Imaging Pearls ❯ Small Bowel ❯ Lymphoma
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- The most common CT/MR patterns of small bowel lymphoma are:
(i) Polypoid/nodular pattern.
(ii) Infiltrative pattern.
(iii) Aneurismal pattern.
(iv) Exophytic mass.
(v) Stenosing mass (rare).
Radiological Features of Gastrointestinal Lymphoma
Giuseppe Lo Re et al.
Gastroenterology Research and Practice Volume 2016, Article ID 2498143 - “The polypoid pattern is characterized by the presence of a solid nodule, with a homogeneous signal density/intensity, that develops in the submucosa and protrudes into the lumen appearing as a polypoid mass. There is no wall thickening and/or lymph adenopathy and the mucosa is intact. This mass may cause intussusception. The infiltrative form is characterized by segmental symmetrical or slightly asymmetrical infiltrating lesions with a medium diameter of 1.5 cm and 2 cm, associated with mild circumferential thickening of the small bowel wall. Usually, the infiltrative lesions show ill-defined margins and a homogeneous contrast enhancement; the latter may rarely be inhomogeneous because of the presence of hypodense/ hypointense areas due to development of necrosis and/or ischemia in the context of the lesion. These lesions may extend to the whole bowel thickness, from the endoluminal mucosa to the tunica serosa.The length of the thickened small bowel segment is variable.”
Radiological Features of Gastrointestinal Lymphoma
Giuseppe Lo Re et al.
Gastroenterology Research and Practice Volume 2016, Article ID 2498143 - “The aneurismal pattern (diameter of dilatation of the lumen over 4 cm), firstly diagnosed byCupps et al. in 1969, represents 31% of small bowel lymphomas. It usually coexists with the infiltrative form since it can represent its natural evolution. Several factors are responsible for the aneurismal dilation secondary to infiltrative growth of neoplastic lesion, as a progressive destruction of myenteric plexus, destruction of muscle layers with stretching of the muscle fibers, and loss of contractile cells; on the other hand, the infiltration of arterial and lymphatic vessels determines anoxia and necrosis within the lesion. According to some authors, this tumour necrosis could lead to cavitation and be also responsible for the aneurismal dilatation.”
Radiological Features of Gastrointestinal Lymphoma
Giuseppe Lo Re et al.
Gastroenterology Research and Practice Volume 2016, Article ID 2498143 - “Differential diagnosis includes all inflammatory, neoplastic, and metastatic lesions involving the small bowel. Primary carcinoma, metastases (especially those from melanoma and renal cancer), and the intestinal leiomyosarcoma are characterized by large necrotic/colliquative cavitations. In rare cases, inflammatory conditions, such as Crohn’s disease and intestinal tuberculosis, have to be differentiated: the significant thickening of the bowel wall (greater than 2 cm), the presence of lymphomatous nodules, and the coexistence of perivisceral multiple lymph nodes are CT features that are suggestive for a lymphoproliferative process.”
Radiological Features of Gastrointestinal Lymphoma
Giuseppe Lo Re et al.
Gastroenterology Research and Practice Volume 2016, Article ID 2498143
- “Posttransplant malignancies can arise by means of three different mechanisms: de novo, donor-related, and recurrent cancers. De novo malignancies are new cancers arising in transplant recipients that originate separately from the transplanted organs, such as NMSC and Kaposi sarcoma. Donor-related cancers can either be from direct transmission of tumors that preexisted in the donor or de novo development of cancer in the transplanted organ without a preexisting history.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “Approximately 50%–75% of PTLD cases manifest in the abdomen and primarily involve the gastrointestinal tract (more often in the distal small bowel than in the proximal small bowel). Imaging findings in gastrointestinal PTLD include irregular bowel wall thickening with eccentric mural masses, aneurysmal dilatation, luminal ulceration, and, rarely, intussusception.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “Direct oncogenic effects of immunosuppressive drugs, impaired immunosurveillance of neoplastic cells, and increased incidence of virally induced malignancies are also mechanisms in the pathogenesis of malignancies that develop in transplant recipients.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407
- "Lymphoma is the most common malignant neoplasm affecting the mesentery . Approximately 30%–50% of patients with non-Hodgkin lymphoma harbor disease in the mesenteric lymph nodes. Markedly mesenteric adenopathy can also be present in chronic lymphocytic leukemia. Patterns of mesenteric lymphoma at CT include multiple, rounded, mildly enhancing, homogeneous masses that often encase the mesenteric vessels and produce the "sandwich sign."
Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis
Sheth S, Horton KM, Garland MR, Fishman EK
RadioGraphics Mar 2003, Vol. 23, No. 2:457–473 - "Patterns of mesenteric lymphoma at CT include multiple, rounded, mildly enhancing, homogeneous masses that often encase the mesenteric vessels and produce the "sandwich sign" ; a large, lobulated, "cakelike, " heterogeneous mass with low-attenuation areas of necrosis displacing small bowel loops ; or an ill-defined infiltration of the mesenteric fat, particularly after successful chemotherapy. Bulky retroperitoneal adenopathy commonly accompanies the mesenteric disease and should be a clue to the diagnosis ."
Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis
Sheth S, Horton KM, Garland MR, Fishman EK
RadioGraphics Mar 2003, Vol. 23, No. 2:457–473
- “GI tract is the most common site for extranodal lymphomas; primary GI lymphomas account for 30–40% of extranodal NHL. Secondary lymphomatous dissemination to the GI tract is even more frequent, and is found in up to 50% of lymphomas at autopsy. The stomach is the most commonly involved site (47–75%) despite the paucity of gastric lymphoid tissue, followed by small intestine (ileum in particular) and then the colon.”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027 - “GI lymphomas are almost always NHL, while GI Hodgkin’s lymphomas are extremely rare. The majority of these GI NHLs are of B-cell origin, while T-cell gives rise to only about 10% of GI NHL. The most common histologic type is diffuse large B-cell lymphoma (DLBCL), followed by extranodal marginal zone lymphoma (ENMZL).”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027 - “DLBCL is an aggressive/high-grade B-cell lymphoma, and is the most common NHL subtype as well as the most com- mon primary and secondary lymphoma in the GI tract, constituting 38–57% of all primary GI lymphomas. DLBCL most frequently occurs in the stomach, particularly the body and fundus. DLBCL actually constitutes 40–78% of all gastric lymphomas, and it is also the most frequent lymphoma in the small bowel (38%) and colon (50%) [8]. DLBCL could arise either de novo or from transformation of low-grade B-cell lymphomas, commonly ENMZL; about 50% co-exist with ENMZL and a subset of these respond to H. pylori eradication treatment. Risk factors for DLBCL include atrophic gastritis, immunodeficiency conditions, inflammatory bowel disease, and EBV.”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027 - “On the contrary, aneurysmal dilation (lumen diameter > 4 cm, with bowel wall thickening) of the involved bowel is seen with 31% of small bowel involvement, this occurs due to tumor invasion into the muscularis propria causing destruction of its intramural autonomic nerve plexus. Aneurysmal dilatation is not very specific, since it can be seen with other non-lymphomatous tumors such as GI stromal tumors, metastatic disease, and leiomyosarcoma.”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027 - “Differential diagnosis of DLBCL includes a variety of malignant and benign lesions, particularly adenocarcinoma, which is much more common than lymphoma in the stomach and colon. In comparison to adenocarcinoma, lymphoma causes more pronounced and extensive wall thickening which could be multifocal, and, lymphadenopathy is much more pro- nounced with lymphoma. In addition, bowel obstruction is less common and perigastric fat planes are usually preserved in lymphoma.”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027 - “The appearance of lymphomatous polyposis dictates the imaging findings of MCL. Barium studies reveal countless polypoid lesions smaller than 4 cm throughout the GI tract, most commonly the ileum. On CT scan, non- obstructive wall thickening is usually seen instead of the polypoid appearance, which is not evident in cross-sectional imaging on most occasions. Lymphadenopathy is seen in most patients, and splenomegaly may be present in up to 50% of the patients. PET/CT usually shows multiple curvilinear FDG-avid lesions corresponding to the affected bowel and lymph nodes.”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027 - “BL is a rare and aggressive B-cell lymphoma. Although it is rare in adults (1–2% of NHLs), BL is the most common pediatric NHL, representing 40% of all pediatric lymphomas. BL is commonly found in immunocompromised patients. It accounts for 5% only of primary GI NHLs. BL has three clinical variants: (1) endemic variant, which is highly associated with EBV and presents clinically as jaw lesions in south Africa or intestinal lesions in the Middle East, (2) a sporadic variant, which commonly involves the GI tract but is only associated with EBV in 30% of the cases, (3) and the immunodeficiency-associated variant which commonly occurs in HIV patients.”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027 - “Mastocytosis is a rare group of lymphoproliferative disorders characterized by proliferation and accumulation of mast cells in one or more organs. Skin is the most commonly affected organ (80%), and may be the only one involved. Organs that can be involved with the systemic presentation include the bone marrow (most common extra-cutaneous site), liver, spleen, lymph nodes, and the GI tract which is involved in 70–80% of systemic mastocytosis cases . Increased release of histamine and prostaglandins from the tumor cells likely results in the clinical manifestations of the disease, which include urticaria pigmentosa, episodic flushing, hypotension, musculoskeletal pain, diarrhea, and peptic ulcer disease.”
