CT of Lymphoma:

Spectrum of Diseas&
Elliot K Fishman, MD
JanetE. Kuhlman, MD
Ricbardj Jones, MD

Computed tomography (CT) is the study of choice for the detection

and staging of Hodgkin and non-Hodgkin lymphoma. CT enables ac-
curate measurement of both tumor extent and volume and provides
information that can be used to plan an appropriate therapeutic regi-
men as well as follow patient response to therapy. This article pre-
sents a systematic review of the common and uncommon appearances
oflymphoma in the chest and abdomen. Potential pitfalls and limita-
tions of CT in staging and follow-up are also addressed.

U INTRODUCTION
Computed tomography (CT) has many roles in the evaluation of Hodgkin or non-
Hodgkin lymphoma. It is used to (a) define the full extent of disease to allow accu-
rate staging, (b) assist in treatment planning (ie, determine the site of nodal biopsy,
create radiation therapy portals, and select the chemotherapy protocol), (C) evaluate
the response to therapy, and (d) monitor patient progress and possible relapse. Nu-
merous articles over the past decade have quantified the value of CT in cases of lym-
phoma (1-14).
In a review of 203 patients with newly diagnosed Hodgkin disease, Castellino et
al (13) found that CT ofthe chest resulted in a change in treatment in 9.4% of pa-
tients (19 of 203), including 13.8% (nine of 65) of those undergoing radiation ther-
apy and 8.2% (10 of 122) of those undergoing combined modality treatment.
Khoury et al (15), in comparing CT and chest radiography in a series of 48 patients
with non-Hodgkin lymphoma, found that chest CT affected management in eight of
25 treated and five of 19 untreated patients.
CT of the abdomen and pelvis has also been shown to be of great value in the
staging and follow-up oflymphoma. Neumann et al (16) reviewed their experience
and found that in cases of non-Hodgkin lymphoma, CT performed at the time of
presentation resulted in upgrading of the clinical stage in 33% of patients; in addi-
tion, CT enabled detection of unsuspected active disease in 43% of patients thought
to be in remission. Clinically important upstaging was the result in 15% ofall exami-
nations.

Abbreviations: AIDS = acquired immunodeficiency syndrome, HIV = human immunodeficiency virus

Index terms: Abdomen, CT, 70. 1 2 1 1 #{149}

Lymphoma, CT, 99. 1299 Lymphoma,
#{149} diagnosis, 99.834 Lymphoma,
#{149} stag.
ing, 99.834 Thorax,
#{149} CT, 60.1211

RadioGraphics 1991; 11:647-669

From the Russell H. Morgan Department of Radiology and Radiological Science (E.K.F., J.E.K.) and the Department of
Oncology (R.J.J.), TheJohns Hopkins Medical Institutions, 600 N Wolfe St. Baltimore, MD 21205. From the 1990 RSNA
annual meeting. Received December 26, 1990; revision requested February 8, 1991, and received February 26; accepted
February 26. Address reprint requests to E.K.F.

C RSNA, 1991

647
 Table 1
Histologic Classification of Non-Hodgkin Lymphoma

International Working Formulation Rappaport Classification

Low grade
A. Small lymphocytic Well-differentiated lymphocytic
B. Follicular, predominantly small cleaved cell Nodular, poorly differentiated lymphocytic
C. Follicular, mixed small and large cell Nodular, mixed
Intermediate grade
D. Follicular, predominantly large cell Nodular, histiocytic
E. Diffuse, small cleaved cell Diffuse, poorly differentiated lymphocytic
F. Diffuse, mixed small and large cell Diffuse, mixed
G. Diffuse, large cell, cleaved or noncleaved
High grade
H. Diffused large cell, immunoblastic
I. Small, noncleaved cell
J. Lymphoblastic Undifferentiated

This article presents a systematic review of Hodgkin lymphoma (2). Although there are
the common and uncommon appearances of minor differences in the clinical presentation
lymphoma in the chest and abdomen. Poten- and course for the subtypes of non-Hodgkin
tial pitfalls and limitations of CT in staging lymphoma within each of the three categories
and follow-up are also addressed. Although an listed, the lymphomas within each category
in-depth discussion of the treatment of lym- can generally be approached similarly. In ad-
phoma is beyond the scope of this article, it is dition, follicular large cell and diffuse small
important to understand the therapeutic deci- cleaved cell lymphoma (grades D and E ) can
sions that are based on accurate CT staging, probably be regarded as low-grade lympho-
including the choice of chemotherapy, radia- mas, while diffuse, mixed small and large cell
tion therapy, or a combination of these mo- and diffuse large cell lymphomas (grades F
dalities. and G) can be approached as high-grade lym-
phomas. High-grade lymphomas are aggres-
U STAGING AND THERAPEUTIC sive, fast-growing malignancies that are rap-
CHOICES idly fatal if not treated; however, of about half
The treatment oflymphoma (both Hodgkin the patients can be cured with current treat-
and non-Hodgkin) is now effective, with a ment. Conversely, low-grade lymphomas are
substantial fraction of patients being cured. slow-growing diseases, and patients have long
However, the prognosis and type of therapy survivals (median, about 7 years) even if un-
are dictated by the histologic type and stage treated. Interestingly, however, with the ex-
ofdisease (1-7). Although the histopathologic ception oflocalized disease, low-grade lym-
subtype of Hodgkin disease correlates with phomas are incurable.
the stage of disease, it does not correlate with Adequate staging is critical
for determining
prognosis if stage is taken into account (1). the correct treatment Hodgkin of both
and
Conversely, the histologic subtype of non- non-Hodgkin lymphoma. Radiation therapy
Hodgkin lymphoma strongly affects prognosis has been the standard treatment for all early-
and treatment strategies. stage lymphomas, with cure rates ranging
The current universally accepted Interna- from about 50% for both low-grade (3) and
tional Working Formulation and the Rappa- high-grade (4) non-Hodgkin lymphomas to
port equivalent for histologic classification of over 80% for Hodgkin disease (5). Stage Ill-N
non-Hodgkin lymphoma are shown in Table Hodgkin disease and high-grade non-Hodgkin
1 . Table 2 shows the staging system for lymphoma require intensive combination che-
motherapy, with cure rates of about 50%
(6,7). Bulky early-stage disease also requires
chemotherapy for cure.

