tbc or lymphoma

7/27/2019 Tbc or Lymphoma

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A JR :17 2 , M a rch 19 99 6 19

Tube rcu los is V e rsus Lym phom as

in the Abdom in a l Lym ph N odes :

E va lua tion w ith Con tras t-Enhanced CT

Z hi -G an g Y an g1

P en g- Qi u M m1

S hu su ke So ne 2

Z hi -Y an H e1

Z hen g-Y in L iao1

X iang -P in Z ho u1

G ai-O in Y an g3

P au l M . S ilv erm an4

OBJECT I VE . T ub ercu los is in th e ab do m ina l ly m ph nod es m ay be d ifficu lt to d is tin gu ish from

ly m phom as . T h is s tu dy eva lu ated spec ific C T im ag ing cr ite ria fo r d iffe ren tiating these en titie s.

M ATER IA LS AND M ETHODS . W e re tros pe c tiv e ly rev iew e d th e a na to mic d is trib utio n

an d C T en hancem ent pa tte rns o f d isease in 69 p atien ts, 26 (3 8% ) w ith tu bercu los is and 43

(62 % ) w ith u n treate d lym ph om as inv olv ing ab dom in al lym ph n ode s. O f th e pat ien ts w ith tu -

bercu losis , five (19 % ) had d issem ina ted d isease an d 21 (81% ) had nond issem ina ted d isease .

O f the pa tien ts w ith lym ph om as, 16 (37% ) had H o dgk in ’s d isease and 27 (6 3% ) h ad no n-H o dgk in ’s lym pho m a.

RESULTS . D issem ina ted and no nd issem ina ted tubercu los is inv o lved p red om inan tly

lesse r o m en tal, m esen te ric , an te rio r para rena l, and upp er paraaortic lym p h n odes. L ow er

paraaort ic lym ph no des w ere inv o lved m o re o ften in H odgk in ’s d isease (1 5 pa tien ts [94% ]),

non-H od gk in ’s lym p hom a (2 4 pa tien ts [8 9% ]), and d issem ina ted tubercu los is (five pa tien ts

[ 1 0 0 %] ) than in nond issem ina ted tu bercu los is (o ne pa tien t [5 ]). M esen te ric lym p h nod es

w ere inv o lved m o re often in d issem ina ted tubercu los is ( four pa tien ts [80 % ]) and n ond issem i-

na ted tubercu los is (I I pa tien ts [52 % ]) than in H od gk in ’s d isease (o ne pa tien t [6 % ]) (p < .01 ) .

Anatomic distribution was not different between disseminated tuberculosis and non-

H o dgkin ’s lym ph om a. T ubercu lous lym ph ad enopa thy co m m only show ed periphera l en -

hancement , f requent ly w ith a m ultilo cu lar appearance , w hereas lym p hom atous adenop athy

ch aracte ristica lly sh ow ed hom og eneous a ttenua tion (1 4 pa tien ts [87 .5% ] w ith H odg k in ’s d is -

ease an d 19 pa tien ts [70% ] w ith non -H o dgk in ’s lym pho m a [p < .01 ] ) .

CONCLUS ION . O ur fin ding s in d ica te tha t the ana tom ic d is trib u tion an d sp ecific en-

hancem en t pa tterns o f ly m phadenop a th y seen on con tras t-enhanced C T can be u sefu l in d if-

fe ren tia ting be tw een tub ercu losis and un trea ted lym ph om as of the abdo m ina l ly m ph nodes .

R ec e iv ed D ece mb er 1 9, 1997: a cc ep te d a fte r re vis io n

September 4 , 1 9 98 .

S up po rted in pa rt b y t he N ation al N atu ra l S cie nc es

F ou nd atio n o f C hin a.

o f R ad io lo gy , F irs t U nive rs ity H os pita l, W e st

C hin a U niv ers ity o f M ed ic al S cie nc es , 3 7 G uo X ue X ia ng ,

C he ng du , S ic hu an 6 10 04 1, C hi na . A dd re ssc o rr e s po n de n ce t o Z . - G .Y a ng .

