Imaging Pearls ❯ Stomach ❯ Gastric Lymphoma
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- “The most common CT patterns of gastric lymphoma are the presence of diffuse or segmental wall thickening of 2–5 cm with low contrast enhancement and extensive lateral extension of the tumour due to submucosal spread; moreover, CT can assess the presence of lymphadenopathies. Less commonly, gastric lymphoma may present on CT as a polypoidal mass, an ulcerative lesion, or a mucosal nodularity. Considering the CT features of lymphoma, in low-grade ones there is less severe gastric wall thickening than in highgrade lymphoma, and abdominal lymphadenopathy is less common.The absence of abnormality or the presence of just minimal gastric wall thickening or a shallow lesion at CT suggests low-grade MALT lymphoma; yet, CT is of limited value in its diagnosis. A greater thickening may indicate transformation to a higher grade lymphoma.”
Radiological Features of Gastrointestinal Lymphoma
Giuseppe Lo Re et al.
Gastroenterology Research and Practice Volume 2016, Article ID 2498143 - “CT is particularly useful both for staging and in the follow-up after surgery or chemoradiotherapy.Nowadays,CT allows the evaluation of wall thickness, mesenteric vasculature, and any associated extramural findings. Small bowel CT, or entero-CT, performed through a multislice CT scanner has led to considerable advances in the detection and staging of intestinal diseases.The advantage of this technique lies in its panoramic view, which allows the evaluation of the intestinal wall thickness, the degree of bowel distension, and the circular folds. Yet, ileal loops and also those of the deep pelvis, the mesentery, the surrounding adipose tissue, and other abdominal organs are studied.”
Radiological Features of Gastrointestinal Lymphoma
Giuseppe Lo Re et al.
Gastroenterology Research and Practice Volume 2016, Article ID 2498143
- “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
- “Air in the gastric wall can be seen in a benign form of gastric emphysema, which can be encountered in the setting of a recent procedure and is typically asymptomatic. Patients with benign gastric emphysema demonstrate few clinical symptoms, whereas emphysematous gastritis causes patients to present with severe pain and potentially with sepsis and shock.”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 - “The term gastric volvulus implies at least 180° rotation of the stomach and gastric outlet obstruction. Coronal reformatted images are particularly helpful in diagnosing gastric volvulus and often show these findings to greater advantage than axial images alone. Organoaxial or mesenteroaxial rotation of the stomach alone does not define volvulus.”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 - “Gastritis is most frequently secondary to Helicobacter pylori infection, nonste- roidal anti-inflammatory drugs (NSAIDs), alcohol, or systemic illness. Patients with gastritis may present with epigastric pain, nausea, vomiting, or loss of appetite. Although CT, given its poor mucosal detail, is not the preferred modality for as- sessing gastritis, it is often the first study performed in patients with acute symptoms and may suggest the diagnosis.” CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921
- “Air in the gastric wall can be seen in a benign form of gastric emphysema, which can be encountered in the setting of a recent procedure and is typically asymptomatic. Patients with benign gastric emphysema demonstrate few clinical symptoms, whereas emphysematous gastritis causes patients
to present with severe pain and potentially with sepsis and shock. In addition to obtaining an appropriate history, absence of gastric wall edema is helpful in diagnosing benign gastric emphysema. The appearance of the intramural gas in benign gastric emphysema is often linear .”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 - “Gastric volvulus is twisting of the stomach resulting in gastric outlet obstruction, and can result in ischemia or perforation. Patients classically present with sudden epigastric pain, intractable retching, and inability to pass a naso-gastric tube (the Borchardt triad).Volvulus occurs most often in elderly patients with a hiatal hernia and may be acute or chronic-recurrent. Paraesophageal hernias, particularly large type III hernias, are at greater risk of gastric volvulus.”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 - “Gastric perforation can also occur with a gastric malignancy, particularly in ulcer- ated masses such as those seen with adenocar- cinoma, lymphoma, and large gastrointestinal stromal tumors (GISTs). Perforation from gastric adenocarcinoma typically occurs in patients more than 65 years of age with advanced stage disease. In patients with lower stage disease, a focal ulcerated mass can perforate if the ulceration is deep. Ulcerated gastric lymphoma can also result in gastric perforation, although small bowel perforation is more common.”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 - “Gastric hemorrhage can be seen in a variety of gastric diseases, including PUD, tumor, varices, gastritis, and arteriovenous malformations. Patient presentation is variable, ranging from asymptomatic to hypovolemic shock. Direct signs of bleeding in- clude hematemesis, coffee-ground emesis, melena, or, in the setting of rapid bleeding, hematochezia. Although endoscopy is the preferred method of
