A b d o m i n a l I m a g i n g • P i c t o r i a l E s s ay

Lee et al.
Abdominal Manifestations of Lymphoma

Abdominal Imaging
Pictorial Essay
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Abdominal Manifestations of
Extranodal Lymphoma: Spectrum
of Imaging Findings
Wai-Kit Lee1 OBJECTIVE. The purpose of this article is to illustrate the spectrum of appearances of
Eddie W. F. Lau2 extranodal lymphoma in the abdomen using cross-sectional imaging techniques.
Vinay A. Duddalwar 3 CONCLUSION. Extranodal lymphoma in the abdomen can mimic other neoplastic or
Anthony J. Stanley4 inflammatory conditions. Although a definitive diagnosis is possible only with biopsy, it is
Yvonne Y. Ho 4 important to consider extranodal lymphoma in the presence of certain imaging appearances
in the appropriate clinical setting for the correct diagnosis, accurate staging, and optimal
Lee WK, Lau EWF, Duddalwar VA, Stanley AJ, Ho management.
YY

Keywords: abdomen, CT, extranodal lymphoma,
PET/CT, sonography
DOI:10.2214/AJR.07.3146
Received September 12, 2007; accepted after revision
January 27, 2008.
1
Department of Medical Imaging, St. Vincent’s Hospital,
University of Melbourne, 41 Victoria Parade, Fitzroy,
Victoria 3065, Australia. Address correspondence to
W. K. Lee (leewk33@hotmail.com).
2
Department of Radiology, Centre for Molecular Imaging,
Peter MacCallum Cancer Centre, University of
Melbourne, East Melbourne, Victoria 3002, Australia.
3 more likely to affect extranodal sites [2].
Department of Radiology, Norris Comprehensive
Cancer Center, University of Southern California,
Los Angeles, CA.
4
Department of Diagnostic Imaging, The National
University Hospital of Singapore, National University of
Singapore, Singapore.
CME
This article is available for CME credit.
See www.arrs.org for more information.
AJR 2008; 191:198–206
0361–803X/08/1911–198
© American Roentgen Ray Society
E
xtranodal lymphoma occurs in
about 40% of patients with lym­
phoma and has been de­scribed in
virtually every organ and tissue
[1]. In decreasing order of frequency, the
spleen, liver, gastrointestinal tract, pancreas,
abdominal wall, genitourinary tract, adrenal,
peritoneal cavity, and biliary tract are
involved [2–5]. Extranodal disease is more
common with non-Hodgkin’s lymphoma
(NHL) than with Hodgkin’s lymphoma and
is often intermediate- to high-grade [2, 3].
AIDS-related lymphoma and post­trans­plant­
ation lymphoproliferative dis­order (PTLD)
are more likely to affect extra­nodal sites and
are of higher grade [2, 4, 5]. Diffuse large
B-cell lymphoma and follicular lymphoma
are the dominant histologic sub­types in
extranodal lymphoma. Mantle cell lymph­
oma, lympho­blastic lymphoma, Burkitt’s
lymphoma, and mucosa-associated lymphoid
tissue (MALT) lymphoma, however, are
MALT lymphoma is a low-grade marginal
zone B-cell lymphoma that is most commonly
found in the stomach. It is closely associated
with chronic inflammation, such as Helico­
bacter pylori gastritis, and has a clinically
indolent course. Secondary involve­ment of
extranodal tissues as part of generalized
lymphoma is signi­ficantly more common
than primary extra­nodal disease, in which
there is a dominant extranodal component
with no or minor nodal in­volve­ment. Splenic,
hepatic, or diffuse involvement of one or more
extranodal organs indicates a more advanc­
ed stage of disease. Extranodal in­volvement is
in general a poor prognostic factor.
The protean imaging appearances of ex-
tranodal lymphoma in the abdomen can
mimic other neoplastic or inflammatory
condi­tions. Misinterpretation of the imaging
findings can lead to delayed diagnosis and
treatment, and incorrect staging may result
in inappropriate treatment. In this article, we
illustrate the appearances of extranodal lym-
phoma in the abdomen of immuno­competent
and immunocompromised patients with cur-
rent cross-sectional im­aging techniques.
Imaging Techniques
MDCT is the principal imaging technique
used for the evaluation of patients with
lymphoma. However, evidence indicates that
PET/CT is superior to CT in detecting
extranodal disease in the abdomen, especially
in the spleen and liver [1, 6]. The role of PET/
CT in low-grade lymphoma such as MALT
lymphoma is controversial. For the routine
evaluation of abdominal lymphoma, no data
are available at present on the effectiveness
of MRI, and sonography has no role. Patients
unsuitable for CT can be assessed with MRI.
Sonography and MRI can be used for targeted
characterization of indeterminate lesions
identified at CT.
At our institution, routine abdominopelvic
CT for the evaluation of lymphoma is usually
performed after the patient has drunk 900
mL of 2.5% diluted sodium amidotrizoate
and meglumine amidotrizoate (Gastrografin,
Bayer HealthCare) 45–60 minutes before the

