appear to represent the same entity. For the first time, a simple immunohistochemical panel with antibodies against ER, PR and p53 useful in diagnosing atypical endometriosis has been described. The marked endometriosis-associated neural changes (endometriotic neuropathy) could be one of the causes of impaired function of the affected organs after debulking surgery with macroscopic negative resection margins as well as pain symptomatology in macroscopic inapparent endometriotic lesions.

Introduction: The evidence for using vacuum suction during EBUS is sparse and the optimal suction pressure for obtaining adequate samples has not yet been determined. Our aim was to assess the influence of suction on the adequacy and diagnostic yield of EBUS-TBNA., Material and Methods: This single-center, prospective, randomized, non-inferiority trial assessed whether no-suction and 10 mL suction are inferior to 20 mL suction for adequacy and diagnostic yield of EBUS-TBNA aspirates., Results: Three hundred twenty three lymph nodes were sampled using EBUS-TBNA. Baseline characteristics of lymph nodes were comparable in the three suction groups. The overall adequacy of EBUS-TBNA aspirates in the no-suction, 10 mL, and 20 mL suction was 90%, 83.49%, and 77.88%, respectively. The differences in adequacy were 12.1% (95% CI: 3.9-20.3) and 5.6% (95% CI: -3.3-14.5) for no-suction vs 20 mL, and 10 mL vs 20 mL suction, respectively. No-suction and 10 mL were not inferior to 20 mL suction in terms of sample adequacy. At a superiority margin of 3.92%, no-suction was superior to 20 mL suction in terms of sample adequacy (p < 0.05). The overall diagnostic yield was comparable (63.6%, 52.3%, and 57.7% in 0, 10 mL, and 20 mL, respectively; p-value was not significant). The proportion of aspirates which were predominantly bloody was similar (no-suction - 10.9%, 10 mL - 13.8%, 20 mL - 15.4%; p = 0.62)., Conclusions: EBUS-TBNA with or without the application of vacuum suction does not influence specimen adequacy and diagnostic yield.

Introduction: We intend to determine the diagnostic power of fine needle aspiration biopsy (FNAB) for differentiation between malignant and benign lesions on axillary masses and draw the physicians' attention to the benefits of FNAB cytology in the diagnosis of axillary masses., Methods: In this study, 1,328 patients with an axillary mass diagnosed by FNAB were retrospectively reviewed. These cases were registered at the affiliated hospital of Southwest Medical University (China), July 2014 to June 2017. Cytological results were verified either by histopathology following surgical resection or clinical follow-up., Results: Of the 1,328 patients affected by axillary masses, 987 (74.3%) cases were female, and 341 (25.7%) cases were male. The highest incidence of patients was in the age group of 41-50 years (375, 28.2%). There were 1,129 (85.0%) patients with benign lesions and 199 (15.0%) with malignant lesions. Of the 199 malignant lesions cases, 21 cases were lymphomas, 2 cases were accessory breast cancers, and 176 cases were lymph node metastatic tumors. Under lymph node metastases, the most frequent primary tumors were breast cancer (141, 80.1%), followed by lung cancer (21, 11.9%). According to the study, the characters of 1,328 cases showed statistically significant difference (χ2 = 4.534, p = 0.033), and the incidence of females with axillary mass was significantly higher than that of males. There was a statistically significant difference in the distribution of benign and malignant cases in the patient age groups (χ2 = 1.129, p = 0.000), and the incidence of patients of 41-50 years of age was significantly higher than that of other patients. The diagnostic accuracy of FNAB in axillary masses was analyzed with the results of 95.98% of sensitivity, 99.56% of specificity, 97.45% of positive predictive value, and 99.29% of negative predictive value., Conclusion: Our results confirm that FNAB is a valuable initial screening method regarding pathologic diagnosis of axillary mass, in particular with respect to malignancy in 41- to 50-year-old female patients., (© 2021 S. Karger AG, Basel.)

