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Marginal Zone B-Cell Non-Hodgkin's Lymphoma of Mucosa-Associated Lymphoid Tissue Type: Imaging Findings

¹ Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany.
² Department of Internal Medicine–Oncology, Eberhard-Karls-University, Tübingen, Germany.
³ Department of Nuclear Medicine, Eberhard-Karls-University, Tübingen, Germany.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —59-year-old woman with mucosa-associated lymphoid tissue lymphoma of ocular adnexa. Axial contrast-enhanced CT scan shows enlargement and asymmetry of right lacrimal gland (arrow) extending into retrobulbar space, presenting diffuse strong enhancement. Differential diagnosis should exclude inflammatory pseudotumors of orbit, benign lymphoproliferation, pseudolymphoma, and other orbital neoplasms.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —49-year-old woman with newly diagnosed mucosa-associated lymphoid tissue (MALT) lymphoma of right parotid gland. Contrast-enhanced axial CT scan shows high attenuation of right parotid gland (arrow). Poor definition of glandular borders is caused by lymphoma infiltration extending into retromandibular space and along main parotid duct. In patients with primary MALT lymphoma of parotid gland without coexistent Sjögren's syndrome, typical imaging finding is focal nodular or diffuse unilateral or bilateral parenchymal infiltration with increased attenuation and contrast enhancement.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —57-year-old woman with Sjögren's syndrome and associated mucosa-associated lymphoid tissue (MALT) lymphoma of parotid gland. Left parotid gland was resected several years previously because of MALT lymphoma. Coronal CT reformation after IV administration of contrast material shows enlargement and induration of contralateral gland (arrow).

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —57-year-old woman with Sjögren's syndrome and associated mucosa-associated lymphoid tissue (MALT) lymphoma of parotid gland. Left parotid gland was resected several years previously because of MALT lymphoma. T2-weighted coronal MR image shows swelling of right parotid gland and dilatation of salivary ducts or cysts (arrow). Changes were caused by ductal epithelial proliferation with obliteration of ductal lumina in late-stage Sjögren's syndrome.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —57-year-old woman with Sjögren's syndrome and associated mucosa-associated lymphoid tissue (MALT) lymphoma of parotid gland. Left parotid gland was resected several years previously because of MALT lymphoma. T1-weighted coronal MR image shows MALT lymphoma involvement (arrow) of parotid gland responsible for progressive soft-tissue infiltration and gadolinium enhancement manifesting as honeycombing. Differentiation of benign lymphoepithelial lesions of parotid gland from MALT lymphoma infiltration requires extensive sampling and immunochemical analysis. In AIDS patients, MALT lymphoma can accompany benign lymphoepithelial lesions.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —59-year-old woman with multifocal cutaneous and subcutaneous involvement of mucosa-associated lymphoid tissue (MALT) lymphoma. Axial contrast-enhanced CT scan of cervical region shows plaquelike infiltration (arrow) of platysma muscle.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —59-year-old woman with multifocal cutaneous and subcutaneous involvement of mucosa-associated lymphoid tissue (MALT) lymphoma. Axial contrast-enhanced CT scan shows focal MALT lymphoma infiltration extending over left maxilla and levator angulus oris muscle (arrow).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —59-year-old woman with multifocal cutaneous and subcutaneous involvement of mucosa-associated lymphoid tissue (MALT) lymphoma. Axial contrast-enhanced CT scan shows masslike MALT lymphoma infiltration (arrows) extending along posterior fascia of trapezius muscle, which is not sharply delineated. Calcifications within tumor are evident. Findings resemble those of dermatomyositis.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —82-year-old woman with histologically proven mucosa-associated lymphoid tissue lymphoma. Axial contrast-enhanced CT scan shows ill-defined star-shaped infiltration (arrows) of gluteal region on both sides and spreading along gluteus maximus muscular fascia. Changes can be easily misinterpreted as hematoma or panniculitis.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —62-year-old woman with histologically proven mucosa-associated lymphoid tissue lymphoma of lung. Axial high-resolution CT scan shows rare form of pulmonary involvement manifesting as generalized septal thickening, reticulation, and moderate ground-glass opacity. Pattern of pulmonary infiltration mimics fibrosis or alveolar proteinosis.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —58-year-old woman with mucosa-associated lymphoid tissue lymphoma of lung. CT scan shows multifocal pulmonary areas of ground-glass opacity and, especially, consolidation, which are in part ill-defined and centered by subsegmental bronchia (arrows). Imaging features and slow kinetics of these pulmonary infiltrates are difficult to differentiate from those of bronchoalveolar carcinoma and nodular amyloidosis.

View larger version (179K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —78-year-old man with histologically proven mucosa-associated lymphoid tissue (MALT) lymphoma of lung. CT scan shows focal nodular mass representing MALT lymphoma. Discrete positive airspace bronchogram is evident. Differential diagnoses include nodular lymphoid hyperplasia, Wegener's granulomatosis, and cryptogenic interstitial pneumonia.