198 AJR:191, July 2008


examination. One hundred milliliters of 370
mg I/mL of iopromide (Ultravist 370, Bayer
HealthCare) is administered IV at a rate of
2.5 mL/s. CT is performed after a 75-second
delay. For 16- and 64-MDCT scanners, 0.75-
and 0.6- mm detectors are used, respectively,
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with 120 kVp and 150–180 mAs. In suspected
gastric or enteric in­volve­ment, CT is per­
formed after the patient has drunk 1,000–
1,500 mL of water or 2% sorbitol. In
suspected colonic involvement, CT is per­
formed after the administration of 500–1,000
mL of water or 2.5% di­luted sodium
amidotrizoate and meglumine amido­­trizoate
(Gastrografin) as rectal contrast medium.
Routine PET/CT for the evaluation of
lymphoma is performed after an IV injection
of 370 MBq of 18F-FDG that is administered
45–60 minutes before the scan. A low-dose
CT acquisition is first performed (120 kVp,
average of 64 mAs) from the skull base to the
mid thigh, without IV or oral contrast material
and no specific breath-holding instructions.
A PET emission scan is immediately per­
formed after the CT acquisition over the same
range as CT, without changing the patient’s
position. Images are reconstructed with a
16-subset, two-iteration algorithm, 256 × 256
matrix, and a CT-based attenuation coeffi­
cient. In suspected gastric or enteric in­
volvement, the study is performed after the
patient has ingested 1,000–1,500 mL of water
or 2% sorbitol. If colonic involvement is
suspected, the study is performed after the
administration of 500–1,000 mL of water as
a rectal contrast medium. In suspected uri­
nary tract involve­ment, the study is per­formed
after IV hydration with 0.9% saline, an IV
bolus of 20 mg of frusemide, and insertion of
a urinary catheter.
At our institution, abdominopelvic MRI
evaluation for lymphoma is performed with a
torso phased-array coil. The protocol consists
of axial 2D T1- and T2-weighted fast spin-
echo sequences; a coronal, fat-suppressed
T2-weighted short tau inversion recovery se-
quence; and coronal breath-hold fat-sup­press­
ed dynamic 3D T1-weighted gradient-echo se-
quences before and after the IV administration
of gadolinium. In suspected gastric or enteric
involvement, the study is performed after the
patient has drunk 1,000– 1,500 mL of water or
2% sorbitol. In suspected colonic involvement,
the study is performed after the administra­
tion of 500– 1,000 mL of water as a rectal
contrast medium. An IV bolus of 20 mg of
N-butyl scopolamine is administered when
enteric or colonic disease is suspected.
AJR:191, July 2008 199
Abdominal Manifestations of Lymphoma
Liver and Spleen
The spleen and liver are involved in 20–
40% and up to 15% of patients with lympho-
ma, respectively [1–3]. The patterns of in-
volvement include diffuse infiltration (Fig. 1),
with or without organomegaly, and focal nod-
ules (Fig. 2). FDG PET/CT is more accurate
than other cross-sectional tech­niques for the
detection of diffuse hepato­splenic involve-
ment [6]. Focal hepatosplenic lym­phoma
appears as cir­cum­scribed nodules that are
hypoechoic, show no posterior acoustic en­
hancement on sono­graphy, and are low-atten-
uation on contrast-enhanced CT. On MRI, the
nodules may appear as hypo- or iso­intense
compared with normal spleen or liver on T1-
weighted images and as hyper­intense on T2-
weighted images, and may show reduced
enhancement after the admin­istration of
gadolinium. Focal hepato­splenic lym­pho­mas
can be in­dis­tin­guishable from meta­stases but
are usually smaller and homo­geneous and
occur with extensive, bulky coalescent lymph
nodes. Hepatosplenic fungal abscesses tend
to be smaller and show hetero­geneous en­
hance­ment compared with lymphoma.
Gastrointestinal Tract