Objective: The aim of the study was to evaluate computed tomography (CT) imaging findings of hyperdense thymic atrophy after chemotherapy in pediatric patients with extrathoracic malignancies., Methods: Seventy-eight pediatric patients with extrathoracic malignancies, who developed thymic atrophy after chemotherapy, were included in this study. All patients underwent CT imaging before and after chemotherapy. We retrospectively reviewed the CT images. Hyperdense thymic atrophy was defined as thymic atrophy with high CT attenuation (≥80 HU)., Results: Hyperdense thymic atrophy after chemotherapy was observed in 7 (9%) of 78 patients. Age (4.3 ± 2.4 vs 8.4 ± 5.4 years, P < 0.01), thymic CT attenuation before chemotherapy (70.4 ± 18.8 vs 55.2 ± 11.9 HU, P < 0.01), reduction rate in thymic area (0.76 ± 0.06 vs 0.60 ± 0.22, P < 0.01), and thymic CT attenuation change (30.3 ± 15.2 vs -16.8 ± 24.0 HU, P < 0.01) were significantly different between patients with and without hyperdense thymic atrophy after chemotherapy. Thymic CT attenuation after chemotherapy (61.2 ± 23.8 vs 33.8 ± 30.1 HU, P < 0.01) and thymic CT attenuation change (-1.3 ± 21.2 vs -19.3 ± 27.9 HU, P < 0.01) were significantly different between patients 5 years or younger (n = 29) and 6 years or older (n = 49)., Conclusions: Hyperdense thymic atrophy after chemotherapy was observed in 9% of pediatric patients with extrathoracic malignancies. It was associated with younger age, greater thymic CT attenuation before chemotherapy, larger reduction rate in thymic area, and greater thymic CT attenuation change.

Various types of lymphoid neoplasms can occur in the lung. Lung parenchyma, the pleura or the pleural cavity can be the primary site of a lymphoid neoplasm or can be involved secondarily as a result of systemic dissemination from a separate primary site. Recognition of pulmonary lymphoid neoplasms (PLN) has increased secondary to technological advances in the medical field. Multiparameter flow cytometry (FC) is a one of the diagnostic tools that serves an essential role in the detecting and categorizing PLNs. FC allows for rapid identification and immunophenotypic characterization of PLN. In this article, we discuss the role of FC in the diagnosis of the most commonly encountered PLNs as well as their basic clinicopathologic features. We briefly discuss the role of FC in identifying non-hematolymphoid neoplasms in lung specimens as well., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Primary lymphatic anomalies may present in a myriad of ways and are highly heterogenous. Careful consideration of the presentation can lead to an accurate clinical and/or molecular diagnosis which will assist with management. The most common presentation is lymphoedema, swelling resulting from failure of the peripheral lymphatic system. However, there may be internal lymphatic dysfunction, for example, chylous reflux, or lymphatic malformations, including the thorax or abdomen. A number of causal germline or postzygotic gene mutations have been discovered. Some through careful phenotyping and categorisation of the patients based on the St George's classification pathway/algorithm. The St George's classification algorithm is aimed at providing an accurate diagnosis for patients with lymphoedema based on age of onset, areas affected by swelling and associated clinical features. This has enabled the identification of new causative genes. This update brings the classification of primary lymphatic disorders in line with the International Society for the Study of Vascular Anomalies 2018 classification for vascular anomalies. The St George's algorithm considers combined vascular malformations and primary lymphatic anomalies. It divides the types of primary lymphatic anomalies into lymphatic malformations and primary lymphoedema. It further divides the primary lymphoedema into syndromic, generalised lymphatic dysplasia with internal/systemic involvement, congenital-onset lymphoedema and late-onset lymphoedema. An audit and update of the algorithm has revealed where new genes have been discovered and that a molecular diagnosis was possible in 26% of all patients overall and 41% of those tested., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Sarcoidosis is a chronic, multisystem, inflammatory disorder of unknown etiology that is characterized by noncaseating granulomas that impair normal organ functioning. Sarcoidosis predominantly affects the lungs, but the skin is often cited as the second most frequently involved organ. Cutaneous manifestations of sarcoidosis are highly variable and ongoing research seeks to better understand the relationship between clinical morphology and disease prognosis. Skin findings in patients with sarcoidosis can be "specific," in which sarcoidal granulomas infiltrate the skin, or they can represent a "nonspecific" reactive inflammatory process, as is seen in calcinosis cutis and erythema nodosum. Cutaneous sarcoidosis can be the initial presenting sign or develop later in the course of the disease. In some patients, the skin will be the most involved and impactful organ system and will drive therapy. In other cases, the skin will be an incidental or minor finding, but may be easily accessible for biopsy to confirm the diagnosis. There are many potential therapies for sarcoidosis, though no one therapy is universally effective., Competing Interests: M.R. serves as a consultant at aTyr Pharma, Processa Pharmaceuticals, Merck, and Janssen and receives research support from Processa Pharmaceuticals. The other authors declare no conflict of interest., (Thieme. All rights reserved.)