648 U RadioGraphics U Fishman et a! Volume 11 Number 4

 Table 2

Ann Arbor Staging Classification of HOdgkin Lymphoma

Stage Features

I Involvement ofa single lymph node region

II Involvement of two or more lymph node regions
on the same side ofthe diaphragm (II), which
may be accompanied by localized involvement of
an extralymphatic organ or site (lIv)
III Involvement oflymph node regions on both sides
of the diaphragm (Ill), which may also be accom-
panied by involvement of the spleen (III) or by
localized involvement of an extralymphatic organ
or site (IIIF)
IV Diffuse or disseminated involvement of one or
more extralymphatic organs or tissues, with or
without associated lymph node involvement

Radiation therapy of stage I or II Hodgkin U THORACIC INVOLVEMENT

disease includes supervoltage radiation deliv-
ered in a wide field by means of a 4-8-MeV . Lymph Nodes
linear accelerator. The treatment is given The most common characteristic of lym-
through a mantle field to include the lymph phoma is that of clinically palpable lymphade-
nodes of the neck, axilla, and mediastinum in nopathy. Lymphoma may involve any nodal
one contiguous treatment volume. Four chain in the body, and enlarged nodes are
blocks are used to shield the normal lung tis- indeed the most common manifestation of
sue, and a calculation to account for irregular lymphoma on CT scans. The accurate detec-
fields allows homogeneous distribution of the tion of nodes is important in the accurate
dose to the lymph nodes. The field is tailored staging oflymphoma. Although an in-depth
to treat the paraaortic nodes and parasplenic discussion oflymphadenopathy is beyond the
nodes and to avoid normal tissue such as kid- scope of this report, a few important but often
ney and liver. Careful calculation of the gap overlooked nodal zones will be addressed.
between the mantle and paraaortic fields is Regardless of the area of involvement,
necessary. Radiation therapy of non-Hodgkin nodal disease typically has attenuation similar
lymphoma is reserved for patients with low- to that of muscle on CT scans. In most cases,
grade disease or is used in combination with the nodes are homogeneous, although occa-
chemotherapy for patients with advanced dis- sionally they may be necrotic. To determine
ease. The dose delivered depends on the his- whether necrosis indicates a more aggressive
tologic type of non-Hodgkin lymphoma. tumor, Hopper et al reviewed the thoracic CT
Although lymphangiography and laparot- scans of 16 patients with Hodgkin disease
omy have historically been standard proce- with necrotic mediastinal nodes (17). They
dures for staging lymphomas, they have been found that the presence of necrosis had no
largely replaced by CT, especially in the evalu- substantial effect on the patient’s clinical re-
ation of non-Hodgkin lymphoma. CT is also sponse to treatment or ultimate survival. 01-
invaluable for the follow-up of patients, since iver et at (14) found nodal necrosis in 26% of
early diagnosis of relapse of Hodgkin and
non-Hodgkin lymphoma can still lead to cure
with the use of bone marrow transplantation.

July 1991 Fishman Ct a! U RadioGraphics U 649

 1. 2.
Figures 1, 2. (1) Non-Hodgkin lymphoma in a 28-year-old man. CT scan shows large anterior mediastinal
nodes with areas ofcystic change and subtle calcification. (2) Hodgkin disease in a 33-year-old woman. CT
scan demonstrates large anterior mediastinal nodes with several cystic zones. Areas of homogeneous nodes
are also seen.

