Intestinal Metastases and Lymphoma

Published on 19/07/2015 by admin

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Last modified 19/07/2015

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 Limited to bowel ± mesenteric nodes

• Secondary lymphoma

image Involvement of spleen, liver, or thoracic nodes

IMAGING

• Intestinal metastases
• Malignant melanoma is most common primary site

image Enhancing masses within SB mesentery and bowel wall
image Bull’s-eye or “target” lesions; intussusception
• Lung and breast carcinoma metastases

image Are scirrhous tumors
image Likely to cause luminal obstruction
• Intraperitoneal metastatic spread (e.g., from ovarian and GI primary tumors)

image Serosal metastases cause clustered adhesion and fixation of SB loops and functional obstruction
• Direct invasion (e.g., from pancreatic or GYN tumor)

image Lumen of affected SB is often narrowed or obstructed
• Intestinal lymphoma
• Circumferential type: Sausage-shaped mass(es)

image Rarely obstructs; may cause aneurysmal dilation
• Polypoid form: Bull’s-eye or “target” lesions
• Mesenteric form: SB masses and nodes
• CT enterography is best protocol, with multiplanar reformation

TOP DIFFERENTIAL DIAGNOSES

• Primary small bowel carcinoma

image Solitary mass causing luminal obstruction
• Infectious and inflammatory etiologies 

image Mucosal hyperenhancement and submucosal edema

CLINICAL ISSUES

• Metastases: Most common with melanoma > lung, breast, others

image SB and mesentery are common sites of metastases from melanoma
image May arise many years after primary tumor removal
• Lymphoma accounts for 1/2 of all malignant SB tumors

image Patients with immune suppression (e.g., transplant recipients, AIDS); celiac disease
• Treatment

image Surgical resection of lesions that bleed, perforate, obstruct, or have aneurysmal dilation
image
(Left) Axial CECT in a 58-year-old man who presented with a known history of malignant melanoma demonstrates 1 of several soft tissue masses image in the mesentery. The metastases subsequently resulted in an intussusception.

image
(Right) Axial CECT in the same patient 5 months later reveals the resultant long-segment intussusception image. One of the bowel wall metastases served as the lead point of the intussusception.
image
(Left) Axial CECT in a 46-year-old man who presented with a known history of non-Hodgkin lymphoma demonstrates extensive, multifocal, bowel wall thickening and aneurysmal dilatation of the lumen of the ileum image.

image
(Right) Coronal CECT reconstruction in the same patient illustrates extensive mesenteric lymphadenopathy image and encasement of the mesenteric vessels, but no bowel or vascular obstruction. Multifocal masses of lymphoma image are also seen.

TERMINOLOGY

Definitions

• Intestinal metastases from extraintestinal primary cancer
• Lymphoma: Malignant tumor of B lymphocytes

image Primary small bowel (SB) lymphoma: Limited to bowel ± mesenteric nodes
image Secondary or generalized lymphoma: Involvement of spleen, liver, or thoracic nodes

IMAGING

General Features

• Best diagnostic clue

image Bull’s-eye or “target” lesions
image Aneurysmal dilation of bowel lumen

Radiographic Findings

• Metastases to bowel
• Barium-enhanced fluoroscopic studies (upper GI, SB follow-through, barium enema)

image Most detailed study of SB is enteroclysis (tube administration of barium into SB with distention of lumen)
image Offer detailed view of mucosal and intramural extent of disease

– Less useful for extrinsic, extraluminal disease
• Malignant melanoma metastases to SB

image Solitary or multiple discrete submucosal masses
image Bull’s-eye or “target” lesions: Centrally ulcerated submucosal masses
image “Spoke-wheel” pattern: Radiating superficial fissures from central ulcer
image Giant cavitated mass (aneurysmal dilation)
image Small or large, lobulated masses

– Large collection of enteric contrast medium contiguous with lumen (melanoma, lymphoma)
• Lung and breast carcinoma metastases

image Are scirrhous tumors; likely to cause luminal obstruction
image Solitary/multiple, flat/polypoid intramural masses
• Intraperitoneal metastatic spread (e.g., from ovarian and GI primary tumors)

image Serosal metastases cause clustered adhesion and fixation of SB loops and functional obstruction
image Lack of peristalsis through affected segments
• Direct invasion (e.g., from pancreatic or GYN tumor)

image Spiculated mucosal folds, nodular mass effect, ulceration, obstruction, rarely fistula
image Lumen of affected SB is often narrowed or obstructed
• Intestinal lymphoma

image Multifocal intramural and mesenteric masses without SB obstruction
image Splenic and hepatic enlargement or focal masses
image Infiltrating lymphoma (most frequent)

– Circumferential thickening and effacement of folds
– Lumen may be compressed or dilated (aneurysmal dilation)

image Due to replacement of muscularis propria by lymphoma
image Lymphoma is not likely to cause high-grade bowel obstruction
image Polypoid lymphoma

– Single/multiple, mucosal/submucosal masses
– “Target” or Bull’s-eye lesions (if centrally ulcerated)
– Rarely lymphomatous polyposis (follicular mantle cell origin)
image Nodular lymphoma

– Multiple small submucosal nodular defects
image Endoexoenteric (cavitary form): Localized perforation into extraluminal tissue

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