Gastric lymphoma may either represent secondary involvement by systemic disease or primary malignancy confined to the stomach.
Gastric lymphoma represents the most common site of extranodal lymphoma, accounting for 25% of all such lymphomas, 50% of all gastrointestinal lymphomas, but comprise only 1-5% of all gastric malignancies 1-3,8.
Typically primary gastric lymphoma occurs in adults in the 6th decade of life, without a distinct gender predilection 9. Secondary gastric lymphoma matches the demographics of the underlying lymphoma.
Typically patients present with long-standing epigastric pain and or dyspepsia which is attributable to Helicobacter pylori rather than the lymphoma per se 6.
Three distinct types of gastric lymphoma are recognised 7-8:
- low-grade MALT lymphoma: 60% of all primary gastric lymphoma
- primary sporadic lymphoma: the vast majority are B-cell non-Hodgkins lymphoma
- secondary involvement of the stomach by systemic lymphoma (usually high grade)
Mucosa-associated lymphoid tissue (MALT) lymphoma is strongly associated with Helicobacter pylori (85-98% of cases). These are low-grade lymphomas and may regress following the treatment of Helicobacter infection 6.
Fluoroscopy: barium meal
Appearances vary from normal, to grossly abnormal. Possible appearances include:
- bull's eye appearance due to central ulceration 4
- filling defects
- thickened gastric rugae
- linitis plastica
Typically gastric lymphoma demonstrates marked thickening of the stomach wall (2-4cm) with a large lateral extension of the tumour (i.e. along the wall of the stomach) representing submucosal spread 3.
In some instances the submucosal spread encompasses the majority of the stomach, giving it a linitis plastica appearance. Such extensive mural involvement can also extend across the pylorus into the duodenum and superiorly into the oesophagus 5.
Despite such extensive involvement, it is uncommon for lymphoma to result in gastric outlet obstruction 3 or perigastric fat invasion.
The mass is usually homogeneous in attenuation, but may contain focal areas of low density representing necrosis.
Extensive retroperitoneal and local nodal enlargement is often seen.
General imaging differential considerations include:
- more likely to cause gastric outlet obstruction 3
- more likely to be in the distal stomach
- more likely to extend beyond the serosa and obliterate adjacent fat plane
- more focal
- lymph nodes tend to be smaller and more localised to immediate draining nodes (unlike in gastric carcinoma, gastric lymphomas are associated with large lymph nodes and with adenopathy often extending below the level of renal veins/hilum10).
- gastrointestinal stromal tumour (GIST)
For diffuse gastric wall thickening also consider:
- overview of lymphoma
WHO classification of tumours of haematopoietic and lymphoid tissues
- Hodgkin lymphoma
mature B-cell lymphoma
- Burkitt lymphoma
- follicular lymphoma
- lymphoplasmacytic lymphoma (Waldenström's macroglobulinaemia)
- lymphomatoid granulomatosis
- mantle cell lymphoma
- mature T-cell and NK-cell lymphoma
- post-transplant lymphoproliferative/lymphoproliferation disorders
- mature B-cell lymphoma
- location-specific lymphomas
- central nervous system
- head and neck lymphoma
- thoracic lymphoma
- gastrointestinal lymphoma
- hepatobiliary lymphoma
- genitourinary lymphoma
- musculoskeletal lymphoma
- cutaneous lymphoma
- lymphoma staging
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