Gastrointestinal
Gastrointest Radiol 1, 157-161 (1976)
Radiology 9 by Springer-Verlag 1976
Gastric Lymphoma, a Radiologic Diagnosis Leslie S. Menuck Departments of Radiology, University Hospital, and Veterans Administration Hospital, University of California at San Diego, School of Medicine, La Jolla, California, U.S.A.
Abstract. Because endoscopy and gastric cytology lack specificity, radiographic evaluation is still the most reliable means of diagnosing gastric lymphoma preoperatively. A retrospective analysis indicates that if careful attention is paid to the radiologic features, gastric lymphoma can be distinguished from gastric carcinoma in most of cases. The radiographic findings of a long segment of involvement, multiplicity of radiographic pattern, and diffuse infiltration consisting of concentric abnormal folds without significant narrowing of the lumen are characteristic of the nonHodgkin's lymphoma. Key words: Gastric lymphoma Gastric carcinoma Abnormal gastric folds -- Ulcerating gastric lesions Gastric masses.
Material and Methods Thirty cases of gastric lymphoma (reticulum cell sarcoma, 14; lymphosarcoma 11; Hodgkin's Disease, 5); were compared with 50 cases of gastric carcinoma to see if there were radiologic features that were significant and easily applicable in the separation of these two entities. This study made no attempt to differentiate primary gastric lymphoma from diffuse lymphoma with gastric involvement. The following parameters were used to evaluate radiographic examinations of the upper gastrointestinal tract: (a) size of the lesion at the time gastric disease was diagnosed; (b) extension of the lesion to involve the esophagus and/or duodenum; (c) the primary radiographic pattern (as most of the lymphomas and some of the carcinomas had more than one radiologic finding, the primary pattern was determined as that which included the greatest area).
Results
The preoperative diagnosis of gastric lymphoma is of obvious importance, yet it is correctly made in less than 25% of the cases [1-4]. The radiographic examination has been successful in identifying gastric abnormalities in 95% of the cases and in making a diagnosis of gastric malignancy in 80% [25], yet the radiologic diagnosis of lymphoma was made in only 10% to 15% of the cases [3, 6-8]. This problem is compounded by the poor yield of endoscopic biopsy, which is positive in only 10% to 20% [3, 4, 6]. While certain recent small series suggest promising results with gastric cytology [3], the yield of this modality is quite low in most studies (9). There are, however, specific radiologic features of gastric lymphoma which permit its easily differentiation from gastric carcinoma in most cases. This paper better defines those characteristics. Address reprint requests to." Leslie S. Menuck, M.D., Department of Radiology, Veterans Administration Hospital, 3350 La Jolla Village Drive, San Diego, CA 92161, U.S.A.
Certain conclusions may be drown from the data obtained and tabulated in Tables 1 and 2: 1. Gastric lymphoma presents as a much larger lesion than gastric carcinoma. The average size of the lymphomas was 11.9 cm (12.8 cm for non-Hodgkin's lymphomas, 7.4 cm for Hodgkin's lymphomas), while that of gastric carcinomas was 5.6 cm. Forty percent of the gastric lymphomas and only 4% of the gastric carcinomas were over 15 cm in length. Conversely, 4% of the lymphomas and 34% of the gastric carcinomas were less than 5 cm at time of the initial diagnosis. Seventy-two percent of the lymphomas but only 16% of the gastric carcinomas were greater than 10 cm, at the time of presentation. Both gastric carcinoma and lymphoma may involve the adjacent duodenum or esophagus. Extension to the duodenal bulb was more common in lymphoma (20%) (Fig. 1) than in carcinoma (6%). Involvement of the adjacent esophagus was found in both, with 12% of the gastric carcinomas and 4%
158
L.S. M e n u c k : Radiologic Diagnosis of Gastric L y m p h o m a
T a b l e 1. Length and extent of lesion
Carcinoma
Length (cm) a 04 5-10 II 15 15 or greater Extension of lesion Distal esophagus Duodenal bulb
(50 cases)
Non-Hodgkin's Hodgkin's lymphoma lymphoma (25 cases) (5 cases)
No.
