Figure 1
Ultrasound liver transverse
Ultrasound (transverse image) of the liver demonstrating a large heterogeneous liver lesion.
Diffuse large B-cell lymphoma with bilateral renal involvement
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsTyler Brown BS1, Clint Walters MD2, Darko Pucar MD PhD2, and Kandace Klein DO2
Connected authors
50 years, male
Clinical History
A 50-year-old male patient presented with a 3-week history of worsening epigastric pain, abdominal distention and constipation. The patient denied fever, chills, nausea, vomiting, or changes in weight. Laboratory results revealed anaemia and elevated liver enzymes.
Imaging Findings
Ultrasound demonstrated a large heterogeneous liver lesion which prompted further evaluation (Fig. 1). Computed tomography (CT) showed a 12 cm liver mass with focal hyperdensity corresponding to haemorrhage (Fig. 2). Magnetic resonance imaging (MRI) revealed rounded areas of T2 hypointensity throughout the left renal parenchyma and involving the upper pole of the right kidney concerning for metastatic disease (Fig. 3, a-c). Tissue sampling of the liver mass confirmed diffuse large B-cell lymphoma (DLBCL) without bone marrow involvement. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT demonstrated intensely increased uptake within the liver mass, upper pole of the right kidney, and throughout the left renal parenchyma (Fig. 4, a-e). Following completion of the initial treatment regimen, 18F-FDG PET-CT revealed a complete metabolic with normal urinary excretion of FDG in the renal collecting systems (Fig. 5, a-e).
Discussion
DLBCL is the most common form of non-Hodgkin’s lymphoma (NHL) accounting for 40% of newly diagnosed cases with the majority of individuals older than 60 years of age [1]. Approximately 33% of patients with DLBCL present with extra-nodal involvement, with the majority of these cases limited to the gastrointestinal tract; renal involvement is rare [2]. Current treatment regimens favour an aggressive approach and include a combination of the monoclonal antibody rituximab with multiple chemotherapy agents (cyclophosphamide, doxorubicin, vincristine and prednisolone) (R-CHOP) [3].
Approximately 2% of patients have renal involvement at the time of diagnosis with half of these cases being bilateral [4]. The overall 5-year survival rate in patients with renal involvement following treatment with R-CHOP is 44% [4]. Therefore, imaging has become an essential component of the workup and staging of patients presenting with DLBCL.
Initial evaluation of a suspected abdominal mass includes ultrasound as it is a quick, cost effective modality that does not utilize ionizing radiation. However, the imaging findings may be nonspecific. Songraphically, DLBCL presents as a large hypoechoic lesion with respect to the surrounding parenchyma that can demonstrate internal heterogeneity [5]. Further workup can involve CT which would reveal a soft tissue attenuating mass with possible cystic lesions and focal areas of necrosis. Diffusion weighted (DW)-MRI provides better soft tissue differentiation and visualization of subtle abnormalities. Though DLBCL can be suspected on imaging, tissue sampling is still a mainstay for making a definitive diagnosis.
18F-FDG PET-CT is the most important imaging examination for staging and evaluating treatment response in patients with NHL. 18F-FDG is preferentially taken up by tumour cells, phosphorylated and trapped due to its inability to participate in glycolysis. The use of this modality for evaluating extra-nodal involvement has an overall sensitivity and specificity of 97% and 100%, respectively [6]. There has been some speculation on the use of DW-MRI with apparent diffusion coefficients for staging and evaluating treatment response due to the lack of ionizing radiation, but studies using this modality to evaluate treatment response in DLBCL are few and far between. However, the results have been promising [7].
In conclusion, DLBCL is the most common form of NHL and presents in older individuals. Imaging is vital in the diagnosis and management of extra-nodal involvement. Since DLBCL rarely presents with renal involvement, it is important to recognize subtle imaging abnormalities as they can impact patient care and therapy.
Approximately 2% of patients have renal involvement at the time of diagnosis with half of these cases being bilateral [4]. The overall 5-year survival rate in patients with renal involvement following treatment with R-CHOP is 44% [4]. Therefore, imaging has become an essential component of the workup and staging of patients presenting with DLBCL.
