Presentation1.pptx, radiological imaging of extra nodal lymphoma.

Extra-nodal

lymphoma.

Dr/ ABD ALLAH

NAZEER. MD.

Extranodal disease refers to lymphomatous infiltration of anatomic sites other than the lymph nodes.Extranodal involvement by lymphoma has been described in almost every tissue of the body, with many different imaging manifestations and simulating other neoplasticor infectious diseases.Although lymphoma involves the lymph nodes predominantly, extranodal disease arises in up to 5% of Hodgkin Lymphoma (HL) and 30% of Non Hodgkin Lymphoma (HL), and their prevalence is increasing, especially in immunocompromised patients and in patients with recurrent disease.Thus, it should be regularly included in the differential diagnosis of mass lesions and focal mucosal thickening.

Initial Imaging:Standard radiological work-up of a newly diagnosed patient with head and neck lymphoma should include:-Posterioanterior and lateral chest X-ray.-Contrast-enhanced computed tomography(CT) of the neck, chest, abdomen and pelvis.-Ultrasound (US) of the neck may be useful as an adjunct study.-Magnetic resonance imaging (MRI) may substitute contrast-enhanced CT of the neck, especially if Waldeyer’s ring is involved or extranodal head and neck disease is present.-At most institutions, 18F-FDG PET has replaced 67Ga-citrate single-photon imaging and is frequently used for the initial staging and for follow-up of many types of lymphoma.Contrast CT is indicated for evaluation of lymph nodes, paranasal sinuses, orbits and for staging and assessing bony involvement.Magnetic Resonance Imaging (MRI) is preferred for the assessment of extension of lymphomas to different fascial spaces and for intracranial and intra-spinal extension.US may be helpful because it can be used to guide fine needle aspiration cytology (FNAC).

ThyroidRare (7% of head and neck lymphoma).Primary thyroid disease is usually (80%) associated with underlying Hashimoto disease.Clinical presentation: asymptomatic; if large mass: may cause dyspnea, dysphagia and hoarseness.The most common presentation of thyroidal involvement by lymphoma is a rapidly enlarging thyroid mass.It may present as a single or multiple masses or by diffuse infiltration. US demonstrates a heterogeneous hypoechoic mass. CT shows a hypodense mass with poor enhancement; in MRI it is hypointense to muscle on T1WI and T2WI.The most important differential diagnosis is with anaplastic thyroid carcinoma (which has a poor prognosis, is heterogeneous and has multifocal calcifications). Goiter may mimic lymphoma with diffuse infiltration.Fine-needle aspiration of thyroid lesions may prove difficult to interpret in lymphoma, particularly with a background lymphocytic infiltrate associated with Hashimoto disease.

Low grade non-hodgkin B-cell lymphoma, with thyroid involvement, in a 83-year-old male and (b) primary diffuse large cell lymphoma of the thyroid, in a 86-year-old male (a) Axial unenhanced CT image reveals an enlarged homogenous thyroid right lobe (yellow arrow), displacing the trachea (orange arrow). (b) Axial unenhanced CT image shows an enlarged homogeneous thyroid left lobe (yellow arrow), that also displaces the trachea (orange arrow).

Primary MALT lymphoma of the thyroid, in a 85 year old female. Axial and (b) coronal unenhanced CT image reveals a enlarged thyroid (yellow arrow), with spontaneous hyperdense heterogeneous nodules (orange arrows).

Thyroid lymphoma. Axial contrast-ehanced CT image shows diffuse enlargement of the thyroid gland by a relatively homogenous mass causing tracheal and jugular vein compression. Thyroid lymphoma may presents as a focal mass, multiple thyroid nodules, or diffuse enlargement of the gland, with rapid growth. An absence of calcification and necrosis aids in distinguishing it from anaplastic carcinoma. It also shows a propensity to encircle the trachea, sometimes producing a characteristic ‘‘doughnut sign’’ on CT. Associated cervical adenopathy is also present in this patient.

Waldeyer’s Ring NHL. Axial contrast-enhanced CT shows a large submucosal mass in the nasopharyngeal lumen and extending bilaterally into the choanae and tonsils. Waldeyer’s lymphoma appears in the lymphoid tissues located superiorly in the nasopharynx (palatine tonsils), laterally in both tonsillar fossae (adenoids) and inferiorly in the base of tongue (lingual tonsils)

A and B, Axial contrast-enhanced arterial phase CT images of neck show homogeneous enhancing mass arising from left side of Waldeyer's ring (arrow, A) with extension into retropharyngeal space (arrow, B). Differential diagnosis includes squamous cell carcinoma. There are no imaging features to specify lymphoma in this case. Biopsy revealed diffuse large B-cell lymphoma.

Oral cavity lymphoma. Axial contrast-enhanced CT shows a mass involving palate, maxilla, and gingiva.

