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Case 3

Lymphoma Involving the Distal Ileum

The MR images (Figs. 3A,3B,3C) show thickening of the bowel wall. As seen on the CT scans (Figs. 3D and 3E), this indicates an excavating mass of the bowel.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —42-year-old woman with right lower quadrant discomfort. Physical examination suggested uterine enlargement. Sonography (not shown) revealed right lower quadrant mass. MR imaging was performed through mid pelvis above level of uterus. Axial T1-weighted image shows mass in right lower quadrant (arrows). This excavating mass contains protenaceous fluid and gas.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —42-year-old woman with right lower quadrant discomfort. Physical examination suggested uterine enlargement. Sonography (not shown) revealed right lower quadrant mass. MR imaging was performed through mid pelvis above level of uterus. Axial T2-weighted image further shows fluid in mass (arrow).

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —42-year-old woman with right lower quadrant discomfort. Physical examination suggested uterine enlargement. Sonography (not shown) revealed right lower quadrant mass. MR imaging was performed through mid pelvis above level of uterus. Sagittal T2-weighted image shows bowel (straight arrows) contiguous with mass. Mass wraps around but does not infiltrate uterus (curved arrow).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D. —42-year-old woman with right lower quadrant discomfort. Physical examination suggested uterine enlargement. Sonography (not shown) revealed right lower quadrant mass. MR imaging was performed through mid pelvis above level of uterus. Typical CT appearance of excavating mass of bowel. Contrast flows freely through mass (arrowheads).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3E. —42-year-old woman with right lower quadrant discomfort. Physical examination suggested uterine enlargement. Sonography (not shown) revealed right lower quadrant mass. MR imaging was performed through mid pelvis above level of uterus. Typical CT appearance of excavating mass of bowel. Contrast flows freely through mass (arrowheads).

Lymphoma of the bowel is the most common extranodal site of lymphoma [1]. The most common type is non-Hodgkin's lymphoma. Primary lymphoma of the gastrointestinal tract is seen most often in the stomach. Lymphoma of the ileum, as in this case, is the most common extragastric site [1]. When lymphoma involves the bowel, it may present as diffuse thickening of the wall, an intramural (submucosal) mass, or an excavating mass. An excavating mass, as in this case, is characteristic. An excavating mass is one that involves the entire bowel wall, with bowel entering it and exiting it. The lumen or cavity of the mass is filled with contrast material and is usually larger than the bowel entering it. This condition is also referred to as aneurysmal dilatation of the bowel. Differential diagnosis of an excavating mass of the bowel includes lymphoma (most often), adenocarcinoma of the bowel, leiomyosarcoma, and metastatic disease of the bowel wall [2, 3]. Visualization of the bowel contents is difficult on MR imaging. If bowel abnormality is suggested by findings on MR imaging, a CT of the abdomen with enteric contrast material should be performed.

Pelvic inflammatory disease is not the correct diagnosis because this process is within the bowel wall and excludes pelvic inflammatory disease. On the axial images alone, it may be difficult to exclude this diagnosis. The sagittal image, however, shows that the mass involves the bowel wall.

Malignant degeneration of auterine fibroid is not the correct diagnosis because the right lower quadrant mass is shown to be adjacent to the fundus of the uterus but clearly separate from it. In addition, the mass seems to be contiguous with a bowel loop on the sagittal image.

Appendicitis with a periappendiceal abscess is not the correct diagnosis because the sagittal images clearly show this is a mass in the bowel wall, even though a periappendiceal abscess may have a similar appearance on axial images. The fluid seen on the T2-weighted MR images is within the lumen of the bowel rather than in an abscess extrinsic to the bowel.

References

1. Cirillo M, Federico M, Curci G, Tamborrino E, Piccinini L, Silingardi V. Primary gastrointestinal lymphoma: a clinicopathological study of 58 cases. Haematologica 1992;77:156 -161[Medline]
2. Carlson HC, Good CA. Neoplasm of the small bowel. In: Margulis A, Burhenne HU, eds. Alimentary tract radiology, 2nd ed., vol. 2, St. Louis: Mosby, 1973:890 -901
3. Zornoza J, Goldstein HM. Cavitating metastases of the small intestine. AJR 1977;129:613 -615[Abstract]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bennett, W. F. Articles by Vaswani, K. Search for Related Content PubMed Articles by Bennett, W. F. Articles by Vaswani, K. Social Bookmarking                      What's this?