2 De pa rtm en t o f R ad io logy , S hins hu U nive rs ity S ch oo l o f

M ed ic in e, A sa hi, M ats um oto 3 90 8 62 1, Ja pa n.

3D epa rtm en t o f A na tom y, W est C hina U niv e rs ity o f

M ed ica l S cie nce s, C he ng du , S ich ua n 6 10 04 1, C hin a.

4 De pa rtm en t o f R ad io lo gy , G eo rg eto wn U niv ers ity

H os pita l, 3 80 0 R es erv oir R d., N W ., W a sh in gto n, DC 2 0 0 0 7 .

AJ R 1999 :172 :619 - 623

0361- 803X/99 /1723- 619

© A meric an R oen tge n R ay S oc ie ty

T h e increased inc idence of tubercu-

losis ha s b een a ttribu ted to se veral

causes , inc lud ing the A ID S ep i-

dem ic, IV d rug ab use , an d an increase in the

num ber of im m unocom p rom ised pa tien ts [I-

41 . A b d o m in a l tubercu los is can affec t the gas-

tro in tes tina l trac t, pe rito neum , lym ph n odes ,

sp leen , live r, and adrena l g land . W hen the

preva lence o f abd om ina l tubercu los is is h igh ,

t he d ia gn os is m ay b e d if fi cu ltt o e st ab li sh [5 ,

61 . L ym p hadenopa thy is the m os t com m on

m anifes ta tion of abdo m in al tubercu los is and

m ay , in up to 55 of cases w itho u t o ther ev i-

dence of abdo m in a l invo lv em en t, be easily

co nfused w ith lym phom as invo lv ing abdo m i-

n al ly m ph no des [7 ] . C lin ica l and rad io log ic

d iffe ren tiation b etw een the tw o can be cha l-

leng ing [6 -81 . T o o ur kn ow ledge , a com p ar i-

son of C T find in gs in tubercu los is and

lym p hom as of the abdom ina l lym ph n odes has

n o t p rev ious ly b een repo rted [7 -1 3]. O ur pur-

p ose w as to con duc t such a com pariso n so as

to im pro ve ph ysician s’ ab i lity to d ist ing u ish

be tw een these en titie s.

M ate r ia ls and M e thods

W e retro spec tive ly rev iew ed the m ed ica l records

of 69 co nse cu t ive p atien ts w ith d ocu m e nte d tu ber -

cu losis (2 6 pa tien ts [38 % ]) and n ew ly d iag nosed ,

un trea ted lym phom as (43 pa tien ts [62% ]) in the ab-

do m in al ly m p h no de s w ho und erw en t c on tras t-

enhanced C T from A p ril 1989 to M a r c h 1996 .

T he group w ith tubercu los is inc luded 17 m en an d

n in e w om en rang in g in ag e from 22 to 67 years

(m ean , 3 9 y ears ) w ith no ev idence of H IV infec tion ,

n eo p lastic d isease , o r opp ortun is tic in fec tion . O f the

26 pa tie n ts w ith tub erc u lo sis , f ive (19 % ) h ad d is-

sem ina ted tubercu lo sis. T h ese five , w hich inc lu ded

th ree men and tw o w om en rang in g in ag e from 2 7 to

3 8 years (m ean , 31 years), p resen ted w ith acu te p u l-

m onary m ilia ry tub ercu lo sis assoc iated w ith sp len ic



Site

Resu l t s

T ab le I su m m arizes the ana tom ic d istribu -

tion find ing s, and T ab le 2 sum m arizes the

enh ancem en t pa tte rn find ings .

C T M an ife sta tio ns o f T ub ercu lo us L ym ph ad en op ath y

D issem ina ted tube rcu los is (F ig . 1 ) a ff ec te d

main ly th e lym ph nodes in the lesse r om en tum ,

the m esen te ry , the an te rio r para rena l space , and

A natomic D is trib u tio n o f L ym phadenopa th y In 69 Pa tie n ts with T ubercu los is a nd U ntre ate d L y m p h o m a s

T uber c u los is Ly m p ho m a s p

O T B n = 5 ) N O T B n = 21 ) H O n = 16 ) N H L n = 27 ) O T B v s H O D T B v s N H L N O T B vs H O N D T B vs N H L

