Computed tomography of abdomen in staging and clinical management of lymphoma

Role of Computed Tomography in Staging and Management of Gastrointestinal Lymphoma

Twenty-six computed tomography (CT) examinations in 18patients with histologically proven gastrointestinal lymphomas are reported. Fourteen CT examinations were performed at the time of initial presentation, the others being performed during the course of the disease. CT did not help in the diagnosis of the disease but it is effective in assessing the extent and thus the stage of the disease. A normal CT scan during follow up is associated with good prognosis. CT may be of help in planning treatment, especially radiotherapy. It is an investigation easily tolerated by patients and can be used in circumstances where other investigations would be impossible.

Lymphography and Abdominal Computed Tomography in the Staging of Non-Hodgkin Lymphoma

Ninety-one patients with non-Hodgkin lymphoma (NHL) were subjected to computed tomography (CT) and lymphography. Both examinations agreed in 74 patients (81%) with regard to the infradiaphragmatic lymph nodes. In patients undergoing CT prior to lymphography, the concordance amounted to 75 per cent. When lymphography was the initial examination, the concordance amounted to 86 per cent. Lymphography was abnormal in 30 per cent of the patients with a normal CT scan and in 93 per cent of those with an abnormal CT scan as the first examination. CT was abnormal in 4 per cent of patients with a normal lymphogram and in 84 per cent of those with an abnormal lymphogram as the first examination. CT did not detect mesenteric or retrocrural lymph node enlargement in the absence of retroperitoneal lymph node involvement. Eleven patients had extranodal manifestations of the disease (excluding liver and spleen), and 3 were detected primarily with CT. Lymphography is the most complete examination for the infradiaphragmatic lymph nodes for staging purposes. Although CT outlined the disease better, it changed the ***lymphographic diagnosis in only 2 per cent of the patients. Lymphography modified the CT stage in 15 per cent of the patients. When abdominal CT is performed first, in staging patients with NHL, lymphography will only yield additional information when CT is normal or equivocal.

The Spleen in Non-Hodgkin Lymphoma

Computed tomography of the spleen was correlated with histologic examination or clinical data in 53 selected patients with non-Hodgkin lymphoma. Calculation of the splenic index with CT by multiplying spleen length, width and thickness is a simple and rapid procedure for defining splenic size in vivo. A good correlation was found between size of the spleen, as estimated by splenic index calculation, and the proven or probable histologic state of the spleen.

Computerised tomography in the staging of Hodgkin's disease and non-Hodgkin's lymphoma

The last 25 years have seen major changes in the imaging investigation and subsequent management of patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL); accurate staging is vital for prognostication and treatment in both, and particularly in HD. The choice of imaging modality for staging depends on its accuracy, impact on clinical decision-making, and availability. Modern CT scanners fulfil most of the desired criteria. The advent of CT scanning, along with the development of ever more effective chemotherapeutic regimens, has resulted in the virtual demise of bipedal lymphangiography (LAG) as a staging tool in patients with lymphoma. It has rendered superfluous a battery of other tests that were in routine use. This contribution reviews the evidence for the use of CT in preference to LAG. CT accurately depicts nodal enlargement above and below the diaphragm, has variable sensitivity for intra-abdominal visceral involvement and is generally outstanding in depicting the extent of disease, especially extranodal extension. Despite the advances in CT technology, there are still areas where CT performs less well (e.g. disease in normal-sized lymph nodes, splenic and bone marrow infiltration). The influence of technical factors, such as the use of intravenous contrast medium, is discussed. In some instances, CT is not the imaging modality of choice and the place of newer techniques such as MRI and endoscopic ultrasound will be reviewed.

