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  1. 1. Lymphoma Dr/ Hytham nafady
  2. 2. CNS lymphoma
  3. 3. CNS lymphoma 1ry CNS lymphoma Rare 2ry CNS lymphoma Common 100 % parenchymal 2/3 leptomeningeal 1/3 parenchymal
  4. 4. Patterns of 2ry CNS lymphoma Meningeal metastases Parenchymal metastases 2/3 Leptomeningeal enhancement 1/3 Pachymeningeal enhancement Cranial nerve enhancement Communicating hydrocephalus Deep periventricular Superficial cerebral
  5. 5. 2ry CNS lymphoma
  6. 6. Primary CNS lymphoma • No co-existing systemic disease at the time of diagnosis.
  7. 7. Predisposing factors of PCNSL • HIV. • EBV • Transplantation.
  8. 8. Pathology of Primary CNS lymphoma High grade B cell (90 % of PCNSL) Low grade T cell
  9. 9. Location • Periventricular deep white matter (abutting the ependymal surface). • Superficial cerebral (abutting the pial surface). • Butterfly distribution (crossing of the corpus callosum).
  10. 10. Radiology CT • Hyperdense. T1 • Hypointense T2 • Mildly hyperintense (low grade). • Isointense (high grade) Contrast MRS • Homogeneous marked enhancement (high grade tumor). • Mild to no enhancement (low grade tumor). • Ring enhancement (immuno-compromised patients). • High choline peak. • +/- high lactate peak. Diffusion • Restricted diffusion Perfusion • Mild increase in rCBV.
  11. 11. PCNSL of the corpus callosum
  12. 12. Primary CNS lymphoma
  13. 13. Steroid therapy
  14. 14. Findings Value Diffusion MRI Restricted diffusion: •hyperintense on DWI & •hypointense on ADC maps Differentiation of CNS lymphoma and malignant glioma/metastases MR perfusion Low maximum CBV Differentiation of CNS lymphoma and malignant glioma/metastases Characteristic intensity time curve related to leakage of contrast into the interstitial space Assessment of microvascular tumor permeability relevant for diagnosis, prognostication, and therapy •Elevated lipid peaks •high Cho/Cr ratios Differentiation of CNS lymphoma and some gliomas and CNS lymphomas and toxoplasmosis/PML in AIDS patients MR spectroscopy High-resolution SWI PET Blood products and calcifications are rare findings14,27 FDG-PET, methionine PET: hypermetabolic lesions with increased uptake of FDG or methionine25,60,62 Differentiation of CNS lymphoma and high-grade gliomas Differentiation of CNS lymphoma and gliomas/metastases/meningiomas Early evaluation of therapeutic response
  15. 15. Spine lymphoma Spine lymphoma 1ry spine lymphoma Rare 2ry spine lymphoma Common Hematogeneous spread Direct spread from adjacent lymph nodes
  16. 16. Spine lymphoma Patterns of Spine lymphoma Paraspinal Vertebral Combined Epidural
  17. 17. Pathology • Diffuse large B cell NHL.
  18. 18. Location • Dorsal > lumbar > cervical. • Posterior epidural space > anterior epidural space.
  19. 19. Vertebral lymphoa Epidural lymphoma Paraspinal • Lytic  vertebra plana. • Sclerotic  ivory vertebra. • Mixed. • Posterior epidural. • Anterior epidural.
  20. 20. Epidural hematoma Epidural abscess Epidural lymphoma No enhancment Heterogeneous enhancment Homogeneous enhancement Vertebral fracture (posttraumatic) Spondylodiscitis Bone marrow infiltration Anterior epidural Anterior epidural Posterior epidural
  21. 21. Thoracic lymphoma
  22. 22. Thoracic lymphoma Mediastinal LN (100% of cases) Pulmonary nodules Pulmonary (10% of cases) Pleural (15% of cases) Alveolar pattern Interstitial pattern (lymphangitis carcinomatosis) Chest wall (5%)
  23. 23. Lymphadenopathy • 100% of cases with thoracic involvement. Involve superior mediastinal lymph node groups including 1. Prevascular LN, 2. Paratracheal LN, & 3. Aorto-pulmonary LN. Other lymph node groups to be involved: • Hilar LN. • Subcarinal LN. • Internal mammary LN. • Paracardiac LN. • Posterior mediastinal LN including paravertebral & retrocrural.