Le sse r om e n tu m 5 1 0 0 ) 9 43 ) 7 4 4 ) 1 5 5 6 ) > 02 5 a nd < .05 N S N S N S

G rea te rom en tum 1 2 0 ) 2 1 0 ) 0 0 ) 2 7 ) N S N S N S N S

M e se n te ry 4 80 ) 1 1 52 ) 1 6 ) 8 30 ) < .0 1 N S < .01 N S

A n te rio r pa ra rena l s pac e 5 100 ) 1 2 5 7 ) 8 5 0 ) 19 70 ) N S N S N S N S

U p p er p a ra ao rtic re g io n 5 10 0 ) 1 3 6 2 ) 1 5 9 4 ) 2 5 9 3 ) N S N S >0 2 5 a n d < .05 > 0 25 a n d < .0 5

L o w e r pa ra ao rtic re g ion 5 100 ) 1 5 ) 1 5 9 4 ) 2 4 8 9 ) N S N S < .01 < .01

N ote -N um bers in p aren the ses a re pe rc en tag es. D TB = d is se m in a te d t ub e rc ul os is , N D TB = n on dis se m in ate d tu be rc ulo sis , H D = H od gk in ’s d is ea se , N H L = n on -H od gk in ’s ly mp ho m a, N S = no t

s ignif icant.

{149}V lU *E nhancer n t P a tte rn s o f L ym phadenopathy in 69 Pa tien ts with Tube rcu los is a nd U ntre ate d L y m p h o m a s

E nh an ce me nt P atte rnT u bercu los is L ym pho m as p

O T B n = 5 ) N O T B n = 21 ) H O n = 1 6) N H L n = 2 7) D T B vs H O O T B vs N H L N O T B vs H O N O T B vs N H L

H om og e ne ou s 0 0 ) 1 5 ) 1 4 8 7 .5 ) 1 9 7 0 ) < .0 1 < .0 1 < .0 1 < .01

P eriphe ra l 4 8 0 ) 19 90 ) 0 0 ) 1 4 ) < .01 < .0 1 < .0 1 < .0 1

H om og e ne ou s m ixe d w ith 1 2 0 ) 1 5 ) 2 1 2 .5 ) 7 2 6 ) N S N S N S N S

per iphe r a l

M u lt iloc u la r a s ub typ e o f 4 8 0 ) 13 62 ) 1 6 ) 3 1 1 ) < .01 < .0 1 < .01 < .0 1

per iphe r a l )

N ote -N um be rs in p are nth es es a re p erce nta ge s. D TB = d is se m in at ed t ub e rc ul os is , N D T B = n on dis se m in ate d t ub erc ulo sis , H D = H od gk in ’s d is ea se , N H L = n on -H od gk in ’s ly mp ho m a, N S = no t

s ignif icant.

Yang e t a l.

62 0 A JR :1 72 , M arch 1 99 9

invo lve m e nt. A ll pat ien ts w ith tu bercu losis had c on-

s titu tio nal sy m p tom s suc h as feve r, w eig h t los s, ea sy

fatig ab ility . n ig h t sw e ats. a nd ob scu re abd om in al

p ains . O ne pa tien t had clin ica lly p alp ab le abdom ina l

m asses . T w e nty -on e pat ien ts (8 1 % ) ha d non dis sem i-

n ate d tube rcu los is. F ou rte en w ere m en a nd se ven

w ere w om en : th ey ran ged in age fro m 22 to 6 7 ye ars

(m e an , 42 ye ars ). T w en ty of the se 21 ha d the con sti-tu tio na l sy m p tom s. and s ix ha d c lin ica lly p alp ab le

ab do m inal m asses . T u be rcu los is w a s d iagn ose d if

ly m p had eno pa thy w as fou nd throug h pa tho log ic

e xam in atio n o f la paro to m y sp ecim e ns ii = 7 ) o r m i-

cro bio log ic exam ina tio n of abdom ina l tis sues n = 3).

T u bercu losis w as a lso d iagn osed in pa tien ts fo r

w ho m C T o r so nog rap hy sh ow ed th at doc um ented

tubercu los is in ex traabdom ina l site s im pro ved afte r

a ntit ub erc ulo us c he mo th era py ii = 16) .