Figure 3. Non-Hodgkin lym-

phoma in a 68-year-old woman. CT
scan obtained after contrast mate-
nat was injected shows enlarged,
enhancing right axillary nodes (ar-
row). Mediastinal nodes did not
enhance.

patients with abdominal lymphoma (a series nodes in patients with lymphoma are second-
of 125 patients); all responded favorably to ary to prior therapy (Figs 5, 6) (18-21). Calci-
therapy. The most common pathologic type of fled nodes are most commonly seen in the
lymphoma in cases of necrotic nodes is nodu- anterior mediastinum, especially in patients
lar sclerosing Hodgkin disease (Figs 1 2). , with Hodgkin disease who have undergone
Nodal necrosis following chemotherapy or radiation therapy. Histologic studies have
radiation therapy is not uncommon. We have shown these catcifications to be of the dystro-
recently noted several cases of nodal enhance- phic type. The significance of nodal calcifica-
ment following dynamic bolus injection of tion with regard to tumor viability and ulti-
iodinated contrast material (Figs 3, 4). In mate prognosis is still uncertain.
nearly all cases, the nodes were axillary. Al- The anterior mediastinal, pretracheal, and
though enhancing nodes are the hallmark of hilar nodal chains are the most common
Castleman disease, they can be seen in non- nodal chains involved by tymphoma in the
Hodgkin lymphoma. The ultimate significance chest. Careful attention to the axillary, para-
of nodal enhancement (if any) has not yet cardiac, and subcarinal nodal chains is impor-
been defined. tant in accurate staging. Two nodal chains
Although in rare cases calcifications may commonly overlooked are the superior dia-
occur within lymph nodes at the time of initial phragmatic and internal mammary lymph
presentation, most cases of calcified lymph node chains (10-12).
The superior diaphragmatic lymph nodes
or paracardiac nodes are located just above or
on the diaphragm and can be divided into

650 U RadioGraphics U Fishman et a! Volume 11 Number 4

 Figure 4. Non-Hodgkin lym-
phoma in a 46-year-old woman. CT
scans demonstrate enhancing right
axillary and internal mammary
nodes (arrow). Other nodal chains,
including those of the subcarinal
zones, do not show enhancement.

5a. 5b.
Figures 5, 6. (5) Large cell lymphoma in a 66-
year-old woman. (a) CT scan obtained before che-
motherapy shows extensive pancreaticoduodenal
nodes. (b) CT scan obtained after chemotherapy
shows that the nodes have decreased in size and
are partially calcified. (6) Hodgkin disease in a 79-
year-old woman in clinical remission for 8 years.
Patient had been treated with radiation delivered
to the mediastinum. CT scan demonstrates calcified
mediastinal nodes without recurrent tumor.

6.

July 1991 FIsIunan Ct a! U RadioGrapbic.s U 651

 7. S.

9. 10.
Figures 7-10. (7)
Diffuse histiocytic lymphoma in a 28-year-old woman. CT scan shows small right para-
cardiac nodes. (8) Hodgkin disease in a 34-year-old woman. CT scan shows large left paracardiac nodes.
(9) Large cell lymphoma in a 79-year-old man. CT scan demonstrates bilaterally enlarged internal mammary
nodes. (10) Burkitt lymphoma in a 72-year-old woman. CT scan demonstrates large right internal mammary
nodes growing through the chest wall.

anterior, middle, and posterior groups. These 23.7% of nodes (nine of 38) in these patients
lymph nodes consist of nodes in the cardio- (Figs 7, 8).
phrenic angles, nodes in the most caudal por- Similarly, internal mammary adenopathy is
tion of the internal mammary chain, and difficult to detect at routine radiography (Figs
nodes along the pericardium. In a series of 9, 10). Scott and Fishman (22) noted that over
Castellino et al (13), the detection of cardio- 60% of cases of internal mammary adenopa-
phrenic angle nodes on CT scans of patients thy will be missed at routine radiography. In-
with Hodgkin disease resulted in modified ternal mammary adenopathy is usually seen in
treatment in 18.8% ofcases (three of 16). In patients with either lymphoma or breast can-
the same series, paracardiac nodes were de- cer. Ifoverlooked, these nodes can enlarge
tected on chest radiographs in only 12.5% and grow into or through the chest wall. Ster-
(two of 16) of the cases. In a review by Suss- nal involvement with either infiltration or de-
man et al (12), 40% of patients with enlarged struction can also occur.
paracardiac nodes had lymphoma. The nodes
associated with lymphoma tended to be bilat- . Lung Parenchyma
eral, multiple, greater than 2 cm in diameter, Involvement of the lung parenchyma at the
and lobulated or matted in appearance. time of initial diagnosis is more common in
Chest radiographs enabled detection of only Hodgkin disease than in non-Hodgkin dis-
ease. The lung parenchyma may be involved
at presentation in as many as 1 1 .6% of cases

652 U RadioGrapbics U Fishinan et a! Volume 11 Number 4

Figures 11, 12. (11) Nodular sclerosing Hodgkin disease in a 38-year-old woman. CT scan shows solitary
mass in the right lower lung, representing tumor recurrence. (12) Nodular sclerosing Hodgkin disease in a
16-yearld boy. CT scan demonstrates bilateral lung nodules ranging in size from 3 to 1 5 mm and distrib-
uted throughout the lungs.