(%)
No.
(%)
17 25 6 2
34 50 12 4
1 6 8 10
4 24 32 40
6 3
12 6
1 5
4 20
No.
(%)
l
20 60 20
3 1
a Average length of c a r c i n o m a = 5 . 6 c m ; n o n - H o d g k i n ' s p h o m a ~ 12.8 cm ; Hodgkin's l y m p h o m a = 7.4 cm
lym-
T a b l e 2. Primary radiologic pattern
Carcinoma (50 cases)
Non-Hodgkin's Hodgkin's lymphoma lymphoma (25 cases) (5 cases)
No.
(%)
No.
(%)
No.
(%)
Solitary mass
18
36
2
8
1
20
Ulcerating lesion
15
30
3
12
2
40
Multiple masses or ulcerations
1
2
6
24
Annular constricting
6
12
1
4
1
20
33
66
4
16
7 4
14 8
0 14~
56
I
20
18
72
Eccentric InfiltratingLinitis plastica Large bizarre folds
Multiple radiographic patterns 12
24
Fig. 1. Gastric lymphoma. Infiltrating submucosal process with replacement of the normal antral folds and extension into the duodenal bulb. Note small focal ulcerations
a Of these 14 cases, 5 had no other abnormality, 4 had associated ulcerating lesions, 5 had nonulcerating masses
of the gastric lymphomas extending into the distal esophagus. 3. Multiple radiographic patterns are common in gastric lymphoma, being seen in 72% compared to 24% of gastric carcinomas (Fig. 2). The most frequent primary radiographic finding in gastric lymphoma was a circumferential, concentric infiltrating pattern consisting of enlarged bizarre rugal folds without significant narrowing of the gastric lumen. This was present in 56% of the cases of gastric lymphoma (many of those cases had additional abnormalities, which often were quite pronounced). This type of infiltrating lesion was uncommon in gastric carci-
Fig. 2. Gastric lymphoma. Several ulcerating lesions in the distal half of the stomach. Large submucosal nodules in the fundus. A b n o r m a l gastric folds extending from the fundus into the antrum, most prominent in the body of the stomach
noma (8%). The most common form of infiltrating lesion in gastric carcinoma was a "linitis plastica", which was found in 14% of the cases but was seen in only 1 case of lymphoma, a case of Hodgkin's
L.S. Menuck: Radiologic Diagnosis of Gastric Lymphoma
159
disease. Multiple gastric masses were seen in 24% of the gastric lymphomas but in only 1 case of gastric carcinoma. A solitary lesion, with or without ulceration, was the most common finding in gastric carcinoma, with 66% of the carciomas presenting this way compared to only 20% of the lymphomas. A discrete annular constricting lesion was seen in only one case of gastric lymphoma but in 12% of those with the gastric carcinomas. 4. Within the subgroups of lymphoma, Hodgkin's disease appeared quite different from lymphosarcoma and reticulum cell sarcoma in that the presenting lesions was much more comparable in size and radiographic appearance to gastric carcinoma.
