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Clinical history:

47-year-old male presents with a several month history of vague abdominal pain and bloating. His primary care physician found no palpable mass on physical exam and referred the patient for sonographic evaluation of the right upper quadrant.



What is the MOST likely explanation for the patient’s symptoms?

  • Chronic Cholecystitis
  • Lymphoma
  • Cirrhosis
  • Renal Cell Carcinoma
  • Hepatocellular Carcinoma

What would be the next MOST logical step in the evaluation of these findings in the setting of an unknown diagnosis?

  • Fine Needle Aspiration/Biopsy
  • Angiography
  • Repeat Ultrasound in 6 months
  • Contrast Enhanced CT
  • No further evaluation is needed

What is the sonographic appearance of lymphomatous involved lymph nodes?

  • Hyperechoic with acoustic shadowing
  • Hypoechoic with enhanced transmission
  • Hypoechoic without enhanced transmission

Answers: Lymphoma, Contrast Enhanced CT, Hypoechoic without increased transmission

This case is biopsy proven follicular lymphoma. Lymphoma is a neoplastic disease originating from the cells of the immune system; it typically arising within lymph nodes. There is a bimodal age distribution for Hodgkins lymphoma with a first peak occurring around age 20 and a second peak occurring after age 50. The incidence of non-Hodgkins lymphoma increases steadily with age. According to the World Health Organization Classification (WHO Classification), lymphomas are categorized based on the cell type most closely resembling cells found within the tumor; the three largest groups are B cell, T cell and Natural Killer cells, respectively. Lymphoma can involve all organ systems and site including the abdomen, thorax, pelvis, head and neck, CNS and bone. At the onset of disease, nodal and splenic involvement is characteristic of Hodgkins lymphoma, while extranodal involvement at onset is more common in non-Hodgkins lymphomas. Diagnostic imaging - including conventional radiography, US, CT and MR - plays an important role in the diagnosis and staging of lymphoma. Sonographic evaluation is typically included in the initial workup of patients with abdominal symptoms. Therefore familiarity with the spectrum of US findings associated with lymphoma is essential to making the diagnosis.

  • Lymph Nodes-The sonographic appearance of lymphoma is variable, but hypoechoic or anechoic lymph nodes without distal enhancement are typical. Nodal involvement can be individual or in groups. Nodal masses may be seen adjacent to the abdominal great vessels, within the retroperitoneum, the prevertebral area and mesentery. Lymph node encasement of the root of the mesentery and SMA may produce the "sandwich sign”, which is created by the lobulated, confluent mesenteric soft-tissue masses and the tubular structures of the mesenteric vessels and perivascular fat.
  • GI tract- Lymphomatous involvement of the bowel produces hypoechoic bowel wall thickening or a focal hypoechoic/complex mass.
  • Spleen- Sonographic findings of splenic involvement can include homogeneous splenomegaly and/or solitary nodules that are hypoechoic in comparison to the normal splenic parenchyma.
  • Liver- Hepatic US findings are similar to those of the spleen and include hepatomegaly and hypoechoic/anechoic nodules
  • Pancreas- Pancreatic involvement may appear as hypoechoic areas of enlargement. Diffuse enlargement of the pancreas has been reported, possibly due to direct infiltration. Peripancreatic lymph nodes may invade or distort the pancreas.
  • Kidneys- Renal US findings can appear as hypoechoic/anechoic nodules which may be mistaken for renal cysts; however, there is a lack of distal enhancement suggesting that the mass is solid.

    In this case, further evaluation with Contrast Enhanced CT was performed. It shows multiple moderately enlarged mesenteric lymph nodes which correlate with the ultrasound findings above.


Michael Packard, DO
Department of Radiology; University of Pittsburgh Medical Center


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