  24. 24. Thoracic LN Anterior Mediastinal LN Highest mediastinal Tracheobronchial LN Paratracheal Prevascular Upper Para-aortic Lower Retrotracheal Subaortic A/P window Posterior mediastinal LN subcarinal Paraesophageal Pulmonary ligament Lung LN Hilar intrapulmonary Inter-lobar Lobar Segmental Subsegmental
  25. 25. Thoracic LN Anterior Mediastinal LN 1 Tracheobronchial LN Paratracheal 3A 2R & 2L 6 4R & 4L 3P Posterior mediastinal LN 5 7 8 9 Lung LN 10 intrapulmonary 11 12 13 14
  26. 26. Plain x-ray findings of mediastinal lymph adenopathy Upper Rt paratracheal LN: Convexity of the upper superior vena cava interface. Thickening of the right paratracheal strip. Lower Rt paratracheal: Enlargement of the azygos arch. Upper Lt paratracheal LN: Convexity of the left subclavian artery interface. Lower left paratracheal ------------------------------------------------------ Aorto-pulmonary LN: Convexity of the aortopulmonary window. Subcarinal LN: Convexity in the superior aspect of azygoesophageal recess. Widening of the carina. Paraoesophageal LN: Thickening of the posterior tracheal band on lateral film.
  27. 27. Aortic knukle
  28. 28. Aortic knukle
  29. 29. Aorto-pulmonary window
  30. 30. Aorto-pulmonary window
  31. 31. Right paratracheal stripe
  32. 32. Right paratracheal stripe
  33. 33. • Multiple LN groups are seen in 85% of cases, while single LN group occur in 15% of cases. • The enlarged LN may be of well defined margin or ill defined margin due to involvement of the adjacent structures. • It may be discrete or matted ( with obliteration of the intervening fat planes). • Enlarged LN appear of homogeneous soft tissue attenuation or may show central necrosis. • Enlarged lymph node may show calcification after TTT, which may be egg shell or stippled.
  34. 34. Pulmonary lymphoma 1ry Pulmonary lymphoma 2ry Pulmonary lymphoma Rare Common
  35. 35. 1ry pulmonary lymphoma • Usually NHL which is limited to the lung with or without mediastinal lymph node involvement and with no evidence of extrathoracic dissemination for at least 3 months after the initial diagnosis. • Usually BALTOMA (B cell low grade lymphoma).
  36. 36. Pulmonary manifestations • 10% of cases. • Associated with mediastinal lymphadenopathy in 100% of cases. • Pulmonary recurrence may occur in without lymph node enlargement in patients with prior mediastinal irradiation.
  37. 37. Patterns of pulmonary lymphoma Interstitial pattern Nodular pattern Alveolar pattern (lymphangitis carcinomatosis)
  38. 38. Pulmonary nodules • • • • • Single or multiple, Well defined or illdefined, Small or large & mass like, Cavitating or non cavitating, & the cavities may be thin or thick walled. Alveolar pattern • Air space consolidation with air bronchogram. Interstitial pattern (lymphangitis carcinomatosis) • Interstitial thickening. • Smooth or nodular . • Central (peribronchovascular interstitium )or peripheral (interlobular septa). • with preserved pulmonary architecture.
  39. 39. Pleural lymphoma • 15% of cases. • Unilateral pleural effusion. Pathology: • lymphatic obstruction (pleural effusion disappears after radiation of mediastinal LN). • Nodular pleural thickening. Pathology: • Direct infiltration from mediastinal mass.
  40. 40. Nodular pleural thickening
  41. 41. Chest wall lymphoma • 5% of cases. Pathology: • Direct spread from anterior mediastinal LN. • Lymphatic spread from axillary or supraclavicular LN.
  42. 42. Enlarged peribronchial LN
  43. 43. Lymphangitis carcinomatosis
  44. 44. CXR • Reticulonodular pattern. • Kerely B lines.