Discussion
Gastric lymphomas comprise 3% to 5% of all gastric neoplasms [8, 10, 11]. The incidence of gastric lymphoma seems to be rising at a time when the rate of gastric carcinoma is rapidly declining [8]. Reticulum cell sarcoma and lymphosarcoma most often demonstrate gastric involvement, each comprising about 40% of the gastric lymphomas [12]. Hodgkin's disease involving the stomach is much less common, being found in 10% to 15% [13]. The separation and differentiation of gastric lymphoma into primary and secondary is often difficult and ambiguous because of the multicentric potential of this disease and the obvious predilection these neoplasms have for lymphoreticular tissue in any organ. While the distinction of primary and secondary gastric lymphoma has obvious therapeutic and prognostic implications, it is of little value when evaluating the morphologic aspects of this disease process. It seems that gastric lymphoma, whether appearing as the primary manifestation or associated with lymphoma elsewhere probably differs only in the presence and location of the disease and the potential for further spread [2]. The gross pathologic features of gastric lymphoma are distinct and are, therefore, helpful in distinguishing it from gastric carcinoma. Gastric lymphomas are extensive rather than focal discrete lesions. Approximately two-thirds of the gastric lymphomas are greater than 10 cm with most series showing the average size from 9 to 14cm [2, 8, 13]. In one large series, almost one-third of the lesions involved the entire stomach [8]. Gastric lymphoma may extend across the pylorus to involve the duodenum (5% to 20%) (14), and sometimes may even extend into the distal esophagus (2% to 5%) [2, 8]. Gross inspection of the stomach demonstrates several common pathologic findings: (a) An infiltrating
Fig. 3. Gastric lymphoma. Infiltrating process extending from the gastric fundus to the antrum. Folds are enlarged and distorted in a concentricsymmetricalmanner without much mucosaldestruction or narrowing of the lumen pattern consisting of thickening of the wall, enlarged and bizarre rugal folds and submucosal nodularity (35% to 60%); (b) ulcerating lesions which may vary from superficial erosion to ulcerating masses (30% to 70%); (c)polypoid masses (20% to 30%); (d)a combination of any of the above with usually one pattern predominating (20% to 70%) (1, 2, 8, 15). Since most lymphomas do not evoke much of a desmoplastic response (Hodgkin's disease is the exception), they infrequently produce significant narrowing of the lumen or loss of pliability even when the entire stomach is involved [8, 14]. Further, since lymphoma has such extensive submucosal infiltration, the mucosa often is preserved and the submucosal infiltration manifests as a nodular bizarre rugal fold pattern (Fig. 3). This differs from the infiltrating gastric carcinoma which usually has a pronounced desmoplastic response and extensive mucosal destruction, producing narrowing of the lumen, loss of pliability, and effacement and destruction of the gastric mucosa and folds (Figs. 4 and 5). The radiologic appearance of gastric lymphoma reflects the gross pathologic findings. It is, therefore, imperative that all of the abnormalities throughout the entire stomach be accurately demonstrated. This is particularly true in cases in which there is an obvious solitary focal abnormality and, in addition, abnormal rugal folds, either contiguous to that lesion
160
L.S. Menuck: Radiologic Diagnosis of Gastric Lymphoma
Fig. 4. Gastric carcinoma. Infiltrating scirrhous carcinoma of the body and proximal antrum with concentric involvement and marked narrowing of the lumen
Fig. 5. Gastric carcinoma. Rigidity and narrowing of the body of the stomach. Extensive shagginess of the contour indicative of mucosal destruction
or at some distance from it. Often, even when the focal abnormality is quite prominent, there may be abnormal folds which comprise a greater area even though they may be somewhat less striking (Fig. 6). When the primary radiographic finding is that of a solitary focal lesion, the appearance is most consistent with gastric carcinoma. If there are associated abnormal folds, i.e., folds contiguous to the primary lesion, it is difficult to distinguish carcinoma from gastric lymphoma. When the abnormal folds are separated from the primary lesion or if they are circumferential without associated narrowing of the lumen, then lymphoma is a much more likely possibility. The finding of multiple masses or a large infiltrating lesion, which is concentric and has large folds without significant narrowing of the lumen, is almost always gastric lymphoma (Fig. 7). Hodgkin's disease involving the stomach acts somewhat differently from other lymphomas. Its ap-
pearance is quite similar to that of gastric carcinoma and it is very difficult to separate the two radiographically. The practical application of these distinguishing criteria are: (a) the preoperative diagnosis of gastric lymphoma, and (b) evaluating its extent. Endoscopy and endoscopic biopsy are often inconclusive in this disease process because submucosal involvement is extensive. As primary gastric lymphoma is potentially curable lesion, best treated by subtotal gastrectomy with irradiation, it is imperative that its full extent be appreciated, yet this may be difficult even at surgery. Patients with lymphoma and secondary gastric involvement are usually treated with radiation therapy and/or chemotherapy. It is important to document the extent of involvement to plan therapy and to serve as an objective standard for therapeutic response.