A prospective study of magnetic resonance imaging in lymphoma staging

In this prospective study, magnetic resonance imaging (MRI) was compared with computed tomography (CT) in patients with non-Hodgkin's lymphoma (NHDL), and with CT and laparotomy in patients with Hodgkin's disease (HD). Among 31 patients with NHDL, there was agreement between MRI and CT findings in 21 patients; MRI findings were positive and CT findings were negative in 8 patients; and MRI findings were negative and CT findings were positive in 2 patients. The false-negative findings of MRI included a laparotomy-proven mesenteric mass and a 6.6-cm lesion in the spleen, both shown by CT. In 13 evaluable patients with HD, there was agreement between MRI and laparotomy findings in 8 patients; MRI findings were positive and laparotomy findings were negative in 4 patients; and MRI findings were negative and laparotomy findings were positive in 1 patient. CT findings agreed with laparotomy findings in nine patients; CT findings were positive and laparotomy findings were negative in one patient: and CT findings were negative and laparotomy findings were positive in three patients. This suggested that MRI, although more sensitive than CT, was less specific with more false-positive findings. The spin-lattice relaxation time (T1) for the spleen was generally higher in patients with HD who had pathologically confirmed splenic involvement, and tended to increase with increasing spleen weight. This study was performed on a prototype 0.15 Tesla (Technicare Inc., Solon, OH) resistive unit at a time when methods and reporting for MRI were still being developed. Although MRI appears to have fewer false-negative findings than CT in evaluating the abdomen of lymphoma patients, the lack of a gastrointestinal contrast agent and specificity of T1 elevations in the spleen would not suggest that MRI could replace CT or laparotomy as a staging technique.

Comparison of lymphangiography and computed tomography scanning in evaluating abdominal disease in stages III and IV Hodgkin's disease. A Southwest Oncology Group study

The authors reviewed the records of 139 patients who had laparotomy plus computed tomography (CT) and/or lymphangiograms (LAG) as part of a their staging workup for Hodgkin's disease, in accordance with Southwest Oncology Group (SWOG) protocol 7808. They evaluated the relative ability of CT and LAG to detect disease in the abdomen. Two regions of the abdomen were designated, the upper and the lower, to further examine the capabilities of CT and LAG in the lower abdomen and CT in the upper abdomen. A LAG was more sensitive (P less than 0.05) than CT in detecting positive lower abdominal nodes. In the upper abdomen, CT scan had low sensitivity for detecting positive nodes, liver, or spleen. This study suggests that LAG of the lower abdomen provided more information than CT, and therefore should not be abandoned as a valid method for detecting nodal disease.

Low field strength magnetic resonance imaging of the spleen: results from volunteers and patients with lymphoma

Low field strength (0.08 Tesla) magnetic resonance imaging (MRI) of the spleen with spin lattice relaxation time (T1) measurement was performed on a total of 79 healthy volunteers and 62 patients with lymphoma. Inhomogeneity was observed on the T1 images of the spleen from 25 volunteers. This was therefore considered a normal variant. The normal range of spleen T1 at 0.08 Tesla was established (362-420 msec). No influence of age on spleen T1 was detected. The range of T1 values observed in males and females was similar, although the mean spleen T1 for females was significantly longer than that for males. The sensitivity of T1 measurement for the detection of lymphoma in the spleen was poor, particularly for patients with Hodgkin's disease. In a minority of untreated patients, however, a spleen T1 value outside the normal range may indicate the presence of lymphoma in the spleen. A significant decrease in spleen T1 following treatment was observed in 9 patients who underwent serial scanning.

Non-Hodgkin's lymphoma of the lung

Non-Hodgkin's lymphoma (NHL) commonly presents with extensive disease involving extranodal tissues. Involvement of the mediastinal and hilar lymph nodes, pleura and lung parenchyma are recognised complications although their incidence is uncertain. However, pulmonary involvement is undoubtedly much less common than involvement at other extra nodal sites. Histologically proven NHL limited to the lung parenchyma, after full staging including computerised tomography and marrow trephines, is extremely rare. We report on two such cases and review the literature.

The radiology of lymphoma

The development of new imaging techniques over recent years has improved the accuracy with which the extent of the disease can be demonstrated in patients with lymphoma. These methods either complement or replace existing conventional radiological methods such as plain films, bariums, intravenous urograms or lymphography. CT in particular, and to a lesser extent ultrasound and radionuclides, now plays an important part in helping the clinician to manage patients with lymphoma. It is impractical and unnecessary to use all available imaging studies. More than ever, close co-operation between the clinician and radiologist is essential to derive the maximum amount of information from the studies and to use the techniques effectively and appropriately. This chapter has reviewed the advantages and limitations of each imaging method, stressing the role of each in staging the lymphomas and in monitoring response to treatment. The common radiological appearances of the effects of lymphoma on each organ system have been described. The possible contribution that other techniques may make in the future has been discussed.