  45. 45. • Thickening of interlobular septa. • Thickening of the bronchovascular interstitium. • Enlarged LN. • Pleural effusion
  46. 46. Pulmonary micronodules
  47. 47. Pulmonary consolidation
  48. 48. Gastric lymphoma
  49. 49. Gastric lymphoma • Gastric lymphoma is the most common extranodal lymphoma (25%). • The most common GIT lymphoma (50%).
  50. 50. Risk factors of gastric lymphoma • • • • • HIV infection Helicobacter pylori infection, Celiac disease, Inflammatory bowel disease, and Immunosuppression after solid organ transplantation.
  51. 51. Pathology • Large B cell lymphoma (most common). • MALToma (2nd most common). • T cell lymphoma.
  52. 52. Barium meal Nodular thickening of gastric rugae Multiple masses Bull’s eye • Mass with central ulceration Linitis plastica • Thickened wall with reduced volume.
  53. 53. Barium meal • Nodular thickening of gastric rugae.
  54. 54. Barium meal • Nodular thickening of gastric ruggae.
  55. 55. Barium meal
  56. 56. Multiple masses with central ulcer
  57. 57. Linitis plastica (leather bottle stomach)
  58. 58. CT • Marked gastric mural thickening (2-4 cm). • Extensive lateral extension (submucosal spread). • Linitis plastica (submucosal spread involving the majority of the stomach). • Large perigastric lymph nodes.
  59. 59. DD • • • • Gastric carcinoma. GIST. Hypertrophic gastritis. Menetrier’s disease.
  60. 60. Gastric lymphoma
  61. 61. Gastric lymphoma
  62. 62. Gastric lymphoma Gastric carcinoma more likely to cause gastric outlet obstruction. more likely to be in the distal stomach Relatively preserve perigastric fat planes. more likely to extend beyond the serosa and obliterate perigastric fat planes More diffuse. More focal. Large perigastric lymph nodes. lymph nodes tend to be smaller and more localized to immediate draining nodes
  63. 63. Small bowel lymphoma
  64. 64. Small bowel lymphoma • Small bowel is 2nd most frequent site of GI tract involvement by lymphoma after stomach. • Ileum is most common site of small bowel lymphoma (Ileum has most lymphoid tissue) • Ileum > jejunum > duodenum.
  65. 65. Risk factors • Immunocompromised patient: – AIDS – Post-transplantation • Celiac disease. • H pylori +ve patients.
  66. 66. Pathology • • • • Most cases of small bowel lymphoma are NHL. B cell lymphoma > T cell lymphoma. MALToma (H pylori). PTLD (EBV)
  67. 67. Staging • 1E: single bowel tumor without nodal involvement • 2E: GI tumor focus with nodal disease below the diaphragm; nodal disease divided into regional and extraregional • 3E: GI tumor focus with nodal disease above and below the diaphragm and or serosal involvement +/- other organs involved • 3ES: Splenic involvement • 4E: Extralymphatic i.e. bone, liver
  68. 68. Primary intestinal lymphoma criteria include • Confinement of disease to a small bowel segment • Only regional lymphadenopathy • No hepatic or splenic involvement except by direct tumor extension • No palpable or mediastinal lymphadenopathy • Normal peripheral blood smear and bone marrow biopsy.
  69. 69. Patterns of intestinal lymphoma Circumferential mural thickening Aneurysmal dilatation Luminal narrowing Solid mass Regional LN enlargement Perforation
  70. 70. Radilogical findings • Circumferential mural thickening – – – – Variable thickness (1-7 cm). Short or long segment. May be assymetrical. May be nodular. • Aneurysmal dilatation • (due to infiltration of the muscular layer with destruction of the myenteric plexus). • Luminal narrowing & small bowel obstruction. • Solid mass. • Regional LN enlargement (50% of cases). • Perforation.
  71. 71. DD • • • • • Crohn’s disease. Adenocarcinoma metastases : melanoma, renal cell carcinoma. infection / enteritis leiomyoma / leiomyosarcoma / GIST.
  72. 72. Bone lymphoma Bone lymphoma Primary Secondary Rare common
  73. 73. Primary lymphoma of bone • Lymphoma within a single bone with or without regional nodal metastases and the absence of distal lesions within 6 months following the diagnosis.
  74. 74. Demographics • Children > adults
  75. 75. Pathology • B cell NHL.
