N u c l e a r M e d i c i n e a n d M o l e c u l a r I m a g i n g • R ev i ew

Thomas et al.
Extranodal Lymphoma CME Extranodal Lymphoma From Head to Toe
SAM
Nuclear Medicine and Molecular Imaging
Review
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Extranodal Lymphoma From

FOCUS ON:

Head to Toe: Part 2, The Trunk

and Extremities
Adam G. Thomas1 OBJECTIVE. Lymphoma can affect virtually every tissue in the body, producing a variety of
Ramachandran Vaidhyanath imaging appearances. In this article, the extranodal manifestations of this disease in the trunk and
Rathy Kirke extremities are illustrated and the imaging features that aid in the diagnosis are reviewed.
Arumugam Rajesh CONCLUSION. Knowledge of the imaging appearances of extranodal lymphoma can
aid the differential diagnosis of mass lesions encountered in tissues throughout the body on
Thomas AG, Vaidhyanath R, Kirke R, Rajesh A different imaging modalities.

Keywords: CT, extranodal lymphoma, MRI, non-Hodgkin
lymphoma
DOI:10.2214/AJR.11.6738
Received June 14, 2010; accepted after revision
January 20, 2011.
1
All authors: Department of Radiology, University
Hospitals of Leicester NHS Trust, Leicester General
Hospital, Gwendolen Rd, Leicester, Leicestershire
LE5 4PW, United Kingdom. Address correspondence to
A. Rajesh (arajesh27@hotmail.com).
CME/SAM
This article is available for CME/SAM credit.
See www.arrs.org for more information.
AJR 2011; 197:357–364
0361–803X/11/1972–357
© American Roentgen Ray Society
L
ymphoma is a relatively common
malignancy affecting all ages, but
it predominantly affects those in
later life. Like various other con­
ditions, such as tuberculosis, lymphoma is
known as a “great imitator” and should be
considered when mass lesions are seen any­
where in the body. This review will continue
the discussion of the imaging manifestations
of extranodal lymphoma that began in part 1
[1] by focusing on the imaging manifestations
of extranodal lymphoma in the trunk and ex­
tremities. The imaging modalities and find­
ings that best allow differentiation of lympho­
ma from other differential diagnoses will also
be considered.
Thorax
Nodal involvement in the chest is common
in both Hodgkin disease and non-Hodgkin
lymphoma (NHL). The site of nodal enlarge­
ment may be suggestive of the diagnosis—
with Hodgkin disease involving the ante­
rior mediastinal nodes and NHL involving
the subcarinal, paraesophageal, and internal
mammary nodes—but is by no means spe­
cific in distinguishing between the two enti­
ties [2] (Fig. 1). The thymus is regarded as a
nodal station with regard to staging [3].
Lung parenchymal involvement is more
common as part of disseminated Hodgkin dis­
ease than NHL, but primary pulmonary lym­
phoma (i.e., without evidence of significant
nodal disease) is more commonly NHL (Figs.
2 and 3). The patterns of pulmonary involve­
ment in either disease are many and varied.
Extension of hilar nodal masses into lung pa­
renchyma, cavitating lung nodules, persistent
consolidation, widespread pulmonary nodu­
larity, and reticular patterns with interlobular
septal thickening have been reported [4].
The differential diagnosis is particular­
ly difficult given the spectrum of coexis­
tent pulmonary diseases in this cohort of pa­
tients. Interstitial change may be related to
drug reactions from chemotherapy regimes,
cavitating nodules may represent atypical in­
fections, and widespread nodularity is seen
in bone marrow transplant recipients with
posttransplant lymphoproliferative disorder.
Pleural effusions are commonly seen in as­
sociation with pulmonary lymphoma but tend
to be reactive and only rarely contain malig­
nant cells in the absence of pleural masses.
The prevalence of nonmalignant pleural effu­
sions is thought to be secondary to proximal
lymphatic obstruction from the underlying
nodal disease. The same cannot be said for
pericardial effusions, which are usually ma­
lignant when seen in association with lym­
phoma [5]. Cardiac involvement is thought to
be common (up to 24%) but underrecognized
on standard imaging protocols [6].
The chest wall may be involved in aggres­
sive disease, usually in association with exten­
sive intrathoracic disease. Primary lympho­
matous masses in the breast are exceedingly
rare, with an incidence of 0.75% of breast
lumps. The breast may be involved as an ex­
tranodal site in 1–2% of cases of systemic
lymphoma; again, NHL predominates [7].
Secondary involvement of the breast in NHL
is more common and may manifest as diffuse
skin thickening seen on mammography [8].