Hematologic malignancies of the gastrointestinal luminal tract
Abdelrahman K. Hanafy et al.
Abdominal Radiology (2020) 45:3007–3027
- "The most common primary malignancy of the duodenum is adenocarcinoma, with 50–70% of small bowel adenocarcinomas occurring either in the duodenum or proximal jejunum. Lymphomatous involvement of the duodenum can occur with both primary duodenal lymphoma and involvement from systemic disease. The duodenum can also be obstructed by local extension of other malignancies, for example, pancreatic adenocarcinoma or gallbladder cancer.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7 - “Radiologists should routinely include the duodenum in their search pattern when patients in the emergency department are imaged for an acute symptomatology. Proper CT technique is essential to evaluate the duodenal wall and involvement of adjacent anatomic structures that includes the use of intravenous contrast, thin section acquisition, and multiplanar reconstructions. Understanding of the range of pathology that involves the duodenum and its CT manifestations will facilitate timely diagnosis and management.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7
- “B cell lymphoma, especially diffuse large B-cell lymphoma (DLBL), is the most common type of primary gastrointestinal lymphoma, of which primary non-Hodgkin lymphoma (NHL) of gastrointestinal tract accounts for 10–15% of NHLs; the most commonly involved site of DLBL is the ileum of the small bowel . T-cell lymphoma, which occurs much less frequently than B-cell lymphoma, tends to develop in the proximal portion of the small bowel, such as the jejunum or proximal ileum.”
Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
Kim SW et al.
Abdominal Radiology (2019) 44:2337–2345 - “Perforation is observed in 16–33% of patients with T-cell lymphoma at the time of clinical presentation, and this is attributed to transmural involvement and necrosis. Additionally, T-cell lymphoma is more likely to be multifocal disease than is B-cell lymphoma. In patients with celiac disease, there is an increased incidence of T-cell lymphoma in the small bowel, especially jejunum.”
Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
Kim SW et al.
Abdominal Radiology (2019) 44:2337–2345
- “B cell lymphoma, especially diffuse large B-cell lymphoma (DLBL), is the most common type of primary gastrointestinal lymphoma, of which primary non-Hodgkin lymphoma (NHL) of gastrointestinal tract accounts for 10–15% of NHLs; the most commonly involved site of DLBL is the ileum of the small bowel . T-cell lymphoma, which occurs much less frequently than B-cell lymphoma, tends to develop in the proximal portion of the small bowel, such as the jejunum or proximal ileum.”
Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
Kim SW et al.
Abdominal Radiology (2019) 44:2337–2345 - “Perforation is observed in 16–33% of patients with T-cell lymphoma at the time of clinical presentation, and this is attributed to transmural involvement and necrosis. Additionally, T-cell lymphoma is more likely to be multifocal disease than is B-cell lymphoma. In patients with celiac disease, there is an increased incidence of T-cell lymphoma in the small bowel, especially jejunum.”
Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
Kim SW et al.