Organ envelopment in lymphoma visualised by computed tomography

In 12 patients computed tomography revealed an unusual pattern of lymphomatous growth resulting in envelopment or engulfment of an organ. The kidneys were involved in eight cases, and the mediastinum and pericardium, oesophagus, stomach and rectosigmoid colon, and psoas muscle in one case each. Ten patients had non-Hodgkin's lymphoma and two had Hodgkin's disease; in every case, lymphomatous masses surrounded but did not destroy the affected tissues. The potential for both Hodgkin's and non-Hodgkin's lymphomas to enwrap both renal and non-renal tissues has not previously been emphasised.

Circumferential para-aortic masses: computed tomographic observations

Of 59 patients in whom computed tomography (CT) demonstrated large para-aortic masses engulfing the aorta, lymphoma was responsible in 32 (54%). In 22 (69%) of these 32 patients the mass appeared confluent while in 10 some nodularity could be discerned. Thirty-five of the 59 patients were known to have an underlying malignancy at the time of the CT; in every case the underlying malignancy proved to be responsible for the mass. Amongst 24 patients in whom the CT abnormality was found in the course of initial diagnosis, lymphoma proved to be responsible in 11 (46%), periaortitis in 4 (17%) and various malignancies in 9 (38%). In none of the patients with periaortitis was the aorta displaced from the vertebral body. The combination of such aortic displacement and mesenteric lymphadenopathy is highly characteristic of non-Hodgkin's lymphoma. Knowledge of these results should assist the choice of the appropriate type of biopsy in this situation.

Computed tomography prior to surgery for ovarian carcinoma

The value of investigation of patients with ovarian carcinoma by preoperative computed tomography scan was evaluated in all the patients operated on during the last 2 years; 22 patients were included in this study and evaluated. In 11 patients the scan was performed prior to the primary surgery and in the other 11 patients before second look following chemotherapy. CT scan was found to be highly sensitive in detecting ascites, pelvic wall extension and spread or involvement of the uterus. Peritoneal and omental spread was detected in only half of the patients before primary surgery. Prior to second look operation CT scan was effective in excluding liver metastasis, ascites, paraaortic lymph node enlargement, pelvic wall extension and pelvic residual tumour. Generally, CT scan failed to detect peritoneal and omental spread. It is an important tool for preoperative evaluation of the extension of the disease and planning of surgery, but still, the final staging deserves explorative laparotomy.

Radiologic imaging modalities, including magnetic resonance, for evaluating lymph nodes

Although lymphography may be more accurate in assessing the extent of abdominal and pelvic Hodgkin's lymphoma, computed tomography (CT) has similar or greater overall accuracy than other imaging modalities in detecting malignant lymph nodes in the neck, chest, abdomen and pelvis. In this early stage of magnetic resonance (MR) imaging, its depiction of nodes is apparently mostly similar to that of CT. In addition, MR imaging shows the capacity to distinguish between enlarged lymph nodes caused by acute inflammation and those caused by malignant processes.

Malignant lymphomas in children and adolescents

Malignant lymphomas constitute the third most common group of childhood cancers in the United States. Hodgkin's disease (HD) exhibits a bimodal age peak, with the first peak occurring in the 15-34-year age group. Nodular sclerosis is the most common histologic subtype of HD seen in children. The disease tends to be primarily supradiaphragmatic at presentation. Accurate staging is essential for determination of appropriate therapy. Staging laparotomy with splenectomy is indicated for those patients with clinically localized disease whose therapy may be altered by pathologic staging. Radiation therapy is curative in the great majority of patients with localized disease. Multimodality therapy has been employed with increasing success in patients with advanced disease. The late sequelae of therapy must be considered in the design of optimum therapeutic regimens. More than 90% of non-Hodgkin's lymphoma (NHL) in childhood can be grouped into one of three histologic subtypes: lymphoblastic, undifferentiated, and diffuse large cell type. Lymphoblastic lymphomas most commonly present with mediastinal involvement. The majority of nonlymphoblastic lymphomas arise within the abdomen. Because of the tendency of NHL for extralymphatic dissemination, systemic therapy is always required. Treatment is determined by stage and histology. Significant improvements in survival rates have resulted from the development of effective combination chemotherapy programs. Cure rates in excess of 90% can be expected in children with localized disease. The outlook for children with advanced disease of undifferentiated histology remains poor. The presence of central nervous system involvement at diagnosis is a particularly ominous sign.

