Imaging of LymphomaImaging of Lymphoma

Dr.: Adel El-BadrawyDr.: Adel El-Badrawy

Assistant Professor of RadiologyAssistant Professor of Radiology

Mansoura Faculty of MedicineMansoura Faculty of Medicine

ImagingImaging = = Tumour assessmentTumour assessment

1- Detection.1- Detection.

2- Staging2- Staging

3- Response to treatment3- Response to treatment

4-Recurrence of disease4-Recurrence of disease

Non-Invasive methods of investigationNon-Invasive methods of investigation

1- Plain films1- Plain films

2- Contrast studies as barium examination2- Contrast studies as barium examination

3- Ultrasound 3- Ultrasound (US)(US)

4- Computerized Tomography 4- Computerized Tomography (CT)(CT)

5- Magnetic Resonance Imaging 5- Magnetic Resonance Imaging (MRI)(MRI)

6- Nuclear medicine 6- Nuclear medicine (NM)(NM) [isotope scanning] [isotope scanning]

7- Positron emission tomography 7- Positron emission tomography (PET) (PET)

CTCT

CT scan is the most commonly used imaging modality for the detection, staging, and follow-up of lymphoma. The role of CT scan in lymphoma is multifold. It is used to

(1) define the full extent of disease to allow accurate staging;

(2) assist in treatment planning (i.e, determine the site of nodal biopsy, create radiation planning portals, and select chemotherapy protocols);

(3) evaluate response to therapy; and(4) monitor patient progress and possible relapse.The diagnosis of abdominal organ involvement is aided

by the use of intravenous contrast.

MRIMRI

• The accuracy of MR imaging in detecting lymph node and organ involvement is similar to that of CT.

• MR imaging reveals the lymphoma masses to be:---- low to iso-signal intensity on T1-weighted images.--- moderately high signal on T2-weighted images. With successful treatment……… > low signal on T2

W.I. due to fibrosis.

Invasive methods of investigationInvasive methods of investigationFor biopsy taken For biopsy taken

What is a biopsy?A biopsy is the removal of a sample of tissue from the body for examination. The tissue will be examined under a microscope to assist in diagnosis. Therefore, only very small samples are needed

Biopsy taken under guidance of:1- US2- CT

Types of biopsy:1-FNAC2- Trucut

CT guided biopsyCT guided biopsy

Functional ImagingFunctional ImagingIs imaging technique giving information about Is imaging technique giving information about

metabolic activity of the tumorsmetabolic activity of the tumors

1- PET & PET-CT.1- PET & PET-CT.

2- Diffusion MR (DMR).2- Diffusion MR (DMR).

3- MRS (MR spectroscopy).3- MRS (MR spectroscopy).

PETPET

• The majority of malignant tumours have an The majority of malignant tumours have an increased glycolytic rate compared to normal increased glycolytic rate compared to normal tissues.tissues.

• PET is a functional scanner allowing the PET is a functional scanner allowing the differentiation of metabolically active tissue differentiation of metabolically active tissue from scar tissue by injection of special material from scar tissue by injection of special material (18FDG) (18FDG) (2-[fluorine-18-]-fluoro-2-deoxy-D-glucose).(2-[fluorine-18-]-fluoro-2-deoxy-D-glucose).

• Active tumor tissues show increase uptake.Active tumor tissues show increase uptake.• No active tumor tissue show no or decreased uptake.No active tumor tissue show no or decreased uptake.

PET-CTPET-CT

Diffusion-weighted MRIDiffusion-weighted MRIIs a new MR technique & depends on ADC values to Is a new MR technique & depends on ADC values to

tumor assessmenttumor assessment

There is increasing interest in the application of DWI for detecting tumor response.