Mammals have two specialized vascular circulatory systems: the blood vasculature and the lymphatic vasculature. The lymphatic vasculature is a unidirectional conduit that returns filtered interstitial arterial fluid and tissue metabolites to the blood circulation. It also plays major roles in immune cell trafficking and lipid absorption. As we discuss in this review, the molecular characterization of lymphatic vascular development and our understanding of this vasculature's role in pathophysiological conditions has greatly improved in recent years, changing conventional views about the roles of the lymphatic vasculature in health and disease. Morphological or functional defects in the lymphatic vasculature have now been uncovered in several pathological conditions. We propose that subtle asymptomatic alterations in lymphatic vascular function could underlie the variability seen in the body's response to a wide range of human diseases., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the effects of the standardized supplement Robuvit® (oak wood extract) in defined diffuse, minimal lymphatic "retention" (DMLR)., Methods: Robuvit® has already been investigated in both primary and secondary (post-surgical, post chemo-radiotherapy) lymphatic insufficiency. This registry included subjects with diffuse, minimal lymphatic "retention" (DMLR). The registry management groups included women with mild-moderate limb swelling using standard management (SM) as controls. A second, comparable group used prevention with Robuvit® at the dosage of 3 cp/day (300 mg/day) for 4 weeks., Results: No tolerability problems or side effects were observed with the preventive supplementation. The management groups (34 women in total), including 18 women in Robuvit® and 16 in SM were comparable in age and baseline evaluations. After 4 weeks, in the Robuvit® group, edema scale values derived from ultrasound observations decreased significantly (P<0.05) at all measurement's sites, from the proximal (inguinal) level to the more distal (ankle-foot) level. No significant changes in edema were observed in control subjects. Generally, in areas with higher level of edema (distal areas at the foot and ankle), the edema decrease was larger than in more proximal, ultrasound measurement sites., Conclusions: Preventive Robuvit® supplementation appears to be safe and effective in controlling DMLR in subjects without significant or apparent clinical conditions. This preventive, concept study should be extended to a larger population for more meaningful observations.

Background: The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy., Methods: Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres., Results: Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention., Conclusion: A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies., (© 2020 The Authors. British Journal of Surgery published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

Background: Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been become an important procedure for the diagnosis and staging of lung cancer. Our research identified the effects of different pathological preparation on the diagnosis of lung cancer for specimens obtained by biopsy., Methods: Patients were clinically considered if lung cancer was accompanied by mediastinal or hilar lymph node enlargement between March 2014 and November 2017. Specimens obtained by EBUS-TBNA were treated by three methods: traditional smear cytology, liquid-based cytology (LBC) and histopathology., Results: Of a total of 154 puncture sites from 153 patients, the total positive rate of combination for the three pathological treatment types (histopathology, direct traditional smear, and LBC) was 77.3%. The diagnostic positive rate for histopathology was 68.6%, direct traditional smear was 65.6%, and LBC was 60.4%; there was no significant differences among the three single pathological treatment types (P = 0.29), but there was a statistically significant difference between the combination of three treatments and any single pathological treatment type (P = 0.01). The diagnostic sensitivities of histopathology combined with traditional smear and histopathology combined LBC were 94.4 and 92.8%, respectively, the specificities and PPVs were both 100%, and the diagnostic accuracies were 95.5 and 94.2%, respectively; the sensitivities, specificities and diagnostic accuracies above were all higher than those of single specimen treatment and lower than those of the three combined., Conclusion: When EBUS-TBNA is used for the diagnosis and staging of lung cancer, the use of histopathological sections combined with direct cytological smear should be sufficient and is the most economical choice.