O f the 43 pa tien ts w ith n ew ly diagn ose d . pre v i-

o usly un trea ted lym phom as , 16 (37 % ) had

H od gk in ’s d is ea se and 2 7 (63% ) ha d non -H odg kin ’s

ly m p ho m a , w ith no ev iden ce o f H IV in fec tio n . T he

p atie n ts w ith H od gkin’s d is ease include d seve n m en

a nd nin e w o m e n ran gin g in ag e f rom 2 3 to 6 5 yea rs

(m ea n , 3 6 yea rs) . T he p atien ts w ith non -H odg kin ’s

ly m p ho m a in clu de d 1 3 m e n an d 1 4 w om en ran gin g

in age f rom 2 0 to 7 1 y ears (m ean , 43 y ears). T h e d i-

agno sis w as m ade by h is to log ic exam ina tion of b i-

o psy spec im ens ofthe en la rg ed lym ph n odes.

A ll pa tie n ts w e re e xam ine d w ith a 9 80 0 Q u ick

C T scanner (G en eral E lec tric M edical S ys tem s ,

M ilw au kee , W I). B efore un dergo ing C T , pat ien ts

d ran k 50 0 m l of a I .5 % diatrizoa te so lu tion . A

70 -m I bo lus o f 60% m eglum ine d ia trizoa te (A n-

g iog ra fin : S chering . B erlin , G erm any) w as ad m in -

iste red IV . C on tiguo us ax ial im ages 10 m m th ick

w e re obtain ed at 1 0-m m inte rva ls from the do m e

of the d iaph rag m to the sym phy sis pu bis . T h e

sca nning tim e w as 3 se c p er slice.

T w o observers u naw are o f the fina l d iagnos is in-

de pen den tly rev iew e d ea ch C T sc an and rec ord ed a

num be r of c hara cte rist ics of th e en larg ed lym ph

nod es, inc lud ing an ato m ic lo cat ion an d e nha nce -

m e nt p atte rns . D isc rep anc ies in in terp reta tio n be -tw e en o bserve rs w e re reso lve d by con se nsu s.

A b dom in al ly m p h n ode s w ere gro up ed an a-

tom ica lly in to the fo l low ing six site s: the les ser

om entum (in clu d in g the h ep atod uo den al lig am ent .

the hep ato gas tric lig am ent . th e hep atic h i lus . and

the sp len ic h ilu s). th e greater om entum , the m e-

sen tery , th e a n ter io r p ara ren al spa ce (includ ing the

roo t of the m esen tery a nd th e p eripan cre atic re-

g io n), th e u pp er paraao rtic and low e r paraao rtic

reg ion s (d iv ided by th e up per bo rde r o f L 3), a nd

th e o rig inat ing site o f th e in fer io r m e sen ter ic ar-

te ry . T he sh ort-ax is d iam ete r w as m ea sured fo r

eac h no de . T he C T im ag es of lym ph ad eno pathy

s ites w ere co m p are d w ith the n orm al size of

ly m ph no des as repo rte d b y D o rfm an e t a l. [14 ].

O fth e 2 12 s ites . 2 5 ha d dis sem in ate d tube rcu los is:

48 . n on dis sem ina ted tu bercu losis: 46 , H o dg kin ’s

d isease : an d 93 , no n-H odgk in ’s lym pho m a.

T he enh ancem en t p a tte rns o f en larged lym p h

no de s w ere cha rac terized as h om oge neo us , p eriph-

c m l, ho m o gen eou s m ix ed w ith per iph eral . o r m ul-

tilocu lar . E n han cem en t w a s con sid ere d per iph era l

w hen e ithe r th ic k and irre gu lar or th in e nha nce m e nt

o f th e rim w as seen . E nh an cem ent w as cons ide red

ho m o ge neo us m ix ed w ith p erip he ral w h en so m e en -

la rged n ode s sho w e d h om oge ne ous e nha nce m e nt

an d o the r n od es at the sam e si te sho w e d per iph era l

e nha nce m e nt. E nha nc em e nt w as co nsid ere d m u l-

tilocular w he n m ore th an th ree a d ja cen t c ong lom er-

ate lym ph no de s show ed p erip he ral e nha nce m e nt

an d cen tral low a tte nua tion . M ulti loc u la r en han ce-

m ent w a s thus c ons ide red a sub typ e of per iph eral

e nha nce m e nt tha t co u ld som etim es be see n in th e

tw o enh an cem en t p atte rns . F o r co m p arison w ith

pa tho log ic find in gs, C T attenua tion of the cen tra lnon en hanc ing tis sue in tubercu lou s n odes w as m ea-

