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CT appearance of acute abdomen as initial presentation in lymphoma of the large and small bowel
ELSEVIER
CI’ APPEARANCE OF ACUTE ABDOMEN As INITIAL PRESENTATION IN LYMPHOMA OF THE LARGE AND SMALL BOWEL ERIC F? TAMM,
MD,
AND ELLIOT K. FISHMAN,
Computed tomography (CT) is playing an increasingly greater role as the initial diagnostic imaging modality for acute abdomen. Abdominal pain is the most common presenting complaint for intestinal Iymphoma, and acute abdomen is a not infrequent admitting complaint. We present the CT findings of five patients with intestinal lymphoma whose initial complaint was acute abdomen. Ofthesefive patients, four had an identifinble mass that was located in the right lower quadrant, with the fifth patient having no identifiable mass on CT. The avemge mass size was 7.8 cm. Three of the patients showed involvement of the colon only, and two showed involvement of the small bowel only, with acute abdomen in only one of the patients with small-bowel involvement being due to direct extension from mesenteric lymph nodes. Pneumoperitoneum and free intraperitoneal fluid were seen in two patients, It is important, therefore, that the radiologist be aware that one of the causes of acute abdomen with primary bowel :involvement is lymphoma, which can simulate appefidicitis or diverticulitis in its presentotion clinically and by physical examination. KEY WORDS:
abdomen;. Lymphoma; Abdominal pain; Small intestine; Small bowel; Colon; Large intestine; Pneumoperitoneum; Computed tomography; Diagnostic radiology
Acute
From The RussQl H. Morgan Department of Radiology and Rediological Science, bhns Hopkins Medical Institutions, Baltimore, Maryland. Address reprint requests to: Elliot K. Fishman, MD, Department of Radiology, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287. Received September 20, 1994; accepted October 20, 1994.
CLINICAL IMAGING 1996;20:21-25 Q Elsevier Science Inc., 1996 655 Avenue of the Americas,
New York, NY 10010
MD
INTRODUCI’ION Computed tomography (CT) is playing an increasingly greater role as the initial diagnostic modality in the evaluation of acute abdomen. Abdominal pain is also a common finding in patients with intestinal lymphoma (1, z), with acute abdomen being a not infrequent admitting diagnosis (3). Therefore, along with the more classic causes of acute abdomen, such as appendicitis and diverticulitis, lymphoma must also be included as a potential cause of acute abdomen. We present here the CT findings for five patients with small- or large-bowel lymphoma, whose initial presenting symptom was an acute abdomen. MATERIAIS
AND METHODS
We searched the medical records for patients with the histopathologically proved diagnosis of primary smallor large-bowel lymphoma since 1976. We were able to identify 53. Of these, 37 had radiographic records still available for review, and of these, 13 patients had CT studies performed when they had an episode of acute abdomen. Acute abdomen was defined as the sudden onset of abdominal pain. Of these, five had acute abdomen as their presenting symptom, prior to a diagnosis of lymphoma, and an abdominal CT as part of their initial evaluation, prior to any surgical intervention. Of these five patients, three were men and two were women. Patient ages were 26, 28, 51, 64, and 68 years. Histological diagnosis was based on specimens obtained by surgical laparotomy in all patients and the pathological findings were diffusely infiltrating largecell lymphoma (non-Hodgkin’s). In one of the five patients, lymphoma was suspected prior to the CT, which was obtained for evaluation of acute abdomen. Other diagnoses entertained were appendicitis with perfo-
0899-7W1/96/$15.00
SSDI 0899~7071(95)00003-9
22
CLINICAL
TAMM AND FISHMAN
ration, pelvic inflammatory disease with abscess, and exacerbation of Crohn’s disease. All studies were reviewed by two radiologists. RESULTS Of the five patients, three were noted as having a single abdominal mass; in one two abdominal masses were noted (Figure 1A and B), and in one patient no identifiable mass or other bowel abnormality was seen on CT (this patient was found on laparotomy to have a perforated transverse colon that histologically was found to be infiltrated with a B-cell lymphoma and to be associated with an abscess). In each of the patients presenting with a mass, the mass or masses were identified as being in the right lower quadrant. In three of the patients, there was only pathological involvement of the colon, and in two, there was only involvement of the small bowel. In one of these latter two patients, the lymphoma was found to have arisen in the mesenteric lymph nodes and to have involved the small bowel by direct extension (Figures 2A and B). The average size of the masses was approximately Z8 cm, with three having a solid appearance, and two containing air bubbles (Figure 3B), with one being frankly cavitary (Figure 4A). Only one patient showed bowel wall thickening (see Figure 2B), and only one showed bowel dilatation. Three patients had associated adenopathy, with one having right paraaortic adenopathy and the other two having mesenteric adenopathy. Three of the five had associated inflammatory changes of the mesentery.