14.
Figures 13-15. (13) Hodgkin disease in a 43-
year-old woman. CT scan shows enlarged left hilar
nodes with direct infiltration into the lung paren-
chyma. Small parenchymal nodules are also seen.
(14) Recurrent nodular sclerosing Hodgkin disease
in a 34-year-old woman. CT scan demonstrates ade-
nopathy in the right hilum, with tumor infiltrating
along lymphatic vessels into the lung parenchyma.
(15) Poorly differentiated lymphocytic lymphoma
in a 73-year-old woman. CT scan demonstrates a
large cavitary mass in the left upper lung.

c.--
15.
. --.,-..
ofHodgkin disease (23-25). In the patient diastinal or hilar adenopathy with direct ex-
with Hodgkin disease, lung involvement is tension along lymphatic vessels into the lung
often associated with mediastinal or hilar ade- parenchyma (Figs 13, 14). The third pattern is
nopathy. Primary lymphoma of the lung is peribronchial or perivascular lymphomatous
rare. deposits in a subsegmental or segmental dis-
The patterns of lymphomatous involvement tribution: These nodules and infiltration may
of the lung parenchyma are variable. One pat- at times be indistinguishable from pneumo-
tern consists of single or multiple nodules nia. Cavitary nodules may also be seen (Fig
similar to those seen in metastatic disease 1 5). Finally, a reticular infiltrative pattern in
(Figs 11 , 1 2). A second pattern consists of me- the lungs may be seen.

July 1991 Fishman et a! U RadioGraphics U 653

 16. 17.
Figures 16, 17. (16) Primary large cell lymphoma ofthe liver in a 46-year-old man. C’l’ scan demonstrates a
10-cm solitary mass in the left lobe ofthe liver. The mass is hypovascular. (17) Immunoblastic histiocytic lym-
phoma in a 58-year-old woman in clinical remission. She presented with acute abdominal pain. CT scan dem-
onstrates multifocal lesions in the liver with areas ofspontaneous hemorrhage. A large subcapsular he-
matoma is also present.

Lewis et al (25) reviewed a series of 3 1 pa- At pathologic examination, Hodgkin disease

tients with recurrent lymphoma with lym- is commonly a diffuse infiltrating process,
phomatous involvement of the lung paren- while non-Hodgkin disease may occur as ei-
chyma as demonstrated by CT and found the ther a diffuse infiltrating process or discrete
following patterns: (a) nodules less than 1 cm tumor nodules.
in diameter, (b) mass or masslike consolida- When discrete nodules are present, con-
tion greater than 1 cm in diameter with or trast-enhanced CT scans usually depict tumor
without cavitation, (c) alveolar or interstitial involvement (30,31). However, in cases with
infiltrates, (d) pleural-based masses, and (e) small nodules (less than 1 cm in diameter) or
peribronchial or perivascular thickening with in cases with diffuse infiltration, CT may not
or without atelectasis. The most common depict tumor involvement. In some cases, the
finding (2 1 of 3 1 patients [68%]) was a mass liver texture is noted to be irregular on CT
or masslike consolidation. In many of these scans, and the appearance is more suggestive
patients, pleural effusion or adenopathy was of benign parenchymal disease (eg, fatty infil-
an associated finding. tration) than primary tumor involvement. The
accuracy of CT in the detection of hepatic
U ABDOMINAL INVOLVEMENT lymphoma is variable. Zornoza and Ginaldi
(30) reported a sensitivity of 57% and a speci-
. Liver ficity of88%. The sensitivity ofCT is probably
Infiltration of the liver at the time of presenta- increasing with the use of dynamic liver scan-
tion occurs in up to 16% ofpatients with non- ning and the newer high-resolution CT scan-
Hodgkin lymphoma and
10% of patients with ners.
Hodgkin disease In autopsy
(26-29). series, The CT appearances of hepatic lymphoma
about 50% of patients with either Hodgkin can be divided into three categories:
disease or non-Hodgkin lymphoma have he-
patic involvement. In rare cases, lymphoma 1 . The solitary hepatic mass. This mass may
may arise as a primary tumor of the liver. be indistinguishable in appearance from met-
astatic disease from any source or from pri-
mary hepatocellular carcinoma (Fig 16). In
our experience, the lesions may range in size

654 U RadioGraphics U Fishman Ct a! Volume 11 Number 4

 ..“i

4- :
18c. 19.
Figures 18, 19. (18) Non-Hodgkin lymphoma in a 39-year-old man. (a) CT scan demonstrates multiple
nodules throughout the liver. CT scans obtained 3 months (b) and 6 months (c) after chemotherapy show
partial resolution of the tumor. (19) Diffuse small cell lymphoma in a 40-year-old man. CT scan of the liver
demonstrates diffuse infiltration of the liver by tumor.

from less than 1 cm to approximately 10 cm. 3. Diffuse hepatic involvement. The diffuse
Calcification is rare within these lesions un- infiltration of the liver by lymphoma is the
less the patient has undergone radiation ther- most difficult feature to detect on CT scans.
apy. Occasionally, these lesions can bleed, The lesions often have the same attenuation
and patients may present with an acute abdo- as hepatic parenchyma, or the appearance
men as a sign oftumor involvement (Fig 17). may be suggestive of fatty infiltration or pa-
2. Multifocal hepatic lesions. These can renchymal disease rather than tumor infiltra-
also be similar in appearance to metastatic tion (Fig 19).
disease or multifocal hepatoma. The lesions
vary in size but typically are 1-5 cm in diame-
ter (Fig 18).

July 1991 Fishman et a! U RadioGraphics U 655

 20.
Figures 20, 21. (20) Primary diffuse histiocytic
lymphoma in a 68-year-old man. CT scans show tu-
mor extending through the splenic capsule and
down to the posterior pararenal space. Associated
chest wall and rib involvement are noted (arrows).
This appearance could
be suggestive of an inflam-
matory process with chest
wall invasion. (2 1) Dif-
fuse histiocytic lymphoma
in a 54-year-old man. CT
scan demonstrates necrotic tumor in the spleen
with multiple air bubbles and invasion of the stom-
ach and pancreas. The CT appearance was initially
suggestive of abscess.