Effective anticancer treatment results in tumor lysis, loss of cell membrane integrity, increased extracellular space, and, therefore, an increase in water diffusion

Diffusion MRI

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Freely Diffusing water

(high ADC)

(benign tumor & resolved tumor

Restricted Diffusing water (low ADC)

(malignant tumor)

Imaging of LymphomaImaging of Lymphoma

NodalParenchymatous

LiverSpleen

GI tractStomach Intestinal

NodalNodal

NodalNodal

Recommendations for upper limits of normal lymph node size (short axis) at CTRecommendations for upper limits of normal lymph node size (short axis) at CT

SiteSiteLocationLocationShort axis nodal diameter (mm)Short axis nodal diameter (mm)

AbdomenAbdomenGastrohepatic ligamentGastrohepatic ligament88

Porta hepatisPorta hepatis88

PortacavalPortacaval1010

Celiac axis to renal arteyCeliac axis to renal artey1010

Renal artery to aortic bifurcationRenal artery to aortic bifurcation1212

PelvisPelvisCommon iliacCommon iliac99

External iliacExternal iliac1010

Internal iliacInternal iliac77

ObturatorObturator88

Inguinal regionInguinal region1010

There are several patterns of hepatic involvement including1. Hepatomegaly.2. Multifocal hepatic masses resemble metastatic disease.3. Miliary lesions (<1 cm in diameter) mostly seen in Hodgkin

disease. 4. Lymphomatous infiltration may be seen extending from the

porta hepatis along the margins of the portal veins resultingin periportal patchy, irregular areas.

Hepatic lymphoma

Multiple hepatic focal lesions

CT abdomen US

Miliary lesions (<1 cm in diameter)

T1 (NON-CONTRAST) T1 (POST-CONTRAST)

Lymphomatous infiltration

Multiple hepatic focal lesions

T2 MRI

High signal

T1 MRI

low signal

Splenic lymphomaSplenic lymphoma

The imaging appearance of lymphoma of the spleen consists of

1. Splenomegaly.

2. Solitary mass.

3. Multifocal nodules.

4. Diffuse infiltration.

GI tract lymphomaGI tract lymphoma

Primary GI tract lymphoma is defined as:• A tumor that predominantly involves the GI tract

with lymph node involvement confined to the drainage area of the primary tumor site

• No liver or spleen involvement or palpable lymph nodes

• Normal chest radiography• Normal peripheral white blood cells.

Gastric lymphomaGastric lymphoma

Patterns of gastric lymphoma may include:-

1- solitary (nodular form).

2- or multiple submucosal nodules (polypoid form) with or without ulcerations,

3- larger exophytic masses with necrosis and ulceration (ulcerative form),

4- diffuse infiltration leading to fold thickening (infiltrative form).

A sharp distinction between these forms is uncommon.

Advanced gastric lymphoma. Axial non-contrast CT scan reveals severe gastric wall thickening up to 7 cm.

Gastric lymphoma: Multislice helical CT scan after oral and intravenous contrast with isotropic coronal reformation demonstrating marked thickening of the gastric antrum.

Gastric & Duodenal Gastric & Duodenal LymphomaLymphoma

CT appearance of intestinal lymphoma areCT appearance of intestinal lymphoma are::

Intestinal wall:Intestinal wall:1- Aneurysmal dilatation.1- Aneurysmal dilatation.2- Nodular.2- Nodular.3- Constrictive.3- Constrictive.

Mesenteric affection:Mesenteric affection:1- Conglomerate mass of mesenteric/retro-1- Conglomerate mass of mesenteric/retro-

peritoneal tissue.peritoneal tissue.2- Sandwich-like complex.2- Sandwich-like complex.

CT revealed : Uniform isoattenuated marked wall thickening without small bowel obstruction. Also note thickening of omentum by lymphomatous mass (arrow). Barium follow through: demonstrating corresponding abnormality with thickened valvula conniventes (arrowheads) and separation from adjacent loops (arrow).