Laryngeal lymphoma. Axial contrast-enhanced CT image at the superior border of the hyoid bone shows left large submucosal mass. Laryngeal lymphomas tend to have a large submucosal component most frequently centered in the supraglottis

A and B, Axial contrast-enhanced CT images of neck show asymmetry of left pyriform fossa with suggestion of infiltrative soft-tissue mass (arrows) in pyriform fossa. Differential diagnosis is between squamous cell carcinoma and lymphoma. Biopsy in this case revealed diffuse large B-cell lymphoma. Again, biopsy was necessary because there were no imaging features to specify lymphoma in this case.

Lacrimal gland NHL. Axial contrast-enhanced CT image shows enlargement of right lacrimal gland, with slight enhancement. There is slight medial and forward displacement of the globe. Orbital lymphomas can involve the conjunctiva, the lacrimal gland or the intra-orbital fat, and are mostly indolent lesions. These are smooth, sharply marginated lesions that show moderate to strong enhancement.

Sinonasal NHL. Contrast-enhanced CT images. Axial and coronal images show a soft-tissue mass with homogenous enhancement centered in the left maxillary sinus. The mass is extending into the nasal cavity.

Nasal NHL. Axial CT image shows a soft-tissue homogenous mass in nasal cavity.

LungPrimary lung lymphoma is very rare (<1% of lymphoprolifrative diseases).The frequency of pulmonary involvement by NHL is 30% (up to 60% in autopsy series) and 10% in HL.Patterns of involvement:Single or multiple nodules sharply or ill defined, with variable size.Masses or "mass-like" consolidation: may simulate pneumonia with air bronchogram and segmental atelectasis.Peribronchial and perivascular interstitial disease, mimicking lymphangitis (brochovascular thickening, interlobular septal thickening, centrilobular nodules and ground glass opacities). In HL may occur by direct lung extension from hilar or mediastinal nodal disease.Mediastinal lymphadenopathy is present in 20-40% in NHL. HL is almost always associated with mediastinal or hiliar lymphadenopathy.

Non-Hodgkin B-cell lymphoma infiltrating the lung, in a 78 years-old male (a) X-ray showing multiple nodules and consolidations (yellow arrows), bilaterally. (b) and (c) Axial contrast enhanced CT shows multiple nodules bilaterally and a mass (yellow arrows) in the right lung.

Hodgkin disease, scleronodular type, of the lung, in a 17 years-old female (a) and (b) Contrast-enhanced CT shows a single nodule (yellow arrow).

Follicular non-Hodgkin B-cell lymphoma infiltrating the pleura, in a 78 years old male (a) and (b) Axial and (c) Coronal contrast enhanced CT reveals a pleural effusion.

Primary diffuse large cell lymphoma of the pleura, in a 78 years-old male (a) Axial and (b) Sagittal contrast-enhanced CT demonstrates a heterogeneous mass (yellow arrows) in the posterior pleura that infiltrates the 8, 9 and 10th posterior Intercostal muscles of the left hemithorax with a calcified plaque (orange arrows) (c) Pet scan revealing FDG uptake in the same location.

Mediastinal (thymic) large B cell lymphoma.Mediastinal large B cell lymphoma is a type of non-Hodgkin’s lymphoma. Lymphoma is cancer of the lymphatic system and can be subdivided into Hodgkin’s and non-Hodgkin’s lymphoma.It is typically present in females (F:M ratio of 3:1) in the 4th or 5th decade of life.Rapidly growing invasive tumour with contiguous spread into mediastinal tissues.Pleural and pericardial invasion with effusion are common. And 30 to 40% of patient have superior vena caval obstruction at diagnosis.The lesions are frequently bulky (65 % being > 10 cm in diameter.

The cause is unknown.It does not run in families or occur because of genetic changes.There does not seem to be a relation to toxic agents. It is non-infectious and cannot be passed on to other people.

X-Ray and CT scan of the chest showing an anterior right mediastinal mass and paratracheal lymphadenopathy. A biopsy of the mass was consistent with mediastinal (thymic) large B cell lymphoma.

Mediastinal (thymic) large B cell lymphoma with pleural and pericardial effusion

EsophagusPrimary lymphoma: <1% of GI lymphomas.Secondary invasion from lymph nodes and direct infiltration from gastric lymphoma is far more common.Symptoms - nonspecific: dysphagia, vomiting, loss of appetite, and weight loss or asymptomatic. (Same of other esophageal tumours).Radiologic patterns – variable: submucosal infiltration (most common), thickened mucosal folds, submucosal nodules accompanying a tumoral mass; erosion/ulceration; and tumoral mass without narrowing or stricture formation. Less common features are polypoid masses, stricture and achalasia-like appearance.CT: local staging, diagnosis of complications (perforation and fistulisation).Esophageal biopsy is necessary for diagnosis; however, it may be difficult to obtain sufficient tissue for diagnosis because of the submucosal location of most lymphomas.

Primary non-Hodgkin B-cell Lymphoma of the esophagus, in a 48 years-old male Contrast enhanced CT in the axial (a) and coronal (b) planes, shows a heterogeneous mass (yellow arrows) in the esophagus with well defined borders that reduces its lumen.