Streptococcus suis serotype 2 is an important bacterial pathogen of swine and is also an emerging zoonotic agent that may be harmful to human health. Although the virulence genes of S. suis have been extensively studied, the mechanisms by which they damage the central immune organs have rarely been studied. In the current work, we wanted to uncover more details about the impact and mechanisms of S. suis on specific populations of thymic and immune cells in infected mice. Terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin nick end labeling (TUNEL) assays revealed that S. suis infection induced apoptosis in CD3 + , CD14 + , and epithelial cells from the thymus. S. suis infection resulted in a rapid depletion of mitochondrial permeability and release of cytochrome c (CytC) and apoptosis-inducing factor (AIF) through upregulation of Bax expression and downregulation of Bcl-xl and Bcl2 expression in thymocytes. Moreover, S. suis infection increased cleavage of caspase-3, caspase-8, and caspase-9. Thus, S. suis induced thymocyte apoptosis through a p53- and caspase-dependent pathway, which led to a decrease of CD3 + cells in the thymus, subsequently decreasing the numbers of CD4 + and CD8 + cells in the peripheral blood. Finally, expression dysregulation of proinflammatory cytokines in the serum, including interleukin 2 (IL-2), IL-6, IL-12 (p70), tumor necrosis factor (TNF), and IL-10, was observed in mice after S. suis type 2 infection. Taken together, these results suggest that S. suis infection can cause atrophy of the thymus and induce apoptosis of thymocytes in mice, thus likely suppressing host immunity., (Copyright © 2020 American Society for Microbiology.)

Purpose: To explore the value of dual-energy CT for the differentiation between stage T1 nasopharyngeal carcinoma (NPC T1 ) and lymphoid hyperplasia (LH)., Method: Patients with histopathological proven nasopharyngeal lesions (stage T1 NPCs, n = 30; LHs, n = 47) who underwent dual-energy CT were enrolled in this retrospective study. Quantitative parameters derived from dual-energy CT were measured. Statistical analyses were performed using the independent sample t-test, Wilcoxon rank sum test, and receiver operating characteristic curve (ROC) analysis., Results: There was significantly higher iodine concentration (IC), normalized iodine concentration (NIC, to internal jugular vein) in NPC T1 compared with LH (p < 0.001). The effective atomic number (Z eff ) was significantly higher in NPC T1 than that in LH (p <  0.001). The virtual monochromatic images (VMIs) at 50 keV-110 keV (20 keV-interval) of NPC T1 were all significantly higher than those of LH (all p <0.001). The slope (k) value of spectral attenuation curve was also significantly higher in NPC T1 than LH (p <  0.001). There was no significant difference in virtual noncontrast (VNC) and 130 keV-190 keV (20 keV-interval) between the NPC T1 and LH. For discriminating NPC T1 from LH, the area under curve (AUC) using 70 keV was the highest in all single parameter (AUC, 0.92; sensitivity, 80.00 %; specificity, 91.49 %). Combined multiple parameters (IC, NIC, Z eff , 50 keV, 70 keV, 90 keV, slope (k)) by performing multivariate logistic regression model significantly improve the diagnostic capability in differentiating these two entities, with AUC, sensitivity, and specificity values of 0.99, 93.33 %, 97.87 %, respectively., Conclusions: Dual-energy CT can be helpful for the differentiation between NPC T1 and LH lesions., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier B.V.)