CT Barium follow through

Small intestinal lymphoma. Small bowel follow-through demonstrating aneurysmal dilatation and complete loss of normal fold pattern in a loop of distal jejunum (arrows).

Intestinal lymphomaIntestinal lymphomaSandwitch-like appearanceSandwitch-like appearance

Small bowel Small bowel lymphomalymphoma

Mesenteric mass

Response to treatmentResponse to treatment ((assessment of tumor response by imaging )

• To assess tumor response, adequate pre-To assess tumor response, adequate pre-treatment staging must be performed.treatment staging must be performed.

• One must be able to define changes in tumor One must be able to define changes in tumor volume and composition.volume and composition.

• VolumeVolume ----------> by CT. ----------> by CT.• Composition Composition ---------- PET-CT--- PET-CT--- decrease activity decrease activity ------------ MR signal--- MR signal--- low T2 signal. low T2 signal. ------------ Diffusion MRI.--- Diffusion MRI.---Increase ADC valueIncrease ADC value

Complete remission * Complete disappearance of all detectable clinical and radiologic evidence of disease.

* All nodal masses to have decreased to normal (<1.5 cm in diameter for nodes that were >1.5 cm before therapy). If the nodes were initially between 1 and 1.5 cm, they must have decreased to 1 cm.

* The spleen, if previously enlarged on CT, must be normal and any focal lesions should have resolved. Similarly, the liver and kidney, if previously involved, must have returned to normal.

* If the marrow was involved it must be clear. Marrow biopsy and not imaging is used for this criterion.

CT Criteria for assessment of response in non-Hodgkin lymphoma and Hodgkin lymphoma

Partial response * More than a 50%decrease in sum of the product of perpendicular diameters of the six largest nodes or masses. These nodes should be from different areas of the body if possible, including the mediastinum and retro peritoneum.

* No increase in the size of other nodes, liver, or spleen.

* Any splenic or hepatic lesions should have decreased by 50%.

* Involvement of other organs is assessable but not measurable disease.

* No new side of ascites.

Stable disease* Less than partial response but not progressive disease.

Progressive disease• Appearance of new lesions or an increase of more than 50%

in established lesions.

• Increase of more than 50% in the greatest diameter of any previously identified node that was greater than 1 cm.

Thank You

Thank you

Imaging of LymphomaImaging of Lymphoma

Dr.: Adel El-BadrawyDr.: Adel El-Badrawy

Assistant Professor of RadiologyAssistant Professor of Radiology

Mansoura Faculty of MedicineMansoura Faculty of Medicine

DetectionDetection1- Plain films1- Plain films

- It is X-ray studies for all body bones.It is X-ray studies for all body bones.- The lesions are osteolytic, sclerotic or mixed.The lesions are osteolytic, sclerotic or mixed.- May detected intestinal obstruction in cases May detected intestinal obstruction in cases

of GI lymphoma.of GI lymphoma.- Detection of calcification in previously Detection of calcification in previously

osteolytic bony lesion indicate improvement. osteolytic bony lesion indicate improvement.

DetectionDetection2- Contrast studies2- Contrast studies

1- Barium meals and enemas for the 1- Barium meals and enemas for the detection of GI lymphomadetection of GI lymphoma

2- IVU may be used in cases of urinary tract 2- IVU may be used in cases of urinary tract lymphoma for assessment of the lesions lymphoma for assessment of the lesions or evaluate the renal function. or evaluate the renal function.

DetectionDetection3- US3- US

• It is either high frequency for superficial organs [7-It is either high frequency for superficial organs [7-10 Mhz] or low frequency [2-5 Mhz] for deep organs10 Mhz] or low frequency [2-5 Mhz] for deep organs

• It may be gray scale or colored.It may be gray scale or colored.• It is cheap, quick to perform, readily available with It is cheap, quick to perform, readily available with

no known harmful effects.no known harmful effects.• When combined with Doppler studies, tumour When combined with Doppler studies, tumour

vascularity and vascular invasion can be assessed.vascularity and vascular invasion can be assessed.• It is operator and machine dependant.It is operator and machine dependant.• It may be used for biopsy takenIt may be used for biopsy taken. .

