Lymphoma

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Gastric lymphoma
Lymphoma most frequently results in generalized thickening of the gastric wall but occasionally focal involvement may occur. The gastric wall is usually greater than 1 cm thick and can be as much as 5 cm thick. The mucosa is usually intact but can be ulcerated. When using the stomach fluid-filled technique, lymphomatous infiltration may be seen as extensive wall thickening of varied echogenicity while the inner wall may be normal or thrown into infiltrated polypoid folds. Circumferential involvement may be associated with bulky focal masses and nodular exophytic involvement. A target or atypical target sign may occur. The echogenicity of lymphoma infiltration tends to be echopoor. Occasionally giant gastric folds with a central star-like configuration of echogenicity may be visible on ultrasound. 70% of lymphomes of the stomach present with a target-like pattern of the gastric antrum with uniform hypoechoic wall thickening.

liver Lymphoma
Lymphoma usually causes diffuse infiltrates of the liver and spleen; focal involvement is less common. Hepatomegaly may be reactive as only 50 pet cent of patients with known lymphoma. The diffusely infiltrating type of liver lymphoma is difficult to image with ultrasound as it may cause subtle architectural distortion or no ultrasound abnormality at all. . Only 5% of patients with lymphoma will have discrete nodular involvement that can be detected by an imaging study.
Focal hepatic lymphoma is less common. There are three liver patterns that predominate when lymphoma is seen. The first and most common is the hypoechoic mass. The mass is usually round or oval, with well-defined smooth borders. There is almost always more than one nodule present. A few low-level internal echoes may be seen. The size of the masses varies from 1 to 15 cm. A second and uncommon pattern is that of extensive hypoechoic liver infiltrates having a "geographic pattern". Occasionally, the third pattern, a hyperechoic mass, may be seen. There has been one reported case of a fourth pattern, a "starry sky" pattern.

Lymp Nodes lymphoma
Lymphadenopathy is frequently encountered in the extremities. High-resolution transducers are capable of routinely identifying normal lymph nodes in the axilla and the groin. They are hypoechoic and oval and usually have a detectable central echogenic hilum. As in the neck, there is overlap in the appearance of reactive and neoplasic lymphadenopathy.
Malignant nodes (and tuberculous nodes) are usually round in shape with a short axis to long axis ratio greater than or equal to 0.5 (S/L > 0,5), whereas reactive and normal nodes are usually long or oval-shaped. Therefore, nodal shape should be considered as the sole criterion in the diagnosis. However, eccentric cortical hypertrophy, which indicates focal intranodal tumor infiltration, is a useful sign to identify malignant nodes.
Lymphomatous nodes tend to have sharp borders, whereas reactive and normal nodes usually show unsharp borders.
Echogenic hilus is a normal sonographic feature of most of the normal lymph nodes and it is commonly seen in larger nodes. Echogenic hilus is appeared to be continuous with the adjacent soft tissues. Although,lymphomatous nodes tend to have absent hilus, they may present with an echogenic hilus in their early stage of involvement. Therefore, the presence/absence of echogenic hilus should not be the sole criterion in the diagnosis.
Lymphomatous nodes are predominantly hypoechoic when compared with the adjacent muscles. Lymphomatous nodes were previously reported to have a pseudocystic appearance, i.e. hypoechoic with posterior enhancement. With the use of newer transducer, lymphomatous nodes are less likely to have the pseudocystic appearance, whereas they demonstrate a micronodular appearance.
Intranodal calcification may be found in lymphomatous nodes after treatment and the calcification is usually dense and shows acoustic shadowing.
Doppler :
Normal and reactive lymph nodes tend to have hilar vascularity or appear apparently avascular, whereas metastatic nodes usually show peripheral or mixed vascularity, and lymphomatous nodes predominantly demonstrate mixed vascularity. As peripheral vascularity is not found in normal or reactive nodes, the presence of peripheral vascularity, regardless of sole peripheral or mixed vascularity, is highly suspicious of malignancy.
The role of the evaluation of the vascular resistance (RI and PI = resistance and pulsatility index) in distinguishing malignant and benign nodes is controversial. It has been reported the metastatic nodes have a higher RI and PI than reactive nodes. However, other studies noted that there was no significant difference in RI and PI between benign and malignant nodes