Endosalpingiosis, a microscopic lesion composed of ectopic Fallopian tube epithelium, frequently involves the peritoneum and lymph nodes in patients with ovarian serous borderline tumour or low-grade serous carcinoma, but its pathogenic significance remains unclear. Using laser-capture microdissection and droplet digital PCR, we investigated whether endosalpingiosis harbours the driver mutations in BRAF and KRAS that characterise ovarian low-grade serous neoplasms. Somatic mutations were detected in 14 (33%) of 43 endosalpingiotic lesions analysed. Of 21 women with endosalpingiosis associated with a synchronous or metachronous ovarian low-grade serous tumour, mutations were identified in endosalpingiotic lesions from 11 (52%) women, with most cases (10/11, 91%) demonstrating identical mutations in both tumour and endosalpingiosis. In contrast, of 13 cases of endosalpingiosis not associated with an ovarian tumour, only one harboured a KRAS mutation. The proliferative activity as assessed by Ki-67 immunohistochemistry was lower in endosalpingiosis than in low-grade serous tumours, and endosalpingiosis with either a BRAF or KRAS mutation had a significantly lower Ki-67 index than those without. Ectopic expression of KRAS G12V in Fallopian tube epithelial cells led to ERK phosphorylation, p21 induction, growth arrest and cellular senescence. In conclusion, we demonstrate that endosalpingiosis represents an interesting example of cancer driver mutations in deceptively normal-appearing cells, which may be prone to neoplastic transformation upon bypass of endogenous oncosuppressive mechanisms. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd., (© 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.)

Axillary web syndrome (AWS) refers to the development of fibrotic bands or "cords" in the axilla of patients who have undergone axillary lymph node dissection for breast cancer. We review the incidence, pathogenesis, risk factors, and management of AWS. AWS is a common complication in patients who undergo axillary lymph node dissection. Even though AWS is self-limited in most cases, it causes significant morbidity. The optimal management of AWS is unclear but physiotherapy appears to be beneficial. The widespread use of less invasive procedures to evaluate the presence of metastasis in the axillary lymph nodes (ie, sentinel lymph node biopsy) is expected to reduce the incidence of AWS. The close collaboration of surgeons, oncologists, and physiotherapists is necessary for the prevention and management of this frequent condition., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To evaluate a possible regrowth of lingual tonsil lymphatic tissue in patients submitted to lingual tonsil resection with transoral robotic surgery (TORS)., Study Design: Retrospective Study., Methods: Medical records of patients surgically treated by means of TORS to remove excessive lymphatic tissue of the lingual tonsil were retrospectively reviewed. Postoperative endoscopic data after long-term follow-up were analyzed to investigate possible lymphatic tissue regrowth. Preoperative and postoperative lingual tonsil lymphatic tissue were classified according to the standardized Friedman's grading scale ranging from 0 to 4., Results: Sixty-eight patients (41 male and 27 female; mean age = 51.3 years) were considered suitable for the study analysis. Clinical regrowth was observed in six (8.8%) patients: four (5.9%) and two (2.9%) patients with grade 2 and 3 lymphatic hypertrophy, respectively. No correlation between the grade of regrowth, the time interval from surgery, and the volume of lymphatic tissue removed was found., Conclusions: The lymphatic tissue regrowth after TORS resection appears to be very low., Level of Evidence: 4 Laryngoscope, 129:2652-2657, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Lymphoid hyperplasia can be an important mimicker of acute appendicitis by creating a non-compressible appendix more than 6 mm in diameter. The aim of this study was to evaluate methods of distinguishing lymphoid hyperplasia and appendicitis on the basis of sonography, lamina propria thickness, and Alvarado scoring., Methods: This retrospective study included 259 patients (142 appendicitis, 117 lymphoid hyperplasia). The US (ultrasound) reports of the patients were reviewed and the maximum diameter of the appendix, the presence or absence of increased echogenicity of the surrounding pericaecal fat, local fluid collection, the presence of reactive lymph nodes in the periappendiceal area, and mural hyperemia within the appendix were recorded., Results: The use of additional sonographic criteria, lamina propria thickness (≤1 mm is indicative for appendicitis), or Alvarado scoring (>6 mm is indicative for appendicitis) provided a true-positive diagnosis for acute appendicitis., Conclusion: The presence of local fluid collection in the periappendiceal area and a lamina propria thickness ≤ 1 mm are the most successful parameters for distinguishing appendicitis from lymphoid hyperplasia., (Copyright © 2018 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Changes in the intestinal lymphatic vascular system, such as lymphatic obstruction, are characteristic features of inflammatory bowel diseases. The lymphatic vasculature forms a conduit to enable resolution of inflammation; this process is driven by specialized endogenous proresolving mediators (SPMs). To evaluate contributions of lymphatic obstruction to intestinal inflammation and to study profiles of SPMs, we generated a novel animal model of lymphatic obstruction using African green monkeys. Follow-up studies were performed at 7, 21, and 61 days. Inflammation was determined by histology. Luminex assays were performed to evaluate chemokine and cytokine levels. In addition, lipid mediator metabololipidomic profiling was performed to identify SPMs. After 7 days, lymphatic obstruction resulted in a localized inflammatory state, paralleled by an increase in inflammatory chemokines and cytokines, which were found to be up-regulated after 7 days but returned to baseline after 21 and 61 days. At the same time, a distinct pattern of SPMs was profiled, with an increase for D-series resolvins, protectins, maresins, and lipoxins at 61 days. These results indicate that intestinal lymphatic obstruction can lead to an acute inflammatory state, accompanied by an increase in proinflammatory mediators, followed by a phase of resolution, paralleled by an increase and decrease of respective SPMs., (Copyright © 2019 American Society for Investigative Pathology. Published by Elsevier Inc. All rights reserved.)