su red b y a reg io n-o f-in te rest cursor. A dd itio na lly , w e

ob served ex tran oda l s ites of tub erc u lo sis a nd lym -

ph om a.s , in clu d in g sp leen , p anc rea s. a dre nal g land ,

liv er, and ab do m in al w all .

D if ferenc es in a nato m ic d istr ibu tio n and e n-

han ce m en t pa tterns be tw e en the tw o tu bercu losis

group s a nd the tw o ly m p hom a gro ups w ere co m -

pared by sta tist ical an aly sis . B eca use of the sm a ll

nu m b er o f c ase s. the F isher e xa ct test w as u sed to

co m p are d is sem in ate d tu bercu losis w ith the tw o

typ es o f ly m p ho m a an d to co m p are n on dissem i-

n ate d tu bercu losis w ith H od gkin’s d isea se; the ch i-

squa re te st w a s used to com pa re no ndisse m in ate d

tub erc u lo sis w ith non -H odg kin ’s ly m pho m a .



F ig . 2 .-N on disse min ate d tu be rcu lo sis in 2 2- ye ar -o ld m a n.

A , U n e nh a nc e d C T sca n o b ta ine d a t m idd le o f 13 sh ow s s om e e n la rge d lym ph no de s in m e se n te ry ar rows) .

B , A t sa me le ve l a s A , co ntra st-e nh an ce d C T s can s ho ws m ultiloc ula r a pp ea ra nc e o f m esen te ric lym ph ad en op-

a thy a r r ows ) , bu t lo w e r pa raa o r tic lym ph n od es a re no t en la rged .

Tubercu lo s is V e rsu s Lym phom as in A bdom in a l L ym ph Nodes

A J R :1 72 , M arc h 1 99 9 6 21

F ig . 1 .- Co ntra st-e nh an ce d C T s ca ns in 2 4-y ea r- old w om an w ith h em ato ge no us d is se min ate d tu be rc ulo sis .

A , A nte rio r p ara re na l ly mp ha de no pa th y a r r owheads ) s how s p er iph e ra l, m u lti loc u la r e nha nc em en t, a nd m u ltip le le s io ns o f low a tten ua t ion a re se en in s p le en ar rows) .

B , A t le ve l o f L 2, su pe rio r m esen te ric lym ph ad eno pa th y stra ig ht a rro w) a nd u pp er p ara ao rtic lym ph ad en op ath y a r r owheads ) s ho w p er ip he ra l, m ultilo cu la r e nh an ce me nt

S upe rio r m esen te ric a rte ry cu rve d a rro w) a nd a or ta are en cas ed b y en la rg ed lym ph nod es .

C , A t le ve l o f L 4, m e se nt er ic ly m ph ad en op at hy a r r ows ) a nd l ow e r p ar aa or ti c l ym p ha de no pa th y a r r owheads ) s ho w p er ip he ra l, m u lti lo cu la r e nh an ce m en t

the u pper and low er paraaortic reg ions . N ond is-

sem ina ted tubercu los is (F ig . 2 ) a ffec ted m ain lylym ph nodes in th e sam e reg io ns excep t fo r th e

low er paraaortic reg ion , w hich w as invo lved in

on ly 5 o f nond issem ina ted cases as op posed

to 100% of d issem ina ted cases .