Signs of splenic lymphoma
Splenic involvement with Hodgkin's and non-Hodgkin's lymphoma usually occurs in a diffuse distribution which can be detected only microscopically. In general, when an abnormality is noted, only splenomegaly vvithout focal defect is identified on the ultrasound. Sonographic visualization of focal splenic lesions in lymphoma patients is uncommon. However, when detected, the masses are usually focal, hypoechoic, poorly marginated, and homogeneous. Occasionally, inhomogeneities may be present within the lesion due to hemorrhage or necrosis. Other sonographic patterns include target lesions, Large nodules up to 20cm in diameter, Small miliary nodules, or splenic hilar adenopathy. There is a high incidence of simultaneous lymphomatous involvement of the liver and spleen.

Pancreatic lymphoma
Primary pancreatic lymphoma is rare. The clinical presentation is not unlike that of pancreatic carcinoma. Sonography may reveal a homogeneous sonolucent or complex mass. These masses are usually echopoor and mimic cystic lesions. As the prognosis of a pancreatic lymphoma is favorable, differentiation from a carcinoma is crucial. Ultrasound-guided biopsy may reveal the true nature of the mass.

Small bowel lymphoma
Sonography may reveal eccentric wall thickening by lymphomatous infiltrate. This is usually anechoic but hemorrhage and clot may give rise to echogenic areas. There may be aneurismal dilatation of the bowel lumen and enlargement of adjacent nodes. Anechoic deposits may mimic duplication cysts. The combination of eccentric bowel wall thickening with aneurismal dilatation and mesenteric lymphadenopathy produces the so-called 'sandwich sign'. the finding of hypoechoic solid masses surrounding a central linear hyperechoic area has been termed the "sandwich sign." The hyperechoic area represents fat surrounding the mesenteric vessels. The sandwich sign indicates lymphomatous involvement of the mesentery.

Large bowel lymphoma
Sonography, Large bowel lymphoma is usually indistinguishable from a carcinoma causing an atypical or typical target sign. However the bowel thickness tends to be more hypoechoic in lymphoma than bowel carcinoma.

Renal lymphomas
Renal lymphoma may have several appearances. The most common appearance in 90% of cases is multiple renal masses, although renal lymphoma may also present as a single mass. On ultrasound, the masses are generally hypoechoic or anechoic. At times, they may mimic a fluid-filled cyst, but differentiation is generally possible since the solid masses of lymphoma lack a sharply defined wall and posterior acoustic enhancement. Occasionally, the masses may be isoechoic or slightly hyperechoic relative to the adjacent renal parenchyma.
Diffuse infiltration of the kidney may be seen in the other 10% of cases, with the involved kidney usually enlarged and distorted.

Adrenal lymphoma
Adrenal lymphomatous infiltration is not uncommon. Sonographically these tumors, in common with other sites of lymphomas involvement, are echopoor, however areas of echogenicity may occur because of hemorrhage or infarction. The appearances may closely resemble metastases.

Bladder lymphoma (children)
Primary lymphoma of the bladder has no characteristic ultrasound features. The tumor may infiltrate the bladder wall or present as a polyp. Tissue diagnosis is usually required.

Ovarian Lymphoma
The ovaries are a 'sanctuary' organ for lymphoma. Lymphoma of the ovary is usually part of a more extensive disease elsewhere and often results from dissemination from other sites such as lymph nodes; ovarian lymphoma deposits are solid but echopoor. Often bilateral ovarian enlargement is usual.

Lymphoma of the psoas muscle
The psoas muscle is an infrequent site of extra nodal lymphoma. Sonography may reveal a hypoechoic enlargement of the psoas and Para vertebral muscles or an anechoic featureless Para vertebral mass indistinguishable from an abscess or hematoma on sonographic features alone.

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