|Year : 2013 | Volume
| Issue : 1 | Page : 128-130
Imaging of Burkitt's lymphoma-abdominal manifestations
Hanuman Satishchandra, Aralaguppe S Sridhar, Basavaradhya P Pooja
Department of Radiodiagnosis, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India
|Date of Web Publication||10-Apr-2013|
Basavaradhya P Pooja
135, 7th main, 4th block, Jayanagar, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Burkitt's lymphoma is an uncommon form of non-Hodgkin lymphoma in adults. The diagnostic workup for Burkitt's lymphoma includes radiological imaging and like any other form of non-Hodgkin's lymphoma definitive diagnosis is by histopathology. Imaging is necessary to determine the distribution and severity in terms of extent and organs of involvement to further assist in staging and thence to implement appropriate therapy. High incidence of intraabdominal involvement is seen in American Burkitt lymphoma.
Keywords: Adult, Burkitt′s lymphoma, CT, tuberculosis
|How to cite this article:|
Satishchandra H, Sridhar AS, Pooja BP. Imaging of Burkitt's lymphoma-abdominal manifestations. J Can Res Ther 2013;9:128-30
| > Introduction|| |
Burkitt's lymphoma accounts for 40% of all childhood non-Hodgkin lymphoma. In adults it is an uncommon form of Non-Hodgkin's lymphoma and represents less than 5% of lymphoma cases.The clinical variants are endemic, sporadic, and immunodeficiency-associated types.  The endemic form often involves the maxilla or mandible and sporadic form presents commonly with abdominal swelling, often at the ileocaecal region. In adults, Burkitt's lymphoma frequently involves the liver and bone marrow.  The prognosis of Burkitt's lymphoma depends on the extent of the disease, the patient's age, and the timing of diagnosis.  In view of this, urgent imaging is required to assess initial tumour bulk, compromise of vital organs, and for follow-up.  CT is often used because of the multifocality of presentation and a propensity to involve bowel and mesentery. 
| > Case Report|| |
A 49-year-old male patient [Figure 1] presented with pain and mass per abdomen, jaundice, low-grade fever, and caries tooth for 6 months. Physical examination revealed icterus, hepatosplenomegaly, right iliac fossa mass, scrotal swelling and left mandibular hard, fixed, non-tender swelling. Investigations revealed hypochromic anemia, relative neutrophilia, and conjugated hyperbilirubinemia and elevated liver enzymes with normoalbuminemia. Screening for HIV was positive and for Hepatitis B antigen negative.
Ultrasonography of the abdomen showed diffuse hepatosplenomegaly and dilated biliary radicles with smooth, abrupt distal common bile duct cutoff [Figure 2]. Multiple homogenously hypoechoic vascular lymph nodes were noted in the region of head of pancreas, perisplenic, periportal, mesenteric, ileocolic, inguinal, and pre-/para-aortic regions. Patchy early enhancement of these lymph nodes was noted in the CT study with no necrotic areas or calcific foci [Figure 2]. The gall bladder was grossly distended with enhancing focal thickening [Figure 2].
|Figure 2: Axial section at superior mesenteric vessel level showing homogeneouslyenhancing mass causing anterior displacement of pancreas and splaying of superior mesenteric origin. The inset figure (a) is a USG image showing dilated IHBR and EHBR and with smooth abrupt cutoff in intrapancreatic course secondary to hypoechoic lymph nodes in the peripancreatic group. The inset figure (b) is a CT image showing focal nodular thickening at the fundus of the gall bladder|
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A lobulated eccentric vascular mass at the terminal ileal loop causing severe luminal narrowing and thickening of adjacent caecum/ascending colon and appendix was noted. CT showed homogeneous enhancement of the thickened bowel wall and loss of stratification [Figure 3]. No ulcerations, stricture formation, or aneurysmal dilatation of bowel or mesenteric/mesocolic fat stranding were seen.
|Figure 3: Large lobulated soft tissue attenuation mass showing significant homogeneous enhancement consistent with eccenteric bowel wall thickening. The inset figure is a USG image showing circumferential terminal ileal thickening involving cecal wall and ileocecal valve and vascularity of low impedence flow pattern|
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Ultrasonography of scrotum revealed diffuse enlargement of testes and epididymii with focal, moderately vascular, hypoechoic lesions with left-sided varicocele [Figure 4]. Post-contrast CT showed moderate enhancement of these lesions with enlarged, enhancing seminal vesicles. Discrete hypoechoic urinary bladder wall lesions noted involving vesicoureteric junctions and terminal ureters [Figure 5]. Additionally, few discrete peripheral nodular lesions in the lower lobe of the left lung were seen.