Primary diffuse large cell lymphoma of the esophagus, in a 67 years-old male (a) Coronal and (b) and (c) axial unenhanced CT demonstrates a heterogeneous mass (yellow arrow) in the oesophagus that have perfurated and fistulised (orange arrow) to the right main bronchus.

StomachMost frequent site of malignant lymphoma of the GI tract (60 a 75% of cases).Primary gastric lymphoma: 2–5% of gastric malignancies (the most common is MALT lymphoma, and associated with Helicobacter pylori infection).Unifocal (++antrum)Secondary gastric lymphoma: Multi-focal (+fundus and duodenum).Radiologic patterns: polypoidal mass, diffuse or focal submucosal infiltration, ulcerative lesion (bull’s eye appearance), or mucosal nodularity. The infiltrating form is the most common and may be difficult to differentiate from carcinoma.Diffuse gastric thickening is best shown by CT. Linitis plastic appearance results form extension of the tumor along the stomach wall. Gastric luminal diameter, distensibility and perigrastric fat planes are preserved. Transpyloric spread into the duodenum is more commonly seen in lymphoma than adenocarcinoma.CT: mass with homogenous attenuation; may contain areas of low density representing necrosis. Bulky lymphadenopathy or lymphadenopathy beneath the renal hila is highly suggestive of lymphoma. Splenic involvement - suggestive of lymphoma. Hepatic metastases - characteristic of adenocarcinoma.

Primary diffuse large cell lymphoma of the stomach, in a 83 years-old male (a) and a 73 years-old female (b and c). Axial and coronal contrast enhanced CT reveals a homogeneous hypodense lesion in the gastric fundus in both patients (yellow arrow).

Primary diffuse large cell lymphoma of the stomach, in a 32 years-old female Axial non-enhanced CT reveals a homogeneous hypodense lesion in the lesser curvature of the stomach that appears ulcerated and cavitated with contrast in the interior (yellow arrow).

Primary diffuse large cell lymphoma of the stomach, in a 60 years-old female Axial non-enhanced CT shows hypertrophic folds of the stomach in the lesser curvature of the stomach (orange arrow) and circumferential wall thickening (orange arrow).

Primary MALT lymphoma of the stomach, in a 56 years-old male Axial contrast enhanced CT reveals a homogeneous hypodense lesion in the lesser curvature of the stomach that has gas in the interior (yellow arrow).

Mantle cell lymphoma of the duodenum, in a 62 years-old female (a) Axial, (b) coronal and (c) sagittal non-enhanced CT reveals a homogeneous hypodense wall thickening of the duodenum (yellow arrow). There are multiple adenophaties in the mesentery and a mass (orange arrow) that extends and infiltrates the small bowel.

MALT lymphoma of the gastric antrum and duodenum, in a 74 years-old male. Bone marrow examination revealed infiltration with lymphoma. Axial non-enhanced and enhanced CT reveals a homogeneous hypodense wall thickening of the duodenum and gastric antrum (yellow arrow).

Peripheral T-cell lymphoma of the duodenum (a) Axial, (b) coronal and (c) sagittal contrast enhanced CT reveals a homogeneous hypodense wall thickening of the duodenum (yellow arrow) causing dilatation of intra and extra-hepatic biliary ducts (orange arrows).

Small BowellOne of the most common primary malignancies of the small bowel. Several patient groups are at higher risk for developing small bowel lymphoma: long standing celiac disease, systemic Lupus, AIDS and Crohn disease.Primary small bowel lymphoma is usually of B -cell origin, most frequently in the terminal ileum where there is the greatest concentration of lymphoid tissue. Jejunum is the most frequent site for T-Cell lymphoma, which can be a complication of celiac disease.Peripheral T-cell lymphoma has a higher prevalence of multifocal involvement and bowel perforation.There are four radiological patterns of disease in the small bowel:Nodular – cobblestone appearances on barium studies shows. The submucosal polyps may ulcerate (‘bull’s eye’ appearance). May induce intussusception.Exophytic / Endoexoenteric mass - B-Cell lymphoma classically presents as a large circumferential mass in the intestinal wall, frequently spreading to the small bowel mesentery and lymph nodes. Ulceration, perforation and fistulisation may occur. Aneurysmal dilation may be seen due to loss of bowel wall tonicity following infiltration and destruction of the autonomic nerve plexus and muscularis.Infiltrative pattern - presents as diffuse bowel wall thickening. Aneurysmal dilation is also common. Obstruction is unusual.Mesenteric invasion - may involve the small bowel via direct extension and invasion or by displacing bowel. The ‘sandwich sign’ consists in the mesenteric mass surrounding mesenteric vessels, which are separated by mesenteric fat. Bulky retroperitoneal adenopathy commonly accompanies the mesenteric disease.

Non-Hodgkin B-cell lymphoma in the mesentery with infiltration of the small bowel, in a 60 years-old female (a) Coronal and (b) axial contrast enhanced CT shows a hypodense mass, with more hypodense areas inside corresponding to areas of necrosis (yellow arrow), in the mesentery that invades the small bowel wall (orange arrow).