Detection of neoplastic lymph nodes in Hodgkin's disease and non-Hodgkin lymphoma. Comparison between tomography and lymphography

During a period of 17 months, 98 consecutive patients with malignant lymphoma were examined for initial staging before therapy. Both CT and lymphography were performed in 58 patients (19 patients with Hodgkin's disease (HD) and 39 patients with non-Hodgkin lymphoma (NHL], and these were included in the investigation. The results were discrepant in 26 cases where lymph node lesions were detected by only one of the two methods. In 10 patients, 5 with HD and 5 with NHL, the positive finding by one of the methods was taken as determinant of the stage. The conclusion drawn was that CT cannot completely replace lymphography without losing important information. Owing to limited resources for lymphography and CT a reduced staging programme is proposed. Judging by the present results, this reduced programme would probably mean only a minimal loss of information.

The current practice of lymphography: a survey in the age of computed tomography

A postal survey has revealed a reduction in the practice of lymphography in several hospitals where body computed tomography (CT) is available. Nowhere in this country has this reduction been quite so marked as in East Anglia, where very few lymphograms are now performed. Some of the factors which may be responsible are assessed; in particular, the introduction of body CT.

Residual tumor masses following treatment for advanced histiocytic lymphoma. Diagnostic and therapeutic implications

Forty percent or more of patients with advanced diffuse histiocytic (large cell) lymphoma will achieve prolonged disease-free survival with the use of intensive combination chemotherapy. These results are obtained only if complete resolution of all viable tumor is documented prior to the cessation of chemotherapy. Residual tumor masses at the time of re-staging usually are excised or biopsied to confirm the presence or absence of viable tumor. Three patients are reported who had with advanced histiocytic (large cell) lymphoma, and who demonstrated residual intra-abdominal tumor masses on CT scan following four courses of COPP chemotherapy. After two additional courses of a non-cross-resistant regimen and/or supplemental radiotherapy failed to reduce the size of the masses, abdominal exploration with removal of the tumors including splenectomy in one patient was performed, and in each instance no viable tumor was found. The patients have remained disease-free for periods ranging from 24 to 48 months. The various options available to evaluate such patients are presented, and a systematic approach which should avoid the unnecessary prolongation of potentially harmful chemotherapy or radiotherapy is proposed.

Lymphangiography, ultrasonography, and computed tomography in Hodgkin's disease and non-Hodgkin's lymphoma

Findings from histologic analysis, lymphangiography, ultrasonography, and computed tomography were reviewed for 54 cases of Hodgkin's disease and 18 cases of non-Hodgkin's lymphoma. All patients were classified as clinical stage 1 or 2 disease at the time of the imaging studies. The ultrasound and computed tomography studies identified only 30 to 40% of the truly positive patients. This low sensitivity contrasts with lymphangiography, which identified 95% of the truly positive Hodgkin's disease patients and 70% of the patients with abdominal spread of non-Hodgkin's lymphoma. Many errors in interpretation were attributable to location and distribution of disease in these patients and the differing patterns of spread in Hodgkin's disease and non-Hodgkin's lymphoma. The evidence indicates that when findings are positive on computed tomography or ultrasound, no other study is necessary. In stage 1 or 2 lymphoma, non-Hodgkin's patients with negative noninvasive findings and all Hodgkin's patients, regardless of their noninvasive findings, should undergo lymphangiography.

Investigation of retroperitoneal lymph nodes in Hodgkin's disease

For staging of Hodgkin's disease 45 patients underwent lymphography and abdominal computed tomography (CT); in 31 of them ultrasound examination was also performed. In cases of retroperitoneal lymph node enlargement lymphography and CT are diagnostically equivalent, whereas the poorer resolution of ultrasound reduces the reliability of this method when the lymph nodes are only slightly enlarged. Theoretically with lymphography also small lymphomatous lesions in normal-sized lymph nodes should be possible to demonstrate, but there is a clear tendency to overdiagnosis. CT is therefore recommended as the initial method and this examination is considered sufficient both in clearly negative and clearly positive cases. In doubtful cases and in those where CT has revealed solitary slightly enlarged lymph nodes, the examination should be supplemented with ultrasonic scanning and lymphography.

