Burkitt lymphoma

Case contributed by Dr Craig Hacking

Presentation

PR bleeding, abdominal distension. External US showed multiple liver masses.

Patient Data

Age: 36
Gender: Male
CT

Multiple mass lesions are demonstrated within the liver with the largest in segment 2. The mass measures 6 cm x 9.4 cm and displaces the hepatic vessels. The largest mass has an area of central hypodensity indicating central necrosis. No intra or extrahepatic biliary duct dilatation.

There is significant enlargement of the adrenals bilaterally. The left adrenal measures 9.9 cm x 9.1 cm in size. The right adrenal measures 11.4 cm x 9.6 cm in size.

There is poor enhancement of the right kidney in comparison to the left. This appears to be secondary to compression of the right renal artery at the level of the renal hilum secondary to the presence of a mass lesion. There is dilatation of the renal collecting system. Multiple renal mass lesions are demonstrated with enlargement of the right kidney. There is significant enlargement of the prostate which is causing obstruction of the distal right ureter.

Multiple mass lesions are seen associated with the left kidney with enlargement of the left kidney. There is poor enhancement of the anterior and medial aspect of the left kidney at the level of the renal hilum with the presence of a mass lesion. The mass is extending down the left ureter with marked distension of the left ureter proximally. There is no significant dilatation of the renal collecting system.

There is a filling defect within the left renal vein. It is difficult to ascertain if this enhances but has the appearance of tumour thrombus rather than bland thrombus. It is difficult to visualise the right renal vein which appears to be occluded secondary to the presence of a mass lesion and likely tumour thrombus.

There is significant compression of the IVC secondary to the large right adrenal mass lesion. A filling defect is present within the intrahepatic IVC which may represent the presence of thrombus. There is a 6cm x 4 cm mass in the right atrium extending into the right ventricle. A small pericardial effusion is noted.

There is satisfactory enhancement of the spleen which is not enlarged. The gall bladder is unremarkable in its appearance.

There appears to be a large mass lesion associated with the pancreas which measures up to 3.6 cm x 3.9 cm. No pancreatic duct dilatation.

There is satisfactory enhancement of the SMV and the splenic vein which are displaced by the adrenal mass lesions and there is satisfactory enhancement of the portal vein, though minor compression secondary to the adrenal mass lesion and hepatic mass lesions.

Omental masses on the right are associated with the inferior edge of the liver.

There is wall thickening of the ascending colon and hepatic flexure. No obstruction. No source for the documented PR bleeding is demonstrated.

A soft tissue mass lesion is present on the left of the rectum measuring up to 3.5 cm x 1.4 cm.

There is pleural thickening/pleural fluid on the right. Atelectatic changes arepresent at both lung bases. Note is made of a 4 mm pulmonary nodule in the left lowerlobe laterally.

Multiple lucent lesions are seen within the axial skeleton. Several of these are slightly sclerotic. There is a lucent erosive lesion involving the left sacral ala extending to involve the sacroiliac joint. Further assessment of the axial skeleton with a nuclear medicine bone scan could be considered.

Incompletely imaged there is expansion of a left lower lobe pulmonary vessel by a low density filling defect, also consistent with tumour thrombus. As this vessel is located next to the left interior pulmonary vein, the tumour thrombus is almost certainly located within a pulmonary artery.

Conclusion

  • Multiple mass lesions are demonstrated within the solid organs and lymph nodes highly suggestive of an aggressive lymphoma.
  • Thrombus is noted within the renal veins bilaterally, IVC and RA/RV.
  • A left renal mass extends down the left ureter and there is obstruction to the distal right ureter secondary to a prostatic mass.
  • Omental mass.
  • Likely skeletal metastases.
CT

Chest

Approximately 5cm x 5cm hypodense mass in the right atrium has extension into the right ventricle consistent with tumour thrombus. Hypodensities within the left lower lobar pulmonary artery likely also represents tumour thrombus.

There is bilateral lower lobe ground-glass opacification. Bilateral pulmonary nodules have been marked with arrows, the largest measuring 4mm. A 9mm pleurally-based nodule is identified in the right upper lobe. Small right pleural effusion.

Trace pericardial effusion.

There is axillary lymphadenopathy with the largest node identified in the right axilla and measuring 50mm x 38mm in maximal axial dimensions. No mediastinal or hilar lymphadenopathy.

No destructive osseous lesion.

Neck

Jugular chain and submandibular lymphadenopathy. The largest node in the left jugular chain measures 16mm x 12mm. The right palatine tonsil is markedly enlarged with narrowing of the airway (which remains patent).

The parotid glands are normal. There are bilateral subcentimetre hypodense thyroid nodules. The internal jugular veins are patent.

Conclusion

  • Right atrial and left lower lobe pulmonary artery masses are likely tumour thrombus - echocardiography recommended if not already performed.
  • Cervical and axillary lymphadenopathy.
  • Subcentimetre pulmonary nodules.

Case Discussion

Any of the massive abdominal lesions could have been biopsied.

US guided biopsy of the largest liver lesion was performed and histology confirmed Burkitt's lymphoma. The patient is of African descent and tested positive for HIV.

Anecdotally, Burkitt's lymphoma is known as the fast growing tumour with a doubling time of 36 hours 1. Choriocarcinoma is the second fast growing 1.

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Case information

rID: 34686
Case created: 5th Mar 2015
Last edited: 12th Aug 2017
Inclusion in quiz mode: Included

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