Extranodal lymphoma in the gastrointes­
tinal tract occurs in 10–30% of all patients
with NHL [2, 7]. The stomach, small bowel,
pharynx, large bowel, and esophagus are in-
volved in decreasing order of frequency [7].
The patterns of gastric involvement include
polypoidal mass, diffuse or focal infiltration
(Fig. 3), ulcerative lesion, or mucosal nod­
ularity [8]. The patterns of small-bowel in-
volvement include solitary or multiple nod­ules
(Fig. 4), circumferential wall thick­ening with
or without aneurysmal dilatation (Figs. 4 and
5), and direct extension from mesenteric
nodes [7, 9]. The cecum and rectum are the
most commonly involved parts of the large
bowel. The patterns of large-bowel involve­
ment include bulky poly­poidal mass, infil­
trative tumor (Fig. 6), and aneurysmal dilata-
tion [7]. Bowel per­foration is an un­com­mon
complication of gastro­intestinal lympho­ma
but is more likely with T-cell lymphoma,
with PTLD, and after chemo­therapy or radi-
ation therapy [5, 7–9]. Bowel obstruction is
uncom­mon at present­ation despite signifi­
cant lym­phomatous in­filtration of the bowel
wall because of absent desmoplastic reaction
[7, 9]. In contrast to gastrointestinal adeno­
carcin­oma, lymphoma is more likely to in-
volve multiple and longer segments of gut and
is less likely to cause bowel obstruction [8].
Genitourinary Tract
Renal involvement occurs in 3–8% of
patients with lymphoma; the kidney is the most
commonly involved part of the genito­urinary
tract [10]. The patterns of renal in­volve­ment, in
descending order of frequency, include multiple
circumscribed masses (Figs. 7 and 8), direct
infiltration from adjacent nodes, a solitary
mass, an isolated perinephric mass (Fig. 9),
and diffuse infiltration [10] (Fig. 10). Renal
metastases can mimic renal lym­pho­ma. Renal
cell carcinomas can often be differentiated
from renal lymphoma by their hypervascular
enhancement pattern. Trans­itional cell car­ci­
no­ma and severe pyelo­nephritis may mimic
diffuse renal in­filtration by lym­pho­ma. Ex­
ten­sive bulky coalescent lymph nodes and
absence of features of an infective process are
supportive of the dia­gnosis of lym­pho­ma.
Predominant peri­pelvic or renal sinus in­volve­
ment by lym­pho­ma is uncommon [10, 11].
Despite peripelvic lymphoma encasing
renal hilar structures, the vessels often remain
patent, and there is often minimal hydro­
nephrosis (Fig. 11). This helps to differentiate
peripelvic lymphoma from transitional cell
carcinoma or metastases. The ureter is often
affected by involved retroperitoneal nodes,
but primary involvement of the ureter by
lymphoma is rare [12]. About 8% of patients
with lymphoma have bladder involvement at
autopsy [10, 13]. The patterns of bladder
involvement include circumscribed solitary
or multiple masses (Fig. 12) and diffuse in­
filtration [13]. Transitional cell carcinoma
may mimic bladder lymphoma. Approx­i­
mately 6% of patients with lymphoma have
testicular involvement at autopsy [10]. Lym­
pho­ma is the most common testicular tumor
in older men; bilateral involvement occurs in
38% of cases [1]. The patterns of testicular
involvement include focal masses (Fig. 13)
and diffuse infiltration with or without tes­
ticular enlargement [2].
Pancreas
The pancreas is involved in about 30% of
cases of NHL, usually from contiguous nodal
infiltration [14]. The patterns of involvement
include a circumscribed mass (Figs. 14 and
15) and diffuse glandular enlargement
mimicking acute pancreatitis [14]. Although
bile duct obstruction may occur with pan­
creatic lymphoma, moderate to severe dilata­
tion of the main pancreatic duct despite a
bulky tumor is uncommon. Vascular invasion,
pancreatic atrophy distal to the tumor, and
tumor calcification and necrosis are unusual