Diffuse large cell lymphoma in the mesentery with infiltration of the jejunum and, after three months of evolution, ileum and transverse colon, in a 60 years-old female. Axial and coronal CT (with and without contrast enhancement) reveals a hypodense mass, with areas of necrosis (yellow arrow), in the mesentery invading the small bowel, duodenum and colon (orange arrow)

Primary non-Hodgkin B-Cell lymphoma of the terminal ileum, that perforated after chemotherapy, in a 35 years-old male. a) Axial non-enhanced CT reveals a homogenous, circumferential wall thickening of the ileum (yellow arrow). b) and c) Axial and coronal non-enhanced CT shows stranding of tissue surrounding the ruptured ileum (green arrow) and Pneumoperitoneum (orange arrow).

Primary non-Hodgkin B-Cell lymphoma of the terminal ileum, that grew in 9 months, infiltrating the ascendant colon, in a 77 years-old male. a) Axial non-enhanced CT reveals a hypodense, homogenous wall thickening of the terminal ileum (yellow arrow), b) Axial and c) coronal non-enhanced CT shows the mass after 9 months: significant increase of the volume, more heterogenous, with lobulated contours, with the cecum in the center (orange arrow). d) Pet scan shows the mass with FDG uptake (green arrow).

ColonThe cecum and rectum are the most commonly involved segments.Most are NHL (++ B-cell).The patterns of large-bowel involvement include:Polypoidal masses (frequently near the ileocaecal valve), Infiltrative tumour with long segment of mural thickening with loss of haustrae , Large cavitating mass excavating into the mesentery, Fold thickening , Paradoxical aneurysmal dilation.Usually involves multiple and longer segments of gut.Unlikely to cause bowel obstruction. With cecal disease, intussusception can occur.MRI: used in local staging of rectal cancers. Usually has homogeneous intermediate signal intensity on T1-WI and heterogeneous hyperintensity on T2-WI and mild to moderate enhancement after Gadolinium injection.Massive regional, mesenteric and retroperitoneal adenopathy is highly suggestive of lymphoma.Features that help to differentiate from colorectal adenocarcinoma: extension into the terminal ileum, well defined margins, preservation of fat planes, lack of invasion, and perforation in the absence of desmoplastic reaction.Bowel perforation is an uncommon complication of gastrointestinal lymphoma but is more likely with T-cell lymphoma, with PTLD, and after chemotherapy or radiation therapy.An important entity in the differential diagnosis is neutropenic colitis.

Non Hodgkin B cell lymphoma of the colon, in a 61 year old male, (a) Axial, (b) coronal and (c) sagittal unenhanced CT reveals a mass in the wall of the sigmoid colon (yellow arrow). There is evidence of colo-colonic intussusception (purple arrow).

Mantle lymphoma of the colon, in a 74 year old male, (a) Axial and (b) coronal contrast enhanced CT reveals a circumferential wall thickening of the right colon (yellow arrow). There are innumerous adenophaties in the mesentery and lombo-aortic territory (purple arrow).

Burkett lymphoma of the thyroid, in a 26 year old pregnant woman, with involvement of the right colon a) T2 weighted MRI of the neck show homogeneous enlargement of the thyroid left lobe (orange arrow). (b) Axial, (c and d) coronal and (e) sagittal T2 weighted MRI, reveals a mass in the right colon (yellow arrow), hyperintense comparing to the liver, and the fetus (purple arrow).

NHL in a 16-year-old girl. Axial contrast-enhanced CT of the pelvis reveals soft-tissue mass involving the rectal region (arrows).

Peritoneum and Peritoneal Reflections: Peritoneal lymphomatosis is a rare clinical presentation that is often associated with high grade primary gastrointestinal NHL and is radiologically indistinguishable from peritoneal carcinomatosis. The patterns of involvement include discrete nodules, a diffuse infiltrative mass, and ascites. Exudative ascites from peritoneal lymphomatosis shows high attenuation because of the increased proteinaceous content . Loculated high-attenuation ascites and smooth peritoneal enhancement are more characteristic of tuberculous peritonitis. Diffuse lymphomatous infiltration of the mesentery produces a stellate appearance of the mesentery and causes fixation of the small-bowel loops.

Diffuse large B-cell lymphoma involving retroperitoneum, abdominal wall, and lumbar spine. A, Axial T2-weighted fast spin-echo image shows large right-sided retroperitoneal mass (arrows) that infiltrates paravertebral muscle (M), causes adjacent L1 vertebral destruction (arrowhead), and extends into epidural space to displace cauda equina. Right kidney (K) is anteriorly displaced. B, Axial fused PET/CT image at L3–L4 disk level 1 year after initial treatment shows multiple new 18F-FDG-avid subcutaneous tumor nodules (arrowheads).