AJR:197, August 2011 357

 Thomas et al.
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Fig. 1—38-year-old man with night sweats and weight loss. Fig. 2—58-year-old woman who presented with
A and B, Fused PET/CT images, coronal reconstruction (A) and axial source image (B), show marked uptake in shortness of breath and weight loss. Radiograph
right paracardiac mass (arrows). Mediastinal masses may represent conglomerates of lymph nodes, thymic shows bilateral parenchymal alveolar opacification
masses, or diffuse mediastinal soft-tissue extranodal spread. Solid nature of mass excludes foregut duplication (arrows). Although opacification appears masslike,
cyst, and there is no connection to pericardium to suggest pericardial cyst or defect in this case. CT-guided bilateral perihilar alveolar shadowing can be caused
biopsy in this case revealed diffuse large B-cell lymphoma. by pulmonary edema, drug-induced changes, or
atypical infection. Imaging appearances are not
specific for lymphoma in this case. Postmortem
Upper Abdominal Solid Organs lignancy to affect the spleen [11]. Appear­ findings in this case revealed diffuse alveolar
As in other parts of the body, the most ances may be subtle with only homogeneous anaplastic lymphoma.
common form of lymphoma in the abdom­ enlargement to suggest infiltration. Multipla­
inal cavity involves widespread lymphade­ nar reformations of cross-sectional CT may
nopathy that may be paraaortic or may extend be helpful in measuring splenic size, but a as calcification or clinical features of infec­
into the mesentery. Appearances on imaging sign of significant (i.e., clinically palpable) tion should also raise suspicion of a lympho­
are of homogeneous, hypoechoic masses on splenic enlargement on axial images is ex­ matous deposit. The appearance of a solitary
ultrasound. CT shows homogeneous soft- tension of splenic tissue below the left cos­ splenic mass in a patient with previously di­
tissue–density masses in the distribution of tal margin. Solitary splenic masses have also agnosed low-grade lymphoma should raise
known nodal chains and locations. Nodal been reported in cases of lymphoma and are the suspicion of high-grade transformation
masses may form out of a conglomeration usually of low attenuation in relation to the particularly if there are aggressive features
of multiple enlarged nodes. Calcification of surrounding spleen on enhanced CT (Fig. 5). such as capsular breach [9].
lymph nodes in lymphoma is usually seen Other features such as associated adenopathy Normal nodal tissue surrounds the pancreas,
only after treatment [9]. Involvement of the and absence of nonaggressive features such and because small low-attenuation pancreatic
solid abdominal viscera may be seen in com­
bination with nodal disease or may be seen
as primary extranodal disease.
Lymphomatous disease in the liver may
take various forms. Diffuse hepatic enlarge­
ment, often seen in conjunction with sple­
nomegaly, is common. Multiple hypodense
enhancing masses involving multiple organs
mimicking multiple metastatic deposits have
been described. Lymphoma remains on the
differential of a solitary liver deposit (Fig. 4).
Peripheral ring enhancement may be seen and
should be differentiated from fungal infection,
particularly in an immunocompromised pa­
tient [4]. Finally, a periportal infiltrative pat­ Fig. 3—60-year-old man with known diffuse large B-cell lymphoma.
tern may be seen, particularly in association A and B, Axial contrast-enhanced CT scans of thorax on soft-tissue windows (A) and lung windows (B)
with splenomegaly in Hodgkin disease [10]. show multiple parenchymal soft-tissue masses (arrows). Patient did not respond to antibiotic therapy, which
As with the liver, the spleen is common­ prompted biopsy of two areas of persistent consolidation. Biopsy findings confirmed pulmonary involvement
by diffuse large b-cell lymphoma. Pulmonary involvement in patients with lymphoma can be difficult to
ly involved in abdominal lymphoma; indeed, differentiate from atypical infection and drug reactions. Imaging appearances in this case were not specific for
lymphoma is the most common primary ma­ lymphoma over other differential possibilities.