L.S. Menuck: Radiologic Diagnosis of Gastric Lymphoma
6
161
7
Fig. 6. Gastric lymphoma. A large ulcerating mass along the greater curvature of the body of the stomach, associated abnormal fundal folds with circumferential involvement and nodularity which is not contiguous to the primary ulcerating mass Fig. 7. Gastric lymphoma. Double contrast spot film demonstrates absence of normal folds throughout body and antrum with small diffuse ulcerations and without significant narrowing of the lumen
Summary A retrospective analysis indicates that if the following criteria are adhered to, the diagnosis of gastric lymphoma should be easy in most cases: (a)If the presenting lesion is greater than 15 cm, it is essentially always gastric lymphoma. If the lesion is less than 5 cm, it is almost gastric carcinoma. If the following radiographic patterns are carefully evaluated, the following conclusions can be drawn: (a)a radiographic pattern consisting either of multiple masses, or a combination of multiple radiologic .findings, or a diffuse infiltrating pattern with large nodular folds or submucosal nodularity without significant narrowing, is usually gastric lymphoma; (b) if the lesion is that of a solitary mass, an annular constricting lesion or a linitis plastica pattern, the appearance is essentially that of a gastric carcinoma; and (c) the basic exception is Hodgkin's disease involving the stomach, which, because of its desmoplastic response, tends to more closely simulate gastric carcinoma than the other forms gastric lymphoma. References 1. Friedman AI: Primary lymphosarcoma of the stomach. Am J Med26: 783-796, 1959 2. Joseph JI, Lanes R: Gastric lymphosarcoma. Am J Clin Pathol 45:653 659 1966 3. Kline TS, Goldstein F: The role of cytology in the diagnosis of gastric lymphoma. Am J Gastroenterol 213: 193-198, 1971
4. Naqui MS, Burrows L, Kark AE : Lymphoma of the gastrointestinal tract, prognostic guides. Ann Surg 170: 221~31, 1969 5. Loehr W J, Mjahed Z, Zahn FD, et al: Primary lymphoma of the gastrointestinal tract. Ann Surg 170: 232-238, 1969 6. Katz S, Klein MS, Winawer SJ, Sherlock P: Disseminated lymphoma involving the stomach: Correlation of endoscopy with directed cytology and biopsy. Am J Dig Dis': 18: 370-374, 1973 7. Nelson RS, Langor FL: Endoscopy in the diagnosis of gastric tymphoma and sarcoma. Am J Gastroenterol 50: 37~46, 1968 8. Sherrick DW, Hodgson JR, Dockerty MB: The roentgenologic diagnosis of primary gastric lymphoma. Radiology 84:925 932, 1965 9. Nelson RS: Recent Results in Cancer Research, Vol. 32, Endoscopy in Gastric Cancer. New York: Springer-Verlag 1970, pp. 28-48 10. Kline TS, Goldstein F: Malignant lymphoma involving the stomach. Cancer 32:961 968, 1973 11. Thorbjarnavson B, Beal JM, Pearce JM: Primary malignant lymphoid tumours of the stomach. Cancer 9:712 717, 1956 12. Ehrlich AN, Stalder G, Geller W, et al: Gastrointestinal manifestations of malignant lymphoma. Gastroenterology 54:1115 1121, 1968 13. McNeer G, Berg JW: Clinical behavior and management of primary malignant lymphoma of the stomach. Surgery 46 : 829 840, 1959 14. Meyers MA, Katzen B, Alonso D: Transpyloric extension to duodenal bulb in gastric lymphoma. Radiology 115: 575-580, July 1975 15. Wang CC, Peterson JA: Malignant lymphoma of gastrointestinal tract, roentgenographic consideration : Acta Radio146 : 523 532, 1956 16. Sherlock P, Winawer SJ, Goldstein M J, et al: Malignant Lymphoma of the gastrointestinal tract, Progress in Gastroenterology. Vol. 2. Edited by GBJ Glass. New York: Grune and Stratton 1970. pp. 367 391
Gastrointest Radiol 1, 157-161 (1976)
Radiology 9 by Springer-Verlag 1976
Gastric Lymphoma, a Radiologic Diagnosis Leslie S. Menuck Departments of Radiology, University Hospital, and Veterans Administration Hospital, University of California at San Diego, School of Medicine, La Jolla, California, U.S.A.