IMAGING VOL. 20, NO. 1
Pneumoperitoneum (see Figure 4B) was seen in two patients and was associated with free intraperitoneal fluid. One of these two patients also showed free intraabdominal contrast. A third patient was found on surgical exploration to have perforation with spillage of bowel contents, neither of which were evident by CT examination. One patient showed dilatation of small-bowel loops proximal to a right-lower-quadrant mass. All five patients went to surgery, with two undergoing a right hemicolectomy, and in one patient each a transverse colectomy, an ileocolectomy, and an ileostomy following small-bowel resection. DISCUSSION The entity of lymphoma encompasses both Hodgkin’s and non-Hodgkin’s lymphoma. While Hodgkin’s lymphoma uncommonly involves extranodal tissue at initial diagnosis, non-Hodgkin’s lymphoma often does. Castellino (4) cited, in his review of the literature, a study showing 132 (31%) of 423 patients with newly diagnosed non-Hodgkin’s lymphoma as having extranodal tissue involvement. In patients infected with human immunodeficiency virus (HIV), this percentage appears to be even higher, with one study showing 86% of 112 HIV-positive patients with lymphoma (10 diagnosed as having Hodgkin’s disease) as having extranodal intraabdominal disease (5). Non-Hodgkin’slymphoma is responsible for approximately 3% of cancers diagnosed yearly; occurs at all ages, with a median age of 55 years; and has a male/
FIGURE 1. (A) Axial CT scan. with oral conkast materialonly, showinga 6 x
4-cm lymphomatous mass (solid oI1YIW) mising from the terminal ileum. (B) Axial CT scan from the same patient, showing a mesenteric bilobed ~5 x 4.5-cm mass (sojjd arrow) identified on pathology examination as mesenteric adenopathy.
IANUARY-MARCH1996
INITIALPRESENTATION OF LYMPHOMA
23
B FIGURE 2. (A) An axial CT scan, with oral contrast material only, showing an 8-cm lymphomatous mass (solid QP row) arising from the distal part of the small bowel. (B) Axial CT scan from the same patient as in (A), demonstrating thickened bowel loops (open arrow) and an adjacent mesenteric nodal mass [solid arrow).
female ratio of 1.4:1(4).Of these, approximately 10 to 20% will have the gastrointestinal tract as the initial site of involvement (6).The most common symptoms cited in patients with lymphoma of the small bowel have been, in order to frequency, abdominal pain, anorexia or weight loss, bowel obstruction, abdominal mass, diarrhea, nausea and vomiting, and rectal bleeding (2, 7, 8). In large-bowel involvement, in order of frequency, the symptoms on presentation have been abdominal pain, abdominal distention, weight loss, gastrointestinal tract transit problems, fatigue, and hemorrhage (1). Irrespective of the region of occurrence, whether stomach, small intestine, ileocecal region, or large intestine, pain was the most frequently occurring symptom, occurring in up to 90% of patients
B FIGURE 3. (A) Axial CT image, with oral contrast material only, showing a lymphomatous soft-tissue mass (solid arrow), arising from the ascending colon. (B) Axial CT image from the same patient as in (A), showing air bubbles in the same mass [solid arrow). Also present is a left renal cyst.
