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Findings in this case: 1) PET imaging of the chest and abdomen. 2) Increased tracer uptake is demonstrated in the RIGHT lower quadrant, which was demonstrated on the CT scan to represent a markedly thickened ileum. 3) Uptake of tracer is present in the mesentery of the RIGHT lower quadrant. 4) Uptake of tracer is present in the RIGHT axilla.
Diagnosis: Small bowel non-Hodgkin’s lymphoma.
File:3D
Organ system: 3.0 GI Tract
Organ: D. – Small Bowel
Etiology and incidence: A) Non-Hodgkin’s lymphoma of the small bowel is the cause for approximately 20-25% of small bowel malignancies. Hodgkin’s disease can involve the small bowel however though this is much less common. B) May be associated with celiac disease. C) PET imaging is used for staging.
Diagnosis: 1) CT: a) There are a number of different appearances which include a polypoid or nodular type of appearance, diffuse and/or irregular thickening of the bowel and excavating/necrotic/cavitating mass associated with the bowel. b)”Aneurysmal” dilatation of the bowel. c) Frequently have associated lymphatic involvement. d) There can be multiple organ involvement with enlargement of the spleen being frequent. e) Distal ileum is slightly more common than other portions of the small bowel. The stomach is the most frequent site of involvement however. 2) PET: PET is sensitive particularly in cases of high-grade non-Hodgkin’s lymphoma. Lower grade cases of lymphoma show slightly more variability in tracer uptake however uptake is usually present to some degree. 3) Differential diagnosis: a) Crohn’s disease and to a lesser extent other infectious and/or inflammatory processes of the small bowel. b) Additionally, there can be activity which is physiologic in any part of the bowel, however when compared with the CT, there will be no additional findings associated with the uptake.
Prognosis/Clinical: 1) Symptoms: a) Patients are typically asymptomatic until late in the disease process. b) Symptoms include small bowel obstruction. c) There can be malabsorption. d) During therapy with chemotherapy, if there has been no bowel resection, perforation of the primary lesions can occur. 2) Prognosis: a) Prognosis depends on staging. b) Stage III and stage IV malignancy has malignancy on both sides of the diaphragm and a more diffuse or disseminated involvement being more than one extrahepatic organ or tissue area with or without lymphatic involvement respectively. c) In this case, there is extensive involvement within the subdiaphragmatic area but there is also abnormal lymph node uptake in the RIGHT axilla. d) Up to 75% of patients will have 2year survival in low stage cases, however high stage cases have a very low 2 to five-year survival rate.
References:
EJ Balthazar, M Noordhoorn, AJ Megibow, and RB Gordon
CT of small-bowel lymphoma in immunocompetent patients and patients with AIDS: comparison of findings
Am. J. Roentgenol., Mar 1997; 168: 675 – 680.
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CT Findings in Peripheral T-Cell Lymphoma Involving the Gastrointestinal Tract Radiology April 2003 227:59-67; Published online February 11, 2003, doi:10.1148/radiol.2271012129
Jae Ho Byun, Hyun Kwon Ha, Ah Young Kim, Tae Kyoung Kim, Eun Young Ko, Jeong Kyong Lee, Eun-Sil Yu, Seung-Jae Myung, Suk-kyun Yang, Hwoon-Yong Jung, and Jin Ho Kim
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Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis Radiographics March 2003 23:457-473; doi:10.1148/rg.232025081
Sheila Sheth, Karen M. Horton, Melissa R. Garland, and Elliot K. Fishman
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Primary Non-Hodgkin Lymphoma of the Small Bowel Radiology April 1999 211:183-187
Chul S. Ha, Moon-June Cho, Pamela K. Allen, Lillian M. Fuller, Fernando Cabanillas, and James D. Cox
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Bowel Wall Thickening in Children: CT Findings Radiographics May-June 2008 28:727-746; doi:10.1148/rg.283065179
Maria d’Almeida, Jean Jose, Julieta Oneto, and Ricardo Restrepo
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