E n la rged lym ph nodes in pa tien ts w ith d is -

se m inate d o r n ond issem ina ted tub ercu los is

w ere circu la r o r ovo id and ran ged from I .2 to

4 .0 c m in diam eter (m e an , 2 .0 cm ). D issemi-

na ted tubercu los is had tw o enh ancem en t p a t-

te rns : pe riphera l (four pa tien ts [80% ]) and

hom ogeneous m ix ed w ith periph era l (one pa-

tien t [20% ]). N o des in four (80% ) o f these pa-

tien ts had in add ition a m ultilocu lar appearance .

N ond issem ina ted tub ercu los is h ad thre e e n-

hancem ent pa tte rn s: pe riph eral (19 pa tien ts

[90% ]), hom o geneous (one pa tien t [5 ] ) , an d

hom og en eous m ix ed w ith periph era l (one pa tien t

[5 ] ) . O f the 20 w it h e nh an ce m en t that was pe-

r iphera l o r h o m og e n eo u s m ixed w ith periph era l,

13 ha d in a dditio n a m ultilo cu lar a ppe ara nce . C T

a tten ua tio n of the cen tra l no nenhanc ing tis su e

rang ed from 28 to 84 H .F ive pa tien ts w ith d issem ina ted tubercu los is

had hom og en eous hepa tom ega ly and h ete ro -

geneo us sp lenom ega ly w ith m u ltip le lo w -a t-

tenua tion les ions rang ing fro m 0.5 to I .5 cm

in d iam ete r (F ig . IA ). O ne pa tien t w ith d is-

sem in ate d tu bercu losis and tw o w ith no ndis-

sem ina ted tubercu los is had tubercu lous

periton itis, w ith asc ite s h av ing a C T attenua-

tion of m ore th an 20 H . T w o pa tien ts h ad

o men tal th ic ke nin g, and o ne pa tien t h ad peri-

to ne al im pla nts.

P ath olo gic F in din gs o f T ub ercu lo us L ym ph ad en op ath y

S ev en p at ie nt s w it h t ub er cu lo si s h ad a l oc al

m u ltilocu lar m a ss in the in trape rito nea l (n =5 )

o r an terio r p ara ren al (n = 2 ) sp ace . O n su bse-

qu en t ce lio tom y , the m asses w ere seen to be

fu sed , w ith m u ltip le en larged lym p h nod es ad-

her ing to th e b o w e l , m esen tery , o r om en tum in

t he p er it on ea l s pa ce a nd t o t he p an cr ea s i n t he

an te rio r para rena l space . C ro ss -sec tio na l spec-

im ens sho w ed tha t caseo us or liqu efac tive sub-s tan ces in the cen ter of the en larg ed lym p h

n o d e s w ere su rround ed by in flam m ato ry lym -

p ha tic tis sue an d prese rv ed b lood vesse ls .

C T M an ifesta t ions o f U n trea ted Lym pho m as

In pa tien ts w ith H odgk in ’s d isease and

n on-H odg k in ’s ly m phom a (F igs. 3 -5 ), the

lesse r o m en tal, an te rio r para rena l, an d up per

an d low er paraaortic ly m ph nodes w ere fre -

q uen tly inv o lved . T he m esen te ric ly m ph

n odes w ere invo lv ed in e ig h t pa tien ts (30% )

w ith n on-H o dgk in’s lym p hom a an d in o ne

p a tien t (6% ) w ith H odg k in ’s d isease .

In the p atien ts w ith H odgk in ’s disease , th e

en la rg ed lym ph nodes w ere c ircu la r o r o vo id

o n C T and sh ow ed tw o enhancem ent pa tte rn s.

F ou rteen cases (8 7 .5 % ) w ere hom og eneous

(F ig . 3 ), and tw o (12 .5% ) w ere hom og eneous

m ixed w ith periphera l (F ig . 4 ). O ne (6% ) of th e

tw o latte r had in add ition a m ultilocu la r ap pear-

a nc e (F ig . 4 ). In on e p atie n t, th e righ t m a jor

p so a s m usc le w as invo lved ; in a second , th e pan-

c reas ; an d in a th ird , the adrena l g land . Three pa -

tien ts had sp lenom ega ly , and si x pa t ien ts ha d a

space-occupy ing les ion in the sp leen .