Peritoneal lymphomatosis. A, Axial unenhanced CT image shows ascites that is similar in attenuation to adjacent muscle. Linear bands of soft-tissue attenuation run through mesenteric fat, indicating tumor infiltration (arrowheads) that causes tethering of small bowel. B, Corresponding axial fused PET/CT image shows ascites and mesenteric tumor that are intensely 18F-FDG-avid.

PancreasMost commonly NHL, B-cell.Primary pancreatic lymphoma is rare (<1% of pancreatic tumor,< 2% of extranodal lymphoma).Secondary lymphoma of the pancreas is much more common (30% of patients with widespread lymphoma)Because the pancreas has no definable capsule, it may be difficult to distinguish adjacent LN disease from intrinsic pancreatic infiltrationOn CT:Well-defined, homogeneous low-attenuation masses relative to the enhancing pancreatic parenchyma with only mild enhancement or diffuse enlargement of the gland with infiltrative tumor (mimicking pancreatitis).Peripancreatic fat stranding and peripancreatic inflammation, if present, is minimal. Pancreatic atrophy and calcifications are not common also.Although bile duct obstruction may occur, severe dilatation of the main pancreatic duct is uncommon.On MRILesions are more circumscribed and homogeneous on T1-weighted images.Hypo or hyper-intense to normal parenchyma on T2-weighted images.Contrast enhancement is homogeneous, (but less than normal parenchyma).

Diffuse large cell lymphoma infiltrating the pancreas, in a 57 years-old male (a) Axial non-enhanced CT shows a slightly heterogeneous mass with lobulated contours, in the head of pancreas (yellow arrow), (b) that grew and infiltrated the entire pancreas and compressed the common biliary duct (orange arrow) requiring a stent (purple arrow). (c) US image shows a hypoechoic and enlarged pancreas (yellow arrow).

Diffuse large cell lymphoma of the pancreas, in a 54 years-old male (a) Axial and (b) coronal contrast enhanced CT shows a hypodense ill-defined nodule (yellow arrow) in the body of the pancreas. (c) T1 weighted MRI image with gadolinium enhancing shows a hypointense nodule (yellow arrow) in the pancreas body. Posterior to the nodule, outside the pancreas but contacting it, there are two adenopathies.

Non-Hodgkin, diffuse large cell lymphoma in the mesentery with infiltration of the pancreas, duodenum, small bowel, and colon in a 55 years-old female (a) Axial and (b) coronal unenhanced CT shows an isodense mass in the mesentery that infiltrates de duodenum and pancreas (yellow arrow), (c) Pet scan showing extensive lesion with FDG uptake in the abdomen (purple arrow)

B-cell lymphoma involving pancreas

B-cell lymphoma involving pancreas. Axial fused PET/CT image shows 18F-FDG-avid pancreatic body lymphomatous deposit(arrowhead).

LiverMost commonly NHL.Primary hepatic lymphoma is extremely rare and occurs most commonly in immunocompromised patients.Secondary involvement is relatively common.Diffuse infiltration is easily overlooked on cross-sectional images because the liver has a homogeneous appearance. Hepatomegally is nonspecific for hepatic lymphoma. It can also appear as discrete nodules or a miliary pattern.Dominant liver masses are atypical in secondary lymphoma but are characteristic of primary lymphoma. May be heterogeneous and mimic primary or metastatic carcinoma of the liver.Fungal microabscesses of the liver may mimic lymphomas. CT and US do not allow reliable differentiation.Differentiation of hepatic lymphomas from carcinoma is based on the fact that lymphoma nodules tend to be smaller and more homogeneous than carcinoma metastases and do not usually show the rim like and targetlike enhancement patterns characteristic of carcinoma metastases.

Two patients with diffuse large cell lymphoma with liver involvement. CT scan shows multiple low-attenuation lesions within the liver (yellow arrows).

Hodgkin disease, classic type in a 60 year old male, with liver involvement. (a) Coronal and (b) axial CT scan shows multiple low-attenuation lesions (yellow arrows) within the liver. (c) Pet scan show diffuse infiltration by Hodgkin Disease (purple arrows).

Longitudinal sonogram shows diffuse, asymmetric mural thickening of gallbladder (arrowheads). B, Axial contrast enhanced CT image shows homogeneous soft-tissue thickening of wall of gallbladder (arrowheads) without tumoral invasion of adjacent liver. Biopsy proved lymphoma.

KidneyPrimary renal lymphoma is rare.Secondary renal lymphoma, which occurs mainly in late-stage disease, is more common;It is much more frequently non-Hodgkin lymphoma than Hodgkin disease, (7%–14% of patients with NHL develop renal lymphoma, by direct extension from contiguous retroperitoneal lymphoma or by hematogenous spread)The patterns of renal involvement include:Multiple circumscribed massesDirect infiltration from adjacent nodes,A solitary mass,Isolated perinephric massDiffuse infiltrationUsually the vessels remain patent, and there is minimal hydronephrosis.Ureter involvement is rare.