358 AJR:197, August 2011


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Fig. 4—55-year-old man with itching, weight
loss, and night sweats. Axial contrast-enhanced
portal venous phase CT image shows focal
hypodense lesion (arrows) in left lobe of liver and
also multiple low-attenuation lesions in spleen.
Appearances could be caused by multiple epithelial
metastatic deposits or even by sarcoidosis or
other granulomatous conditions; however, low-
attenuation nature of lesions and clinical history
suggest lymphoma as primary consideration. Biopsy
of superficial hepatic lesion revealed diffuse large
B-cell lymphoma.
malignancies can be difficult to detect, particu­
larly on CT, it can be difficult to discern the ori­
gin of marked lymphadenopathy in this region.
One clue is that metastatic nodal involvement
from pancreatic adenocarcinoma rarely ex­
tends below the level of the renal veins; in such
cases, a lymphoproliferative disorder should be
suspected [9]. Direct involvement of pancre­
atic tissue by lymphoma may be through con­
tiguous spread from surrounding nodal tissue
(seen in 30% of patients with NHL involving
the pancreas) or, like with the liver and spleen,
through diffuse homogeneous enlargement by
infiltrative lymphomatous disease [12] (Fig. 6).
There may be stranding of the peripancreatic
fat, which may be difficult to differentiate from
the appearances of pancreatitis. In such cases,
in the absence of other nodal or extranodal dis­
ease, follow-up imaging is necessary to differ­
entiate inflammatory change from underlying
malignant infiltration.
With the increasing use of cross-section­
al imaging, the detection of bilateral adre­
nal enlargement is increasingly common.
The cause of enlargement may be difficult
to determine. In the case of disseminat­
ed NHL, there is a significant chance adre­
nal enlargement may be due to lymphoma­
tous infiltration (seen in 25% of patients with
disseminated disease [9]). Other patterns
of involvement include focal masses or uni­
lateral enlargement [11, 13]. The increased
use of PET in staging lymphoma patients is
helpful here: Lymphomatous disease will be
FDG avid, whereas adrenal hyperplasia will
not. Sometimes the extent of disease will re­
AJR:197, August 2011 359
Extranodal Lymphoma
Fig. 5—39-year-old man with deranged liver function
tests and weight loss. Axial contrast-enhanced
CT image of abdomen shows solitary hypodense
lesion (arrow) in anterior part of spleen that later
disappeared after chemotherapy. Differential
diagnosis includes splenic metastasis, abscess,
and hemangioma. No specific features are seen on
imaging to suggest lymphoma, but clinical features
led to bone marrow aspiration, which revealed
follicular lymphoma.
sult in adrenal insufficiency. Given the prev­
alence of steroids in chemotherapy regimens
for lymphoma, the possibility of adrenal in­
sufficiency raised by imaging features is im­
portant to communicate to the clinical team.
Diffuse mesenteric disease in advanced
malignancy may present a challenge to the
radiologist in suggesting the site of primary
disease. A few clues are helpful in identifying
lymphomatous disease. Diffuse sheetlike in­
filtration of the mesentery is seen almost ex­
clusively in NHL [14]. The sandwich sign, in
which the mesenteric vessels are compressed
between nodal and soft-tissue masses with­
out evidence of distal vascular compromise,
has been described [15]. Nodular mesenter­
ic soft-tissue masses with ascites and subdia­
phragmatic deposits are more suggestive of
epithelial malignancies such as ovarian or
colonic tumors. Even advanced disease may
show a dramatic response to therapy in lym­
phoma; the residual of diffuse mesenteric in­
volvement may be as little as a “misting” of
the mesenteric fat on follow-up CT [9].
Genitourinary System
The kidneys contain no intrinsic lymphoid
tissue, so involvement by lymphoma is usual­
ly late in the disease process and in the pres­
ence of disseminated disease [9]. Like with
lymphoma of other solid abdominal organs,
both solitary or multiple focal masses (Figs.
6 and 7) and diffuse infiltration (Figs. 8 and
9) in the kidney have been described [16].
Clues to differentiate lymphoma from oth­
er renal soft-tissue masses on imaging include
Fig. 6—45-year-old man with generalized abdominal
pain and weight loss. Contrast-enhanced portal
venous phase CT image of abdomen shows
diffuse low-attenuation, poorly enhancing mass
(white arrow) enlarging pancreas. Additional
low-attenuation deposits (black arrow) are seen
in upper pole of right kidney. Primary differential
consideration is metastatic epithelial malignancy and
none of imaging features present suggest lymphoma
as more likely diagnosis. Diagnosis of follicular
lymphoma was made on bone marrow aspirate and
trephine biopsy.
hyperechogenicity relative to the kidney on
ultrasound scanning and higher attenuation
relative to kidney on unenhanced CT scans.
Renal cell carcinoma tends to be both hy­
poechoic and hypoattenuating in these cir­
cumstances [17]. Direct renal extension from
paraaortic or retroperitoneal lymphadenopathy
Fig. 7—33-year-old man who presented with
abdominal pain, enlarged testicle, and diplopia.
Coronal contrast-enhanced reconstructed CT image
shows multiple low-attenuation, poorly enhancing
cortical bilateral renal masses (arrows) in case of
disseminated diffuse mixed cell lymphoma. Medial
rectus involvement (not shown) accounted for
diplopia, and diffuse testicular involvement (not
shown) accounted for scrotal pain and swelling.
Although diffuse infection, pyelonephritis, or
metastases could be considered, clinical features
and disseminated involvement are more suggestive
of lymphoma in this case.
 Thomas et al.