Abstract. Because endoscopy and gastric cytology lack specificity, radiographic evaluation is still the most reliable means of diagnosing gastric lymphoma preoperatively. A retrospective analysis indicates that if careful attention is paid to the radiologic features, gastric lymphoma can be distinguished from gastric carcinoma in most of cases. The radiographic findings of a long segment of involvement, multiplicity of radiographic pattern, and diffuse infiltration consisting of concentric abnormal folds without significant narrowing of the lumen are characteristic of the nonHodgkin's lymphoma. Key words: Gastric lymphoma Gastric carcinoma Abnormal gastric folds -- Ulcerating gastric lesions Gastric masses.
Material and Methods Thirty cases of gastric lymphoma (reticulum cell sarcoma, 14; lymphosarcoma 11; Hodgkin's Disease, 5); were compared with 50 cases of gastric carcinoma to see if there were radiologic features that were significant and easily applicable in the separation of these two entities. This study made no attempt to differentiate primary gastric lymphoma from diffuse lymphoma with gastric involvement. The following parameters were used to evaluate radiographic examinations of the upper gastrointestinal tract: (a) size of the lesion at the time gastric disease was diagnosed; (b) extension of the lesion to involve the esophagus and/or duodenum; (c) the primary radiographic pattern (as most of the lymphomas and some of the carcinomas had more than one radiologic finding, the primary pattern was determined as that which included the greatest area).
Results
The preoperative diagnosis of gastric lymphoma is of obvious importance, yet it is correctly made in less than 25% of the cases [1-4]. The radiographic examination has been successful in identifying gastric abnormalities in 95% of the cases and in making a diagnosis of gastric malignancy in 80% [25], yet the radiologic diagnosis of lymphoma was made in only 10% to 15% of the cases [3, 6-8]. This problem is compounded by the poor yield of endoscopic biopsy, which is positive in only 10% to 20% [3, 4, 6]. While certain recent small series suggest promising results with gastric cytology [3], the yield of this modality is quite low in most studies (9). There are, however, specific radiologic features of gastric lymphoma which permit its easily differentiation from gastric carcinoma in most cases. This paper better defines those characteristics. Address reprint requests to." Leslie S. Menuck, M.D., Department of Radiology, Veterans Administration Hospital, 3350 La Jolla Village Drive, San Diego, CA 92161, U.S.A.
Certain conclusions may be drown from the data obtained and tabulated in Tables 1 and 2: 1. Gastric lymphoma presents as a much larger lesion than gastric carcinoma. The average size of the lymphomas was 11.9 cm (12.8 cm for non-Hodgkin's lymphomas, 7.4 cm for Hodgkin's lymphomas), while that of gastric carcinomas was 5.6 cm. Forty percent of the gastric lymphomas and only 4% of the gastric carcinomas were over 15 cm in length. Conversely, 4% of the lymphomas and 34% of the gastric carcinomas were less than 5 cm at time of the initial diagnosis. Seventy-two percent of the lymphomas but only 16% of the gastric carcinomas were greater than 10 cm, at the time of presentation. Both gastric carcinoma and lymphoma may involve the adjacent duodenum or esophagus. Extension to the duodenal bulb was more common in lymphoma (20%) (Fig. 1) than in carcinoma (6%). Involvement of the adjacent esophagus was found in both, with 12% of the gastric carcinomas and 4%
158
L.S. M e n u c k : Radiologic Diagnosis of Gastric L y m p h o m a
T a b l e 1. Length and extent of lesion
Carcinoma
Length (cm) a 04 5-10 II 15 15 or greater Extension of lesion Distal esophagus Duodenal bulb
(50 cases)
Non-Hodgkin's Hodgkin's lymphoma lymphoma (25 cases) (5 cases)
No.