DetectionDetection4- Computerised Tomography4- Computerised Tomography

What is CT Scanning of the Body?What is CT Scanning of the Body?* CT scanning—sometimes called CAT scanning—is a noninvasive * CT scanning—sometimes called CAT scanning—is a noninvasive

medical test that helps physicians diagnose and treat medical medical test that helps physicians diagnose and treat medical conditions.conditions.

* CT scanning combines special x-ray equipment with sophisticated * CT scanning combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied the body. These cross-sectional images of the area being studied can then be examined on a computer monitor or printed.can then be examined on a computer monitor or printed.

* CT scans of internal organs, bone, soft tissue and blood vessels * CT scans of internal organs, bone, soft tissue and blood vessels provide greater clarity and reveal more details than regular x-ray provide greater clarity and reveal more details than regular x-ray exams.exams.

* Using specialized equipment and expertise to create and interpret CT * Using specialized equipment and expertise to create and interpret CT scans of the body, radiologists can more easily diagnose problems scans of the body, radiologists can more easily diagnose problems such as cancers, cardiovascular disease, infectious disease, trauma such as cancers, cardiovascular disease, infectious disease, trauma and musculoskeletal disorders.and musculoskeletal disorders.

BenefitsBenefitsCT scanning is painless, noninvasive and accurate. CT scanning is painless, noninvasive and accurate. A major advantage of CT is its ability to image bone, soft tissue and blood vessels all at the same A major advantage of CT is its ability to image bone, soft tissue and blood vessels all at the same time. time. Unlike conventional x-rays, CT scanning provides very detailed images of many types of tissue Unlike conventional x-rays, CT scanning provides very detailed images of many types of tissue as well as the lungs, bones, and blood vessels. as well as the lungs, bones, and blood vessels. CT examinations are fast and simple; in emergency cases, they can reveal internal injuries and CT examinations are fast and simple; in emergency cases, they can reveal internal injuries and bleeding quickly enough to help save lives. bleeding quickly enough to help save lives. CT has been shown to be a cost-effective imaging tool for a wide range of clinical problems. CT has been shown to be a cost-effective imaging tool for a wide range of clinical problems. CT is less sensitive to patient movement than MRI. CT is less sensitive to patient movement than MRI. CT can be performed if you have an implanted medical device of any kind, unlike MRI. CT can be performed if you have an implanted medical device of any kind, unlike MRI. CT imaging provides real-time imaging, making it a good tool for guiding minimally invasive CT imaging provides real-time imaging, making it a good tool for guiding minimally invasive procedures such as needle biopsies and needle aspirations of many areas of the body, procedures such as needle biopsies and needle aspirations of many areas of the body, particularly the lungs, abdomen, pelvis and bones. particularly the lungs, abdomen, pelvis and bones. A diagnosis determined by CT scanning may eliminate the need for exploratory surgery and A diagnosis determined by CT scanning may eliminate the need for exploratory surgery and surgical biopsy. surgical biopsy. No radiation remains in a patient's body after a CT examination. No radiation remains in a patient's body after a CT examination. X-rays used in CT scans usually have no side effects. X-rays used in CT scans usually have no side effects.

