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LETTER TO THE EDITOR
Year : 2010  |  Volume : 6  |  Issue : 3  |  Page : 403-404

Sandwich sign in mesenteric lymphoma


Department of General Surgery, Thiruvananthapuram Medical College, Kerala, India

Date of Web Publication29-Nov-2010

Correspondence Address:
Noushif Medappil
'Grace', Thenhipalam, Malappuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.73333

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How to cite this article:
Medappil N, Reghukumar R. Sandwich sign in mesenteric lymphoma. J Can Res Ther 2010;6:403-4

How to cite this URL:
Medappil N, Reghukumar R. Sandwich sign in mesenteric lymphoma. J Can Res Ther [serial online] 2010 [cited 2019 Oct 20];6:403-4. Available from: http://www.cancerjournal.net/text.asp?2010/6/3/403/73333

Sir,

Mesenteric lymphomas are asymptomatic in the early stage and present late in the course of disease. They have typical imaging findings among which 'sandwich sign' is the most specific.

A 31-year-old female presented with self detected upper abdominal lump of one week duration. There was no associated pain, bowel symptoms, fever, weight loss or night sweats. Clinical examination revealed a firm irregular mobile 10 × 8 cm intra abdominal mass in epigastrium and umbilical region. Laboratory parameters were within normal limits. CT scan of abdomen showed multiple large rounded and ovoid, homogenous soft tissue density mass lesions involving the small bowel mesentery measuring up to 5 cm in size, some of which were confluent, with no evidence of calcification or central necrosis. The lesions were encasing the mesenteric vessels without significant luminal narrowing (sandwich sign). Para aortic, inter aortico caval and para caval lymphnodes were enlarged [Figure 1]. Mesenteric lymph node biopsy was suggestive of follicular lymphoma [Figure 2].
Figure 1: Sandwich sign

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Figure 2: Intraoperative image- Enlarged mesenteric nodes

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Mesenteric lymphadenopathy can result from lymphoma, sarcoma, acquired immunodeficiency syndrome (AIDS), tuberculosis, Whipple's disease and post transplant lymphoproliferative disorder (PTLD), of which non Hodgkin's lymphoma is the most common cause. [1] Mesenteric lymphomas grow to a large size and cause bulky adenopathy encasing mesenteric vessels without producing clinical symptoms. On CT or ultrasound imaging, the confluent mesenteric nodes resemble two halves of a sandwich and the tubular mesenteric vessels and perivascular fat resemble the sandwich filling. [1],[2] This sign is also seen in PTLD, which should be considered in patients who have undergone transplantation. PTLD is characterized by gastrointestinal involvement and the absence of superficial nodal disease. Other causes of mesenteric adenopathy have typical clinical symptoms and do not produce the large bulky adenopathy that results in the sandwich sign. [1],[3] Mesenteric lymphomas can also show retroperitoneal adenopathy and increased attenuation of the mesentery (misty mesentery). [1],[2]

In our case, the absence of symptoms, imaging findings of mesenteric soft-tissue nodules producing sandwich sign and retroperitoneal lymph nodes made lymphoma the most likely diagnosis. The sandwich sign is specific for mesenteric lymphoma (typically non-Hodgkin's) unless the patient has had a transplant.

 
 > References Top

1.Hardy SM. The sandwich sign. Radiology 2003;226:651-2.  Back to cited text no. 1
    
2.Mueller PR, Ferrucci JT Jr, Harbin WP, Kirkpatrick RH, Simeone JF, Wittenberg J. Appearance of lymphomatous involvement of the mesentery by ultrasound and body computed tomography: The 'sandwich sign'. Radiology 1980;134:467-73.  Back to cited text no. 2
    
3.Hokama A, Nakamoto M, Kinjo F, Fujita J. The sandwich sign of mesenteric lymphoma. Eur J Haematol 2006;77:363-4.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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