  76. 76. Location • Long bones > Flat bones. • Distribution: • Metadiaphyseal.
  77. 77. Patterns of Bone lymphoma Lytic Sclerotic Mixed
  78. 78. Radiography • • • • • • Permeative bone destruction. Sclerotic pattern or mixed. Cortical tunneling. Bone sequestrum (DD osteomyelitis or Ewing). Aggressive periosteal reaction. Disproportionate large soft tissue mass, with apparently intact cortex (DD round cell tumors as Ewing or PNET).
  79. 79. Cortical tunelling
  80. 80. Renal lymphoma
  81. 81. Typical patterns of renal lymphoma Typical renal lymphoma Multiple masses Solitary mass Contiguous retroperitoneal extension Perirenal lymphoma Nephromegally with preserved renal contour
  82. 82. Patterns of renal lymphoma Multiple masses • Multiple hypovascular masses with smooth margin & little mass effect Solitary mass • Solitary hypovascular mass with smooth margin & little mass effect. Contiguous • Retroperitoneal mass with infiltration of the renal hilum & encasement of the renal vessels. retroperitoneal extension Perirenal lymphoma Nephromegaly with preserved renal contour • Perirenal mass surrounding the kidney with no parenchymal compression or functional impairment • infiltrative growth along the renal interstitium.
  83. 83. Multiple masses • This is the most common pattern. • Multiple • Hypovascular masses (hypodense relatively to the enhanced renal parenchyma). • with smooth margin & • Little mass effect (due to infiltrative growth pattern)
  84. 84. Solitary mass • Solitary mass, • Hypovascular (hypodense relatively to the enhancing renal parenchyma). • Smooth margin. • Little mass effect. • On the contrary of renal cell carcinoma which is hypervascular, with irregular margin & frank mass effect due to expansile growth pattern. • However it may show expansile growth pattern like renal cell carcinoma.
  85. 85. Renal lymphoma Multiple > single Hypo-vascular Smooth margin Infiltrative growth pattern Renal cell carcinoma Single > multiple Hyper-vascular Irregular margin Expansile growth pattern
  86. 86. Contiguous retroperitoneal extension • Retroperitoneal mass with infiltration of the renal hilum & encasement of the renal vessels (which remain patent despite of tumor encasement, a criteria specific for lymphoma).
  87. 87. Perirenal lymphoma • The perirenal lymphoma surrounding the kidney with no parenchymal compression or functional impairment.
  88. 88. Nephromegaly with preserved renal contour • Due to infiltrative growth along the renal interstitium.
  89. 89. Atypical CT patterns of renal lymphoma • • • • • Hemorrhage. Necrosis. Heterogeneous attenuation. Cystic transformation. Calcification.
  90. 90. Hepatic lymphoma
  91. 91. Hepatic lymphoma 1ry Extremely rare 2ry Common
  92. 92. Pathology • NHL.
  93. 93. Radiology • Multiple hepatic focal lesions. • Diffuse infiltration with organomegaly CT: • Hypodense. MRI: • Hypointense on T1. • Hyperintense on T2 (relative to the liver parenchyma). • Transient increased perilesional enhancement.
  94. 94. Splenic lymphoma
  95. 95. Splenic lymphoma 1ry Extremely rare 2ry Common
  96. 96. Patterns of splenic lymphoma Diffuse splenomegaly with no focal lesions Diffuse infiltration with milliary focal lesions < 5 mm Multiple focal lesions Large solitary focal lesions
  97. 97. • Diffuse splenic infiltration.
  98. 98. Pancreatic lymphoma
  99. 99. Pancreatic lymphoma Primary Secondary Rare common
  100. 100. Pathology • B cell NHL.
  101. 101. Patterns of pancreatic lymphoma Focal Diffuse Large pancreatic mass Diffuse pancreatic enlargement
  102. 102. DD Of pancreatic lymphoma Focal form Diffuse form Adenocarcionma Features suggestive of lymphoma Acute pancreatitis No dilatation of the distal pancreatic duct, even with proximal invasion. Preserved peri-pancreatic fat planes No encasement of the blood vessels, even with large bulky mass. Homogeneous mass. Lymph node enlargement below the level of renal veins.