sound, and both solitary hypoechoic masses

and diffuse hypoechoic infiltrative appear­
ances have been described (Fig. 10). In pa­
tients with bilateral symmetric enlargement,
the epididymis may also be enlarged, mak­
ing it difficult to distinguish between lym­
phoma and epididymoorchitis [21]. Other
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differential diagnoses include other testicu­

Fig. 8—74-year-old man with abdominal pain and
weight loss. Axial contrast-enhanced CT image
shows poorly enhancing, infiltrating right renal
mass (arrow) involving extrarenal pelvis. Differential
diagnosis includes both renal and transitional cell
carcinomas. No imaging features make lymphoma
more likely diagnosis in this case. Biopsy revealed
diffuse large B-cell lymphoma.
may be difficult to differentiate from other
retroperitoneal soft-tissue masses (e.g., ret­
roperitoneal fibrosis), particularly in the ab­
sence of IV contrast administration. Lym­
phomatous infiltration tends to occur via the
renal capsule or sinus (Fig. 8); the aorta may
be elevated anteriorly off the spine by ret­
roaortic lymphadenopathy. Retroperitoneal
fibrosis tends to encase the aorta and inferior
vena cava and to extend toward the kidneys
along the vascular pedicle [18].
Perinephric soft-tissue stranding and soft
tissue may be difficult to distinguish from
hemorrhagic renal masses (e.g., renal cell car­
cinoma or angiomyolipomas). Lymphomatous
involvement of the perinephric space tends
to show more nodularity (Fig. 9).
Fig. 9—46-year-old man previously treated for
diffuse large B-cell lymphoma who presented with
lethargy and weight loss. Axial contrast-enhanced
CT image shows large soft-tissue destructive
lymphomatous mass involving left kidney. Soft-tissue
mass is homogeneous and extends outward, with
mass effect on Gerota fascia (white arrow). There
is nodularity in left posterior pararenal space (star).
Low-attenuation solid liver lesion (black arrow) is
also seen. Renal and hepatic findings were new and
biopsy confirmed relapse. Although hypovascular
renal cell carcinoma with liver metastasis is possible
explanation of imaging findings, clinical history
makes lymphoma most likely diagnosis in this case.
The diagnosis of lymphoma of the blad­
der is made difficult by nonspecific imaging
features such as wall thickening [19]. Pros­
tatic involvement is similarly nonspecific,
with diffuse enlargement difficult to differ­
entiate from underlying benign prostatic hy­
perplasia on the basis of imaging features
alone [20].
Lymphoma is an important consideration
in determining the cause of testicular masses
in adults. In fact, lymphoma is the most com­
mon testicular malignancy in men older than
60 years [9]. Imaging is primarily by ultra­
lar malignancies and sarcoidosis.
Bilateral ovarian enlargement from lym­
phoma with retroperitoneal lymphadenopa­
thy and mesenteric deposits is difficult to dis­
tinguish from primary nonepithelial ovarian
tumors or metastases from other tumors such
as uterine or breast cancer [9]. In such cases,
other supportive imaging features (e.g., intra­
thoracic nodal disease) may be helpful, but bi­
opsy is frequently necessary to differentiate
lymphoma from other ovarian neoplasms. It
may be difficult to identify the organ of origin
in cases of large adnexal masses. Experience
using MRI to examine patients with ovarian
NHL has been reported [22].
Uterine involvement is rare in cases of
lymphoma, but lymphoma again may show
diffuse enlargement with preservation of the
endometrium [23]. A similarly rare site of in­
volvement is the cervix (Fig. 11) with low-at­
tenuation masses (relative to the enhancing
myometrium) encountered on CT.
Gastrointestinal Tract
The gastrointestinal tract is the most com­
mon extranodal site of involvement in NHL,
with disease seen at some site in up to 20%
of patients [24]. Again, a distinction is made

Fig. 10—70-year-old man with 2-week history of right testicular swelling.

