Imaging of Lymphoma
Dr.: Adel El-Badrawy
Assistant Professor of Radiology
Mansoura Faculty of Medicine
Imaging = Tumour assessment
1- Detection.
2- Staging
3- Response to treatment
4-Recurrence of disease
Non-Invasive methods of investigation
1- Plain films
2- Contrast studies as barium examination
3- Ultrasound (US)
4- Computerized Tomography (CT)
5- Magnetic Resonance Imaging (MRI)
6- Nuclear medicine (NM) [isotope scanning]
7- Positron emission tomography (PET)
CT
CT scan is the most commonly used imaging modality
for the detection, staging, and follow-up of lymphoma.
The role of CT scan in lymphoma is multifold. It is
used to
(1) define the full extent of disease to allow accurate
staging;
(2) assist in treatment planning (i.e, determine the site
of nodal biopsy, create radiation planning portals, and
select chemotherapy protocols);
(3) evaluate response to therapy; and
(4) monitor patient progress and possible relapse.
The diagnosis of abdominal organ involvement is aided
by the use of intravenous contrast.
MRI
• The accuracy of MR imaging in detecting lymph node
and organ involvement is similar to that of CT.
• MR imaging reveals the lymphoma masses to be:--- low to iso-signal intensity on T1-weighted images.
--- moderately high signal on T2-weighted images.
With successful treatment……… > low signal on T2
W.I. due to fibrosis.
Invasive methods of investigation
For biopsy taken
What is a biopsy?
A biopsy is the removal of a sample of tissue from the body for
examination. The tissue will be examined under a microscope to assist
in diagnosis. Therefore, only very small samples are needed
Biopsy taken under guidance of:
1- US
2- CT
Types of biopsy:
1-FNAC
2- Trucut
CT guided biopsy
Functional Imaging
Is imaging technique giving information about
metabolic activity of the tumors
1- PET & PET-CT.
2- Diffusion MR (DMR).
3- MRS (MR spectroscopy).
PET
• The majority of malignant tumours have an
increased glycolytic rate compared to normal
tissues.
• PET is a functional scanner allowing the
differentiation of metabolically active tissue
from scar tissue by injection of special material
(18FDG) (2-[fluorine-18-]-fluoro-2-deoxy-D-glucose).
• Active tumor tissues show increase uptake.
• No active tumor tissue show no or decreased uptake.
PET-CT
Diffusion-weighted MRI
Is a new MR technique & depends on ADC values to
tumor assessment
There is increasing interest in the application of DWI
for detecting tumor response.
Effective anticancer treatment results in tumor lysis,
loss of cell membrane integrity, increased
extracellular space, and, therefore, an increase in
water diffusion
Diffusion MRI
Freely Diffusing water
(high ADC)
Restricted Diffusing water (low
ADC)
(malignant tumor)
(benign tumor & resolved
tumor
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Imaging of Lymphoma
Nodal
Parenchymatous
GI tract
Liver
Spleen
Stomach
Intestinal
Nodal
Nodal
Recommendations for upper limits of normal lymph node size (short axis) at CT
Short axis nodal diameter (mm)
Site
Location
Abdomen
Gastrohepatic ligament
8
Porta hepatis
8
Portacaval
10
Celiac axis to renal artey
10
Renal artery to aortic bifurcation
12
Common iliac
9
External iliac
10
Internal iliac
7
Obturator
8
Pelvis
Inguinal region
10
Hepatic lymphoma
There are several patterns of hepatic involvement including
1. Hepatomegaly.
2. Multifocal hepatic masses resemble metastatic disease.
3. Miliary lesions (<1 cm in diameter) mostly seen in Hodgkin
disease.
4. Lymphomatous infiltration may be seen extending from the
porta hepatis along the margins of the portal veins resultingin
periportal patchy, irregular areas.
Multiple hepatic focal lesions
CT abdomen
US
Miliary lesions (<1 cm in diameter)
T1 (NON-CONTRAST)
T1 (POST-CONTRAST)
Lymphomatous infiltration
Multiple hepatic focal lesions
T2 MRI
T1 MRI
High signal
low signal
Splenic lymphoma
The imaging appearance of lymphoma of
the spleen consists of
1. Splenomegaly.
2. Solitary mass.
3. Multifocal nodules.
4. Diffuse infiltration.
GI tract lymphoma
Primary GI tract lymphoma is defined as:
• A tumor that predominantly involves the GI tract
with lymph node involvement confined to the
drainage area of the primary tumor site
• No liver or spleen involvement or palpable
lymph nodes
• Normal chest radiography
• Normal peripheral white blood cells.
