Duodenal Metastases and Lymphoma

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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 Metastases: Bull’s-eye or “target” lesion; submucosal or polypoid mass

image Lymphoma: Bulky submucosal mass without obstruction
• Best imaging tool: Upper GI series, CECT
• Metastases: “Target” or bull’s-eye lesion with rounded submucosal mass

image Luminal obstruction and ulceration are common
• Lymphoma: Large smooth or lobulated submucosal mass 

image Aneurysmal dilation of lumen without obstruction
• Direct invasion: From primary cancer of pancreas, colon, kidney, gallbladder

image  

TOP DIFFERENTIAL DIAGNOSES

• Villous adenoma, duodenal carcinoma, secondary duodenal invasion, duodenal GIST
•  
•  
•  

PATHOLOGY

• Etiology

image Metastases: Melanoma, cancer of breast, lung, colon, pancreas, or kidney
image Lymphoma: Non-Hodgkin lymphoma of B-cell origin or mucosa-associated lymphoid tissue

CLINICAL ISSUES

• Most common signs/symptoms: Abdominal pain, nausea, vomiting, weight loss, palpable mass, upper GI bleeding

image  

DIAGNOSTIC CHECKLIST

• Consider duodenal carcinoma (usually obstructs lumen)
• Lymphoma: Bulky submucosal mass without obstruction
image
(Left) Spot film from from an upper GI series shows an ulcerated mass image arising from the 2nd portion of the duodenum. There is a persistent pooling of barium within the lesion after the remainder of the duodenum has cleared.

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(Right) Axial CECT in the same patient reveals a high-attenuation mass image within the wall of the 2nd duodenum. A metastatic tumor was confirmed at surgery with the same histology as the primary colon cancer.
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(Left) Small bowel follow-through in a liver transplant recipient, who presented with upper gastrointestinal pain and bleeding, shows a large amorphous collection of barium image apparently arising from, and in continuity with, the distal duodenum. There is no evidence of bowel obstruction.

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(Right) Axial CECT in the same patient shows a large soft tissue density mass image arising from the distal duodenum. This is a good example of aneurysmal dilation of the bowel lumen caused by lymphoma.

TERMINOLOGY

Definitions

• Involvement of duodenum with malignant lymphoma or metastatic disease

IMAGING

General Features

• Best diagnostic clue

image Metastases: Bull’s-eye or “target” lesion; submucosal or polypoid mass
image Lymphoma: Bulky submucosal mass without obstruction of lumen
• Location

image Submucosal lesion in any portion of duodenum
• Size

image 1-5 cm
• Morphology

image Lymphoma: Smooth submucosal, often bulky mass

Fluoroscopic Findings

• Upper GI

image Metastases: “Target” or bull’s-eye lesion with rounded submucosal mass; luminal obstruction and ulceration are common

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image Lymphoma: Large smooth or lobulated submucosal mass; aneurysmal dilation of lumen without obstruction

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CT Findings

• CECT

image Hematogenous metastasis appears as rounded submucosal mass
image Direct invasion from primary tumor of pancreas, colon, kidney, gallbladder, or retroperitoneal node
image Lymphoma: Bulky hypovascular soft tissue mass 

– Stomach and duodenum may be involved contiguously

MR Findings

• T1WI

image Low signal duodenal mass
• T2WI

image Intermediate signal mass
• T1WI C+

image Variable enhancement: Adenocarcinoma typically hypovascular; melanoma may be hypervascular

Imaging Recommendations

• Best imaging tool

image Upper GI series, CECT

DIFFERENTIAL DIAGNOSIS

Villous Adenoma

• Bulky mucosal polypoid mass (3-9 cm); rarely causes obstruction
• Risk of cancer increases with size; 30-60% of tumors have malignant changes

Duodenal Carcinoma

• More likely to appear as an “apple core,” annular, obstructing  lesion
• 1% of all GI neoplasms
• Increased incidence in Gardner syndrome, celiac disease, Crohn disease, neurofibromatosis
• Regional lymphadenopathy and pancreatic invasion are common

Secondary Duodenal Invasion

• Most commonly due to pancreatic, colon, or renal cell carcinoma
• Large extramural mass; often asymptomatic but may lead to outlet obstruction

Duodenal GIST

• Large submucosal mass ± central ulceration
• Duodenum is 2nd to stomach as site for GIST

PATHOLOGY

General Features

• Etiology

image Metastases: Melanoma, cancer of breast, lung, colon, pancreas, or kidney
image Lymphoma: Non-Hodgkin lymphoma of B-cell origin or mucosa-associated lymphoid tissue (MALT)

– MALT lymphomas associated with H. pylori infection
• Associated abnormalities

image Regional lymphadenopathy; metastases may cause outlet obstruction

Staging, Grading, & Classification

• GI lymphoma staging

image I: Tumor confined to bowel wall
image II: Limited spread to local nodes
image III: Widespread nodal metastases
image IV: Spread to bone marrow, solid viscera (e.g., liver)

Gross Pathologic & Surgical Features

• Metastases: Polypoid mucosal/submucosal masses (melanoma or secondary extrinsic mass invading duodenum)
• Lymphoma: Most often associated with gastric lymphoma extending through pylorus into duodenum

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Abdominal pain, nausea, vomiting, weight loss, palpable mass, upper GI bleeding

Demographics

• Age

image 55-60 years
• Gender

image M < F

Treatment

• Options, risks, complications

image Metastases: Chemotherapy best option
image Localized lymphoma: Surgery best option, to avoid bleeding and perforation

DIAGNOSTIC CHECKLIST

Consider

• Duodenal carcinoma

Image Interpretation Pearls

• Lymphoma: Bulky submucosal mass without obstruction
image
Axial CECT shows a submucosal soft tissue infiltrating mass image due to lymphoma.

image
Axial CECT demonstrates a bulky soft tissue mass involving the duodenum image. Biopsy revealed lymphoma.
image
Axial CECT of duodenal lymphoma shows extensive infiltration of the duodenum by a soft tissue mass image.
image
Axial CECT of duodenal lymphoma demonstrates that a bulky mass infiltrates the duodenum, invades the mesentery, and extends into the superior mesenteric vein image.
image
CT shows no sign of gastric outlet obstruction in this patient with massive small bowel lymphoma
image
CT in the same case shows a huge tumor mass enveloping the duodenum and jejunum. The center of the mass is cavitated and oral contrast media and gas flow through the mass into distal small bowel. The “lumen” of the bowel appears to be dilated, but the bowel wall has been completely replaced by tumor.
image
CT in the same case shows “aneurysmal dilation” of the bowel lumen.
image
CT shows the huge tumor mass enveloping the duodenum and jejunum. The center of the mass is cavitated and oral contrast media and gas flow through the mass into distal small bowel. The “lumen” of the bowel image appears to be dilated (aneurysmal dilation), but the bowel wall has been completely replaced by tumor.
image
In the same case, a section through the pelvis shows peritoneal metastases image.

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