Lymphoblastic lymphoma (non-Hodgkin) in a 19 year-old male infiltrating both kidneys. (a) Axial contrast enhanced CT shows nodular homogeneous hypodense soft tissue masses (yellow arrows) in both kidneys. (b) Transverse and (c) Longitudinal US images reveal hypoechoic masses in left kidney (orange arrows).

Burkitt lymphoma in a 4 year-old boy infiltrating both kidneys, liver and spleen. a) Axial contrast enhanced CT reveals a homogeneous hypodense nodular lesion in the left kidney (white arrow) and another one that almost replaces the right kidney (yellow arrow). b) Two months later, after chemotherapy, the left kidney lesion was unapparent and the lesion in the right shrunken significantly (yellow arrow).

Diffuse large cell lymphoma (non-Hodgkin) in a 84 year-old female infiltrating the left kidney. Axial non-enhanced CT shows a left homogeneous isodense soft tissue masse that distorts the normal anatomy of the left kidney (yellow arrows).

Primary diffuse large cell lymphoma of the kidney, in a 74 year-old male Axial enhanced CT in the corticomedular phase (a) and in the excretory phase (b) shows a homogeneous isodense soft tissue mass (yellow arrow) in the renal pelvis of the right kidney. (c) enhanced CT in the excretory phase shows the homogeneous isodense soft tissue masse in the renal pelvis (yellow arrow) of the right kidney.

Primary diffuse large cell lymphoma of the kidney, in a 71 year-old male (a) Axial, (b) coronal and (c) sagittal enhanced CT in the corticomedular phase shows a homogeneous slightly hypodense (in relation to the parenchyma) soft tissue masse in the cortex, renal pelvis of the right kidney. There are lumbo-aortic adenopathies (orange arrows).

Primary diffuse large cell lymphoma of the kidney, in the same patient of Fig. 37. Coronal unenhanced CT (a) and contrast-enhanced (b) shows homogeneous wall thickening of the right ureter (orange arrow) that (b) required the placement of an ureteric stent (yellow arrow) . There are lombo-aortic adenopathies (green arrow).

Biopsy-proven peri-pelvic follicular lymphoma of kidney.

Adrenal GlandThe adrenal gland is involved in about 4% of cases of NHL. Bilateral adrenal involvement occurs in approximately 50% of these cases. The patterns of involvement include a rounded circumscribed homogeneous Mass and an enlarged adrenal gland that maintains its normal shape.

Large B-cell lymphoma involving adrenals.

TestisTesticular lymphoma is rare (1%-2% of all lymphomas and approximately 5% of all testicular tumours).The most common form of testicular lymphoma is diffuse large B-cell lymphoma.Secondary involvement of the testis by NHL is more common than primary extranodal disease.Lymphoma is the most common testicular tumor in patients older than 60 years (bilateral involvement in 40% of cases).Usually involves the body of the testis and spares the tunica vaginalis. The epididymis and spermatic cord are frequently affected.US findings are not diagnostically specific. The most common US features are well-defined hypoechoic areas within an enlarged testis.

Diffuse large cell lymphoma of the testes, in a 67 year-old male (a) And (b) US image of both testes shows enlarged testes with hypoechoic areas with infiltrative appearance (yellow arrows) and hydrocele (green arrow). (c) Pet scan shows multiple nodules with FDG uptake in both testes (purple arrow).

Primary diffuse large cell lymphoma of the testes, in a 60 year-old male (a) And (d) Longitudinal and (c) transverse US image of both testes shows hypoechoic areas with infiltrative appearance (yellow arrows). Presence of hydrocele in the left side (green arrow). (d) Pet scan shows involvement of both testes (purple arrow).

Large B-cell lymphoma involving testes. Longitudinal sonogram shows large, hypoechoic, circumscribed mass in left testis (arrowheads).

Transverse (A), longitudinal (B), and color Doppler (C) ultrasound images of right testicle show diffuse hypoechogenicity and increased color Doppler flow of B-Cell lymphoma of the testis.

UterusLymphoma of the uterus is uncommon. Secondary involvement is more common than primary lymphoma.Intermittent vaginal bleeding is the most common. symptom.May show diffuse enlargement with preservation of the endometrium.As lymphoma of the uterine cervix originates within the cervical stroma, the epithelium is initially preserved and therefore, cytology is often normal.OvaryPrimary lymphoma of the ovary is very rare, but involvement of the ovary is not uncommon in patients with advanced lymphoma, particularly in high-grade lymphomas.Bilateral ovarian enlargement from lymphoma with retroperitoneal lymphadenopathy and mesenteric deposits is difficult to distinguish from primary nonepithelial ovarian tumors or metastases from other tumors such as uterine or breast cancer.Biopsy is frequently necessary to differentiate lymphoma from other ovarian neoplasms.It may be difficult to identify the organ of origin in cases of large adnexal masses.