(6,s). Acute abdomen is not an unusual finding in patients with small- or large-bowel lymphoma. While some studies showed as many as 50 to 60% of patients with small-bowel lymphoma presenting as acute abdomen, generally the presentation is much more insidious (3,7,10). Studies of primary colonic lymphoma find percentages of patients presenting with acute abdomen varying between 4 and 14% (1,11).One study, focusing just on non-Hodgkin’s lymphoma of the ileocecal region, showed 19% as presenting as acute surgical emergencies (12). The most common extranodal abdominal locations for non-Hodgkin’s lymphoma are, in order of frequency,
24
TAMMANDFISHMAN
B FIGURE 4. (A) Axial CT scan, followingadministrationof
oral and intravenouscontrast material, showing a cavitary mass in the right lowerquadrantmeasuring 8 x 12 cm. (8) Axial CT image, same patient as (A), showingthe presence of free air [solid arrow) superior to the liver. the stomach, the small bowel, and colon (6,13-W). Primary colonic involvement, however, is rare, with coionic lymphoma constituting 0.1% of primary rectal tumors (16). Interestingly, three of the five patients in our study had involvement of the colon shown pathologically. In the same study cited in Castellino’s review (4), paraaortic, mesenteric, and splenic hilar adenopathy was seen in 49%) 51%) and 53%, respectively, of the 197 patients who underwent exploratory laparotomy as staging for lymphoma. In our study, one patient showed paraaortic adenopathy, and two showed mesenteric adenopathy.
CLINICALIMAGINGVOL.20,NO. 1
The CT appearance of lymphomatous involvement of the bowel has been previously described. In the small bowel, there is commonly bowel wall thickening, with the affected lumen appearing relatively dilated in comparison to the uninvolved bowel (13, 17). Mesenteric adenopathy is frequently associated (~$17). In one group of 14 HIV-positive patients with smallbowel involvement, 12 showed small-bowel wall thickening, with one showing a large mass involving the ileum (5). Lymphomatous involvement of the colon can vary, causing mucosal nodularity or mural invasion, or an endoexoenteric or an intraluminal mass, as well as mesenteric invasion (18). In a study (19) of seven patients with colonic lymphoma shown by CT and in barium studies, the lymphoma was seen on CT as focal masses in three and presented as infiltrating lesions in four. Bowel wall thickening can be marked (13,20). The diagnosis of lymphoma is much more likely if the tumor is well demarcated from the pericolonic fat, and has a cecal location that extends to the terminal ileum. The cecum is the most common site of involvement in the colon, ranging from 52 to 85% of cases in various studies, followed by the rectum at approximately 21 to 40%) with coincident involvement of the terminal ileum in up to 38% (1, 16, 18, 20). In one study, involvement of the ileocecal region alone accounted for 20% of patients who had lymphoma of the bowel (15). In our study, four of the five patients had a rightlowerquadrant mass. The findings were more in keeping with lymphomatous involvement of the colon, with involvement of the cecum in two patients and the terminal ileum in two. The one patient with involvement of the transverse colon showed no localizing signs on CT, and no evidence of bowel wall thickening or mass. Acute surgical complications of lymphoma are varied. In one group of 45 patients with gastrointestinal lymphoma, 19 presented as emergencies with hemorrhage, perforation, pyloric stenosis, or intestinal obstruction (21). In a study of gastrointestinal perforation in thirty-one cancer patients, 45% involving the small bowel and 55% involving the colon, 12 (40%) patients were found to have lymphoma (the highest percentage in the study) (22). The rate of perforation in patients with small-bowel lymphoma varies in the literature from 11% in one study (10) to as high as 30% in a study of 119 patients (2). Perforation of colonic lymphoma, however, is rare (11). Obstruction is relatively uncommon in lymphoma as compared to other tumors of the large and small bowel, with a review of 15 patients with small-bowel lymphoma showing no evidence of obstruction. Of our patients, unusually, lymphoma involved the colon in the two with CT evidence of perforation. Both
JANUARY-MARCH
INITIAL PRESENTATION
1996
pneumoperitoneum and free fluid were present in these patients. The perforation seen only pathologically was in lymphoma of the mesenteric nodes involving the small bowel by direct extension. Only one patient showed dilatation of a few small-bowel loops adjacent to an ileal mass, compatible with a possible partial small-bowel obstruction. In conclusion, CT has become the imaging study of choice in the patient with abdominal pain of unknown source. CT, by its cross-sectional imaging techniques, allows determination of the location and in most patients, the cause of the underlying clinical complaints. It is important for the radiologist to be aware that one of the causes of acute abdomen with primary bowel involvement is lymphoma. Patients with lymphoma can present with a clinical history as well as physical findings simulating appendicitis or diverticulitis. Careful analysis of the images should help in making the correct diagnosis.