Gastric lymphoma
Patterns of gastric lymphoma may include:1- solitary (nodular form).
2- or multiple submucosal nodules (polypoid form) with
or without ulcerations,
3- larger exophytic masses with necrosis and ulceration
(ulcerative form),
4- diffuse infiltration leading to fold thickening (infiltrative
form).
A sharp distinction between these forms is uncommon.
Advanced gastric lymphoma. Axial non-contrast CT scan reveals severe
gastric wall thickening up to 7 cm.
Gastric lymphoma: Multislice helical CT scan after oral and
intravenous contrast with isotropic coronal reformation
demonstrating marked thickening of the gastric antrum.
Gastric & Duodenal
Lymphoma
CT appearance of intestinal lymphoma are:
Intestinal wall:
1- Aneurysmal dilatation.
2- Nodular.
3- Constrictive.
Mesenteric affection:
1- Conglomerate mass of mesenteric/retroperitoneal tissue.
2- Sandwich-like complex.
CT revealed : Uniform isoattenuated marked wall thickening without small
bowel obstruction. Also note thickening of omentum by lymphomatous mass
(arrow).
Barium follow through: demonstrating corresponding abnormality with thickened
valvula conniventes (arrowheads) and separation from adjacent loops (arrow).
CT
Barium follow through
Small intestinal lymphoma. Small bowel follow-through demonstrating
aneurysmal dilatation and complete loss of normal fold pattern in a
loop of distal jejunum (arrows).
Intestinal lymphoma
Sandwitch-like appearance
Small bowel
lymphoma
Mesenteric mass
Response to treatment
(assessment of tumor response by imaging )
• To assess tumor response, adequate pre-
treatment staging must be performed.
• One must be able to define changes in tumor
volume and composition.
• Volume ----------> by CT.
• Composition
----- PET-CT--- decrease activity
------ MR signal--- low T2 signal.
------ Diffusion MRI.---Increase ADC value
CT Criteria for assessment of response in nonHodgkin lymphoma and Hodgkin lymphoma
Complete remission
* Complete disappearance of all detectable clinical and radiologic evidence of
disease.
* All nodal masses to have decreased to normal (<1.5 cm in diameter for nodes
that were >1.5 cm before therapy). If the nodes were initially between 1 and 1.5
cm, they must have decreased to 1 cm.
* The spleen, if previously enlarged on CT, must be normal and any focal lesions
should have resolved. Similarly, the liver and kidney, if previously involved,
must have returned to normal.
* If the marrow was involved it must be clear. Marrow biopsy and not imaging is
used for this criterion.
Partial response
* More
than a 50%decrease in sum of the product of perpendicular
diameters of the six largest nodes or masses. These nodes should be
from different areas of the body if possible, including the mediastinum
and retro peritoneum.
* No increase in the size of other nodes, liver, or spleen.
* Any splenic or hepatic lesions should have decreased by 50%.
* Involvement of other organs is assessable but not measurable disease.
* No new side of ascites.
Stable disease
* Less than partial response but not progressive disease.
Progressive disease
• Appearance of new lesions or an increase of more than 50%
in established lesions.
• Increase of more than 50% in the greatest diameter of any
previously identified node that was greater than 1 cm.
Thank You
Thank you
Imaging of Lymphoma
Dr.: Adel El-Badrawy
Assistant Professor of Radiology
Mansoura Faculty of Medicine
Detection
1- Plain films
- It is X-ray studies for all body bones.
- The lesions are osteolytic, sclerotic or mixed.
- May detected intestinal obstruction in cases
of GI lymphoma.
- Detection of calcification in previously
osteolytic bony lesion indicate improvement.
Detection
2- Contrast studies
1- Barium meals and enemas for the
detection of GI lymphoma
2- IVU may be used in cases of urinary tract
lymphoma for assessment of the lesions
or evaluate the renal function.