(%)
No.
(%)
17 25 6 2
34 50 12 4
1 6 8 10
4 24 32 40
6 3
12 6
1 5
4 20
No.
(%)
l
20 60 20
3 1
a Average length of c a r c i n o m a = 5 . 6 c m ; n o n - H o d g k i n ' s p h o m a ~ 12.8 cm ; Hodgkin's l y m p h o m a = 7.4 cm
lym-
T a b l e 2. Primary radiologic pattern
Carcinoma (50 cases)
Non-Hodgkin's Hodgkin's lymphoma lymphoma (25 cases) (5 cases)
No.
(%)
No.
(%)
No.
(%)
Solitary mass
18
36
2
8
1
20
Ulcerating lesion
15
30
3
12
2
40
Multiple masses or ulcerations
1
2
6
24
Annular constricting
6
12
1
4
1
20
33
66
4
16
7 4
14 8
0 14~
56
I
20
18
72
Eccentric InfiltratingLinitis plastica Large bizarre folds
Multiple radiographic patterns 12
24
Fig. 1. Gastric lymphoma. Infiltrating submucosal process with replacement of the normal antral folds and extension into the duodenal bulb. Note small focal ulcerations
a Of these 14 cases, 5 had no other abnormality, 4 had associated ulcerating lesions, 5 had nonulcerating masses
of the gastric lymphomas extending into the distal esophagus. 3. Multiple radiographic patterns are common in gastric lymphoma, being seen in 72% compared to 24% of gastric carcinomas (Fig. 2). The most frequent primary radiographic finding in gastric lymphoma was a circumferential, concentric infiltrating pattern consisting of enlarged bizarre rugal folds without significant narrowing of the gastric lumen. This was present in 56% of the cases of gastric lymphoma (many of those cases had additional abnormalities, which often were quite pronounced). This type of infiltrating lesion was uncommon in gastric carci-
Fig. 2. Gastric lymphoma. Several ulcerating lesions in the distal half of the stomach. Large submucosal nodules in the fundus. A b n o r m a l gastric folds extending from the fundus into the antrum, most prominent in the body of the stomach
noma (8%). The most common form of infiltrating lesion in gastric carcinoma was a "linitis plastica", which was found in 14% of the cases but was seen in only 1 case of lymphoma, a case of Hodgkin's
L.S. Menuck: Radiologic Diagnosis of Gastric Lymphoma
159
disease. Multiple gastric masses were seen in 24% of the gastric lymphomas but in only 1 case of gastric carcinoma. A solitary lesion, with or without ulceration, was the most common finding in gastric carcinoma, with 66% of the carciomas presenting this way compared to only 20% of the lymphomas. A discrete annular constricting lesion was seen in only one case of gastric lymphoma but in 12% of those with the gastric carcinomas. 4. Within the subgroups of lymphoma, Hodgkin's disease appeared quite different from lymphosarcoma and reticulum cell sarcoma in that the presenting lesions was much more comparable in size and radiographic appearance to gastric carcinoma.