Castleman disease (CD) is divided clinically into unicentric or multicentric type. Pathologically, CD is divided into hyaline-vascular and plasma cell variants. Unicentric CD is most common, about 75% of these cases are hyaline-vascular variant, and surgical excision is often curative. In contrast, there are a number of types of multicentric CD including HHV8-associated, idiopathic, and a subset of cases that arise in association with POEMS syndrome. Therapy is required for most patients with multicentric CD, but there is no consensus approach currently. As is evidence, the designation Castleman disease encompasses a heterogeneous group of diseases of varied pathogenesis and which require different therapies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We performed an epidemiological, clinical and histopathological analysis of oral lymphoid lesions (OLLs) during a 47-year period. Data regarding patient age, sex, duration, location, symptomatology, type of growth, implantation, staining, presence of ulceration and bleeding of all cases were compiled from the clinical data. For the histopathological analyses, all slides stained by H/E were reassessed. During the analyzed period, 14,565 patients with oral and maxillofacial lesions were diagnosed, with 45 cases diagnosed as OLLs. The most prevalent location was the tongue. Females were more affected, and the mean age was 40.8 years. OLLs presented a heterogeneous frequency, with the prevalence of reactive lesions (42.3%) followed by developmental lesions (35.6%). Among the reactive lesions, foreign body granulomas were the most common. Regarding diagnosed neoplasms, malignant represented 13.2% of the cases. The average time of evolution of OLLs in general was of 22.2 months. Regarding the histopathological characteristics, the presence of primary lymphoid follicles was observed in 37.8% of the cases, while inflammatory infiltrates were diffuse in 66.7% and epimyoepithelial islands were observed in 13.3%. Our study concludes that OLLs involves a broad spectrum of lesions that share the presence of the lymphoid component, which can range from indolent to more aggressive behavior.

The INHAND Project (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions in Rats and Mice) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP), and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative changes in rats and mice. The purpose of this publication is to provide a standardized nomenclature for classifying changes observed in the hematolymphoid organs, including the bone marrow, thymus, spleen, lymph nodes, mucosa-associated lymphoid tissues, and other lymphoid tissues (serosa-associated lymphoid clusters and tertiary lymphoid structures) with color photomicrographs illustrating examples of the lesions. Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. The nomenclature for these organs is divided into 3 terminologies: descriptive, conventional, and enhanced. Three terms are listed for each diagnosis. The rationale for this approach and guidance for its application to toxicologic pathology are described in detail below.