21.
. Spleen
Splenic lymphoma can be classified as either
primary splenic lymphoma or lymphomatous The CT appearances and clinical presenta-
splenic involvement as part of more systemic tions (fever, left upper quadrant pain, mal-
disease (32). Primary splenic lymphoma is aise) of primary splenic lymphoma and
rare. When it does occur, it is usually a large splenic abscess can be similar (Figs 20, 21).
cell lymphoma. Non-Hodgkin lymphoma is This can be true with both Hodgkin and non-
the most common primary tumor of the Hodgkin lymphoma. One helpful point in the
spleen. In a series by Meyer et al (32), a large differential diagnosis is that splenic abscesses
solitary mass was the most common finding. rarely occur with lymphadenopathy.
At presentation, primary splenic lymphoma One of the weaknesses of any noninvasive
may be associated with disease in the splenic, imaging study has been the accurate detec-
hilar, or paraaortic nodal chains. tion of splenic involvement by lymphoma.
This weakness is partially due to the fact that
in most cases the disease either is infiltrative

656 U RadioGraphics U Fishman Ct a! Volume 11 Number 4

23. 24.
Figures 22-24. (22) Primary histiocytic lymphoma of the spleen in a 64-year-old woman. CT scans demon-
strate splenomegaly with multiple discrete lesions. (23) Histiocytic lymphoma in a 68-year-old man. CT scan
demonstrates multiple lesions in the spleen. Splenomegaly is possibly due to cirrhosis and resultant portal
hypertension. (24) Large cell lymphoma of the spleen in a 59-year-old woman. Multiple lesions and diffuse
infiltration are seen.

or occurs as tumor foci well under a centime- They include (a) homogeneous enlargement
ter in diameter (32-34). Absolute measure- without a discrete mass, (b) solitary mass,
ments of splenic size are of limited value, with (c) multifocal lesions
(Figs 22, 23), and (d)
up to 30% ofenlarged spleens in lymphoma diffuse infiltration. appearance The at CT typi-
being free of tumor. Another study found a cally is one of diffuse areas of low attenuation
sensitivity of 38% and a specificity of 6 1% for or diffuse irregular splenic enhancement
detection of splenic lymphoma based on or- (Fig 24).
gan enlargement found at either physical or
imaging examination (33).
The CT appearances of splenic lymphoma
mirror the variety of pathologic appearances.

July 1991 Fishman et al U RadioGraphics U 657

 Figures 25-27. (25) Diffuse histiocytic lym-
phoma in a 67-year-old man. CT scan shows a 3.5-
cm-diameter solitary lesion in the left kidney that
was proved by means ofbiopsy to be lymphoma.
The lesion measured 2 1 HU. The kidney was dis-
placed by an enlarged spleen. (26) Diffuse large
cell lymphoma in a 49-year-old man. The solitary
mass in the right kidney (arrows) was the only site
of intraabdominal disease. The lesion was hypoat-
tenuated with respect to normal kidney following
contrast enhancement. (27) Nodular sclerosing
Hodgkin disease in a 27-year-old woman. CT scan
shows multiple bilateral renal masses of low attenu-
ation.

27.

. Kidney enhanced CT, the majority of these lesions

Renal involvement by lymphoma has been can be detected. Renal involvement by lym-
documented in autopsy series to occur in up phoma is usually secondary to either he-
to one-third ofcases (35). In 75% of these matogenous or lymphatic dissemination. The
cases, involvement was bilateral. The majority CT appearance of renal involvement by lym-
of cases are non-Hodgkin lymphoma, al- phoma can be classified into four categories:
though its appearance on CT scans is indistin-
guishable from that of Hodgkin lymphoma 1. Solitary mass. The tumor is usually in a
(35-41). normal-sized kidney and may occur with or
Renal involvement represents stage N without associated paraaortic adenopathy.
Hodgkin disease. With the use of contrast- The lesion may have the same attenuation as
normal kidney on non-contrast-enhanced CT
scans and is best detected on contrast-en-
hanced studies (Figs 25, 26).

658 U Ra4ioGrapbics U Fishman et a! Volume 11 Number 4

28. 29.
Figures 28, 29. (28) Biopsy-proved diffuse lymphoblastic malignant lymphoma in a 5-year-old girl with
enlarged neck nodes and decreased renal function. On the CT scan both kidneys are diffusely enlarged but
homogeneous. Small paraaortic nodes are seen. (29) Diffuse histiocytic lymphoma in a 60-year-old woman.
CT scan reveals irregular enhancement ofboth kidneys, which is compatible with diffuse tumor infiltration.
Interestingly, the kidneys are not significantly enlarged.