Diffuse large cell lymphoma of the uterine cervix, in a 28 year old female (a) Pet scan show a large uptake of FDG in the pelvis (green arrow). (b) Sagittal and (c) axial T2 weighted MRI shows a hyperintense heterogeneous mass (yellow arrows), comparing to the muscle, in the uterine cervix that involves the vagina and extends to the vulva. It contacts with the sigmoid colon posteriorly and compresses the bladder. There is some ascitis (orange). (d) In Axial T1 weighted MRI, the mass is isointense to the muscle. (e) Axial contrast enhanced CT shows a heterogeneous mass (yellow arrow) with a hypodense area (purple arrow) in the interior.

Primary diffuse large cell lymphoma of the uterus, in a 71 year old female (a) Axial unenhanced CT shows a mass (yellow arrow) in the uterine fundus with well defined borders. (b) Sagittal and (c) axial T2 weighted MRI shows a heterogeneous mass (yellow arrow), comparing to the muscle, in the uterine fundus, that shows well-defined contours and has in the interior areas with more signal intensity (orange arrow). (d) In Axial T1 weighted MRI, the mass is isointense to the muscle. (e) Axial T1 weighted image with gadolinium enhancing shows hypervascularity of the lesion

Diffuse large cell lymphoma of the uterine cervix, in a 74 years old female. (a) Axial, (b) coronal and (c) sagittal contrast enhanced CT shows a well-defined mass (yellow arrow) in the uterus with necrotic interior (green arrow).

Contrast-enhanced CT image shows infiltrative soft tissue (arrow) centered in cervix and extending into parametria. Biopsy results revealed diffuse large B-cell lymphoma.B, Contrast-enhanced CT image obtained after treatment shows good response to chemotherapy with resolution of abnormal cervical soft tissue (arrow). Primary differential consideration is cervical carcinoma.

Diffuse large cell lymphoma of the kidney, in a 69 year-old female (a) Axial T1 weighted MRI shows a hypointense heterogeneous mass in the left adnexal area (yellow arrow) (b) axial, (d) oblique and (e) sagittal T2 weighted MRI reveals a hypointense, heterogeneous mass (yellow) irregular contours in the right adnexal area and ascites (purple arrow) in the Douglas pouch (c) Suprapubic pelvic US And (f) transvaginal US shows a hypoechoic mass (yellow arrow) in the right adnexal area with cystic areas in the interior. It also reveals ascites (purple arrow).

ProstateMalignant lymphoma involving the prostate is rare.Lymphoma of the prostate must be considered when a large prostatic mass is palpated in a young man.The clinical presentation of malignant lymphoma of the prostate is difficult to distinguish from other prostatic diseases causing lower urinary tract obstructive symptoms.Primary prostatic lymphomas are much less common than secondary lymphomas.Trans-rectal US reveal large hypoechoic masses within both the central and peripheral zones and beyond the confines of the prostate gland in young men.CT findings of lymphomas are homogeneous soft-tissue masses in the vast majority of cases.

Secondary follicular lymphoma of the prostate, in a 76 years old male Axial contrast enhanced CT shows a hypodense enlarged prostate.

Axial contrast-enhanced CT image shows polypoid soft-tissue mass arising from right lateral wall of bladder (arrow). B, Corresponding axial fused PET/CT image shows moderate 18F-FDG activity in tumor (arrow) compared with “hot” urine. Biopsy-proven mucosa-associated lymphoid tissue lymphoma involving bladder

BreastPrimary lymphoma of the breast is extremely rare, (0.04-0.5% of all breast malignancies, 1-2% of extranodal lymphomas).Secondary involvement of the breast is not uncommon.Most frequent subtype: large B-cell lymphoma, followed by follicular lymphoma.Most common presentation: unilateral painless breast mass in an older woman.The right breast is involved more often than the left.Ipsilateral axillary lymphadenopathy is present in 30-40%.Breast lymphomas manifest most frequently as a lobular or irregular mass with indistinct margins at mammography and a solid, hypervascular irregular mass with indistinct margins or an echogenic boundary at US. No microcalcifications present.MRI shows a hypointense lesion on T1 and hyperintense on T2 with enhancement and washout

Primary non-Hodgkin B-cell lymphoma of the breast, in a 79 years-old female (a) And (b) Mammography shows a diffuse increased density of the breast with several micronodules. (c) And (d) Ultrasound shows a hypoechoic well-defined nodule (yellow arrow), in the upper external quadrant of the right breast, hypervascular

Secondary extranodal marginal cell lymphoma, in a 60 years-old female, with a nodule in the upper external quadrant of the left breast (a) And (b) Mammography shows a diffuse increased density of the breast without defined nodules, and without microcalcifications. (c) Ultrasound shows a hypoechoic well-defined nodule (yellow arrow), with 27x6 mm in the superior external quadrant of the left breast (d) Pet scan shows the nodule in the upper external quadrant of the left breast with high uptake of FDG (green arrow).

Secondary diffuse large B-cell lymphoma of the left breast, in a 64 year old female (a) And (b) Mammography shows a large irregular, lobulated mass (yellow arrow) with ill defined contours. No microcalcifications. (c) Axial contrast enhanced CT reveals the lobulated mass (green arrow). (d) Ultrasound shows a hypoechoic well-defined lobulated nodule, with weak signal on color-Doppler (orange arrow).