Peripancreatic lymph node enlargement in Hodgkin's disease, non-Hodgkin's lymphoma, and pancreatic carcinoma

The distribution of enlarged lymph nodes in the upper abdomen and retroperitoneum were classified according to their relationship to the pancreas in 47 patients with non-Hodgkin's lymphoma; in nine patients with Hodgkin's disease; and in 40 patients with pancreatic carcinoma. Four patterns of lymph node enlargement were evident: (1) preaortic retropancreatic lymphadenopathy; (2) pancreaticosplenic lymphadenopathy; (3) isolated celiac and/or portal lymphadenopathy; and (4) diffuse extensive lymphadenopathy. Features differentiating lymphoma from primary pancreatic neoplasm are discussed.

Abdominal computed tomography in small cell lung cancer: assessment of extent of disease and response to therapy

Abdominal computed tomography (CT) was performed as part of the initial staging evaluation in 77 patients with small cell carcinoma (SCC) of the lung. CT scans revealed mass lesions in 26 patients (34%). Abnormalities were confined to the liver in 15 patients and to retroperitoneal structures (lymph nodes, adrenal glands, psoas muscle region masses) in eight, and occurred in both areas in three. However, only three of 29 patients otherwise staged as having limited disease (confined to one hemithorax and regional nodes) had evidence of abdominal metastases on CT scan. Most (23/26) positive studies were in patients already known to have more extensive tumor dissemination. In 71 patients with pathologic confirmation of liver status, CT had a sensitivity of 63%, specificity of 91%, and overall accuracy of 85% in assessing the liver. Comparison of radionuclide liver scan findings with hepatic biopsies gave similar results. During therapy, 65 follow-up CT scans were obtained in 46 patients. Scan abnormalities improved or disappeared in 11/12 cases with tumor response documented in other ways, appeared or worsened in 5/13 cases of tumor progression that was diagnosed by other tests, and only rarely (2/65 scans) improved at the time of documented tumor progression, or vice versa. In only three patients, however, did CT scan provide the sole site of evaluable disease during treatment or detect either the only area of residual disease in a patient in otherwise complete remission or the initial evidence of tumor progression. Although abdominal CT scans in SCC can demonstrate metastatic dissemination not evaluable by other means, they provide relatively little therapeutically relevant information beyond that obtained with standard staging procedures.

Computed tomography of the body: when should it be used?

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The role of abdominal computed tomography in lymphoma following treatment

Two hundred and six patients with biopsy-proven lymphoma, 74 with Hodgkin's disease and 132 with non-Hodgkin's lymphoma had abdominal computed tomography for assessment of remission status (108 patients) or for investigation of relapse (98 patients). In 43 patients with diffuse large cell lymphomas scanned at a time of apparent complete remission CT was abnormal in 21. Sixteen of these patients have relapsed and died. Only one patient has relapsed in the group who have normal CT scans. This difference was significant (p=0.00001). This difference was not seen in nodular lymphomas. There were very few patients with Hodgkin's disease in whom the CT scan was abnormal and there is a suggestion that many abnormalities following treatment may represent inactive Hodgkin's disease or fibrosis only. CT played a major role in diagnosing the full extent of relapse in both non-Hodgkin's lymphoma and Hodgkin's disease. Over 50% of the abnormal sites detected by CT would not have been shown by any other non-invasive investigation. Five patients with treated Hodgkin's disease who had "B" symptoms only suggesting relapse were all shown by CT to have extensive intra-abdominal disease.

New approaches to the management of patients with non-Hodgkin's lymphoma of high-grade pathology. First Gordon Hamilton-Fairley memorial lecture

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Lymphomatous involvement of intrahepatic and extrahepatic biliary ducts. PTC and ERCP findings

The intra- and extrahepatic biliary ducts were examined by endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography in 10 patients with malignant lymphoma and suggested hepatic involvement. Different radiologic appearances of the biliary tract are described, related to lymphomatous involvement of the liver or extrahepatic tissues, and compared with laparoscopic findings and final diagnosis. The results demonstrate the accuracy of cholangiography by PTC and ERCP and its usefulness in patients in whom non-invasive techniques fail to provide a reliable diagnosis.