RisksRisksThere is always a slight chance of cancer from excessive exposure to radiation. There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. However, the benefit of an accurate diagnosis far outweighs the risk. The effective radiation dose from this procedure ranges from approximately two to 10 The effective radiation dose from this procedure ranges from approximately two to 10 mSv, which is about the same as the average person receives from background mSv, which is about the same as the average person receives from background radiation in three to five years. radiation in three to five years. See the Safety page for more information about See the Safety page for more information about radiation dose. radiation dose. Women should always inform their physician and x-ray or CT technologist if there is Women should always inform their physician and x-ray or CT technologist if there is any possibility that they are pregnant. any possibility that they are pregnant. See the Safety page for more information about See the Safety page for more information about pregnancy and x-rays.pregnancy and x-rays. CT scanning is, in general, not recommended for pregnant women unless medically CT scanning is, in general, not recommended for pregnant women unless medically necessary because of potential risk to the baby. necessary because of potential risk to the baby. Nursing mothers should wait for 24 hours after contrast material injection before Nursing mothers should wait for 24 hours after contrast material injection before resuming breast-feeding. resuming breast-feeding. The risk of serious allergic reaction to contrast materials that contain iodine is The risk of serious allergic reaction to contrast materials that contain iodine is extremely rare, and radiology departments are well-equipped to deal with them. extremely rare, and radiology departments are well-equipped to deal with them. Because children are more sensitive to radiation, they should have a CT study only if Because children are more sensitive to radiation, they should have a CT study only if it is essential for making a diagnosis and should not have repeated CT studies unless it is essential for making a diagnosis and should not have repeated CT studies unless absolutely necessary. absolutely necessary.

DetectionDetection5- MRI5- MRI

Magnetic Resonance ImagingMagnetic Resonance Imaging ( (MRIMRI), or ), or nuclear magnetic nuclear magnetic resonance imagingresonance imaging ( (NMRINMRI), is primarily a medical imaging ), is primarily a medical imaging technique most commonly used in radiology to visualize detailed technique most commonly used in radiology to visualize detailed internal structure and limited function of the body. MRI provides internal structure and limited function of the body. MRI provides much greater contrast between the different soft tissues of the body much greater contrast between the different soft tissues of the body than computed tomography (CT) does, making it especially useful in than computed tomography (CT) does, making it especially useful in neurological (brain), musculoskeletal, cardiovascular, and neurological (brain), musculoskeletal, cardiovascular, and oncological (cancer) imaging. Unlike CT, it uses no ionizing oncological (cancer) imaging. Unlike CT, it uses no ionizing radiation, but uses a powerful magnetic field to align the nuclear radiation, but uses a powerful magnetic field to align the nuclear magnetization of (usually) hydrogen atoms in water in the body. magnetization of (usually) hydrogen atoms in water in the body. Radio frequency (RF) fields are used to systematically alter the Radio frequency (RF) fields are used to systematically alter the alignment of this magnetization, causing the hydrogen nuclei to alignment of this magnetization, causing the hydrogen nuclei to produce a rotating magnetic field detectable by the scanner. This produce a rotating magnetic field detectable by the scanner. This signal can be manipulated by additional magnetic fields to build up signal can be manipulated by additional magnetic fields to build up enough information to construct an image of the body.[1]:36 enough information to construct an image of the body.[1]:36

Gastric lymphomaGastric lymphomaOverall, the appearance of gastric lymphomasat barium fluoroscopy varies. Patterns may includesolitary (nodular form) or multiple submucosalnodules (polypoid form) with or without ulcerations,larger exophytic masses with necrosis andulceration (ulcerative form), and diffuse infiltrationleading to fold thickening (infiltrative form). A sharpdistinction between these forms is uncommon,and the terms are purely descriptive. Even though90% to 95% of gastric lymphomas are detectedon barium studies, that specific diagnosis ismade less than 20% of the time because of thesimilarity in appearances to the more commoncarcinoma and the other differential diagnosticconsiderations like hypertrophic gastritis or Menetrier’sdisease.

CT appearance of intestinal lymphoma areCT appearance of intestinal lymphoma are::

Intestinal wall:-Intestinal wall:-1- Aneurysmal dilatation.1- Aneurysmal dilatation.2- Nodular.2- Nodular.3- Constrictive.3- Constrictive.