diagnosing and treating upper gastrointestinal bleeding, CT is useful in cases where endoscopy is not clinically feasible or is nondiagnostic.”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 - “CT findings of gastric hemorrhage include intraluminal contrast blush from active bleeding or hyperattenuating clot from recent bleeding. Clots in these cases are often seen in the fundus, which is the most dependent location in the supine patient. The location of the highest- attenuation clot (the sentinel clot) can indicate the source of bleeding. Hyperattenuating material in the stomach, including ingested material such as residual contrast medium or medications, surgical material, or foreign bodies, can potentially result in both false-positive and false-negative studies by mimicking or obscuring bleeding.”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 - “Gastric ischemia is an uncommon condition caused by diffuse or focal vascular insufficiency. Although the extensive collateral blood supply to the stomach is protective, systemic hypotension (as is seen in sepsis or shock) may result in gastric ischemia. Other described causes of gastric ischemia include celiac and mesenteric stenosis, vasculitis, and disseminated thrombo- embolism. Imaging findings in gastric ischemia range from focal ulceration to gastric wall thickening to intramural gas. Ischemic ulcerations most commonly occur along
the anterior and posterior gastric walls near the anastomoses between the two arterial arches over the lesser and greater curvatures. Gastric dilatation may also be seen and is thought to be due to ischemic gastroparesis.”
CT of Gastric Emergencies Guniganti PG et al. RadioGraphics 2015; 35:1909–1921 
- “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. - “Gastric lymphoma can present as ulcerations or polypoid masses, although diffuse or focal gastric wall thickening is also commonly seen. Ulcerative or polypoid lesions can mimic gastric adenocarcinoma or GI stromal tumor.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “Diffuse infiltration of the gastric wall by lymphoma can cause rugal enlargement. The differential diagnosis for gastric wall thickening includes nonmalignant inflammatory conditions such as hypertrophic gastritis, Ménétrier disease, peptic ulcer disease, Zollinger-Ellison syndrome, tuberculosis, or malignancies such as scirrhous-type gastric adenocarcinoma.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “For reference, the normal thickness of the gastric wall is approximately 1 cm with proper distention.While adenocarcinoma cannot be relatively distinguished from lymphoma, lymphoma can demonstrate a more lobular luminal contour corresponding to thickened rugal folds.Additionally, it has been reported that gastric lymphoma demonstrates bulkier lymph nodes extending beneath the renal hilum compared with adenocarcinoma”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65.
- “ The most common findings in Gastric Lymphoma were ulcers of variable size, depth and number in 43% of cases, a mass with or without an ulcer in 36% of cases, and rugal thickening in 21% of cases.”
CT evaluation of gastric lymphoma.
Gligorievski A
Prilozi. 2009 Dec;30(2):125-38. - “The stomach is the most frequent site of gastrointestinal tract involvement by non-Hodgkin lymphoma. At CT, gastric lymphoma typically appears as segmental or diffuse wall thickening. In a 1982 study by Buy and Moss of 12 patients with gastric lymphoma, the average gastric wall thickness was 4.0 cm. In contrast to gastric adenocarcinoma, lymphoma typically involves more than one region of the stomach.”
Current Role of CT in Imaging of the Stomach
Horton KM, Fishman EK
RadioGraphics 2003 23:1, 75-87
- “ Primary gastrointestinal (GI) lymphoma most often arises from stomach, small bowel, or colon. The 2 most common subtypes of primary GI lymphoma include low-grade mucosa-associated lymphoid tissue lymphoma, strongly associated with Helicobacter pylori infection, and high-grade diffuse, large B-cell lymphoma. Primary GI lymphoma demonstrates a myriad of imaging manifestations that can commonly mimic other pathologies. Timely and accurate diagnosis remains important because treatment and prognosis of primary GI lymphoma differ significantly from other GI malignancies and even lymphoma of other primary sites.”
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “ Primary gastrointestinal (GI) lymphoma most often arises from stomach, small bowel, or colon. The 2 most common subtypes of primary GI lymphoma include low-grade mucosa-associated lymphoid tissue lymphoma, strongly associated with Helicobacter pylori infection, and high-grade diffuse, large B-cell lymphoma.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65. - “ Primary GI lymphoma demonstrates a myriad of imaging manifestations that can commonly mimic other pathologies. Timely and accurate diagnosis remains important because treatment and prognosis of primary GI lymphoma differ significantly from other GI malignancies and even lymphoma of other primary sites.”