Initial evaluation of a suspected abdominal mass includes ultrasound as it is a quick, cost effective modality that does not utilize ionizing radiation. However, the imaging findings may be nonspecific. Songraphically, DLBCL presents as a large hypoechoic lesion with respect to the surrounding parenchyma that can demonstrate internal heterogeneity [5]. Further workup can involve CT which would reveal a soft tissue attenuating mass with possible cystic lesions and focal areas of necrosis. Diffusion weighted (DW)-MRI provides better soft tissue differentiation and visualization of subtle abnormalities. Though DLBCL can be suspected on imaging, tissue sampling is still a mainstay for making a definitive diagnosis.
18F-FDG PET-CT is the most important imaging examination for staging and evaluating treatment response in patients with NHL. 18F-FDG is preferentially taken up by tumour cells, phosphorylated and trapped due to its inability to participate in glycolysis. The use of this modality for evaluating extra-nodal involvement has an overall sensitivity and specificity of 97% and 100%, respectively [6]. There has been some speculation on the use of DW-MRI with apparent diffusion coefficients for staging and evaluating treatment response due to the lack of ionizing radiation, but studies using this modality to evaluate treatment response in DLBCL are few and far between. However, the results have been promising [7].
In conclusion, DLBCL is the most common form of NHL and presents in older individuals. Imaging is vital in the diagnosis and management of extra-nodal involvement. Since DLBCL rarely presents with renal involvement, it is important to recognize subtle imaging abnormalities as they can impact patient care and therapy.
Differential Diagnosis List
Primary hepatic diffuse large B-cell lymphoma with bilateral renal involvement.
Other types of aggressive high-grade lymphoma
Metastatic disease
Final Diagnosis
Primary hepatic diffuse large B-cell lymphoma with bilateral renal involvement.
References
[1] Coiffier B, E Lepage, J Brière, et al. (2002) CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large B-cell lymphoma. New Engl J Med 346: 235-242 (PMID: 11807147)
[2] Castillo J., E. Winer, and A. Olszewski (2014) Sites of extranodal involvement are prognostic in patients with diffuse large B-cell lymphoma in the rituximab era: An analysis of the Surveillance, Epidemiology and End Results database. Am. J. of Hematology 89(3): 310-314 (PMID: 24273125)
[3] Sohn BS, Kim SM, Yoon DH, et al (2012) The comparison between CHOP and R-CHOP in primary gastric diffuse large B-cell lymphoma. Ann Hematol 91(11): 1731-9 (PMID: 22752193)
[4] Villa D., J. Connors, L. Sehn, R. Gascoyne and K. Savage (2011) Diffuse large B-cell lymphoma with involvement of the kidney: outcome and risk of central nervous system relapse. Haematologica 96(7):1002-1007 (PMID: 21486867)
[5] Castroagudinf J. E Molina, I. Abdulkader et al (2007) Sonographic features of liver involvement by lymphoma. J. Ultrasound Med 26: 791-796 (PMID: 17526610)
[6] Saboo S, K Krajewski, K O’Regan, et al (2012) Spleen in haematological malignancies: spectrum of imaging findings. Br J Radiology 85(1009): 81-92 (PMID: 22096219)
[7] Siegel, M., C. Jokerst, D. Rajderkar, et al. (2014) Diffusion –weighted MRI for staging and evaluating response in diffuse large B-celL lymphoma: A pilot study. NMR Biomed 27(6): (681-691) (PMID: 24700565)
Case information
| URL: | https://eurorad.org/case/13970 |
| DOI: | 10.1594/EURORAD/CASE.13970 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Coronal CT
Coronal CT showing a 12 cm liver mass with focal hyperdensity corresponding to haemorrhage.
Figure 3
Rotating MIP, fused axial and coronal PET-CT post-treatment
Rotating MIP demonstrating complete metabolic response following 3 cycles of R-CHOP with normal urinary excretion of FDG in the bilateral renal collecting system.
Fused Axial PET-CT showing no abnormal FDG uptake in the liver consistent with complete metabolic response following 3 cycles of R-CHOP.
Fused Axial PET-CT showing complete metabolic response in the bilateral upper pole. There is normal urinary excretion of FDG in the bilateral collecting system.
Fused Coronal PET-CT revealing complete metabolic response of prior focus in the lateral upper pole of the right kidney after treatment (arrow). There is normal urinary excretion of FDG in the bilateral renal collecting systems.