|Figure 5: Axial section at urinary bladder shows lobulated intramural and enhancing lesion involving distal left ureter and a vesicoureteric junction causing no proximal obstructive changes. The figure in the inset is the USG image showing the same|
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Burkitt's lymphoma was suspected in view of lymph node enlargement showing increased vascularity, characteristic enhancement pattern and left mandibular hard swelling. Histopathology [Figure 6] revealed numerous blasts having irregular clumped chromatin, prominent nucleoli, and rim of blue cytoplasm with vacuolations and good number of mitotic figures. Positive c-myc oncogene and t (8; 14) translocation and deletion in chromosome 6 were detected on cytogenetic evaluation.
| > Discussion|| |
Burkitt's lymphoma accounts for 59% of all adult Burkitt lymphoma cases aged more than 40 years in the United States.  The endemic/African form is associated with the Epstein Barr virus in 95% of cases and the sporadic/American form in 15% of patients. The immunodeficiency-associated form occurs mainly in patients with HIV but can also occur in allograft recipients and congenital immunodeficiencies.  Burkitt's lymphoma is an aggressive disease and urgent imaging is required to assess initial tumour bulk, compromise of vital organs, and for follow-up of patients during therapy. Ultrasound is used initially if the patient presents with an abdominal or pelvic mass. CT would often follow to allow a more global assessment for bowel and visceral involvement as well as tumor staging. However, tissue diagnosis is definitive. 
The distal small bowel, caecum, and appendix are common sites of involvement of non-Hodgkin's lymphoma including Burkitt lymphoma and involvement of the proximal gastrointestinal tract occurs rarely. Abdominal and pelvic disease is seen at presentation with the ileocaecal region as the most common site.  Terminal ileum is commonly affected because of increased lymphoid tissue.  Focal mass or diffuse bowel wall thickening is seen commonly on imaging with cavitations/abscess formation being uncommon. , Our case showed similar features with no proximal obstruction despite significant luminal compromise. Appendix involvement includes enlargement and thickening with preserved vermiform appearance. 
Diifuse or focal hypoechoic pancreatic enlargement and localized tumor or diffuse enlargement infiltrating the whole gland on CT is the major finding in the United States. Sometimes amidst a massive peripancreatic lymphadenopathy, to determine the pancreatic involvement or its mere compression is difficult, as seen in our case. Lymphoma can mimic pancreatic head carcinoma as a well-circumscribed, focal involvement of pancreas with subjacent enlarged lymph node mass at head/uncinate process/neck of pancreas.  Gallbladder involvement presents similar to acute cholecystitis.  Hepatic and splenic involvement includes hepatosplenomegaly (as in our case), solitary/multicentric, hypoechoic/attenuating lesions, periportal infiltrating mass, and distal biliary duct dilatation. 
Scrotal involvement include enlarged testes with hypoechoic lesions, thickened echogenic epididymis on sonography, or diffusely enlarged spermatic cord with enhancement in post-contrast CT.  Jaw involvement [Figure 1] shows a patchy infiltrative process beneath the alveolus with resorption of lamina-dura and destruction of tooth buds resulting in dislodged teeth, appear as floating teeth on the tumor mass. 
The differential diagnosis considered was tuberculosis. In view of homogeneously enhancing enlarged lymph nodes predominantly in the body and margin of mesentery, peripancreatic region, and thickened bowel wall without causing obstruction and mandibular involvement, Burkitt's lymphoma was favored.
| > Conclusion|| |
Burkitt's lymphoma is a rare, rapidly progressing malignant tumor with varied clinical and imaging features. It differs from other types of lymphoma in that it involves multiple extranodal sites. Its infrequent occurrence among the population should not deter the radiologist to include it as a part of differential diagnosis. Abdominal USG has been advocated as the initial investigation. CT scanning is the modality of choice with the advantage of rapid imaging of multiple organ systems, direct visualization of lymphomatous masses, estimation of tumor bulk and better delineation of its relationship to adjacent structures.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]