Lymphoma most frequently results in generalized
thickening of the gastric wall but occasionally focal involvement
may occur. The gastric wall is usually greater than 1 cm thick
and can be as much as 5 cm thick. The mucosa is usually intact
but can be ulcerated. When using the stomach fluid-filled technique,
lymphomatous infiltration may be seen as extensive wall thickening
of varied echogenicity while the inner wall may be normal or thrown
into infiltrated polypoid folds. Circumferential involvement may
be associated with bulky focal masses and nodular exophytic involvement.
A target or atypical target sign may occur. The echogenicity of
lymphoma infiltration tends to be echopoor. Occasionally giant
gastric folds with a central star-like configuration of echogenicity
may be visible on ultrasound. 70% of lymphomes of the stomach
present with a target-like pattern of the gastric antrum with
uniform hypoechoic wall thickening.
Lymphoma usually causes diffuse infiltrates of the liver and spleen;
focal involvement is less common. Hepatomegaly may be reactive
as only 50 pet cent of patients with known lymphoma. The diffusely
infiltrating type of liver lymphoma is difficult to image with
ultrasound as it may cause subtle architectural distortion or
no ultrasound abnormality at all. . Only 5% of patients with lymphoma
will have discrete nodular involvement that can be detected by
an imaging study.
Focal hepatic lymphoma is less common. There are three liver patterns
that predominate when lymphoma is seen. The first and most common
is the hypoechoic mass. The mass is usually round or oval, with
well-defined smooth borders. There is almost always more than
one nodule present. A few low-level internal echoes may be seen.
The size of the masses varies from 1 to 15 cm. A second and uncommon
pattern is that of extensive hypoechoic liver infiltrates having
a "geographic pattern". Occasionally, the third pattern, a hyperechoic
mass, may be seen. There has been one reported case of a fourth
pattern, a "starry sky" pattern.
Lymphadenopathy is frequently encountered
in the extremities. High-resolution transducers are capable of
routinely identifying normal lymph nodes in the axilla and the
groin. They are hypoechoic and oval and usually have a detectable
central echogenic hilum. As in the neck, there is overlap in the
appearance of reactive and neoplasic lymphadenopathy.
Malignant nodes (and tuberculous nodes) are usually round in shape
with a short axis to long axis ratio greater than or equal to
0.5 (S/L > 0,5), whereas reactive and normal nodes are usually
long or oval-shaped. Therefore, nodal shape should be considered
as the sole criterion in the diagnosis. However, eccentric cortical
hypertrophy, which indicates focal intranodal tumor infiltration,
is a useful sign to identify malignant nodes.
Lymphomatous nodes tend to have sharp borders, whereas reactive
and normal nodes usually show unsharp borders.
Echogenic hilus is a normal sonographic feature of most of the
normal lymph nodes and it is commonly seen in larger nodes. Echogenic
hilus is appeared to be continuous with the adjacent soft tissues.
Although,lymphomatous nodes tend to have absent hilus, they may
present with an echogenic hilus in their early stage of involvement.
Therefore, the presence/absence of echogenic hilus should not
be the sole criterion in the diagnosis.
Lymphomatous nodes are predominantly hypoechoic when compared
with the adjacent muscles. Lymphomatous nodes were previously
reported to have a pseudocystic appearance, i.e. hypoechoic with
posterior enhancement. With the use of newer transducer, lymphomatous
nodes are less likely to have the pseudocystic appearance, whereas
they demonstrate a micronodular appearance.
Intranodal calcification may be found in lymphomatous nodes after
treatment and the calcification is usually dense and shows acoustic
Normal and reactive lymph nodes tend to have hilar vascularity
or appear apparently avascular, whereas metastatic nodes usually
show peripheral or mixed vascularity, and lymphomatous nodes predominantly
demonstrate mixed vascularity. As peripheral vascularity is not
found in normal or reactive nodes, the presence of peripheral
vascularity, regardless of sole peripheral or mixed vascularity,
is highly suspicious of malignancy.