Detection
3- US
• It is either high frequency for superficial organs [7•
•
•
•
•
10 Mhz] or low frequency [2-5 Mhz] for deep organs
It may be gray scale or colored.
It is cheap, quick to perform, readily available with
no known harmful effects.
When combined with Doppler studies, tumour
vascularity and vascular invasion can be assessed.
It is operator and machine dependant.
It may be used for biopsy taken.
Detection
4- Computerised Tomography
What is CT Scanning of the Body?
* CT scanning—sometimes called CAT scanning—is a noninvasive
medical test that helps physicians diagnose and treat medical
conditions.
* CT scanning combines special x-ray equipment with sophisticated
computers to produce multiple images or pictures of the inside of the
body. These cross-sectional images of the area being studied can
then be examined on a computer monitor or printed.
* CT scans of internal organs, bone, soft tissue and blood vessels
provide greater clarity and reveal more details than regular x-ray
exams.
* Using specialized equipment and expertise to create and interpret CT
scans of the body, radiologists can more easily diagnose problems
such as cancers, cardiovascular disease, infectious disease, trauma
and musculoskeletal disorders.
Benefits
CT scanning is painless, noninvasive and accurate.
A major advantage of CT is its ability to image bone, soft tissue and blood vessels all at the same
time.
Unlike conventional x-rays, CT scanning provides very detailed images of many types of tissue as
well as the lungs, bones, and blood vessels.
CT examinations are fast and simple; in emergency cases, they can reveal internal injuries and
bleeding quickly enough to help save lives.
CT has been shown to be a cost-effective imaging tool for a wide range of clinical problems.
CT is less sensitive to patient movement than MRI.
CT can be performed if you have an implanted medical device of any kind, unlike MRI.
CT imaging provides real-time imaging, making it a good tool for guiding minimally invasive
procedures such as needle biopsies and needle aspirations of many areas of the body,
particularly the lungs, abdomen, pelvis and bones.
A diagnosis determined by CT scanning may eliminate the need for exploratory surgery and
surgical biopsy.
No radiation remains in a patient's body after a CT examination.
X-rays used in CT scans usually have no side effects.
Risks
There is always a slight chance of cancer from excessive exposure to radiation.
However, the benefit of an accurate diagnosis far outweighs the risk.
The effective radiation dose from this procedure ranges from approximately two to 10
mSv, which is about the same as the average person receives from background
radiation in three to five years. See the Safety page for more information about
radiation dose.
Women should always inform their physician and x-ray or CT technologist if there is
any possibility that they are pregnant. See the Safety page for more information
about pregnancy and x-rays.
CT scanning is, in general, not recommended for pregnant women unless medically
necessary because of potential risk to the baby.
Nursing mothers should wait for 24 hours after contrast material injection before
resuming breast-feeding.
The risk of serious allergic reaction to contrast materials that contain iodine is
extremely rare, and radiology departments are well-equipped to deal with them.
Because children are more sensitive to radiation, they should have a CT study only if
it is essential for making a diagnosis and should not have repeated CT studies unless
absolutely necessary.
Detection
5- MRI
Magnetic Resonance Imaging (MRI), or nuclear magnetic
resonance imaging (NMRI), is primarily a medical imaging
technique most commonly used in radiology to visualize detailed
internal structure and limited function of the body. MRI provides
much greater contrast between the different soft tissues of the body
than computed tomography (CT) does, making it especially useful in
neurological (brain), musculoskeletal, cardiovascular, and
oncological (cancer) imaging. Unlike CT, it uses no ionizing
radiation, but uses a powerful magnetic field to align the nuclear
magnetization of (usually) hydrogen atoms in water in the body.
Radio frequency (RF) fields are used to systematically alter the
alignment of this magnetization, causing the hydrogen nuclei to
produce a rotating magnetic field detectable by the scanner. This
signal can be manipulated by additional magnetic fields to build up
enough information to construct an image of the body.[1]:36
Gastric lymphoma
Overall, the appearance of gastric lymphomas
at barium fluoroscopy varies. Patterns may include
solitary (nodular form) or multiple submucosal
nodules (polypoid form) with or without ulcerations,
larger exophytic masses with necrosis and
ulceration (ulcerative form), and diffuse infiltration
leading to fold thickening (infiltrative form). A sharp
distinction between these forms is uncommon,
and the terms are purely descriptive. Even though
90% to 95% of gastric lymphomas are detected
on barium studies, that specific diagnosis is
made less than 20% of the time because of the
similarity in appearances to the more common
carcinoma and the other differential diagnostic
considerations like hypertrophic gastritis or Menetrier’s
disease.