A–C, Transverse (A), longitudinal (B), and color Doppler (C) ultrasound images of right testicle show diffuse hypoechogenicity and increased color Doppler flow.
D, Left testicle is shown in transverse section for comparison. FDG PET scan (not shown) showed large retroperitoneal paraaortic lymph node mass, which was biopsied.
Biopsy results revealed diffuse large B-cell lymphoma. Differential diagnosis includes orchitis and even atypical primary testicular malignancy, but clinical features and
lack of focal testicular mass made lymphoma most likely in this case. Orchidectomy confirmed testicular involvement.

360 AJR:197, August 2011


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Fig. 11—48-year-old woman who presented with
vaginal discharge.
A, Contrast-enhanced CT image shows infiltrative
soft tissue (arrow) centered in cervix and extending
into parametria. Biopsy results revealed diffuse
large B-cell lymphoma.
B, Contrast-enhanced CT image obtained after
treatment shows good response to chemotherapy
with resolution of abnormal cervical soft tissue
(arrow). Primary differential consideration is cervical
carcinoma. Imaging features are not specific in this
case.
between primary gastrointestinal tract lympho­
ma, in which there is little retroperitoneal
lymphadenopathy or hepatosplenomegaly,
and involvement of the gastrointestinal tract
in disseminated NHL from other body sites.
Both the imaging features and prognosis are
distinctly different. Primary gastrointestinal
lymphoma carries a better prognosis than in­
volvement in disseminated disease. The sites
of disease in order of decreasing frequency
are the stomach, small intestine, colon, and
esophagus. Primary gastrointestinal lympho­
mas are usually mucosa-associated lymphoid
tissue lymphomas, also referred to as
“MALTomas,” except in the stomach, which
contains no MALT tissue. The prevalence of
gastric lymphoma can be explained as fol­
lows: MALT tissue arises in abnormal loca­
tions (e.g., stomach, thyroid, ocular adnexa) in
response to chronic antigen stimulation. In the
case of the stomach, this stimulation is thought
to be caused by Helicobacter pylori infection
[24, 25]. Repetitive stimulation by antigens is
thought to promote monoclonal cell lines that
are more likely to develop into lymphoprolif­
AJR:197, August 2011 361
Extranodal Lymphoma
Fig. 12—76-year-old man who presented with weight
loss and anemia. Axial contrast-enhanced CT image
shows diffuse gastric wall thickening (arrow) with
homogeneous enhancement. Differential diagnosis
includes submucosal epithelial gastric malignancy.
Imaging features are not specific for lymphoma in
this case. Endoscopic biopsy revealed mucosa-
associated lymphoid tissue lymphoma.
erative disorders or lymphoma. T-cell lym­
phomas are particularly prone to bowel wall
involvement in the ileum and jejunum. They
are aggressive tumors with higher rates of
perforation as a result [26].
As we mentioned earlier, the esophagus is
the least common site of gastrointestinal tract
involvement. Like the stomach, the esopha­
gus contains no MALT tissue, but lympho­
ma may develop in the presence of Barrett
esophagus. The appearances of esophageal
lymphoma are difficult to differentiate from
epithelial esophageal malignancies with an­
nular lesions, irregular strictures, polypoid
masses, and ulcerative lesions [27]. Esopha­
geal biopsy is required for diagnosis; how­
Fig. 14—82-year-old man who presented with anemia
and abdominal mass. Axial contrast-enhanced
CT image shows aneurysmal dilatation of loop of
thickened small bowel (white arrow) that has been
infiltrated by disseminated non-Hodgkin lymphoma
and left renal deposit (black arrow). Although other
differentials to consider include other inflammatory
small-bowel diseases, aneurysmal dilatation and
renal deposit make lymphoma most likely diagnosis
in this case. Ultrasound-guided biopsy of mesenteric
lesion revealed diffuse large B-cell lymphoma.
Fig. 13—63-year-old woman who presented with
abdominal pain and palpable abdominal mass.
Axial contrast-enhanced CT image shows diffusely
thickened loop of small bowel (arrow). Differential
diagnosis includes inflammatory bowel disease.
Imaging features presented are not specific for
lymphoma. Resection of small bowel revealed diffuse
large B-cell lymphoma.
ever, the submucosal location of most lym­
phomas may cause difficulty in obtaining
sufficient tissue for diagnosis.
As in esophageal lymphoma, gastric lym­
phoma may have many varied appearances at
imaging. Mucosal lesions are best shown at im­
aging by upper gastrointestinal barium studies.
Diffuse nodular thickening of the gastric rugae
may be confused with Ménétrier disease, al­
though the latter has a propensity to involve the
proximal half of the stomach, with lymphoma­
tous thickening usually seen in the antrum or
pylorus [24]. A submucosal lesion with central
ulceration—that is, a typical bull’s-eye appear­
ance—may be seen. This sign is by no means
specific, however, with a similar appearance
Fig. 15—69-year-old woman who presented with
abdominal pain and history of diverticular disease.
Axial contrast-enhanced (oral and IV media) CT
image shows large pelvic cavitating lesion (arrow)
arising from ileocecal lymphomatous perforation.
Resection showed diffuse large B-cell lymphoma.
Other differential diagnoses include large pelvic
abscess secondary to diverticular perforation.
Imaging features are not specific for lymphoma in
this case.