Musculoskeletal systemLymphoma affecting the bones is rare, particularly primary bony lymphoma in the absence of systemic disease.Bony involve ment is seen in approximately 5% of cases of disseminated lymphoma.Lymphomatous spread to skeletal muscle is usually seen as part of widespread NHL (usually the thigh, upper limb and chest).The typical appearance of the bone lesion is of a lytic lesion, although mixed lytic and primarily scleroti c lesions have been reported. NHL forms part of the differential diagnosis of a solitary dense (ivory) vertebral body.MRI is less adept at showing bony destruc tion than CT.MRI is good for delineation of soft tissue masses, with lymphoma showing intermediate T1 signal, high T2, and variable enhancement.

Skin lymphoma. Axial CT image shows frontal soft-tissue homogenous mass. Skin lymphoma may presents as a palpable mass or a diffuse tumefaction. When palpation is felt to be insufficient for local staging, CT or MRI can be used for mapping pre-therapeutic disease extent and document response post therapy.

Low grade B-cell non-hodgkin lymphoma infiltrating the subcutaneous fat in a 75 year old female. Axial contrast enhanced CT shows a hyperdense in the left buttock subcutaneous fat

Diffuse large cell lymphoma infiltrating the subcutaneous fat in a 70 year old female (a) Axial unenhanced CT shows a hyperdense mass in the subcutaneous fat (b) T1 weighted MRI shows an isointense mass, comparing to the muscle, in subcutaneous fat (c) In T2 weighted MRI the mass has high signal intensity.

Primary diffuse large cell lymphoma of the mediastinum, in a 26 year-old male (a) Sagittal, (b) and (c) axial contrast enhanced CT images show a mass (yellow arrow) that is isodense to the muscle and has some hypodense areas in the interior. There is invasion and destruction (green arrow) in the manubrium of the sternum. (d) Chest x-ray shows an enlarged mediastinum (orange arrow). (e) Pet scan reveals increased accumulation of FDG in the mediastinum (purple arrow).

Diffuse large cell lymphoma of the left tibia, in a 13 years old boy. (a) X-ray of the left leg shows a ill-defined lytic lesion of the tibia (b) sagittal, (c) axial and (d) coronal CT images showing the lytic lesion of the tibia (e) Coronal Pet scan show focal increased FDG accumulation in the proximal tibia and distal femur (f) Bone scintigraphy shows uptake in the same location.

Non-Hodgkin B cell lymphoma, infiltrating the second lumbar vertebra (a) Sagittal T1 weighted MRI shows global hypointensity of L2 (yellow arrow) (b) Sagittal CT shows global hyperdensity of L2 (yellow arrow)

Axial contrast-enhanced CT images (soft-tissue windows, A; bone windows, B) show large soft-tissue mass (arrow) in right hemipelvis with destruction of right posterior acetabular wall. Other considerations include sarcoma (e.g., Ewing sarcoma), but homogeneity of signal along with clinical features made lymphoma most likely diagnosis in this case. Biopsy revealed follicular lymphoma. C, Axial STIR MR image shows ability of MRI to delineate soft-tissue extension of lymphomatous mass (arrow).

Disseminated Burkitt lymphoma. A and B, Coronal T1-weighted (A) and STIR (B) MR images of pelvis reveal focal deposit in right femoral neck (white arrows) that shows low signal on T1 and high signal on STIR. Nodal masses (black arrows, B) are seen in pelvis. Primary Burkitt lymphoma usually affects jaw, making femoral deposit more likely distant or metastatic than primary involvement. Presence of pelvic lymph node masses makes diagnosis of lymphoma more likely than sarcoma in this case (other differential consideration).

Primary central nervous system lymphoma (PCNSL), a rare form of extranodal lymphoma, occurs in the brain, leptomeninges, spinal cord, or eyes; typically, it remains confined to the CNS, and accounts for 3.1% of all primary brain tumors. Its incidence increased nearly 3-fold between 1973 and 1984, but, recent data suggest that it may be stabilizing or declining slightly. Congenital or acquired immunodeficiency is the only established risk factor; persons infected with the human immunodeficiency virus (HIV) have a 3600-fold increased risk of developing PCNSL compared with the general population. In HIV-infected patients, a CD4+ count <50 cells/μl and a high peripheral HIV viral load are risk factors for PCNSL development. More than half of patients will have had an acquired immunodeficiency syndrome (AIDS)-defining illness prior to the development of PCNSL, offering additional evidence that immune function must be markedly impaired before this lymphoma arises. AIDS-PCNSL is usually associated with Epstein–Barr virus (EBV); this infection and the c-myc translocation result in the development and proliferation of PCNSL. With the advent of highly active antiretroviral therapy (HAART), the incidence of AIDS-related PCNSL has declined.

CNS Lymphoma

Primary CNS lymphoma.

AIDS-related PCNSL.

Primary Central Nervous System Lymphoma

Primary Central Nervous System Lymphoma.

Primary CNS lymphoma

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