7. Cooper BT, Read AE. Small intestinal 1985;9:930-937.
lymphoma.
World J Surg
8. Morgan DR, Holgate CS, Dixon MF, Bird CC. Primary small intestine lymphoma: a study of 39 cases. J Path01 1985;147:211-221, 9. Herrmann R, Panahon AM, Barcos MP, Wlash D, Stutzman L. Gastrointestinal involvement in non-Hodgkins lymphoma. Cancer 1980:46:215-222. 10. O’Rourke MG, Lancashire RP, Vattoune JR. Lymphoma small intestine. Aust NZ J Surg 1986;56:351-355.
of the
11. Shepherd NA, Hall P, Coates PJ, Levison DA. Primary malignant lymphoma of the colon and rectum: a histopathological and immunohistochemical analysis of 45 cases with clinicopathological correlations. Histopathology 1988;12:235252. 12. Sweetenham JW, Mead GM, Wright DH, et al. Involvement of the ileocecal region by non-Hodgkins lymphoma in adults: clinical features and results of treatment. Br J Cancer 1989;60: 366-369. 13. Megibow AJ, Balthazar EJ. Naidich DP, Bosniak MA. Computed tomography of gastrointestinal lymphoma. AJR 1983;141:541-547. 14. Freeman C. Berg JW, Cutler SJ. Occurrence and prognosis extranodal lymphomas. Cancer 1972;29:252-260.
of
15. Lewin KJ, Ranched M, Dorfman RF. Lymphomas of the gastmintestinal tract: a study of 117 cases presenting with gastmintestinal disease. Cancer 1978;42:693-767. 16. Bruneton JN, Thyss A, Bourry J, Bidoli R, Schneider M. Colonic and rectal lymphomas. Fortschr Rontgenstr 1983;138:283-287.
REFERENCES 1. Kayabali I, Gtikcora B-I, Bacaci
K, Cavusoglu T, Kutlu K. Primary colonic non-Hodgkin lymphomas: a retrospective clinicopathologic study of 14 cases. Int Surg 1992:77:195-197
2. Domizio P, Owen RA, Shepherd
NA, Talbot IC, Norton AJ. Primary lymphoma of the small intestine: a clinicopathological study of 119 cases. Am J Surg Path01 1993;17:429-442.
3. Back H, Gustavsson B, Ride11 B, Rijdjer S, Westin J. Primary gastrointestinal lymphoma: incidence, clinical presentation and surgical approach. J Surg Oncol 1986;33:234-238. 4. Castellino RA. The non-Hodgkins cepts for the diagnostic radiologist.
25
OF LYMPHOMA
lymphoma: practical conRadiology 199l;l78:315-321.
5. Radin DR, Esplin JA, Levine AM, Ralls PW. AIDS-related nonHodgkin’s lymphoma: abdominal CT findings in 112 patients. AJR 1993:180:1133-1139. 6. Brady IW, Asbell SO. Malignant lymphoma tinal tract. Radiology 1980;137:291-296.
of the gastrointes-
17. Megibow AJ. Gastrointestinal lymphoma: the mle of CT in diagnosis and management. Semin Ultrasound CT MR 1986;7: 43-57. 18. O’Connell DJ, Thompson AJ. Lymphoma of the colon: the spectrum of mdiologic changes. Gastmintest Radio1 1978;2:377-385. 19. Wyatt SH, Fishman EK, Jones B. Primary lympboma of the colon and rectum: CT and barium enema correlation. Abdom Imaging 1993;18:376-380. 20. Dodd GD. Lymphoma of the hollow abdominal Clin North Am 1990;28:771-783.
viscera. Radio1
21. Green JA, Dawson AA, Jones PE Brunt PW. The presentation of gastrointestinal lymphoma: study of a population. Br J Surg 1979;86:798-801. 22. Torosian MH, Turnbull AD. Emergency laparotomy for spontaneous intestinal and colonic perforations in cancer patients receiving corticostemids and chemotherapy. J Clin Oncol 1988;6:291-296.