at initial presentation [14]. These features can
help to differentiate pancreatic lymphoma
from adenocarcinoma.
Adrenal Gland
The adrenal gland is involved in about 4%
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of cases of NHL [1, 15]. Bilateral adrenal in­
volve­ment occurs in approximately 50% of
these cases. The patterns of involvement in-
clude a rounded circumscribed homo­geneous
mass (Fig. 16) and an enlarged adrenal gland
that main­tains its normal shape [15].
Biliary Tract
Lymphomatous involvement of the biliary
tree is rare. The patterns of involvement of the
gallbladder include an intraluminal poly­
poidal mass, a large mass replacing the gall­
bladder, and diffuse mural thickening [16]
(Fig. 17). The patterns of involvement of the
bile ducts include a biliary stricture mimicking
chol­angio­carcinoma and a focal mass [17].
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 peri­ton­
eal carcinomatosis [18]. The patterns of
involvement include discrete nodules, a diffuse
infiltrative mass, and ascites (Fig. 18). Exudative
ascites from peritoneal lympho­matosis shows
high attenuation because of the increased pro­
teinaceous content [18]. Loc­u­lat­ed high-attenu­
ation ascites and smooth peritoneal enhance­
ment 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 (Fig. 18).
Abdominal Wall
Lymphoma may involve the abdominal wall
by direct extension from bone or may occur
200 AJR:191, July 2008
Lee et al.
separately in the muscle, subcutaneous fat,
or skin from hematogenous spread (Fig. 19).
Conclusion
The wide spectrum of imaging appearances
of extranodal lymphoma in the abdomen
presented in this article should serve to alert
the radiologist to consider its diagnosis in
patients with or without a history of lymph­o­
ma in the presence of supportive collective
imaging findings and suggestive clinical
features. Although a definitive diagnosis of
extranodal lymphoma is possible only with
biopsy, certain findings (e.g., a bulky tumor
of the gastrointestinal tract involving multiple
segments with aneurysmal dilatation or with­
out bowel obstruction; a bulky, homogene­
ous, noncalcified pancreatic mass with­out
significant dilatation of the main pan­creatic
duct; or a peripelvic renal mass without
significant hydronephrosis) together with
extensive bulky coalescent lymph nodes and
absent features of an infective process are
strongly suggestive of the diagnosis.
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 Abdominal Manifestations of Lymphoma

Fig. 1—52-year-old woman with large B-cell lymphoma involving spleen. Axial
fused PET/CT image shows diffuse increased 18F-FDG uptake in normal-sized
spleen (arrow), indicating splenic involvement.
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A B
Fig. 2—74-year-old woman with biopsy-proven large B-cell lymphoma involving liver and spleen.
A, Longitudinal sonogram of right lobe of liver shows multiple hypoechoic nodules (arrowheads).
B, Axial contrast-enhanced CT image shows multiple circumscribed low-attenuation nodules in liver and spleen (arrowheads).

A B
Fig. 3—62-year-old man with biopsy-proven large B-cell lymphoma involving stomach.
A, Axial contrast-enhanced CT image shows focally infiltrative tumor involving body of stomach (arrow).
B, Corresponding axial fused PET/CT image shows 18F-FDG-avid tumor (arrow).

AJR:191, July 2008 201

 Lee et al.
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Fig. 4—52-year-old man with mantle cell lymphoma
involving small bowel. Coronal contrast-enhanced CT
image shows nodular masses in proximal small bowel
(arrowheads) and marked mural thickening of distal
ileum (large arrow). Note mesenteric nodes (M) and
right inguinal node (small arrow).
Fig. 5—62-year-old man with follicular lymphoma
of small bowel. Axial contrast-enhanced CT image
shows circumferential thickening and aneurysmal
dilatation of segment of distal ileum (arrows).
Fig. 6—73-year-old man with biopsy-proven large
B-cell lymphoma involving small and large bowel.
Coronal contrast-enhanced CT image shows bulky
infiltrative tumor (arrows) involving distal ileum (I),
cecum (C), and ascending colon (A). No small-bowel
dilatation is seen proximal to tumor.