Imaging of primary gastrointestinal lymphoma.
Chang ST, Menias CO
Semin Ultrasound CT MR. 2013 Dec;34(6):558-65.
- Gastric Lymphoma
1. Most frequent GI site of malignant lymphoma (50% of all GI lymphomas)
2. 1-5% of gastric malignancies
3. Most are Non-Hodgkin
- Gastric Hodgkin disease accounts for 9% of all gastric lymphomas
- Primary gastric Hodgkin disease is extremely rare - Gastric Lymphoma: CT Findings
Radiographic appearance often reflects the gross pathologic findings
1. Infiltrating form
- Wall thickening(with little enhancement)
- average 4-5 cm ( now picking up earlier)
- diffuse or segmental
- May be difficult to differentiate from scirrhous carcinoma
2. Polypoid mass
3. Adenopathy - CT Findings
Lymphoma vs Adenocarcinoma
1. CT findings can overlap
2. Lymphoma
- Adenopathy can extend below the renal hilum without perigastric adenopathy
- Can extend into duodenum
- Nodes usually larger in lymphoma
- Perigastric fat plane more likely to be preserved. - Gastric Carcinoid
- Originate from Kulchitsky cells in the crypts of Lieberkuhn
- Cytoplasm contains eosinophilic granules that have an affinity for solver stain (argenaffinomas)
- < 35% of GI carcinoids are located in stomach
- Most are in distal antrum - Gastric Carcinoid
Presentation
- Asymptomatic
- Abdominal pain
- Nausea, vomiting
- Weight loss
- Bleeding - Gastric Carcinoid
1. Rare but recognized complication of prolonged severe hypergastrinemia
- chronic atrophic gastritis
- gastrinoma
- ? H2 blockers
2. Elevated gastrin levels can result in hyperplasia of ECL cells or carcinoid - Gastric Carcinoid
CT Findings
- Submucosal mass or masses
- Usually 1-4 cm
- Can mimic gastric polyps
- May have associated gastric fold thickening due to elevated gastrin levels. - Gastric Carcinoid
1. Low grade malignancies
2. Can metastasize
3. Treatment
- Treatment of hypergastrinemia
- Endoscopic excision
- Surgical resection
- Endoscopic surveillance
"The gastric wall was found to be significantly thicker in large B-cell lymphoma than in other disorders (p<0.001). The overall diagnostic accuracy of MDCT in the four diseases was 100%. Loss of wall stratification was deemed the best MDCT predictor of the presence of malignancy."
MDCT of Giant Gastric Folds: Differential Diagnosis
Chen CY et al.
AJR 2010; 195:1124-1130- CT Patterns of Involvement
- Polypoidal mass
- Diffuse or focal infiltration
- Ulcerative lesion
- Mucosal nodularity Radiographic appearance often reflects the gross pathologic findings
Infiltrating form
- Wall thickening(with little enhancement)
- average 4-5 cm ( now picking up earlier)
- diffuse or segmental
- May be difficult to differentiate from scirrhous carcinoma
Polypoid mass
AdenopathyLymphoma vs Adenocarcinoma
CT findings can overlap
Lymphoma
- Adenopathy can extend below the renal hilum without perigastric adenopathy
- Can extend into duodenum
- Nodes usually larger in lymphoma
- Perigastric fat plane more likely to be preserved.- Gastric Lymphoma: CT Patterns of Involvement
- Polypoidal mass
- Diffuse or focal infiltration
- Ulcerative lesion
- Mucosal nodularity - Gastric Lymphoma
- Most frequent GI site of malignant lymphoma (50% of all GI lymphomas)
- 1-5% of gastric malignancies
- Most are Non-Hodgkin
- Gastric Hodgkin disease accounts for 9% of all gastric lymphomas
- Primary gastric Hodgkin disease is extremely rare - CT Findings
- Radiographic appear often reflect the gross pathologic findings
- Infiltrating form
- Wall thickening (with little enhancement)
- average 4-5 cm (now picking up earlier)
- diffuse or segmental
- may be difficult to differentiate from scirrhous carcinoma
- polypoid mass
- adenopathy - CT Findings
- Lymphoma vs Adenocarcinoma
- CT findings can overlap
- Lymphoma
- Adenopathy can extend below the renal hilum without perigastric adenopathy
- Can extend into duodenum
- Nodes usually larger in lymphoma
- Perigastric fat plane more likely to be preserved.