2. Multiple masses. The multiple nodules This is especially true in patients with lym-
are usually bilateral and variable in size. The phomatous infiltration of the perirenal space.
nodules in one series were between 1 and 4.5 Renal function may be absent in these cases,
cm in diameter. The kidney is usually en- and the patients can have renal failure at pre-
larged but may occasionally be normal in size sentation (Figs 30-33).
(Fig 27). Depending on the specific CT appearance,
3. Infiltration of kidney. The kidney is par- renal involvement by lymphoma can look sim-
tially or totally replaced by tumor. The kid- ilar to renal cell carcinoma, metastasis, pyelo-
neys are usually enlarged, with decreased re- nephritis, focal abscess, or transitional cell
nal function not uncommon (Figs 28, 29). carcinoma (Fig 34). Primary lymphoma of the
4. Infiltration by contiguous retroperito- kidney is rare due to the lack of lymphoid tis-
neal disease. The kidney is directly invaded or sue within the kidney.
engulfed by adjacent tumor or enlarged
nodes. In cases with massive adenopathy, the
renal outline may be lost or poorly defined.

July 1991 Fishman Ct a! U RadioGrapbics U 659

 30. 31.

33. 34.
Figures 30-34. (30) Histiocytic lymphoma in a 68-year-old man. CT scan shows enlarged lymph nodes
infiltrating the right kidney as well as perirenal and pararenal spaces on the right side. (31) Lymphocytic-
histiocytic nodular lymphoma in a 74-year-old woman. CT scan reveals extensive paraaortic adenopathy di-
rectly invading the left kidney. Left hydronephrosis is also seen. (32) Histiocytic lymphoma in a 56-year-old
man. (a) CT scan demonstrates the left kidney replaced by tumor and extensive paraaortic nodes. The kid-
ney was nonfunctioning. (b) CT scan obtained 1 year after therapy demonstrates near resolution of tumor.
The left kidney is atrophic. (33) Diffuse histiocytic large cell lymphoma in a 59-year-old man. Extensive ade-
nopathy is seen, infiltrating pararenal and perirenal space bilaterally. Tumor involves the kidney by direct
extension. (34) Small cleaved cell follicular lymphoma in a 75-year-old man. CT scan shows tumor infiltrating
the right renal pelvis and kidney. Decreased renal function was noted. Tumor appearance is similar to that of
transitional cell carcinoma.

660 U RadioGraphics U Fishman et a! Volume 11 Number 4

 4

r.

;,‘: : I
I

.
*, I

36.
Figures 35-37. (35) B cell lymphoma (primary
adrenal tumor) in a 92-year-old man with a history
of abdominal pain. CT scan demonstrates bilateral
adrenal masses without evidence of adenopathy.
The diagnosis was made at percutaneous biopsy.
(36) Biopsy-proved large cell lymphoma in a 53-
year-old woman with a mass above the orbit. CT
scan demonstrates bilateral triangular adrenal
masses. An incidental splenic lesion is also seen.
(37) Diffuse histiocytic lymphoma in a 55-year-old
woman. CT scan demonstrates diffuse infiltration
of both adrenal glands by tumor. Extensive
paraaortic nodes are also seen.

37.

. Adrenal Glands Feldberg et al (43) reported two cases of

Involvement of the adrenal glands by lym- primary adrenal lymphoma in which the adre-
phoma has been documented in an autopsy nal glands were involved bilaterally and mea-
series to occur in up to 25% ofcases (27). The sured 15 and 17 cm in diameter, respectively.
majority of cases are seen with associated In both cases, the glands were homoge-
bulky lymphadenopathy, although primary neously enlarged without necrosis or calcifica-
adrenal lymphoma can occur. Bilateral in- tions. The authors believed that in the sce-
volvement is common, with adrenal insuffi- nario of no known biochemical abnormalities
ciency or hemorrhage a possible clinical pre- and no known primary tumor, the isolated
sentation (Figs 35-37). In a series byjafri et appearance of massive adrenal masses is sug-
al, the adrenal gland varied in size from 2 to gestive of lymphoma.
12 cm (42). Adrenal gland involvement is
more common in non-Hodgkin lymphoma.

July 1991 Fishman et a! U RadioGraphics U 661

 Figures 38-41. (38) Diffuse histiocytic lym-
phoma of the stomach in a 49-year-old woman.
(a) CT scan demonstrates ulcerating lesion in the
gastric fundus. (b) Another scan obtained at a
lower level shows bulky tumor involving the gastric
antrum. (39) Diffuse histiocytic lymphoma in a 63-
year-old man. CT scan shows diffuse gastric infiltra-
tion by bulky tumor mass. (40) Biopsy-proved large
cell lymphoma in a 63-year-old man with epigastric
pain. CT scan demonstrates a bulky tumor of the
body ofthe stomach. No associated adenopathy
was seen. (41) Biopsy-proved diffuse large cell lym-
phoma in a 68-year-old man. CT scan shows bulky
tumor infiltrating the gastric annum. No evidence
of adenopathy was present.

41.

662 U RadioGrapbics U Fishman et a! Volume 11 Number 4

 Figures 42, 43. (42) Non-Hodgkin lymphoma of
the bowel in a 63-year-old woman. (a) Initial CT
scan demonstrates small bowel obstruction due to
intussusception. (b) CT scan obtained after sponta-
neous reduction of intussusception clearly shows
the polypoid tumor mass (arrows). (43) Lymphoma
in a 65-year-old woman with a long history of sprue.
CT scan demonstrates large ulcerating tumor of the
ileum (arrows) compatible with lymphoma. Surgi-
cal resection ofbowel was performed, and the final
pathologic diagnosis was diffuse large cell lym-
phoma. The bowel was thickened with mucosal ul-
cerations.

