Mediastinum;

Chest CT scan of my patient with congestive heart failure (CHF) and shortness of breath shows mediastinal adenopathy.  Can mediastinal adenopathy be caused by CHF alone?

FA Manian MD, MPH, , , , , , Leave a comment

Yes! Mediastinal adenopathy (commonly defined as 1 or more lymph nodes with a short axis diameter >1 cm) may be caused by CHF alone (AKA “congestive adenopathy”). 1-4

Although not as common as alveolar/interstitial edema on chest CT scan, hypertrophy of mediastinal lymph nodes may occur in a significant number of patients with CHF.  In a study involving 215 patients with CHF and no confounding etiology of adenopathy, 68% had evidence of adenopathy, particularly involving the right paratracheal and precarinal, subcarinal and other mediastinal lymph nodes; hilar and single station adenopathy were less common. The findings of pulmonary edema on CT and pleural effusion were significantly associated with adenopathy.1

In a study involving 3 patients with mediastinal adenopathy and CHF, lymph node biopsy showed noninflammatory, benign lesions that did not affect the node structure. Follow-up CT scan in 2 patients at 8 and 10 months showed no changes in the morphologic characteristics of mediastinal lymph nodes, while in another patient most of the enlarged lymph nodes disappeared at 5 months post- acute phase of the CHF.2   Interestingly, another study involving 31 cases of “subacute left heart failure” found that average ejection fraction was lower among patients with adenopathy (34% vs 43%).3

One potential mechanism for CHF-related adenopathy is that the excess lung fluid causes increased flow of fluid through the lymphatic channels and into the lymph nodes resulting in their congestion and enlargement.1

 

Bonus Pearl: Did you know that experimental animal studies have shown that acute CHF is associated with significant increases in mediastinal lymphatic flow and lymphatic vessel dilatation? 4-5

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References

  1. Shweihat YR, Perry J, Etman Y, et al. Congestive adenopathy: A mediastinal sequela of volume overload. J Bronchol Intervent Pulmonol 2016; 23:298-302. https://pubmed.ncbi.nlm.nih.gov/27623420/
  2. Ngom A, Dumont P, Diot P, et al. Benign mediastinal lymphadenopathy in congestive heart failure. CHEST 2001;119: 653-656. https://pubmed.ncbi.nlm.nih.gov/11171755/
  3. Chabbert V, Canevet G, Baixas C, et al. Mediastinal lymphadenopathy in congestive heart failure: a sequential CT evaluation with clinical and echocardiographic correlations. Eur Radiol 2004;14:881-889. https://pubmed.ncbi.nlm.nih.gov/14689226/
  4. Drake RE, Dhother S, Teague RA, et al. Lymph flow in sheep with rapid cardiac ventricular pacing. Am J Physiol 1997; 272:1595-1598. https://pubmed.ncbi.nlm.nih.gov/9176352/
  5. Leeds SE, Uhley HN, Telesky LB. Direct cannulation and injection lymphangiography of the canine cardiac and pulmonary efferent mediastinal lymphatics in congestive hart failure. Invest Radiol 1981;16:193-200. https://pubmed.ncbi.nlm.nih.gov/6266975/

Disclosures/Disclaimers: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Chest CT scan of my patient with congestive heart failure (CHF) and shortness of breath shows mediastinal adenopathy.  Can mediastinal adenopathy be caused by CHF alone?

My middle-aged patient with a history of mediastinal irradiation for Hodgkin’s lymphoma in his 20s now has moderate aortic regurgitation. Could his valvular disease be related to the radiation he received over 20 years ago?

FA Manian MD, MPH, , , , , , , , , , , , , , , , Leave a comment

Absolutely! Mediastinal irradiation is associated with several cardiac complications, including coronary artery disease, pericarditis, systolic or diastolic dysfunction and valvular disease. Valvular disease may occur in 2-37% of patients after mediastinal irradiation, is dose-dependent, and generally does not manifest until 10-20 years after the radiation exposure.1 Since mediastinal irradiation is common in young adults diagnosed with Hodgkin’s lymphoma, these complications may be seen in early middle-age or later.

Valvular retraction is usually the first radiation-induced valvular change, and most commonly leads to mitral and aortic valve regurgitation.2 This retraction tends to occur within 10 years of the radiation therapy, followed by fibrosis and calcification of the valves after 20 years.

Although the pathophysiology of radiation-induced valvular disease is not entirely understood, activation of fibrogenic growth factors (eg, tissue growth factor β1 and myofibroblasts) which promote the synthesis of collagen has been postulated.1 Additionally, irradiation of aortic interstitial cells has been shown to cause transformation to an osteogenic phenotype that produces bone morphogenic protein 2, osteopontin and alkaline phosphatase, all important factors in bone formation and possibly valvular calcification.3

Since radiation-induced heart disease is the most common cause of non-malignant morbidity and mortality in patients who have undergone mediastinal irradiation, some have recommended screening of asymptomatic patients for valvular disease every 5 years by echocardiography beginning 10 years after radiation therapy. 2  If an abnormality is found, the screening frequency should increase to every 2-3  years,  if the valvular abnormality is mild, or annually if the abnormality is moderate. For severe valvular abnormalities, the patients should be considered for valve replacement.

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References

    1. Gujral DM, Lloyd G, Bhattacharyya S. Radiation-induced valvular heart disease. Heart 2016;102:269–276. https://heart.bmj.com/content/heartjnl/102/4/269.full.pdf
    2. Cuomo JR, Sharma GK, Conger PD, Weintraub NL. Novel concepts in radiation-induced cardiovascular disease. World J Cardiol. 2016; 8 (9):504-519. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039353/
    3. Nadlonek NA, Weyant MJ, Yu JA, et al. Radiation induces osteogenesis in human aortic valve interstitial cells. J Thorac Cardiovasc Surg 2012;144:1466–70. doi:10.1016/j.jtcvs.2012.08.041 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665422/

Contributed by Rachel Wallwork, MD, Mass General Hospital, Boston, MA

 

My middle-aged patient with a history of mediastinal irradiation for Hodgkin’s lymphoma in his 20s now has moderate aortic regurgitation. Could his valvular disease be related to the radiation he received over 20 years ago?