The role of the evaluation of the vascular resistance (RI and
PI = resistance and pulsatility index) in distinguishing malignant
and benign nodes is controversial. It has been reported the metastatic
nodes have a higher RI and PI than reactive nodes. However, other
studies noted that there was no significant difference in RI and
PI between benign and malignant nodes
of splenic lymphoma
Splenic involvement with Hodgkin's and non-Hodgkin's lymphoma
usually occurs in a diffuse distribution which can be detected
only microscopically. In general, when an abnormality is noted,
only splenomegaly vvithout focal defect is identified on the ultrasound.
Sonographic visualization of focal splenic lesions in lymphoma
patients is uncommon. However, when detected, the masses are usually
focal, hypoechoic, poorly marginated, and homogeneous. Occasionally,
inhomogeneities may be present within the lesion due to hemorrhage
or necrosis. Other sonographic patterns include target lesions,
Large nodules up to 20cm in diameter, Small miliary nodules, or
splenic hilar adenopathy. There is a high incidence of simultaneous
lymphomatous involvement of the liver and spleen.
Primary pancreatic lymphoma is rare. The clinical presentation
is not unlike that of pancreatic carcinoma. Sonography may reveal
a homogeneous sonolucent or complex mass. These masses are usually
echopoor and mimic cystic lesions. As the prognosis of a pancreatic
lymphoma is favorable, differentiation from a carcinoma is crucial.
Ultrasound-guided biopsy may reveal the true nature of the mass.
Sonography may reveal eccentric wall thickening by lymphomatous
infiltrate. This is usually anechoic but hemorrhage and clot may
give rise to echogenic areas. There may be aneurismal dilatation
of the bowel lumen and enlargement of adjacent nodes. Anechoic
deposits may mimic duplication cysts. The combination of eccentric
bowel wall thickening with aneurismal dilatation and mesenteric
lymphadenopathy produces the so-called 'sandwich sign'. the finding
of hypoechoic solid masses surrounding a central linear hyperechoic
area has been termed the "sandwich sign." The hyperechoic area
represents fat surrounding the mesenteric vessels. The sandwich
sign indicates lymphomatous involvement of the mesentery.
Sonography, Large bowel lymphoma is usually indistinguishable
from a carcinoma causing an atypical or typical target sign. However
the bowel thickness tends to be more hypoechoic in lymphoma than
Renal lymphoma may have several appearances. The most common appearance
in 90% of cases is multiple renal masses, although renal lymphoma
may also present as a single mass. On ultrasound, the masses are
generally hypoechoic or anechoic. At times, they may mimic a fluid-filled
cyst, but differentiation is generally possible since the solid
masses of lymphoma lack a sharply defined wall and posterior acoustic
enhancement. Occasionally, the masses may be isoechoic or slightly
hyperechoic relative to the adjacent renal parenchyma.
Diffuse infiltration of the kidney may be seen in the other 10%
of cases, with the involved kidney usually enlarged and distorted.
Adrenal lymphomatous infiltration is not uncommon. Sonographically
these tumors, in common with other sites of lymphomas involvement,
are echopoor, however areas of echogenicity may occur because
of hemorrhage or infarction. The appearances may closely resemble
Primary lymphoma of the bladder has no characteristic ultrasound
features. The tumor may infiltrate the bladder wall or present
as a polyp. Tissue diagnosis is usually required.
The ovaries are a 'sanctuary' organ for lymphoma. Lymphoma of
the ovary is usually part of a more extensive disease elsewhere
and often results from dissemination from other sites such as
lymph nodes; ovarian lymphoma deposits are solid but echopoor.
Often bilateral ovarian enlargement is usual.
of the psoas muscle
The psoas muscle is an infrequent site of extra nodal lymphoma.
Sonography may reveal a hypoechoic enlargement of the psoas and
Para vertebral muscles or an anechoic featureless Para vertebral
mass indistinguishable from an abscess or hematoma on sonographic
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