. Stomach and adenocarcinoma is that in lymphoma, the

The stomach is the most frequent site of lym- nodes are usually bulkier and extend beneath
phomatous involvement of the gastrointesti- the renal hilum. Gastric involvement with
nal tract (44). Non-Hodgkin lymphoma ac- bulky tumor masses is not uncommon with
counts for approximately 80% ofcases. In a American Burkitt lymphoma (48).
series of 23 patients with gastric lymphoma,
Megibow found an average gastric wall thick- . Small Bowel and Mesentery
ness of 5 cm (range, 2.5-8 cm) (45). Buy and The small bowel is the second most frequent
Moss found an average wall thickness of 4 cm site of gastrointestinal tract involvement by
in their series of 12 patients (46). lymphoma (49-52). Lymphomas constitute
The patterns of gastric involvement can be approximately one-half of all primary malig-
divided into the following categories (47): nant small bowel tumors. The ileum is the
(a) diffuse infiltration involving greater than most common site of occurrence, the duode-
50% of the length of the stomach (Figs 38- num the least frequent. The clinical presenta-
40), (b) segmental infiltration (Fig 41), and tion is variable, ranging from bowel obstruc-
(c) localized polypoid form. The latter form is tion, intussusception (Fig 42), or perforation
often associated with an ulcer. Tumor infiltra- to a sprue-like syndrome (Fig 43). Multifocal
tion is usually homogeneous, although low- sites of involvement are not uncommon. The
attenuation regions may be seen. Most pa-
tients with gastric lymphoma have associated
adenopathy. One of the key points in the dif-
ferential diagnosis between gastric lymphoma

July 1991 Fishman et a! U RadioGrapbics U 663

 Figure 44. Lymphocytic lym-
phoma in a 72-year-old man. CT
scans demonstrate diffuse infiltra-
tion ofa 12-cm segment of ileum.
Infiltration into mesenteric fat is
also seen.

CT appearance oflymphoma is variable. The

typical appearances canbe classified as aneu-
rysmal, constrictive, nodular, and ulcerative
infiltration (Figs 44, 45).
Mesenteric involvement by lymphoma may
involve the small bowel directly by direct ex-
tension or indirectly by displacement due to
mass effect. Although mesenteric involvement
may be an isolated finding, it is usually seen
as part of a more systemic involvement. Mes-
enteric involvement can be manifested by any
of the four general patterns of mesenteric dis-
ease: rounded masses, ill-defined masses, --t -- _5. Burkitt lymphoma ofthe terminal il-
cakelike masses, and stellate mesentery (Figs eum in a 32-year-old man. CT scan demonstrates
46, 47) (53-56). The rounded mass appear- diffuse tumor infiltration of the ileum.

ance is the most common and is usually seen

with non-Hodgkin lymphoma. Discrete mes- lymphoma. Since the initial description of the
enteric nodes may directly involve or encase increased prevalence of lymphomas in pa-
small bowel with a classic “sandwich” appear- tients with renal transplants, there have been
ance. numerous reports of this occurrence. Most
Lymphomatous involvement of the gas- recently, an increased prevalence of gas-
trointestinal tract is more common in the im- trointestinal tract lymphoma in patients with
munocompromised patient who develops acquired immunodeficiency syndrome (AIDS)
has been reported (57,58). In nearly all cases,
the pathologic type was non-Hodgkin lym-

664 U RadioGraphics U Fishman et a! Volume 11 Number 4

 I. p L L

Figures 46-48. (46) Malignant lymphocytic lym-

phoma in a 61-year-old man. CT scans show exten-
sive mesenteric adenopathy in a pattern of round-
ed masses arising from the root of the mesentery.
(47) Non-Hodgkin lymphoma in a 53-year-old man.
1 CT scans demonstrate multiple round tumor im-
plants on the proximal jejunum. Several of the im-
plants are cystic. Nodes in the mesentery are also
noted. (48) Large cell histiocytic lymphoma of
bowel in a 35-year-old man. The patient tested pos-
itive for human immunodeficiency virus (HIV). CT
scan demonstrates multiple ulcerating lesions in
the duodenum and proximal jejunum. Ascites is
also present.

48.

phoma (Fig 48). The prevalence of non- guishable from that oflymphoma in the im-
Hodgkin lymphoma is 35 times greater in pa- munocompetent patient (60-62). However,
tients with renal transplants than in the gen- posttransplantation lymphomas involve extra-
eral population. De novo malignancies affect nodal sites more frequently, especially the
6% of renal transplant recipients (59). Non- central nervous system. In patients with renal
Hodgkin lymphoma accounts for more than transplants, the transplant itself was the organ
20% of transplant-related malignancies. The most often infiltrated by tumor.
CT appearance of non-Hodgkin lymphoma in
the immunocompromised host is indistin-

July 1991 Fishman et a! U RadioGraphics U 665

 Figures 49-52. (49) Diffuse large cell lymphoma in a 29-year-old man with constitutional symptoms and
HIV-positive test CT scan demonstrates
results. a solid mass (arrow) in the cecum. Colonoscopy with biopsy
revealed the diagnosis. (50) Biopsy-proved poorly differentiated lymphocytic lymphoma in a 63-year-old
woman with increasing abdominal pain and distention. CT scan demonstrates diffuse infiltration of the
transverse colon and greater omentum. (51) Biopsy-proved diffuse histiocytic lymphoma of the right colon
and proximal transverse colon in a 70-year-old woman with recent onset of right upper quadrant pain. Tu-
mor infiltration ofthe colon is noted (arrows). (52) Mixed large and small cell lymphoma in an 83-year-old
man. CT scan demonstrates extensive pelvic tumor with infiltration and encasement of the rectum.