Discussion
Gastric lymphomas comprise 3% to 5% of all gastric neoplasms [8, 10, 11]. The incidence of gastric lymphoma seems to be rising at a time when the rate of gastric carcinoma is rapidly declining [8]. Reticulum cell sarcoma and lymphosarcoma most often demonstrate gastric involvement, each comprising about 40% of the gastric lymphomas [12]. Hodgkin's disease involving the stomach is much less common, being found in 10% to 15% [13]. The separation and differentiation of gastric lymphoma into primary and secondary is often difficult and ambiguous because of the multicentric potential of this disease and the obvious predilection these neoplasms have for lymphoreticular tissue in any organ. While the distinction of primary and secondary gastric lymphoma has obvious therapeutic and prognostic implications, it is of little value when evaluating the morphologic aspects of this disease process. It seems that gastric lymphoma, whether appearing as the primary manifestation or associated with lymphoma elsewhere probably differs only in the presence and location of the disease and the potential for further spread [2]. The gross pathologic features of gastric lymphoma are distinct and are, therefore, helpful in distinguishing it from gastric carcinoma. Gastric lymphomas are extensive rather than focal discrete lesions. Approximately two-thirds of the gastric lymphomas are greater than 10 cm with most series showing the average size from 9 to 14cm [2, 8, 13]. In one large series, almost one-third of the lesions involved the entire stomach [8]. Gastric lymphoma may extend across the pylorus to involve the duodenum (5% to 20%) (14), and sometimes may even extend into the distal esophagus (2% to 5%) [2, 8]. Gross inspection of the stomach demonstrates several common pathologic findings: (a) An infiltrating
Fig. 3. Gastric lymphoma. Infiltrating process extending from the gastric fundus to the antrum. Folds are enlarged and distorted in a concentricsymmetricalmanner without much mucosaldestruction or narrowing of the lumen pattern consisting of thickening of the wall, enlarged and bizarre rugal folds and submucosal nodularity (35% to 60%); (b) ulcerating lesions which may vary from superficial erosion to ulcerating masses (30% to 70%); (c)polypoid masses (20% to 30%); (d)a combination of any of the above with usually one pattern predominating (20% to 70%) (1, 2, 8, 15). Since most lymphomas do not evoke much of a desmoplastic response (Hodgkin's disease is the exception), they infrequently produce significant narrowing of the lumen or loss of pliability even when the entire stomach is involved [8, 14]. Further, since lymphoma has such extensive submucosal infiltration, the mucosa often is preserved and the submucosal infiltration manifests as a nodular bizarre rugal fold pattern (Fig. 3). This differs from the infiltrating gastric carcinoma which usually has a pronounced desmoplastic response and extensive mucosal destruction, producing narrowing of the lumen, loss of pliability, and effacement and destruction of the gastric mucosa and folds (Figs. 4 and 5). The radiologic appearance of gastric lymphoma reflects the gross pathologic findings. It is, therefore, imperative that all of the abnormalities throughout the entire stomach be accurately demonstrated. This is particularly true in cases in which there is an obvious solitary focal abnormality and, in addition, abnormal rugal folds, either contiguous to that lesion
160
L.S. Menuck: Radiologic Diagnosis of Gastric Lymphoma
Fig. 4. Gastric carcinoma. Infiltrating scirrhous carcinoma of the body and proximal antrum with concentric involvement and marked narrowing of the lumen
Fig. 5. Gastric carcinoma. Rigidity and narrowing of the body of the stomach. Extensive shagginess of the contour indicative of mucosal destruction
or at some distance from it. Often, even when the focal abnormality is quite prominent, there may be abnormal folds which comprise a greater area even though they may be somewhat less striking (Fig. 6). When the primary radiographic finding is that of a solitary focal lesion, the appearance is most consistent with gastric carcinoma. If there are associated abnormal folds, i.e., folds contiguous to the primary lesion, it is difficult to distinguish carcinoma from gastric lymphoma. When the abnormal folds are separated from the primary lesion or if they are circumferential without associated narrowing of the lumen, then lymphoma is a much more likely possibility. The finding of multiple masses or a large infiltrating lesion, which is concentric and has large folds without significant narrowing of the lumen, is almost always gastric lymphoma (Fig. 7). Hodgkin's disease involving the stomach acts somewhat differently from other lymphomas. Its ap-
pearance is quite similar to that of gastric carcinoma and it is very difficult to separate the two radiographically. The practical application of these distinguishing criteria are: (a) the preoperative diagnosis of gastric lymphoma, and (b) evaluating its extent. Endoscopy and endoscopic biopsy are often inconclusive in this disease process because submucosal involvement is extensive. As primary gastric lymphoma is potentially curable lesion, best treated by subtotal gastrectomy with irradiation, it is imperative that its full extent be appreciated, yet this may be difficult even at surgery. Patients with lymphoma and secondary gastric involvement are usually treated with radiation therapy and/or chemotherapy. It is important to document the extent of involvement to plan therapy and to serve as an objective standard for therapeutic response.