Mesenteric affection:Mesenteric affection:1- Conglomerate mass of mesenteric/retro-1- Conglomerate mass of mesenteric/retro-

peritoneal tissue.peritoneal tissue.2- Sandwich-like complex.2- Sandwich-like complex.

Limitation of MRILimitation of MRI

1- Claustrophobia overcomed by open MRI.1- Claustrophobia overcomed by open MRI.

2- Metallic implant.2- Metallic implant.

3- Long duration than CT3- Long duration than CT

* IMAGING TECHNIQUES- Cross-sectional imaging (CT scan, MR imaging) is

primarily used to detect lymphadenopathy and the pattern of nodal involvement. Anatomic imaging is limited in accurate lymphoma evaluation as small lymph nodes may harbor malignant cells, whereas large lymph nodes may be benign.

- Functional imaging, such as positron emission tomography (PET) with fluorodeoxyglucose (FDG),has shown promising results in the diagnosis of lymphoma and complete assessment of the extent of disease. It is also very useful in the follow-up of lymphoma

Complete remission: unconfirmed or uncertain

* As above (first and third point), but with a residual mass greater than 1.5 cm, which must have regressed by more than 75% from the original product of perpendicular diameters. Individual nodes that were confluent must have decreased by more than 75% of pre therapy sum of the

product of perpendicular diameters.

Imaging pitfallsReporting of increased number of normal-sized lymph nodes in the initial, early staging CT is important. This finding should be reported because these normal-sized but increased number of lymph nodes may represent early abdominal disease, which may be relevant in staging; however, this finding is still of unknown significance. This is different in patients who have had multiple prior studies, which have established stable lymph nodes.

Comparison with the most recent CT study is often not sufficient because the growth becomes obvious only if serial studies are compared. Small difference in measurement (approximately 15%) in near normal-sized lymph nodes between two CT examination is often related to ‘‘plane of section’’ artifact (ie, related to slice section). A follow-up study in 3 months is not sufficient for follow-up of slow-growing lymphoma.

Splenic lymphoma Splenic lymphoma

The imaging appearance of lymphoma of the spleen consists of

1. Splenomegaly.

2. Solitary mass.

3. Multifocal nodules.

4. Diffuse infiltration.

Gastric lymphomaGastric lymphomaOverall, the appearance of gastric lymphomasat barium fluoroscopy varies. Patterns may includesolitary (nodular form) or multiple submucosalnodules (polypoid form) with or without ulcerations,larger exophytic masses with necrosis andulceration (ulcerative form), and diffuse infiltrationleading to fold thickening (infiltrative form). A sharpdistinction between these forms is uncommon,and the terms are purely descriptive. Even though90% to 95% of gastric lymphomas are detectedon barium studies, that specific diagnosis ismade less than 20% of the time because of thesimilarity in appearances to the more commoncarcinoma and the other differential diagnosticconsiderations like hypertrophic gastritis or Menetrier’sdisease.

There are several patterns of hepatic involvement including

1. Hepatomegaly.2. Multifocal hepatic masses resemble metastatic

disease.3. Miliary lesions (<1 cm in diameter) mostly seen in

Hodgkin disease. 4. Lymphomatous infiltration may be seen extending

from the porta hepatis along the margins of the portal veins resultingin periportal patchy, irregular areas.

Esophageal lymphoma.(A) Right posterior oblique barium esophagogram demonstrating smooth stricture above midesophagus, indicating circumferential tumor narrowing the lumen. (B) Axial contrast enhanced thoracic CT demonstrating markedly concentricallythickened esophagus with uniform iso-attenuated density of esophageal wall, and narrow slit-like lumen.

MRIMRI

• The accuracy of MR imaging in detecting lymph node and organ involvement is similar to that of CT.

• MR imaging reveals the lymphoma masses to be:---- low to iso-signal intensity on T1-weighted images.--- moderately high signal on T2-weighted imaging. With successful treatment------ > low signal on T1

&T2 W.I. due to fibrosis.