CI’ APPEARANCE OF ACUTE ABDOMEN As INITIAL PRESENTATION IN LYMPHOMA OF THE LARGE AND SMALL BOWEL ERIC F? TAMM,
MD,
AND ELLIOT K. FISHMAN,
Computed tomography (CT) is playing an increasingly greater role as the initial diagnostic imaging modality for acute abdomen. Abdominal pain is the most common presenting complaint for intestinal Iymphoma, and acute abdomen is a not infrequent admitting complaint. We present the CT findings of five patients with intestinal lymphoma whose initial complaint was acute abdomen. Ofthesefive patients, four had an identifinble mass that was located in the right lower quadrant, with the fifth patient having no identifiable mass on CT. The avemge mass size was 7.8 cm. Three of the patients showed involvement of the colon only, and two showed involvement of the small bowel only, with acute abdomen in only one of the patients with small-bowel involvement being due to direct extension from mesenteric lymph nodes. Pneumoperitoneum and free intraperitoneal fluid were seen in two patients, It is important, therefore, that the radiologist be aware that one of the causes of acute abdomen with primary bowel :involvement is lymphoma, which can simulate appefidicitis or diverticulitis in its presentotion clinically and by physical examination. KEY WORDS:
abdomen;. Lymphoma; Abdominal pain; Small intestine; Small bowel; Colon; Large intestine; Pneumoperitoneum; Computed tomography; Diagnostic radiology
Acute
From The RussQl H. Morgan Department of Radiology and Rediological Science, bhns Hopkins Medical Institutions, Baltimore, Maryland. Address reprint requests to: Elliot K. Fishman, MD, Department of Radiology, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287. Received September 20, 1994; accepted October 20, 1994.
CLINICAL IMAGING 1996;20:21-25 Q Elsevier Science Inc., 1996 655 Avenue of the Americas,
New York, NY 10010
MD
INTRODUCI’ION Computed tomography (CT) is playing an increasingly greater role as the initial diagnostic modality in the evaluation of acute abdomen. Abdominal pain is also a common finding in patients with intestinal lymphoma (1, z), with acute abdomen being a not infrequent admitting diagnosis (3). Therefore, along with the more classic causes of acute abdomen, such as appendicitis and diverticulitis, lymphoma must also be included as a potential cause of acute abdomen. We present here the CT findings for five patients with small- or large-bowel lymphoma, whose initial presenting symptom was an acute abdomen. MATERIAIS
AND METHODS
We searched the medical records for patients with the histopathologically proved diagnosis of primary smallor large-bowel lymphoma since 1976. We were able to identify 53. Of these, 37 had radiographic records still available for review, and of these, 13 patients had CT studies performed when they had an episode of acute abdomen. Acute abdomen was defined as the sudden onset of abdominal pain. Of these, five had acute abdomen as their presenting symptom, prior to a diagnosis of lymphoma, and an abdominal CT as part of their initial evaluation, prior to any surgical intervention. Of these five patients, three were men and two were women. Patient ages were 26, 28, 51, 64, and 68 years. Histological diagnosis was based on specimens obtained by surgical laparotomy in all patients and the pathological findings were diffusely infiltrating largecell lymphoma (non-Hodgkin’s). In one of the five patients, lymphoma was suspected prior to the CT, which was obtained for evaluation of acute abdomen. Other diagnoses entertained were appendicitis with perfo-
0899-7W1/96/$15.00
SSDI 0899~7071(95)00003-9
22
CLINICAL
TAMM AND FISHMAN
ration, pelvic inflammatory disease with abscess, and exacerbation of Crohn’s disease. All studies were reviewed by two radiologists. RESULTS Of the five patients, three were noted as having a single abdominal mass; in one two abdominal masses were noted (Figure 1A and B), and in one patient no identifiable mass or other bowel abnormality was seen on CT (this patient was found on laparotomy to have a perforated transverse colon that histologically was found to be infiltrated with a B-cell lymphoma and to be associated with an abscess). In each of the patients presenting with a mass, the mass or masses were identified as being in the right lower quadrant. In three of the patients, there was only pathological involvement of the colon, and in two, there was only involvement of the small bowel. In one of these latter two patients, the lymphoma was found to have arisen in the mesenteric lymph nodes and to have involved the small bowel by direct extension (Figures 2A and B). The average size of the masses was approximately Z8 cm, with three having a solid appearance, and two containing air bubbles (Figure 3B), with one being frankly cavitary (Figure 4A). Only one patient showed bowel wall thickening (see Figure 2B), and only one showed bowel dilatation. Three patients had associated adenopathy, with one having right paraaortic adenopathy and the other two having mesenteric adenopathy. Three of the five had associated inflammatory changes of the mesentery.