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Fig. 16—82-year-old man who presented with
change in bowel habit and anemia. Axial contrast-
enhanced (oral and IV media) CT image shows
diffuse colonic soft-tissue thickening (arrow) with
low homogeneous enhancement in case of diffuse
large B-cell lymphoma involving descending colon.
Other diagnostic considerations in this case include
colitis or adenocarcinoma. Imaging features are not
specific for lymphoma in this case. Abdominal aortic
aneurysm is also noted.
seen in metastatic breast and lung cancers,
Kaposi sarcoma, and melanoma.
Diffuse gastric thickening is best shown by
CT, ideally with distention by negative oral
contrast agents. It may be difficult to distin­
guish between lymphoma and adenocarci­
noma of the stomach (linitis plastica). In dif­
fuse gastric lymphoma, the normal layering
pattern of the wall is lost, but the stomach
should still be distensible and the surrounding
fat planes should be preserved in comparison
with adenocarcinoma [27] (Fig. 12). Gastro­
scopic biopsy is still necessary for definitive
diagnosis. The ulcerative form may be exo­
phytic in nature, which can cause difficulty in
differentiating lymphoma from gastrointesti­
nal stromal tumors. Image-guided biopsy may
be necessary for biopsy of tumors that cannot
be accessed from an endoluminal approach.
The duodenum contains minimal lymphoid
tissue, so lymphoma here is usually seen as
part of extension from gastric or small-bow­
el disease. Primary small-bowel lymphoma is
usually of B-cell origin and tends to arise in
the terminal ileum where there is the great­
est concentration of lymphoid tissue. The ap­
pearances are varied; infiltrative disease in
a submucosal location causes diffuse bowel
wall thickening [28] (Fig. 13). Aneurysmal
dilatation, thought to be caused by infiltration
of the myenteric plexuses, is thought to con­
tribute to the lack of small-bowel obstruction
in these cases (Fig. 14). Multiple nodular fill­
ing defects may be seen, particularly associat­
ed with mantle cell lymphoma [24]. An endo­
exenteritic form has been described that may
present with multiple fistulas between bow­
362 AJR:197, August 2011
Thomas et al.
el loops—appearances that may be closely
mimicked by Crohn disease (Fig. 15). Lym­
phoma complicating celiac disease usually
occurs in the jejunum with multiple nodular
filling defects and ulceration. It is usually of
T-cell origin [26].
Colonic lymphoma is rare but is again
more commonly seen in cases in which there
is chronic inflammation—for example, Crohn
disease and ulcerative colitis [29]. Appearanc­
es on cross-sectional imaging may show a long
segment of wall thickening with loss of haus­
trae; the length is usually sufficient to differen­
tiate from adenocarcinoma, although divertic­
ular disease is also on the differential diagnosis
[26] (Fig. 16). Lymphoma should also be con­
sidered in the presence of multiple nodular in­
traluminal filling defects and focal intramural
masses (including in the rectum). The presence
of associated nodal masses may help to suggest
lymphoma over other pathologic entities.
Musculoskeletal System
Lymphoma affecting the bones is rare,
particularly primary bony lymphoma in the
absence of systemic disease. Bony involve­
ment is seen in approximately 5% of cases
of disseminated lymphoma [30]. Appear­
ances at imaging are mixed. On radiography, Fig. 17—64-year-old man who presented with right
the typical appearance is of a lytic lesion, hip pain.
A and B, Axial contrast-enhanced CT images
although mixed lytic and primarily sclerot­ (soft-tissue windows, A; bone windows, B) show
ic lesions have been reported; indeed, NHL large soft-tissue mass (arrow) in right hemipelvis
forms part of the differential diagnosis of a with destruction of right posterior acetabular
wall. Other considerations include sarcoma (e.g.,
solitary dense (ivory) vertebral body. CT is Ewing sarcoma), but homogeneity of signal along
an excellent modality for displaying cortical with clinical features made lymphoma most likely
disruption, periosteal reaction, soft-tissue diagnosis in this case. Biopsy revealed follicular
lymphoma.
masses, and sequestration (Fig. 17).
C, Axial STIR MR image shows ability of MRI to
MRI is less adept at showing bony destruc­ delineate soft-tissue extension of lymphomatous
tion than CT but is excellent for the depiction mass (arrow).
Fig. 18—12-year-old girl with disseminated Burkitt lymphoma.
A and B, Coronal T1-weighted (A) and STIR (B) MR images of pelvis reveal focal deposit in right femoral neck
(white arrows) that shows low signal on T1 and high signal on STIR. Nodal masses (black arrows, B) are seen in
pelvis. Primary Burkitt lymphoma usually affects jaw, making femoral deposit more likely distant or metastatic
than primary involvement. Presence of pelvic lymph node masses makes diagnosis of lymphoma more likely
than sarcoma in this case (other differential consideration).

