Imaging of Lymphoma

1. Imaging of Lymphoma Dr.: Adel El-Badrawy Assistant Professor of Radiology Mansoura Faculty of Medicine

2. Imaging = Tumour assessment 1- Detection. 2- Staging 3- Response to treatment 4-Recurrence of disease

3. Non-Invasive methods of investigation 1- Plain films 2- Contrast studies as barium examination 3- Ultrasound (US) 4- Computerized Tomography (CT) 5- Magnetic Resonance Imaging (MRI) 6- Nuclear medicine (NM) [isotope scanning] 7- Positron emission tomography (PET)

4. CT 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.

5. MRI • 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.

6. Invasive methods of investigationFor 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- US 2- CT Types of biopsy: 1-FNAC 2- Trucut

7. CT guided biopsy

8. Functional ImagingIs imaging technique giving information about metabolic activity of the tumors 1- PET & PET-CT. 2- Diffusion MR (DMR). 3- MRS (MR spectroscopy).

9. PET • The majority of malignant tumours have an increased glycolytic rate compared to normal tissues. • PET is a functional scanner allowing the differentiation of metabolically active tissue from scar tissue by injection of special material (18FDG) (2-[fluorine-18-]-fluoro-2-deoxy-D-glucose). • Active tumor tissues show increase uptake. • No active tumor tissue show no or decreased uptake.

10. PET-CT

11. Diffusion-weighted MRIIs a new MR technique & depends on ADC values to tumor 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

12. Diffusion MRI Freely Diffusing water (high ADC) (benign tumor & resolved tumor Restricted Diffusing water (low ADC) (malignant tumor) . . . . . . . . . .

15. Nodal

16. Nodal

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

18. Hepatic lymphoma There are several patterns of hepatic involvement including • Hepatomegaly. • 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.

19. Multiple hepatic focal lesions US CT abdomen

20. Miliary lesions (<1 cm in diameter) T1 (NON-CONTRAST) T1 (POST-CONTRAST)

21. Lymphomatous infiltration

22. Multiple hepatic focal lesions T1 MRI low signal T2 MRI High signal

23. Splenic lymphoma The imaging appearance of lymphoma of the spleen consists of • Splenomegaly. • Solitary mass. • Multifocal nodules. • Diffuse infiltration.

25. GI 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.

26. Gastric 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.

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

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

30. Gastric & Duodenal Lymphoma

31. CT appearance of intestinal lymphoma are: Intestinal wall: 1- Aneurysmal dilatation. 2- Nodular. 3- Constrictive. Mesenteric affection: 1- Conglomerate mass of mesenteric/retro-peritoneal tissue. 2- Sandwich-like complex.

32. 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

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

35. Intestinal lymphomaSandwitch-like appearance

36. Small bowel lymphoma Mesenteric mass

37. Response to treatment(assessment of tumor response by imaging ) • To assess tumor response, adequate pre-treatment staging must be performed. • One must be able to define changes in tumor volume and composition. • Volume ----------> by CT. • Composition ----- PET-CT--- decrease activity ------ MR signal--- low T2 signal. ------ Diffusion MRI.---Increase ADC value

38. Table 1 Recommendations for upper limits of normal lymph node size (short axis) at CT Site Location Short Axis Nodal Diameter (mm) Abdomen Gastrohepatic ligament 8 Porta hepatis 8 Portacaval 10 Celiac axis to renal artery 10 Renal artery to aortic bifurcation 12 Pelvis Common iliac 9 External iliac 10 Internal iliac 7 Obturator 8 Inguinal region 10 Professional judgment should be used in applying these recommendations. A normal-sized lymph node could be involved with lymphoma and be PET avid. A lymph node could remain enlarged, however, after successful treatment of lymphoma because of posttreatment changes. Data from Refs. [14–16]. Fig. 5. CT Criteria for assessment of response in non-Hodgkin lymphoma and Hodgkin lymphoma 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.

39. 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.

40. 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.

41. جزاكم الله خيرا Thank You

42. جزاكم الله خيرا Thank you

43. Imaging of Lymphoma Dr.: Adel El-Badrawy Assistant Professor of Radiology Mansoura Faculty of Medicine

44. Detection1- Plain films • It is X-ray studies for all body bones. • The lesions are osteolytic, sclerotic or mixed. • May detected intestinal obstruction in cases of GI lymphoma. • Detection of calcification in previously osteolytic bony lesion indicate improvement.

45. Detection2- Contrast studies 1- Barium meals and enemas for the detection of GI lymphoma 2- IVU may be used in cases of urinary tract lymphoma for assessment of the lesions or evaluate the renal function.

46. Detection3- US • It is either high frequency for superficial organs [7-10 Mhz] or low frequency [2-5 Mhz] for deep organs • It may be gray scale or colored. • It is cheap, quick to perform, readily available with no known harmful effects. • When combined with Doppler studies, tumour vascularity and vascular invasion can be assessed. • It is operator and machine dependant. • It may be used for biopsy taken.

48. Detection4- Computerised Tomography • What is CT Scanning of the Body? * CT scanning—sometimes called CAT scanning—is a noninvasive medical test that helps physicians diagnose and treat medical conditions. * CT scanning combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied can then be examined on a computer monitor or printed. * CT scans of internal organs, bone, soft tissue and blood vessels provide greater clarity and reveal more details than regular x-ray exams. * Using specialized equipment and expertise to create and interpret CT scans of the body, radiologists can more easily diagnose problems such as cancers, cardiovascular disease, infectious disease, trauma and musculoskeletal disorders.

49. Benefits • 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 time. • Unlike conventional x-rays, CT scanning provides very detailed images of many types of tissue as well as the lungs, bones, and blood vessels. • CT examinations are fast and simple; in emergency cases, they can reveal internal injuries and 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 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 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, particularly the lungs, abdomen, pelvis and bones. • A diagnosis determined by CT scanning may eliminate the need for exploratory surgery and surgical biopsy. • No radiation remains in a patient's body after a CT examination. • X-rays used in CT scans usually have no side effects.

50. Risks • There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. • 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 radiation in three to five years. See the Safety page for more information about radiation dose. • Women should always inform their physician and x-ray or CT technologist if there is any possibility that they are pregnant. See the Safety page for more information about pregnancy and x-rays. • CT scanning is, in general, not recommended for pregnant women unless medically necessary because of potential risk to the baby. • Nursing mothers should wait for 24 hours after contrast material injection before resuming breast-feeding. • 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. • 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 absolutely necessary.