The utility of computed tomography in evaluation of extracranial diseases

The application of CT to the extracranial portions of the body has only been possible since 1975, when technological advances made scanning in less than 20 seconds available to radiologists. Our experience during the first 5 years with body CT have been rewarding and we have demonstrated several significant contributions in the radiologic diagnosis of disease entities that have changed the ideal approach to the evaluation of many patients. The introduction and development of body CT has also been controversial on several issues, primarily related to cost. Increasing clinical experience will improve our definition of the strengths and limitations of CT and allow a more precise definition of the efficient utilization of this new technology. Improvements continue to be reported and it is safe to predict that CT will have further applications to clinical diagnosis in the near future.

Results of surgical staging in Hodgkin's disease

The results of surgical staging in Hodgkin's disease in 107 patients under the care of one surgeon over an 8-year period are presented. The inaccuracy of clinical staging is re-emphasized as 43 per cent of patients had their disease stage altered by surgical staging. Lymphangiography correctly predicted the presence of intra-abdominal disease in only 70 per cent of patients. Spleen size was not an indication of involvement, and furthermore the spleen was involved by disease in the absence of nodal involvement in 6 patients. In 2 cases mesenteric nodes were involved in the absence of pancreatic or coeliac nodal involvement. As a consequence of surgical staging many patients received a more extensive field of radiotherapy, and 18 per cent of patients were treated by combination chemotherapy instead of radiotherapy. There was no hospital mortality and a low operative morbidity following surgical staging. At present surgical staging is an essential part of the overall strategy of management of patients with Hodgkin's disease.

Computed tomography (CT) in the staging of patients with Hodgkin's Disease: a report on 136 patients

One hundred and thirty-six patients with biopsy proven Hodgkin's disease (HD) had conventional staging investigations and CT carried out at presentation. CT did not detect 20 out of 24 positive spleens and did not detect disease at 16 involved lymph node sites proven at laparotomy. In 60 cases in whom lymphography was performed, CT detected all disease shown by lymphography and showed additional disease in 13 other cases (three within the lymphogram area). In 43 patients CT was the only investigation of the abdomen that could be performed and identified 31 unexpected areas of disease in this group. CT altered the stage of the patients in 16% of cases compared with 8% (lymphography) and 34% (laparotomy). The importance of CT as a baseline investigation for the subsequent monitoring of the complete remission of all known disease is discussed, and the routine use of CT when available as the primary non-invasive staging investigation of the abdomen in HD is recommended.

Computerised tomographic (CT) abdominal scanning in Hodgkin's disease

Thirty-nine patients with Hodgkin's disease (HD) with little or no clinical evidence of abdominal disease were investigated by abdominal CT scanning. The results were compared with those of bipedal lymphography and laparotomy and splenectomy. In the assessment of para-aortic lymph nodes, CT scanning and lymphography were of equal efficacy in determining the presence or absence of disease (87 and 79% respectively). Although CT scan could occasionally demonstrate disease in nodes in areas other than the retroperitoneum, its value was limited by its inability to detect involvement of nodes which were not significantly enlarged. CT assessment of splenic HD was unreliable, focal deposits being detected in only one of the 11 spleens involved. In this selected group of patients, CT scan had little advantage over lymphography in the description of disease extent. However, CT scan would appear to be the investigation of choice in patients with suspected abdominal relapse because of the more frequent presence of disease in sites not seen on lymphography. When treatment decisions are dependent on accurate knowledge of distribution of disease, CT scanning cannot yet effectively replace staging laparotomy and splenectomy as the means of achieving this information.

Demonstration of lesions of cerebral toxoplasmosis by computerized tomography

A patient who was treated for 11 years with cytotoxic drugs for Hodgkin's disease developed cerebral toxoplasmosis. Discrete lesions including an occipital abscess were visualized in the brain by computerized tomography (CT). This permitted a brain biopsy to be taken but the appearances were non-specific. At post-mortem pseudocysts of Toxoplasma gondii were found in several sites within the CNS. The recognition of these CT appearances as being due to toxoplasmosis should in future prompt serological investigation and urgent treatment of this potentially curable condition, despite negative biopsy material.