of soft-tissue masses (Figs. 17 and 18). On
T1-weighted images, lymphoma within bone
marrow displays low signal intensity (similar
to adjacent muscle) but high signal intensity
on T2-weighted and STIR image sequenc­
es [31] (Fig. 18). Because T2-weighted se­
quences also display surrounding bone mar­
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row edema, T1-weighted images are better for
assessing the extent of disease and avoiding
overestimation [3].
Bone scanning is good for showing whole-
body distribution of disease but is nonspecific
because increased uptake is seen in other tu­
mors, infection, inflammation, and degenera­
tive diseases. PET will show increased uptake
both in focal bony lymphoma and also in high-
grade marrow involvement [32]. Findings need
to be interpreted in light of knowledge of che­
motherapy because diffuse increased uptake of
tracer is seen immediately after chemotherapy
and also in association with splenic uptake af­
ter the administration of granulocyte colony-
stimulating factor [30, 33].
Lymphomatous spread to skeletal muscle is
usually seen as part of widespread NHL. Sites
are usually the thigh or upper limb and chest
[30]. MRI is good for delineation of soft-tissue
masses, with lymphoma showing intermediate
T1 signal, high T2, and variable enhancement.
However, MRI findings are nonspecific with a
wide range of differential diagnoses including
primary sarcomas, infection, other metastases,
and sequelae of trauma [34].
Conclusion
Extranodal involvement by lymphoma has
been described in every tissue of the body
with multiple different appearances even
within one organ system. Thus, it should
be regularly included in the differential di­
agnosis of mass lesions and focal mucosal
thickening. Some general themes have been
outlined: When extranodal disease is en­
countered, the underlying histology is more
likely to be NHL than Hodgkin disease. Cer­
tain imaging findings that should suggest
lymphoma include widespread lymphade­
nopathy or conglomerate nodal masses; large
soft-tissue masses with little evidence of lo­
cal destruction; and, in the bowel, diffuse
wall thickening with absence of obstruction.
When imaging features are nonspecific, ra­
diologic assessment still plays a role in deter­
mining the site and strategy of biopsy.
Making the diagnosis of lymphoma often
requires multiple imaging modalities. As we
have discussed, PET is playing a progressive
role in the staging and follow-up of lympho­
AJR:197, August 2011 363
Extranodal Lymphoma
ma. With longer survival times from modern
treatment, the interpretation of imaging must
take into account any prior therapy the pa­
tient has received.
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364 AJR:197, August 2011