Ultrasound and CT in lymphoma: Bring out the particulars

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1 Ultrasound and CT in lymphoma: Bring out the particulars Poster No.: C-1774 Congress: ECR 2012 Type: Educational Exhibit Authors: A. Anton, S. M. Petrescu, C. ZAHARIA, C. A. Minoiu ; Ploiesti/ RO, Bucharest/RO, BUCHAREST/RO Keywords: Lymphoma, Diagnostic procedure, Ultrasound, CT, Oncology, Lymphatic, Gastrointestinal tract, Obstruction / Occlusion DOI: /ecr2012/C-1774 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23

2 Learning objectives To illustrate various imaging findings in lymphomas, mostly non-hodgkin, using ultrasound (US) and CT in a complementary approach. To highlight the relevance of ultrasound examination compared to CT in difficult patients. A presentation of various types of lymphoma with emphasis on extranodal type. Background Extranodal lymphomas may arise anywhere outside the lymph node region: from sites with primary lymphoid organs (e.g. spleen, thymus, Waldeyer ring); from organs or tissues devoid of lymphoid tissue (e.g. brain, soft tissue); or from organs with a significant lymphoid tissue component (e.g. gastrointestinal tract). The group study had 52 patients examined in our clinic between January 2009 and June 2011, the majority of them with non-hodgkin lymphoma. Ultrasonography has proven vital in first hand diagnosis of suspected lymphoma patients, providing a quick evaluation with higher accuracy for superficial and intestinal lesions. Dose reduction necessity recommends ultrasound for the therapeutic management and frequent follow-up. Allergic and renal impaired patients require a cost-efficient alternative to contrast CT, ultrasound being the ubiquitous choice. Imaging findings OR Procedure details In this section we will present a series of cases discussing the correlation of pathology with the imaging findings. A concise review regarding the most frequent extranodal lesion: hepatic, splenic and renal lessions where CT results are almost superimposable on ultrasound, non-contrast CT in patients with allergies and/or renal impairment being inferior to US. Page 2 of 23

3 Description of intestinal lesions where US can better evaluate enteric layers, and small parts - superficial lesions (testicle, thyroid) where US is essential, with no indication for CT. US can be used for lesions of the chest-wall, and pleura, being highly orientative for the pancreas, mesentery, pararenal space and adrenal glands. A 37-year-old male, presented with clinical signs and symptoms of bowel obstruction; later confirmed with non-hodgkin lymphoma (NHL); Ultrasound reveals the hypoechoic nodular lesions in the descending colon, the distended small bowel and thickened bowel wall. CT exam shows multiple nodular masses at the level of the stomach, enlarged small bowel with airfluid levels and intussusception in the right lower quadrant. Fig. 7 References: C. ZAHARIA et al. Department of Radiology and Medical Imaging, Coltea Clinical Hospital, Bucharest, Romania Page 3 of 23

4 Fig. 6 References: C. ZAHARIA et al. Department of Radiology and Medical Imaging, Coltea Clinical Hospital, Bucharest, Romania Fig. 8 Page 4 of 23

5 Fig. 9 Female patient with thickened small bowel loop with a tendency to intussuscept at the proximal end and moderate infiltration of the mesentery. Fig. 10 Page 5 of 23

6 Fig. 11 on page 17 and Fig. 12 on page 18: Patchy and nodular thickening of bowel wall in a patient with NHL; also we can notice diffuse adjacent fat infiltration. Female diagnosed with non-hodgkin lymphoma after ultrasound evaluation and non-contrast CT exam (due to allergic reaction); on ultrasound the hypoechoic lesion has a diffuse contour and appears to infiltrate the biliary ducts; CT shows a diffuse hypodense area with intrahepatic biliary tree dilatation; under these circumstances, ultrasonography was able to reveal the important lesions as good as the CT scan. Fig. 13 References: C. ZAHARIA et al. Department of Radiology and Medical Imaging, Coltea Clinical Hospital, Bucharest, Romania Page 6 of 23

7 Fig. 14 Fig. 1 Page 7 of 23

8 Fig. 15 A 69-year-old female with NHL; Ultrasound examination shows the polynodular mass that surrounds the renal vein and artery but without Doppler signal alteration. Contrast-enhanced CT shows an enlarged left kidney with architectural distortion. The heterogenous mass extends into the hilum and appears that the renal vein and artery are enclosed within the tumor. Page 8 of 23

9 Fig. 16 References: C. ZAHARIA et al. Department of Radiology and Medical Imaging, Coltea Clinical Hospital, Bucharest, Romania Fig. 17 Page 9 of 23

10 Fig. 18 Female with non-hodgkin lymphoma presents with a nodular lesion at the level of her right adrenal gland and with multiple masses in her right kidney. Page 10 of 23