L.S. Menuck: Radiologic Diagnosis of Gastric Lymphoma
6
161
7
Fig. 6. Gastric lymphoma. A large ulcerating mass along the greater curvature of the body of the stomach, associated abnormal fundal folds with circumferential involvement and nodularity which is not contiguous to the primary ulcerating mass Fig. 7. Gastric lymphoma. Double contrast spot film demonstrates absence of normal folds throughout body and antrum with small diffuse ulcerations and without significant narrowing of the lumen
Summary A retrospective analysis indicates that if the following criteria are adhered to, the diagnosis of gastric lymphoma should be easy in most cases: (a)If the presenting lesion is greater than 15 cm, it is essentially always gastric lymphoma. If the lesion is less than 5 cm, it is almost gastric carcinoma. If the following radiographic patterns are carefully evaluated, the following conclusions can be drawn: (a)a radiographic pattern consisting either of multiple masses, or a combination of multiple radiologic .findings, or a diffuse infiltrating pattern with large nodular folds or submucosal nodularity without significant narrowing, is usually gastric lymphoma; (b) if the lesion is that of a solitary mass, an annular constricting lesion or a linitis plastica pattern, the appearance is essentially that of a gastric carcinoma; and (c) the basic exception is Hodgkin's disease involving the stomach, which, because of its desmoplastic response, tends to more closely simulate gastric carcinoma than the other forms gastric lymphoma. References 1. Friedman AI: Primary lymphosarcoma of the stomach. Am J Med26: 783-796, 1959 2. Joseph JI, Lanes R: Gastric lymphosarcoma. Am J Clin Pathol 45:653 659 1966 3. Kline TS, Goldstein F: The role of cytology in the diagnosis of gastric lymphoma. Am J Gastroenterol 213: 193-198, 1971
4. Naqui MS, Burrows L, Kark AE : Lymphoma of the gastrointestinal tract, prognostic guides. Ann Surg 170: 221~31, 1969 5. Loehr W J, Mjahed Z, Zahn FD, et al: Primary lymphoma of the gastrointestinal tract. Ann Surg 170: 232-238, 1969 6. Katz S, Klein MS, Winawer SJ, Sherlock P: Disseminated lymphoma involving the stomach: Correlation of endoscopy with directed cytology and biopsy. Am J Dig Dis': 18: 370-374, 1973 7. Nelson RS, Langor FL: Endoscopy in the diagnosis of gastric tymphoma and sarcoma. Am J Gastroenterol 50: 37~46, 1968 8. Sherrick DW, Hodgson JR, Dockerty MB: The roentgenologic diagnosis of primary gastric lymphoma. Radiology 84:925 932, 1965 9. Nelson RS: Recent Results in Cancer Research, Vol. 32, Endoscopy in Gastric Cancer. New York: Springer-Verlag 1970, pp. 28-48 10. Kline TS, Goldstein F: Malignant lymphoma involving the stomach. Cancer 32:961 968, 1973 11. Thorbjarnavson B, Beal JM, Pearce JM: Primary malignant lymphoid tumours of the stomach. Cancer 9:712 717, 1956 12. Ehrlich AN, Stalder G, Geller W, et al: Gastrointestinal manifestations of malignant lymphoma. Gastroenterology 54:1115 1121, 1968 13. McNeer G, Berg JW: Clinical behavior and management of primary malignant lymphoma of the stomach. Surgery 46 : 829 840, 1959 14. Meyers MA, Katzen B, Alonso D: Transpyloric extension to duodenal bulb in gastric lymphoma. Radiology 115: 575-580, July 1975 15. Wang CC, Peterson JA: Malignant lymphoma of gastrointestinal tract, roentgenographic consideration : Acta Radio146 : 523 532, 1956 16. Sherlock P, Winawer SJ, Goldstein M J, et al: Malignant Lymphoma of the gastrointestinal tract, Progress in Gastroenterology. Vol. 2. Edited by GBJ Glass. New York: Grune and Stratton 1970. pp. 367 391