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —56-year-old man with mucosa-associated lymphoid tissue (MALT) lymphoma of lung. Coronal reformation of whole-body FDG PET scan shows discrete focal uptake in nodular MALT lymphoma (arrow) of right lung. Average standard uptake value was 1.3, which allows no further differentiation from infection, inflammation, or benign lung tumor.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —62-year-old woman with mucosa-associated lymphoid tissue lymphoma involving gallbladder. Contrast-enhanced CT scan shows massive thickening of gallbladder wall (arrow) due to lymphoma.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —62-year-old woman with mucosa-associated lymphoid tissue lymphoma involving gallbladder. Subcostal conventional B-mode sonogram shows gallbladder wall thickening (arrow) up to 8 mm thick (asterisks) predominantly in fundal region. Unlike findings in gallbladder carcinoma, all wall layers of gallbladder are preserved. Differentiation from adenomyomatous hyperplasia can prove difficult and relies mainly on visualization of small cystic spaces (Rokitansky-Aschoff sinuses) and concretions apparent on sonograms and T2-weighted MR images.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —56-year-old man with gastric mucosa-associated lymphoid tissue (MALT) lymphoma. Coronal reformation of abdominal contrast-enhanced CT scan shows circular growth of MALT lymphoma (small arrow) at gastric angle. Nodal involvement (large arrows) also is evident.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —56-year-old man with gastric mucosa-associated lymphoid tissue (MALT) lymphoma. CT scan shows circular growth of MALT lymphoma (arrow) at gastric angle mimicking carcinoma. As with most gastrointestinal lymphomas, there is no luminal stenosis.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —80-year-old man with gastric mucosa-associated lymphoid tissue (MALT) lymphoma. CT scan shows strong segmental wall thickening in fundus and body of stomach. Contrast enhancement (arrow) along lesser curvature changes owing to lymphoma infiltration.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —80-year-old man with gastric mucosa-associated lymphoid tissue (MALT) lymphoma. Contrast-enhanced CT scan shows polypoid multifocal gastric wall thickening along greater curvature with moderate contrast enhancement (arrow). At macroscopic inspection, low-grade MALT lymphoma usually exhibits multiple instances of superficial spreading of lesions without ulceration, whereas high-grade lymphoma exhibits solitary tumor-forming lesion. Shallow ulcer usually indicates high-grade lymphoma or, more commonly, gastric carcinoma.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —62-year-old woman with duodenal mucosa-associated lymphoid tissue lymphoma. Axial contrast-enhanced CT scan shows segmental circular wall thickening (arrow) in duodenum. Definition of mucosa and submucosa is poor owing to diffuse lymphoma infiltration.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —62-year-old woman with duodenal mucosa-associated lymphoid tissue lymphoma. Subcostal conventional B-mode sonogram shows duodenal wall thickening with good delineation of all mural layers (arrow).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14A —70-year-old man with histologically proven gastrointestinal mucosa-associated lymphoid tissue (MALT) lymphoma with involvement of stomach, mesentery, and colon. T2-weighted turbo spin-echo (TR/TE, 4,260/95) MR image shows diffuse moderate thickening (arrow) of intestinal wall. As expected, luminal stenosis is not present. Small-intestinal MALT lymphoma usually is preceded by immune proliferative small-intestinal disease.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14B —70-year-old man with histologically proven gastrointestinal mucosa-associated lymphoid tissue (MALT) lymphoma with involvement of stomach, mesentery, and colon. Axial contrast-enhanced CT scan shows right colonic wall thickening (large arrow) with infiltration of adjacent greater omentum (small arrow). Morphologic features are difficult to differentiate from those of carcinoma with peritoneal spread.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14C —70-year-old man with histologically proven gastrointestinal mucosa-associated lymphoid tissue (MALT) lymphoma with involvement of stomach, mesentery, and colon. CT scan shows severe rectal wall thickening (arrow) due to MALT lymphoma infiltration.

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15 —79-year-old woman with bilateral histologically proven mucosa-associated lymphoid tissue lymphoma of breast. CT scan shows bilateral well-marginated breast masses (arrows) with homogeneous attenuation. Differentiation from other rare tumors, such as phyllodes tumor, is difficult and requires biopsy.

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16 —78-year-old woman with mucosa-associated lymphoid tissue (MALT) lymphoma of breast. CT scan shows solitary breast involvement by MALT lymphoma (arrow) evidenced by homogeneous low-attenuation mass with mild contrast enhancement. Mild to moderate CT attenuation in breast parenchyma results from short delay time used for chest imaging with whole-body investigation protocols. Delayed CT scans show progressive enhancement.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17A —80-year-old man with mucosa-associated lymphoid tissue (MALT) lymphoma involving tonsils. Axial contrast-enhanced CT scan of cervical region shows involvement of Waldeyer's tonsillar ring by MALT lymphoma. Arrow indicates right palatine tonsil.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17B —80-year-old man with mucosa-associated lymphoid tissue (MALT) lymphoma involving tonsils. CT scan shows infiltration of right lingual tonsil (arrow). Use of 18F-FDG PET for differentiation from high-grade tonsillar lymphoma or carcinoma can prove beneficial because low tracer avidity is expected only in low-grade lymphoma, including MALT lymphoma (not shown). Diffusion-weighted imaging seems useful for differentiating tumor and nontumorous masses and even for establishing biologic aggressiveness of tumors reflected by different cellularities and macromolecular interactions. Apparent diffusion coefficient (ADC) measurement with diffusion-weighted imaging may be useful in differentiation of extranodal lymphoma and carcinoma. Low ADC values are characteristic of malignant lymphoma in head and neck and other locations.

View larger version (61K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18A —58-year-old man with mucosa-associated lymphoid tissue (MALT) lymphoma with additional nodal involvement at follow-up. Fusion FDG PET/CT scan shows focal nodal uptake (average standard uptake value, 3.4) in paracardial mass (arrow).

View larger version (54K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18B —58-year-old man with mucosa-associated lymphoid tissue (MALT) lymphoma with additional nodal involvement at follow-up. Fusion FDG PET/CT scan 6 weeks after institution of chemotherapy shows marked reduction in FDG uptake (arrow) accompanying tumor shrinkage. Use of FDG PET is especially beneficial to patients with MALT lymphoma and plasmacytic differentiation ( 30% of all MALT lymphomas) because of higher avidity for FDG in this group. As is FDG PET, whole-body diffusion-weighted MRI for survey of nodal involvement by MALT lymphoma should be considered as an alternative functional imaging technique.

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