Purpose: Kaposiform lymphangiomatosis (KLA) is a rare, frequently aggressive, systemic disorder of the lymphatic vasculature, occurring primarily in children. Even with multimodal treatments, KLA has a poor prognosis and high mortality rate secondary to coagulopathy, effusions, and systemic involvement. We hypothesized that, as has recently been found for other vascular anomalies, KLA may be caused by somatic mosaic variants affecting vascular development., Methods: We performed exome sequencing of tumor samples from five individuals with KLA, along with samples from uninvolved control tissue in three of the five. We used digital polymerase chain reaction (dPCR) to validate the exome findings and to screen KLA samples from six other individuals., Results: We identified a somatic activating NRAS variant (c.182 A>G, p.Q61R) in lesional tissue from 10/11 individuals, at levels ranging from 1% to 28%, that was absent from the tested control tissues., Conclusion: The activating NRAS p.Q61R variant is a known "hotspot" variant, frequently identified in several types of human cancer, especially melanoma. KLA, therefore, joins a growing group of vascular malformations and tumors caused by somatic activating variants in the RAS/PI3K/mTOR signaling pathways. This discovery will expand treatment options for these high-risk patients as there is potential for use of targeted RAS pathway inhibitors.

Background: Melanosis of lymph nodes in black pigs has generally been related to regression of congenital melanoma and, occasionally, to ingestion of acorns. The aim of this manuscript is to confirm the hypothesis of a possible acquired acorn-related pseudomelanosis in the Nero Calabrese pig, a swine breed belonging to the group of Italian native breeds and whose coverage area corresponds to the region of Calabria, southern Italy. This pig is characterized by slow-growing subjects, producing, however, high quality meat suitable for the production of sausages and fine hams. The study was carried out on 142 normally slaughtered pigs. All organs were examined. Lymph nodes and intestine (jejunum) were sampled. Histochemistry was performed on deparaffinized histological sections to identify the cell types involved and to characterize the pigment stored. To further confirm the pigmentation disorder, immunohistochemistry was carried out. Total phenolic substances were identified in acorns through the use of a biochemical reaction., Results: Lymph node pigmentation appears directly related to acorn ingestion, with a higher incidence in the group which was 70% natural fed (acorn of Quercus virgiliana). Moreover, findings obtained revealed how different amounts of phenolic substrates present in Q. virgiliana and Q. ilex acorns can influence the incidence of such exogenous pigmentation., Conclusion: The findings obtained in this study confirm the acquired nature of the melanin-like pigmentation detected in lymph nodes from acorn-fed swine. Acquired pigmentation must be differentiated from true melanosis as well as from melanosis related to tumor regression of congenital melanoma. This thesaurismosis can be proposed as a marker of wellbeing and quality, confirming that the pigs have been bred and fed in natural conditions.

Two cases in which a neurological disorder was identified pathologically to be due to a granulomatous infiltration were found after diagnosis to have an associated testicular seminoma with pathologically proven lymphatic metastasis. We present the clinical and imaging features, and pathological appearances of the lymphatic tissue and the brain. We summarise the literature to date and discuss the pathogenesis of the disorder and its treatment.

Background and Aims: Our previous data showed that lymphatic function impairment occurs before the onset of atherosclerosis in mice and is precociously associated with a defect in the propelling capacity of the collecting lymphatic vessels. Concomitantly, we found that lymphatic transport can be restored in mice by systemic injections of a mutant form of VEGF-C (VEGF-C 152s), a growth factor known to increase mesenteric collecting lymphatic vessel pumping through a VEGFR-3-dependent mechanism in rats. In the present study, we aimed to determine whether and how early modulation of collecting lymphatic vessel function could restrain atherosclerosis onset and limit its progression., Methods: Before the administration of a pro-atherosclerotic regimen, Ldlr -/- mice at 6 weeks of age were injected intraperitoneally with VEGF-C 152s or PBS every other day for 4 weeks, fed on high fat diet (HFD) for an additional 8 weeks to promote plaque progression, and switched back on chow diet for 4 more weeks to stabilize the lesion., Results: Early treatment with VEGF-C first improved lymphatic molecular transport in 6-week-old Ldlr -/- mice and subsequently limited plaque formation and macrophage accumulation, while improving inflammatory cell migration through the lymphatics in HFD-fed mice. The contraction frequency of the collecting lymphatic vessels was significantly increased following treatment throughout the whole atherosclerotic process and resulted in enhanced plaque stabilization. This early and maintained rescue of the lymphatic dysfunction was associated with an upregulation of VEGFR3 and FOXC2 expression on lymphatic endothelial cells., Conclusions: These results suggest that early treatments that specifically target the lymphatic contraction capacity prior to lesion formation might be a novel therapeutic approach for the prevention and treatment of atherosclerosis., (Copyright © 2019 Elsevier B.V. All rights reserved.)