11 Fig. 19 Fig. 20 Page 11 of 23

12 Fig. 21 on page 18: heterogenous splenic mass showing both on CT and ultrasound in NHL patient. Fig. 22 on page 19: Patient with non Hodgkin lymphoma: nodular lesion on ultrasound, not evident on CT due to the absence of contrast (renal impaired patient); also it associates bulky lymphadenopathy. Male, 39-year-old, diagnosed with NHL, CT exam for axillary mass; first exam shows a diffuse bulky mass; 6 months later the CT exam reveals the mass spreaded caudally, extending into the pectoralis minor muscle and fat tissue; the lesion became infected showing gas bubbles. Fig. 23 References: C. ZAHARIA et al. Department of Radiology and Medical Imaging, Coltea Clinical Hospital, Bucharest, Romania Two different patients with NHL, both with pleural thickening and effusion secondary to lymphoma. Page 12 of 23

13 Fig. 24 Fig. 25 on page 19: Male patient with non-hodgkin lymphoma: (On the left) US of the thoracic wall shows hyperechoic lesion in the pectoralis major muscle highly compatible with fibrous changes (sequelae) after a muscle tear; (on the right) nodular intercostal hypoechoic lesion compatible with muscle lymphoma. Male with NHL, nodular involvement of the mesentery with Doppler signal at this level Page 13 of 23

14 Fig. 26 Page 14 of 23

15 Fig. 27 Fig. 28 on page 20: Patient with NHL: hypoechoic area in the right testicle towards the inferior end, with diffuse margins, and increased Doppler signal compared to the adjacent parenchyma. Male with non-hodgkin lymphoma, performs US for a mass situated at the level of the thoracic wall, on the right, postero-lateral. The lesion appears to infiltrate the muscle tissue, with no certain costal invasion and comes in contact with the pleura, having inside areas with high vascularity. Page 15 of 23

16 Fig. 29 Page 16 of 23

17 Fig. 30 Fig. 31 on page 20: Female with NHL with a nodular hypoechoic subcutaneous lesion found on ultrasound examination, presenting vascular signal at the periphery with underlying inflammatory changes. Images for this section: Page 17 of 23

18 Fig. 11 Fig. 12 Page 18 of 23

19 Fig. 21 Fig. 22 Page 19 of 23

20 Fig. 25 Fig. 28 Page 20 of 23

21 Fig. 31 Page 21 of 23

22 Conclusion Lymphoma can mimic a large variety of conditions. Ultrasound can be a quick and trustworthy method for the evaluation of lymphoma and can be as accurate as CT in the hands of an experienced radiologist. Ultrasound can be a useful tool in assessing small and/or superficial parts like testes, lymphadenopathy, subcutaneous tissue and muscular lesions. Personal Information A. Anton, C. A. Minoiu, S. M. Petrescu, C. ZAHARIA. Department of Radiology and Medical Imaging, Coltea Clinical Hospital, Bucharest, Romania. alexandruanton84@gmail.com References Primary Gastrointestinal Lymphoma: Spectrum of Imaging Findings with Pathologic Correlation - Sangeet Ghai, MD, FRCR et al; RadioGraphics 2007; 27: Non-Hodgkin Lymphoma of the Gastrointestinal Tract - Claire Smith, MD, Robert A Kubicka, MD, Charles R. Thomas, Jr, MD; RadloGraphics 1992; 12: Imaging of Primary Non-Hodgkin's Lymphoma of the Liver. Maher, M. M. et al. Clinical Radiology (2001). 56, 295±301 Primary Diffuse Large B-Cell Lymphoma of the Epididymis and Testis - Jason M. Zicherman MD, David Weissman MD, Christopher Gribbin MD, Robert Epstein MD, January 2005 RadioGraphics, 25, Cross-sectional Imaging of Extranodal Involvement in Abdominopelvic Lymphoproliferative Malignancies - Nuno Pinto Leite, MD, Norbert Kased, BS, Robert F. Hanna, BS, Michele A. Brown, MD, Jose M. Pereira, MD, Rui Cunha, MD and Claude B. Sirlin, MD, November 2007 RadioGraphics,27, Page 22 of 23

23 Imaging of Renal Lymphoma: Patterns of Disease with Pathologic Correlation - Sheila Sheth, MD, Syed Ali, MD, Elliot Fishman, MD, RadioGraphics 2006; 26: Extranodal Hodgkin Disease: Spectrum of Disease - Ali Guermazi, Pauline Brice,Eric de Kerviler, Christophe Fermé, Christophe Hennequin, Véronique Meignin, Jacques Frija. RadioGraphics 2001; 21: Abdominal Manifestations of Extranodal Lymphoma: Spectrum of Imaging Findings. WK Lee et al AJR 2008; 191: Page 23 of 23

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