IMAGING VOL. 20, NO. 1
Pneumoperitoneum (see Figure 4B) was seen in two patients and was associated with free intraperitoneal fluid. One of these two patients also showed free intraabdominal contrast. A third patient was found on surgical exploration to have perforation with spillage of bowel contents, neither of which were evident by CT examination. One patient showed dilatation of small-bowel loops proximal to a right-lower-quadrant mass. All five patients went to surgery, with two undergoing a right hemicolectomy, and in one patient each a transverse colectomy, an ileocolectomy, and an ileostomy following small-bowel resection. DISCUSSION The entity of lymphoma encompasses both Hodgkin’s and non-Hodgkin’s lymphoma. While Hodgkin’s lymphoma uncommonly involves extranodal tissue at initial diagnosis, non-Hodgkin’s lymphoma often does. Castellino (4) cited, in his review of the literature, a study showing 132 (31%) of 423 patients with newly diagnosed non-Hodgkin’s lymphoma as having extranodal tissue involvement. In patients infected with human immunodeficiency virus (HIV), this percentage appears to be even higher, with one study showing 86% of 112 HIV-positive patients with lymphoma (10 diagnosed as having Hodgkin’s disease) as having extranodal intraabdominal disease (5). Non-Hodgkin’slymphoma is responsible for approximately 3% of cancers diagnosed yearly; occurs at all ages, with a median age of 55 years; and has a male/
FIGURE 1. (A) Axial CT scan. with oral conkast materialonly, showinga 6 x
4-cm lymphomatous mass (solid oI1YIW) mising from the terminal ileum. (B) Axial CT scan from the same patient, showing a mesenteric bilobed ~5 x 4.5-cm mass (sojjd arrow) identified on pathology examination as mesenteric adenopathy.
IANUARY-MARCH1996
INITIALPRESENTATION OF LYMPHOMA
23
B FIGURE 2. (A) An axial CT scan, with oral contrast material only, showing an 8-cm lymphomatous mass (solid QP row) arising from the distal part of the small bowel. (B) Axial CT scan from the same patient as in (A), demonstrating thickened bowel loops (open arrow) and an adjacent mesenteric nodal mass [solid arrow).
female ratio of 1.4:1(4).Of these, approximately 10 to 20% will have the gastrointestinal tract as the initial site of involvement (6).The most common symptoms cited in patients with lymphoma of the small bowel have been, in order to frequency, abdominal pain, anorexia or weight loss, bowel obstruction, abdominal mass, diarrhea, nausea and vomiting, and rectal bleeding (2, 7, 8). In large-bowel involvement, in order of frequency, the symptoms on presentation have been abdominal pain, abdominal distention, weight loss, gastrointestinal tract transit problems, fatigue, and hemorrhage (1). Irrespective of the region of occurrence, whether stomach, small intestine, ileocecal region, or large intestine, pain was the most frequently occurring symptom, occurring in up to 90% of patients
B FIGURE 3. (A) Axial CT image, with oral contrast material only, showing a lymphomatous soft-tissue mass (solid arrow), arising from the ascending colon. (B) Axial CT image from the same patient as in (A), showing air bubbles in the same mass [solid arrow). Also present is a left renal cyst.