To describe the clinicopathological features of nine patients with acute Epstein-Barr virus (EBV)-positive cytotoxic T cell lymphoid hyperplasia (EBV+TLH) in the upper aerodigestive tract, in which initial findings led to a preliminary misdiagnosis of extranodal NK/T cell lymphoma, nasal type (ENKTL). A series of nine cases of EBV+TLH in one Chinese institution over a 9-year interval was retrospectively analyzed. Median age was 16 years (range 5-29 years) with a M:F ratio of 5:4. All patients were previously healthy with an acute onset period of < 1 month. Six patients (66%) presented with masses or polypoid protrusions in the upper aerodigestive tract. Nasopharyngeal symptoms, cervical lymphadenopathy, and fever were found in 89%, 78%, and 56% of patients, respectively. In seven cases, morphology mainly showed small-sized irregular cells and in two cases medium-to-large cells. In all cases, the cells diffusely expressed cytoplasmic CD3 and at least one marker for cytotoxic granules, but were negative for CD56. CD5 expression was detected in eight cases (8/9, 89%). In all cases, double staining for CD3 and EBER indicated that most T cells were infected with EBV. T cell receptor gene rearrangement was performed in five cases and all showed polyclonal results. All patients achieved complete remission within 1 month after diagnosis without any chemoradiotherapy and were followed up 19-124 months without recurrent disease. EBV+TLH in the upper aerodigestive tract is occasionally observed in China. The histopathologic features of EBV+TLH can mimic ENKTL. EBV+TLH should be taken into consideration as a potential diagnosis when the disease duration is short, spontaneous remission is achieved without intervention, and when histology shows infiltration with EBV-infected T lymphocytes.

Introduction: Diffusion weighted imaging (DWI) has shown its potential as a reliable noninvasive technique for tissue characterization. DWI reflects the tissue specific diffusion capacity which can be used for tissue characterization. Hypercellular tissue (e.g; malignant tumors) had restricted diffusion capacity with increased signals on DWI and low ADC values. Non-tumoral tissues show low cellularity, and diffusion capacity is not restricted resulting in signal loss on DWI and high apparent diffusion coefficient (ADC). Differential diagnosis of mediastinal lymphadenopathy is an issue of debate, especially in malignant benign differentiation. Diffusion weighted imaging with magnetic resonance could improve the diagnostic accuracy in differentiation between benign and malignant mediastinal nodes., Objectives: to determine the efficacy of diffusion weighted MRI in evaluation of mediastinal lymphadenopathy with histopathological correlation to differentiate benign from malignant lymph nodes., Material and Methods: 30 patients with mediastinal lymphadenopathy underwent diffusion weighted MRI. ADCs of lymph nodes were derived and constructed from b = 0 and b = 1000 sec/mm2 values by drawing regions of interests (ROI). Consequently, mediastinal nodes were studied, biopsies and histopathological analysis were done after MRI examination., Results: The best cutoff point of ADC to differentiate benign from malignant lesions was 1.15 mm/sec (sensitivity 77%, specificity 92% and AUC 81.4%). Significant negative correlation of ADC by DW MRI and the size of the LNs. The mean ADC values in the lymphoma group was lower than in the sarcoidosis group, and the difference was statistically significant., Conclusion: The study supports that MRI with diffusion weighted images can differentiate benign from malignant mediastinal lymphadenopathy and differentiate lymphoma from sarcoidosis non-invasively.