. Colon cecum. Occasionally, this can lead to intussus-

Primary colonic
lymphoma is uncommon and ception. The CT appearance is similar to that
is responsible for less than 0.1% of primary of a primary adenocarcinoma of the colon.
rectal tumors (63,64). The cecum and rectum The diffuse form is variable, with infiltration
are the most common sites of involvement ofvariable lengths of colon (Figs 50, 5 1). UI-
(Fig 49). Non-Hodgkin lymphoma is the most cerations, strictures, or fistulas may occur.
frequent histologic type in these cases. Diffuse infiltration is often associated with
Primary colonic lymphoma can be either abdominal adenopathy or extensive bowel
focal or diffuse. The focal form is often a pol- infiltration by tumor (Fig 52). The patient
ypoid mass, not uncommonly found in the with colonic infiltration may present with an
acute abdomen due to colonic perforation.
Primary colonic lymphoma appears to be
more common in patients with AIDS.

666 U RadioGraphics U Fishman Ct a! Volume 11 Number 4

 -- -S 53, 54. (53) Lymphocytic lymphoma in a
-year-old man. CT scan shows tumor directly in-
4,.
rating the entire pancreas, with an appearance
1’
similar to that ofpancreatic cancer. (54) Large cell
lymphoma and multiorgan system involvement in a
-year-old man with HIV-positive test results. CT
ans demonstrate a mass in the pancreatic head
___J dilated intrahepatic and common bile ducts.
This appearance would be indistinguishable from
that of a primary pancreatic carcinoma. Lymphoma-
tous involvement of the right kidney is also noted,
which helps suggest the correct diagnosis.

V. .

. .,.‘. . .1
. ., . .
.;.

. .-‘“
4
.
. \.‘ .
#{149}
, .
k-’ . .-. ‘

54-

. Pancreas Pancreaticoduodenal lymph nodes lie be-

Although pancreatic involvement is found in tween the duodenal sweep and the pancreatic
up to one-third of patients with non-Hodgkin head (66). The nodes can be confused with
lymphoma at postmortem examination, pri- enlargement of the pancreatic head. In one
mary involvement of the pancreas is rare. In series, pancreaticoduodenal lymphadenopa-
one series, 2.2% (nine of 402) ofpatients with thy could not be distinguished from intrinsic
non-Hodgkin lymphoma had lymphoma pri- pancreatic abnormality in 56% ofcases (18 of
manly involving the pancreas (65). However, 32) (66). Enlargement of pancreaticoduode-
even in these patients, the retroperitoneal nal nodes can result from colon carcinoma,
nodes were substantially enlarged. Five of the lung carcinoma, and breast and gastric cancer
patients in that series presented with jaun- in addition to lymphoma. The potential diffi-
dice. culty then is in differentiation of lymphoma-
Primary pancreatic lymphoma is usually tous involvement of the pancreas from a pri-
difficult to distinguish from pancreatic infiltra- mary pancreatic neoplasm (Fig 54).
tion by peripancreatic nodes (Fig 53). En-
larged nodes in the pancreaticoduodenal
chain can in fact simulate a pancreatic mass.
Fortunately, there is no difference in therapy
between pancreatic and peripancreatic lym-
phoma.

July 1991 Fishman et a! U RadioGraphics U 667

 U CONCLUSION 13. Castellino RA, Blank N, Hoppe RT, Cho C.
CT continues to remain the imaging study of Hodgkin disease: contributions ofchest CT in
the initial staging evaluation. Radiology 1986;
choice for the staging and follow-up of cases
160:603-605.
of lymphoma. Since every organ system can
14. Oliver TW, Bernardino M, Jones PJ. Moni-
be involved by this disease process (with a
toring the response of lymphoma patients to
variety of appearances), it is important to therapy: correlation of abdominal CT findings
carefully and systematically analyze all CT with clinical course and histologic type. Radi-
scans to determine the true extent of disease. ology 1983; 149:219-224.
15. Khoury MB, GodwinJD, Halvorsen R, Hanun
Acknowledgments: The authors thank Robert Y, Putman CE. Role ofchest CT in non-
Albani and Siemens Medical Systems for their sup- Hodgkin lymphoma. Radiology 1986; 158:
port ofthis work and continuing support of our 659-662.
research and Lynn Alonso for manuscript prepara- 16. Neumann CH, Robert NJ, Canellos G,
tion. Rosenthal D. Computed tomography of the
abdomen and pelvis in non-Hodgkin lym-
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July 1991 Fishman et a! U RadioGrapbics U 669