(6,s). Acute abdomen is not an unusual finding in patients with small- or large-bowel lymphoma. While some studies showed as many as 50 to 60% of patients with small-bowel lymphoma presenting as acute abdomen, generally the presentation is much more insidious (3,7,10). Studies of primary colonic lymphoma find percentages of patients presenting with acute abdomen varying between 4 and 14% (1,11).One study, focusing just on non-Hodgkin’s lymphoma of the ileocecal region, showed 19% as presenting as acute surgical emergencies (12). The most common extranodal abdominal locations for non-Hodgkin’s lymphoma are, in order of frequency,
24
TAMMANDFISHMAN
B FIGURE 4. (A) Axial CT scan, followingadministrationof
oral and intravenouscontrast material, showing a cavitary mass in the right lowerquadrantmeasuring 8 x 12 cm. (8) Axial CT image, same patient as (A), showingthe presence of free air [solid arrow) superior to the liver. the stomach, the small bowel, and colon (6,13-W). Primary colonic involvement, however, is rare, with coionic lymphoma constituting 0.1% of primary rectal tumors (16). Interestingly, three of the five patients in our study had involvement of the colon shown pathologically. In the same study cited in Castellino’s review (4), paraaortic, mesenteric, and splenic hilar adenopathy was seen in 49%) 51%) and 53%, respectively, of the 197 patients who underwent exploratory laparotomy as staging for lymphoma. In our study, one patient showed paraaortic adenopathy, and two showed mesenteric adenopathy.
CLINICALIMAGINGVOL.20,NO. 1
The CT appearance of lymphomatous involvement of the bowel has been previously described. In the small bowel, there is commonly bowel wall thickening, with the affected lumen appearing relatively dilated in comparison to the uninvolved bowel (13, 17). Mesenteric adenopathy is frequently associated (~$17). In one group of 14 HIV-positive patients with smallbowel involvement, 12 showed small-bowel wall thickening, with one showing a large mass involving the ileum (5). Lymphomatous involvement of the colon can vary, causing mucosal nodularity or mural invasion, or an endoexoenteric or an intraluminal mass, as well as mesenteric invasion (18). In a study (19) of seven patients with colonic lymphoma shown by CT and in barium studies, the lymphoma was seen on CT as focal masses in three and presented as infiltrating lesions in four. Bowel wall thickening can be marked (13,20). The diagnosis of lymphoma is much more likely if the tumor is well demarcated from the pericolonic fat, and has a cecal location that extends to the terminal ileum. The cecum is the most common site of involvement in the colon, ranging from 52 to 85% of cases in various studies, followed by the rectum at approximately 21 to 40%) with coincident involvement of the terminal ileum in up to 38% (1, 16, 18, 20). In one study, involvement of the ileocecal region alone accounted for 20% of patients who had lymphoma of the bowel (15). In our study, four of the five patients had a rightlowerquadrant mass. The findings were more in keeping with lymphomatous involvement of the colon, with involvement of the cecum in two patients and the terminal ileum in two. The one patient with involvement of the transverse colon showed no localizing signs on CT, and no evidence of bowel wall thickening or mass. Acute surgical complications of lymphoma are varied. In one group of 45 patients with gastrointestinal lymphoma, 19 presented as emergencies with hemorrhage, perforation, pyloric stenosis, or intestinal obstruction (21). In a study of gastrointestinal perforation in thirty-one cancer patients, 45% involving the small bowel and 55% involving the colon, 12 (40%) patients were found to have lymphoma (the highest percentage in the study) (22). The rate of perforation in patients with small-bowel lymphoma varies in the literature from 11% in one study (10) to as high as 30% in a study of 119 patients (2). Perforation of colonic lymphoma, however, is rare (11). Obstruction is relatively uncommon in lymphoma as compared to other tumors of the large and small bowel, with a review of 15 patients with small-bowel lymphoma showing no evidence of obstruction. Of our patients, unusually, lymphoma involved the colon in the two with CT evidence of perforation. Both
JANUARY-MARCH
INITIAL PRESENTATION
1996
pneumoperitoneum and free fluid were present in these patients. The perforation seen only pathologically was in lymphoma of the mesenteric nodes involving the small bowel by direct extension. Only one patient showed dilatation of a few small-bowel loops adjacent to an ileal mass, compatible with a possible partial small-bowel obstruction. In conclusion, CT has become the imaging study of choice in the patient with abdominal pain of unknown source. CT, by its cross-sectional imaging techniques, allows determination of the location and in most patients, the cause of the underlying clinical complaints. It is important for the radiologist to be aware that one of the causes of acute abdomen with primary bowel involvement is lymphoma. Patients with lymphoma can present with a clinical history as well as physical findings simulating appendicitis or diverticulitis. Careful analysis of the images should help in making the correct diagnosis.