Fused Coronal PET-CT demonstrating complete metabolic response of prior focus in the medial upper pole of the left kidney (arrow). There is normal urinary excretion of FDG in the bilateral renal collecting systems.
Figure 4
Coronal and axial T2-weighted MRI
Coronal T2-weighted MRI revealing a large heterogeneous liver mass.
Axial T2-weighted MRI demonstrating rounded areas of hypointensity involving the lateral right upper pole and medial left upper pole of the right and left kidneys, respectively (arrows).
Coronal T2-weighted MRI revealing rounded areas of hypointensity throughout the left renal parenchyma (arrows).
Figure 5
Rotating MIP, fused axial and coronal PET-CT pre-treatment
Rotating MIP image demonstrating intensely increased uptake in the liver mass (arrowhead), upper pole of the right kidney (+), and throughout the left renal parenchyma (arrows).
Fused axial PET-CT showing intensely increased uptake in the liver mass.
Fused axial PET-CT showing intensely increased uptake in the lateral upper pole of the right kidney and medial upper pole of the left kidney (arrows).
Fused Coronal PET-CT demonstrating intensely increased uptake in the lateral upper pole of the right kidney (arrow).
Fused Coronal PET-CT showing intensely increased uptake in the medial upper pole of the left kidney (arrow).
Ultrasound liver transverse
Ultrasound (transverse image) of the liver demonstrating a large heterogeneous liver lesion.
University hospital, Dept. of Radiology, Augusta, GA, USA.
University hospital, Dept. of Radiology, Augusta, GA, USA.
Coronal CT
Coronal CT showing a 12 cm liver mass with focal hyperdensity corresponding to haemorrhage.
University Hospital, Dept. of Radiology, Augusta, GA, USA.
University Hospital, Dept. of Radiology, Augusta, GA, USA.
Rotating MIP, fused axial and coronal PET-CT post-treatment
Rotating MIP demonstrating complete metabolic response following 3 cycles of R-CHOP with normal urinary excretion of FDG in the bilateral renal collecting system.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused Axial PET-CT showing no abnormal FDG uptake in the liver consistent with complete metabolic response following 3 cycles of R-CHOP.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused Axial PET-CT showing complete metabolic response in the bilateral upper pole. There is normal urinary excretion of FDG in the bilateral collecting system.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused Coronal PET-CT revealing complete metabolic response of prior focus in the lateral upper pole of the right kidney after treatment (arrow). There is normal urinary excretion of FDG in the bilateral renal collecting systems.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused Coronal PET-CT demonstrating complete metabolic response of prior focus in the medial upper pole of the left kidney (arrow). There is normal urinary excretion of FDG in the bilateral renal collecting systems.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Coronal and axial T2-weighted MRI
Coronal T2-weighted MRI revealing a large heterogeneous liver mass.
University Hospital, Dept. of Radiology, Augusta, GA, USA
University Hospital, Dept. of Radiology, Augusta, GA, USA
Axial T2-weighted MRI demonstrating rounded areas of hypointensity involving the lateral right upper pole and medial left upper pole of the right and left kidneys, respectively (arrows).
University Hospital, Dept. of Radiology, Augusta, GA, USA
University Hospital, Dept. of Radiology, Augusta, GA, USA
Coronal T2-weighted MRI revealing rounded areas of hypointensity throughout the left renal parenchyma (arrows).
University Hospital, Dept. of Radiology, Augusta, GA, USA
University Hospital, Dept. of Radiology, Augusta, GA, USA
Rotating MIP, fused axial and coronal PET-CT pre-treatment
Rotating MIP image demonstrating intensely increased uptake in the liver mass (arrowhead), upper pole of the right kidney (+), and throughout the left renal parenchyma (arrows).
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused axial PET-CT showing intensely increased uptake in the liver mass.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused axial PET-CT showing intensely increased uptake in the lateral upper pole of the right kidney and medial upper pole of the left kidney (arrows).
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused Coronal PET-CT demonstrating intensely increased uptake in the lateral upper pole of the right kidney (arrow).
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Fused Coronal PET-CT showing intensely increased uptake in the medial upper pole of the left kidney (arrow).
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.
Medical College of Georgia at Augusta University, Dept. of Radiology, Augusta, GA, USA.