CT appearance of intestinal lymphoma are:
Intestinal wall:1- Aneurysmal dilatation.
2- Nodular.
3- Constrictive.
Mesenteric affection:
1- Conglomerate mass of mesenteric/retroperitoneal tissue.
2- Sandwich-like complex.
Limitation of MRI
1- Claustrophobia overcomed by open MRI.
2- Metallic implant.
3- Long duration than CT
* IMAGING TECHNIQUES
- Cross-sectional imaging (CT scan, MR imaging) is
primarily used to detect lymphadenopathy and the
pattern of nodal involvement. Anatomic imaging is
limited in accurate lymphoma evaluation as small
lymph nodes may harbor malignant cells, whereas
large lymph nodes may be benign.
- Functional imaging, such as positron emission
tomography (PET) with fluorodeoxyglucose (FDG),has
shown promising results in the diagnosis of lymphoma
and complete assessment of the extent of disease. It
is also very useful in the follow-up of lymphoma
Complete remission: unconfirmed or uncertain
* As above (first and third point), but with a residual mass
greater than 1.5 cm, which must have regressed by more
than 75% from the original product of perpendicular
diameters. Individual nodes that were confluent must have
decreased by more than 75% of pre therapy sum of the
product of perpendicular diameters.
Imaging pitfalls
Reporting of increased number of normal-sized lymph nodes in the initial,
early staging CT is important. This finding should be reported because
these normal-sized but increased number of lymph nodes may represent
early abdominal disease, which may be relevant in staging; however, this
finding is still of unknown significance. This is different in patients who
have had multiple prior studies, which have established stable lymph
nodes.
Comparison with the most recent CT study is often not
sufficient because the growth becomes obvious only if
serial studies are compared. Small difference in
measurement (approximately 15%) in near normalsized lymph nodes between two CT examination is
often related to ‘‘plane of section’’ artifact (ie, related
to slice section). A follow-up study in 3 months is not
sufficient for follow-up of slow-growing lymphoma.
Splenic lymphoma
The imaging appearance of lymphoma of
the spleen consists of
1. Splenomegaly.
2. Solitary mass.
3. Multifocal nodules.
4. Diffuse infiltration.
Gastric lymphoma
Overall, the appearance of gastric lymphomas
at barium fluoroscopy varies. Patterns may include
solitary (nodular form) or multiple submucosal
nodules (polypoid form) with or without ulcerations,
larger exophytic masses with necrosis and
ulceration (ulcerative form), and diffuse infiltration
leading to fold thickening (infiltrative form). A sharp
distinction between these forms is uncommon,
and the terms are purely descriptive. Even though
90% to 95% of gastric lymphomas are detected
on barium studies, that specific diagnosis is
made less than 20% of the time because of the
similarity in appearances to the more common
carcinoma and the other differential diagnostic
considerations like hypertrophic gastritis or Menetrier’s
disease.
There are several patterns of hepatic involvement
including
1. Hepatomegaly.
2. Multifocal hepatic masses resemble metastatic
disease.
3. Miliary lesions (<1 cm in diameter) mostly seen in
Hodgkin disease.
4. Lymphomatous infiltration may be seen extending
from the porta hepatis along the margins of the
portal veins resultingin periportal patchy, irregular
areas.
Esophageal lymphoma.
(A) Right posterior oblique barium esophagogram demonstrating smooth stricture above
midesophagus, indicating circumferential tumor narrowing the lumen.
(B) Axial contrast enhanced thoracic CT demonstrating markedly concentrically
thickened esophagus with uniform iso-attenuated density of esophageal wall, and
narrow slit-like lumen.
MRI
• The accuracy of MR imaging in detecting lymph node
and organ involvement is similar to that of CT.
• MR imaging reveals the lymphoma masses to be:--- low to iso-signal intensity on T1-weighted images.
--- moderately high signal on T2-weighted imaging.
With successful treatment------ > low signal on T1
&T2 W.I. due to fibrosis.