7. Cooper BT, Read AE. Small intestinal 1985;9:930-937.
lymphoma.
World J Surg
8. Morgan DR, Holgate CS, Dixon MF, Bird CC. Primary small intestine lymphoma: a study of 39 cases. J Path01 1985;147:211-221, 9. Herrmann R, Panahon AM, Barcos MP, Wlash D, Stutzman L. Gastrointestinal involvement in non-Hodgkins lymphoma. Cancer 1980:46:215-222. 10. O’Rourke MG, Lancashire RP, Vattoune JR. Lymphoma small intestine. Aust NZ J Surg 1986;56:351-355.
of the
11. Shepherd NA, Hall P, Coates PJ, Levison DA. Primary malignant lymphoma of the colon and rectum: a histopathological and immunohistochemical analysis of 45 cases with clinicopathological correlations. Histopathology 1988;12:235252. 12. Sweetenham JW, Mead GM, Wright DH, et al. Involvement of the ileocecal region by non-Hodgkins lymphoma in adults: clinical features and results of treatment. Br J Cancer 1989;60: 366-369. 13. Megibow AJ, Balthazar EJ. Naidich DP, Bosniak MA. Computed tomography of gastrointestinal lymphoma. AJR 1983;141:541-547. 14. Freeman C. Berg JW, Cutler SJ. Occurrence and prognosis extranodal lymphomas. Cancer 1972;29:252-260.
of
15. Lewin KJ, Ranched M, Dorfman RF. Lymphomas of the gastmintestinal tract: a study of 117 cases presenting with gastmintestinal disease. Cancer 1978;42:693-767. 16. Bruneton JN, Thyss A, Bourry J, Bidoli R, Schneider M. Colonic and rectal lymphomas. Fortschr Rontgenstr 1983;138:283-287.
REFERENCES 1. Kayabali I, Gtikcora B-I, Bacaci
K, Cavusoglu T, Kutlu K. Primary colonic non-Hodgkin lymphomas: a retrospective clinicopathologic study of 14 cases. Int Surg 1992:77:195-197
2. Domizio P, Owen RA, Shepherd
NA, Talbot IC, Norton AJ. Primary lymphoma of the small intestine: a clinicopathological study of 119 cases. Am J Surg Path01 1993;17:429-442.
3. Back H, Gustavsson B, Ride11 B, Rijdjer S, Westin J. Primary gastrointestinal lymphoma: incidence, clinical presentation and surgical approach. J Surg Oncol 1986;33:234-238. 4. Castellino RA. The non-Hodgkins cepts for the diagnostic radiologist.
25
OF LYMPHOMA
lymphoma: practical conRadiology 199l;l78:315-321.
5. Radin DR, Esplin JA, Levine AM, Ralls PW. AIDS-related nonHodgkin’s lymphoma: abdominal CT findings in 112 patients. AJR 1993:180:1133-1139. 6. Brady IW, Asbell SO. Malignant lymphoma tinal tract. Radiology 1980;137:291-296.
of the gastrointes-
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