Sonography of peritoneal lymphomatosis: some new and different findings

Safety and efficacy evaluation of contrast-enhanced ultrasound-guided omental biopsy: a single-center prospective study

OBJECTIVES

Contrast-enhanced ultrasound (CEUS) assesses omental lesion nature, but CEUS-guided biopsy feasibility, effectiveness, and safety are uncertain.

METHODS

From January 2020 to January 2024, patients scheduled for ultrasound-guided omental biopsy at the First Hospital of China Medical University were enrolled. They were divided into CEUS-guided and conventional ultrasound-guided groups, balanced using propensity score matching (PSM). Success rate, diagnostic accuracy, and complication rate were compared. Subgroup analyses considered sonographic features, with significance at p < 0.05.

RESULTS

After PSM, 310 CEUS-guided and 160 conventional ultrasound-guided patients were analyzed. Groups were similar in demographics and omental characteristics (p > 0.05). CEUS-guided biopsy had higher sample acquisition (97.42% vs. 93.13%, p = 0.029) and diagnostic accuracy (96.03% vs. 87.92%, p = 0.002). Overall complication rate was 9.36% (44/470), with distant metastasis in 0.43% (2/470). Complication rates did not differ significantly between groups. In hyperechoic group, dense group, and non-nodule group, CEUS-guided biopsy had higher success (97.99% vs. 92.55%, p = 0.042) and accuracy (96.48% vs. 86.17%, p = 0.002). In non-nodule group, CEUS-guided accuracy was superior (93.41% vs. 84.11%, p = 0.015).

CONCLUSION

Ultrasound-guided omental biopsy is a safe and effective method for obtaining samples. CEUS-guided omental biopsy enhances sample acquisition and diagnostic accuracy, especially in hyperechoic group, dense group, and non-nodule group, suggesting it is a more accurate and effective diagnostic method.

KEY POINTS

Question Selecting a puncture site for diffuse lesions of the greater omentum presents challenges, as conventional ultrasound-guided biopsy often encounters difficulties in avoiding local necrotic tissue. Findings Ultrasound-guided biopsy of the greater omentum is a safe and effective diagnostic method, especially when augmented with CEUS, which can significantly enhance diagnostic accuracy. Clinical relevance CEUS can markedly enhance diagnostic accuracy by providing a robust foundation for selecting the biopsy site and pathway. Therefore, it is advisable to routinely employ CEUS-guided puncture pathways for atypical omental lesions.

Gut and liver involvement in pediatric hematolymphoid malignancies

Hematolymphoid malignancies are common neoplasms in childhood. The involvement of the gastrointestinal (GI) tract, liver, biliary system, pancreas, and peritoneum are closely interlinked and commonly encountered. In leukemias, lymphomas, and Langerhans cell histiocytosis (LCH), the manifestations result from infiltration, compression, overwhelmed immune system, and chemotherapy-induced drug toxicities. In acute leukemias, major manifestations are infiltrative hepatitis, drug induced gastritis, neutropenic typhlitis and chemotherapy related pancreatitis. Chronic leukemias are rare. Additional presentation in lymphomas is cholestasis due to infiltration or biliary obstruction by lymph nodal masses. Presence of ascites needs a thorough workup for the underlying pathophysiology that may modify the therapy and affect the outcome. Uncommon hematolymphoid malignancies are primary hepatic, hepatosplenic, and GI lymphomas which have strict definitions. In advanced diseases with extensive spread, it may be impossible to distinguish these diseases from the primary site of origin. LCH produces biliary strictures that mimic as sclerosing cholangitis. Liver infiltration is associated with poor liver recovery even after chemotherapy. The heterogeneity of gut and liver manifestations in hematolymphoid malignancies has a clinical impact on their management. Though chemotherapy is the mainstay of therapy in all hematolymphoid malignancies, debulking surgery and radiotherapy have an adjuvant role in specific clinical scenarios. Rare situations presenting as liver failure or end-stage liver disease require liver transplantation. At their initial presentation to a primary care physician, given the ambiguity in clinical manifestations and the prognostic difference with time-bound management, it is vital to recognize them early for optimal outcomes. Pooled data from robust registries across the world is required for better understanding of these complications.

Peritoneal Lymphomatosis: The Great Mimicker

Peritoneal lymphomatosis (PL) is defined as intraperitoneal dissemination of lymphoma. Although rare, it is associated with high-grade lymphomas and can be easily mistaken for peritoneal carcinomatosis (PC) on imaging, which is a common condition associated with gastrointestinal and gynecological malignancies. Both PL and PC share similar radiographic features, however, they differ considerably in terms of prognosis and management. We present a case of a 58-year-old male with abdominal distention and ascites, initially reported as having PC on imaging. A subsequent peritoneal biopsy revealed PL secondary to a low-grade follicular lymphoma. Since PL responds well to chemotherapy, its prompt diagnosis and differentiation from PC helps avoid unnecessary surgery.

Imaging spectrum of mesenteric masses

Mesenteries are extensions of the visceral and parietal peritoneum consisting of fat, vessels, nerves, and lymphatics. Mesenteric masses have a wide differential diagnosis with neoplastic, infectious, or inflammatory etiologies and can either be solid or cystic. Imaging features are critical for the diagnosis. We review the epidemiology, imaging spectrum, and differentiating features and treatment of mesenteric masses.

Peritoneal Lymphomatosis Masquerading as Pyoperitoneum in a Teenage Boy

A 16-year-old boy presented with 1 month of fever, abdominal pain, and distension. The ascitic tap drained pus-like fluid, and ultrasonography showed diffuse thickening of the omentum and mesentery with echogenic ascites. A diagnosis of pyoperitoneum due to peritoneal tuberculosis with secondary infection was suspected, and antitubercular therapy was started elsewhere, but there was no improvement. Computed tomography of the abdomen revealed enhancing soft-tissue thickening in the retroperitoneum, extending into the mesentery and encasing the superior and inferior mesenteric vessels. The ascitic fluid appearance deceptively resembled pus, but further analysis revealed atypical lymphocytes. Omental and bone marrow biopsies confirmed Burkitt lymphoma. Awareness of this rare presentation is imperative for making a correct diagnosis.