A B
Fig. 7—37-year-old man with T-cell lymphoblastic lymphoma involving kidneys.
A, Axial contrast-enhanced CT image shows multiple bilateral, circumscribed low-attenuation renal masses.
B, Longitudinal sonogram of right kidney shows multiple hypoechoic masses (arrowheads). Similar hypoechoic masses were seen in left kidney (not shown). These
lymphomatous deposits resolved after chemotherapy.

202 AJR:191, July 2008

 Abdominal Manifestations of Lymphoma

Fig. 8—63-year-old woman with newly diagnosed large B-cell lymphoma

involving kidneys. Axial fused PET/CT image shows bilateral 18F-FDG-avid renal
lymphomatous deposits (arrows).
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Fig. 9—60-year-old man with biopsy-proven perinephric mucosa-associated Fig. 10—61-year-old woman with biopsy-proven large B-cell lymphoma involving
lymphoid tissue lymphoma. Coronal contrast-enhanced CT image shows soft- kidney. Coronal contrast-enhanced CT image shows left renomegaly and
tissue perinephric mass that partially encases lower left kidney without frank complete replacement of kidney by lymphoma (arrowheads).
renal invasion (arrowheads).

AJR:191, July 2008 203

 Lee et al.
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A B

C D

Fig. 11—73-year-old man with biopsy-proven peripelvic follicular

lymphoma of kidney.
A, Axial contrast-enhanced prone CT image shows soft-tissue mass
encasing left renal hilum (arrow). Left renal hilar vessels are patent.
No hydronephrosis is seen. Note calyceal diverticulum with dependent
calculi (arrowhead).
B–D, Axial fat-suppressed T2-weighted fast spin-echo (B), axial
T1-weighted fast spin-echo (C), and axial gadolinium-enhanced
fat-suppressed T1-weighted fast spin-echo (D) images show T2
hyperintense and T1 hypointense mass that mildly enhances with IV
gadolinium (arrow). Arrowheads indicate calyceal diverticulum with
dependent calculi.
E, Axial fused PET/CT image shows 18F-FDG-avid tumor (arrow).
E

204 AJR:191, July 2008

 Abdominal Manifestations of Lymphoma
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A B
Fig. 12—55-year-old woman with biopsy-proven mucosa-associated lymphoid tissue lymphoma involving bladder.
A, 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.

Fig. 13—70-year-old man with histologically proven large B-cell lymphoma
involving testes. Longitudinal sonogram shows large, hypoechoic, circumscribed
mass in left testis (arrowheads). Multiple smaller but similar masses were seen
in right testis (not shown). Histopathology of resected left testis revealed large
B-cell lymphoma.
Fig. 14—59-year-old man with large B-cell lymphoma involving pancreas. Axial
contrast-enhanced CT image shows two low-attenuation tumor nodules in
pancreatic body (arrowheads).

Fig. 15—72-year-old woman with large B-cell lymphoma involving pancreas. Axial Fig. 16—55-year-old woman with large B-cell lymphoma involving adrenals.
fused PET/CT image shows 18F-FDG-avid pancreatic body lymphomatous deposit Axial contrast-enhanced CT image shows rounded large bilateral adrenal tumors
(arrowhead). (arrows).

AJR:191, July 2008 205

 Lee et al.

Fig. 17—61-year-old woman

with histologically proven
primary mucosa-associated
lymphoid tissue lymphoma in
gallbladder.
A, Longitudinal sonogram
shows diffuse, asymmetric
mural thickening of
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gallbladder (arrowheads).
B, Axial contrast-
enhanced CT image shows
homogeneous soft-tissue
thickening of wall of
gallbladder (arrowheads)
without tumoral invasion of
adjacent liver.

A B

A B
Fig. 18—57-year-old woman with peritoneal lymphomatosis. (Courtesy of Henderson R, Los Angeles, CA)
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.

A B
Fig. 19—54-year-old man with 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).

F O R YO U R I N F O R M AT I O N

This article is available for CME credit. See www.arrs.org for more information.

206 AJR:191, July 2008