In th e pa tien ts w ith no n-H odgk in ’s ly m -

p hom a, th e en la rged lym p h nodes w ere c ir-

cu la r o r ov o id o n C T and sh ow ed th ree

en hancem en t pa tte rn s. N ine teen cases (7 0% )

we re hom og eneous , seven (26 % ) w ere h o-

m o geneous m ixed w ith p er ip hera l (F ig . 5) ,

and one 4 ) was peripheral. Three 11 ) of

the e igh t w ith enhancem ent tha t w as p erip h-

e ra l o r hom o geneous m ixed w ith periphera l

had in add ition a m ultilo cu la r app earan ce

(F ig . 5 ). In tw o pa tien ts , the righ t m ajo r

psoas m u sc le w as inv o lved ; in tw o , the pan-

c reas; and in o ne , the adren al g land . E leven



Fig.3.-Contrast-enhanced CT s ca ns in 3 7-y ea r-o ld m an w ith H od gk in ’s d is ea se .

A , A t leve l o f L i, a nte rio r pa ra re na l ly m pha de nop athy a r r ow ) s ho w s h om o ge ne ou s a tt en ua tio n.

B , A t le ve l o f ce ntra l p art o f 13 , l ow er pa raa ort ic lym ph ade no pa thy sho ws ho mo ge neo us a tten ua tio n a r r owheads ) .

F ig . 4 -H odg kin ’s d ise ase in 51 -y ea r-o ld m an . C on tras t-

e nh anc ed C T sca n sh ow s ho m o ge n eo us no d e

a r r ow head) m ix ed w ith n od es w ith p erip he ra l, m u lti lo cu la r

e n h a n c e m e n t s tr ai gh t a rr ow s ) in p ara ao rtic re gio n. In fe -

n or ve na cav a c u rv ed a rrow ) w as d i sp l ac e d a n te r io r ly , a s

a lso s een on ad jac en t c ons ec u tive C T i mag es n ot s hown) .

F ig . 5 .-N on-H od gk in ’s ly m pho ma in 54 -ye ar-o ld w om an .

C o nt ra st -e nh an ce d C T s c an s ho w s h om o ge ne ou s n od es

a r r owheads ) m ixed w ith n od es with p erip he ra l, m ul-

t i locular e nh an ce me nt s tra ig ht a rro ws) in p ara ao rtic re -

g ion th a t en ca se a or ta an d d isp la ce in fe r io r v en a cav a

c u rve d a rro w) a n d a o rt a a n te ri or ly .

Yang et a l.

62 2 A J R :17 2 , M arch 19 99

pa tien ts h ad sp len om ega ly , and five pa tien ts

had a space-occu py ing les ion in the sp leen .

S ta ti st ic al A s se ss m en t

Sign ifican t d iffe rences in ana tom ic d is tri-

bu tion be tw een the tw o tubercu los is g roup s

and the tw o lym p hom a g roups w ere sho w n

us ing the ch i-square an d F isher exac t tes ts.

M esen te ric lym ph nod es w ere inv o lved m ore

of ten in pa tien ts w ith d issem ina ted and non -

d issem ina ted tu bercu losis than in pa tien ts

with Hodgkin’s disease p < . 01 ). L ow er

paraaortic lym ph n odes (be low L 3) w ere in -

vo lved m ore often in pa tien ts w ith H odgk in ’s

d isea se o r no n-H od gk in’s lym pho m a th an in

p atie n ts w ith n on dis sem ina ted tub erc u lo sis

(p < .01 ) . A na to m ic d istribu tion d id no t d if -

fe r be tw een d issem ina ted tub ercu lo sis and

no n-H odgk in ’s lym phom a.

P eriphera l en hancem en t and m ultilocu la r

enh an cem ent w ere seen s ig n ifican tly m ore

of ten (p < .01 ) in the tw o tub ercu losis

groups th an in the tw o ly m phom a gro ups,

w h ereas ho m ogeneous enhancem ent w as

seen s ign ifican tly m o re o ften (p < .01 ) in

ly m phom a than in tu bercu losis .

