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While radiologists are familiar with lymphoma manifesting as nodal disease, extranodal lymphoma can present a diagnostic challenge due to considerable imaging overlap with other malignant and benign processes. This comprehensive review illustrates the spectrum of CT manifestations of extranodal NHL in the chest, including the pleura, lung, airways, heart, pericardium, esophagus, chest wall, and breast. Magnetic resonance imaging is a helpful problem-solving tool when equivocal findings would change staging and treatment. Pericardial effusion, pleural soft tissue (even when mild), mass-like consolidation, perilymphatic nodularity, and new lytic bone lesions are particularly suggestive of secondary involvement in a patient with known NHL.
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CT remains heavily used, and identification of subtle extranodal involvement with CT can be improved with use of intravenous contrast material and careful review of multiplanar images.
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For patients with known NHL, positron emission tomography/computed tomography (PET/CT) using fluorine 18 ( 18F)–labeled fluorodeoxyglucose (FDG) is now preferred for routine staging in most cases. Radiologists should have a heightened degree of suspicion in patients at risk (including patients with immune compromise, autoimmune diseases, or a history of stem cell or solid organ transplant) or with particular imaging appearances (including the vertebral wraparound sign, nonresolving consolidation, an infiltrative soft-tissue mass, and lesions demonstrating vascular encasement without invasion). Unfortunately, owing to considerable imaging overlap with other diseases, primary extranodal lymphoma is difficult to diagnose with imaging alone. Because staging and treatment are affected by the presence of extranodal disease at imaging, radiologists’ interpretation and management of suspicious findings are critical to patient care. Non-Hodgkin lymphoma (NHL) frequently manifests in extranodal structures in the chest, often in the form of secondary involvement but occasionally as primary disease.