Abdominal Radiology (2019) 44:2337–2345
- Small Bowel Lymphoma: Facts
• third most common small bowel malignancy
• the stomach is the most commonly affected portion of the gastrointestinal tract followed by the small bowel
• distal ileum has the greatest amount of lymphoid tissue, so it the most commonly affected segment of small bowel
• Most cases involving the small bowel are non-Hodgkin B-cell lymphoma
• T-cell lymphoma has a high association with celiac disease and occurs most commonly in the jejunum - Small Bowel Lymphoma: Facts
• risk factors for development of small bowel lymphoma include;
• acquired immunodeficiency syndrome
• inflammatory bowel disease
• immunosuppression after solid organ transplantantion
• systemic lupus erythematosus
• Chemotherapy
• Epstein-Barr virus has a known association with Burkitt lymphoma which commonly occurs in the ileocecal re- gion in pediatric patients - Small Bowel Lymphoma: Facts
In Western countries, B-cell lymphoma of mucosa- associated lymphoid tissue (MALT lymphoma) is the most common subtype of primary small bowel lym- phoma. T-cell lymphomas are much less common and primarily occur in the setting of celiac disease
- Lymphoma of the Small Bowel: Facts
• Third most common small bowel malignancy.
• Inflammatory bowel disease and history of solid organ transplantation are known risk factors
• Stomach is the most common site of gastrointestinal tract involvement followed by ileum
• Infiltrating mildly enhancing mass ± regional lymphadenopathy and splenomegaly. Classic “aneurysmal bowel dilatation” appearance of affected segment.
• Non-Hodgkin B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is the most common subtype
- “Many risk factors for primary GI lymphoma have been described, including celiac disease, human immunodeficiency virus infection/acquired immunodeficiency syndrome, ulcerative colitis, Crohn's disease, and immunosuppression following solid organ transplantation. Patients with celiac disease have a 200-fold increased risk of developing intestinal lymphoma, particularly enteropathy-associated T-cell lymphoma, which has an extremely poor prognosis with a median survival time of 4 months.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “More than 90% of cases of MALT lymphoma are associated with Helicobacter pylori infection, possibly owing to clonal expansion of lymphoid cells in response to chronic antigen exposure. In some cases, eradication of H. pylori alone can lead to remission of low-grade MALT lymphoma. However, transformation of MALT into high-grade DLBCL is also known to occur.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “Clinical symptoms of primary GI lymphoma on presentation are extremely nonspecific and most commonly include abdominal pain, nausea, vomiting, anorexia, or weight loss. Upper or lower GI bleeding is less common presentations.Up to half of patients can present with palpable abdominal masses, suggesting that these masses can remain asymptomatic for long time. Rarely, primary GI lymphomas can cause intussusception, obstruction, or bowel perforation.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “Numerous studies have demonstrated that the stomach is the most common site of primary GI lymphoma, comprising approximately 47%-54% of all cases. Some have observed differing presentations between high- and low-grade gastric lymphomas on presentation and endoscopy, with high-grade gastric lymphomas presenting more often with vomiting and weight loss, ulcerations on endoscopy, and higher stages at presentation.Low-grade lymphomas are generally associated with H. pylori infection and demonstrate “normal” mucosa, petechial fundal hemorrhage or confinement to the antrum.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “The small bowel represents the second most common site of primary GI lymphoma, comprising approximately 24%-26%. Compared with primary GI lymphoma of the stomach, which tends to be of lower grade, small-bowel lymphomas are diagnosed at higher grades.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “Although the ileum is most often affected by B-cell lymphomas presumably based on the relative abundance of lymphatic tissue, the jejunum appears to be more often involved in uncommon but more aggressive T-cell lymphomas. Lymphoma often affects multiple sites of small bowel with a roughly equal likelihood of affecting the same segment or different segments.Over 77% of lymphoma exceeds 5 cm in diameter, and the average length of affected bowel is 12 cm.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “Lymphoma of the small bowel commonly demonstrates an infiltrative pattern causing diffuse bowel wall thickening with or without aneurysmal dilation and less often an “annular napkin-ring lesion” mimicking adenocarcinoma. Other patterns of small-bowel lymphoma include solitary or multiple nodules or large polypoid masses.The differential diagnosis for these findings includes Crohn's disease, adenocarcinoma, carcinoid, GI stromal tumor, or metastatic disease (eg, melanoma).”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “The survival rate for primary GI lymphoma is highly variable depending on stage, primary site, and subtype, but is generally good, ranging from 44%-67%.Distinguishing between primary and secondary GI lymphoma is clinically important, however, because primary GI lymphoma carries a better 5-year survival rate than disseminated secondary GI lymphoma and a significantly better survival rate than other common GI malignancies such as adenocarcinoma. Tumors are often amenable to chemotherapy and radiation, and can occasionally undergo surgical debulking or resection due to perforation or other acute complication.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65.