U s ing certa in c rite ria o f ana tom ic d is tr ib u tio n

and enhancem ent pa ttern , w e c lassified ly m -

phadenop a th y as be in g assoc iated w ith e ithe r tu -

bercu losis o r lym ph om a. W h en periphera l

e n h a n c e m e n t of lym ph no des, reg ard less o f d is-

tr ib u tio n , w as presen t and w as asso c ia ted w ith

s ple nic le sio ns, disseminated tubercu lo sis w as

d iagnosed . These f ind ings w ere pre se nt in f iv e

of f iv e cases o f d issem ina ted tubercu los is , non e

of 21 cases o f nond issem ina ted tubercu los is, and

one of 4 3 cases of lym ph om a. N ond iss em ina ted

tu bercu los is w as d iag nosed w hen periph eral en -

h an cem ent w as presen t and lym phad en opa thy

spared the low er paraaortic lym ph no des. T hese

f in di ng s w er e p re se nt i n 19 of 21 cases o f no n-

d issem ina ted tubercu los is and o ne of 43 cases o f

lym p hom a. L y m phom a w as d iagno sed w h en

the lo w er paraaortic lym ph nod es w ere in vo lved

and enhancem ent w as h om ogeneou s. T h ese

f ind ings w ere presen t in 3 3 of 43 cases o f lym -

pho m a and one of 2 6 cases o f tu bercu losis . N ine

pat ien ts d id no t m ee t an y of these c rite ria and

there fo re co u ld no t be classified . O v erall, 57 pa-

tien ts (83% ) w ere correc tly c lass if ied , tw o pa -

t ien ts (3% ) w ere incorrec tly classified , an d 10

pa tien ts (1 4% ) co u ld no t b e c lass if ied .

Dis cuss ion

T ubercu lou s lym ph ad en opa thy , the m os t

com m on m anifesta tion of ab dom ina l tubercu lo -

sis , m ay be transm itted by th ree m ajo r rou tes.

T he firs t is ingestion of m ate ria l, such as spu tum

or m ilk , th a t is in fec ted w ith tub erc le bac illi.

C lin ica l s tud ies h av e show n tha t th is rou te o f in -

fec tio n is the m os t co m m on. T he b ac illi a re car -

r ied fro m a lesion in the in testina l subm u co sa l

lay er to th e ly m ph nodes tha t d ra in tha t segm en t

o f the bow el. D ra in age is usu ally f rom the lym -

pha tics o f the ileocecu m , je ju num , ileum , and

righ t sid e of co lon to the peripancrea tic and su-

perio r m esen te ric lym p h n odes (an te rio r para re -

na l a t the leve l o f L l and sub sequ en tly to the

in te stinal trun k and the cis tern a chy li. B ecause

dra inage is ra rely fro m the ly m p hatics on the le ft

side of co lon to the in fer io r m esen te ric lym ph

nodes a t L 3 , the low er paraaortic lym ph nod es

are ra re ly invo lved . T ubercu lou s in vo lvem en t o f

th e duo denum in the F ar E ast is no t un usu a l, an d

th e bac illi are ca rried f rom the lym ph nod es of

th e d uodenu m to those of the hepa todu odena l

ligam en t and peripancrea tic reg ion . L ym pha tic

d rainag e from the b ow el ex p lains the invo lve-

m en t o f th e m esen ter ic , an te rio r p ara rena l, up perparaaortic , an d lesse r om en ta l lym p h nodes w ith

exc lus io n of the low er paraao rtic ly m ph no des.

T he second rou te o f transm iss ion is hem atog-

eno us sp read . B acte ria a re d issem ina ted f rom a

d ista n t site of in fect ion , u sua lly th e lun gs , to the

abd om ina l lym p ha tic sy stem . B ecause th is pro-

cess is sys tem ic , it m ay cause in fec tion of m es-

en te ric , le sse r om en ta l, an te rio r para rena l, and

up per and low er p araao rtic lym ph n odes.

In the th ird rou te o f transm iss ion , in fec -

tion c an sp read direct ly to the abd om ina l

lym ph n odes from the se ro sa of ad jacen t in -

fec ted g land s or struc tu res . T ub ercu lo sis o f

th e re pro du ctiv e organ s ca n sp rea d to the up -

pe r a nd low er paraao rtic ly m p h nod es by

lym pha tic d ra in ag e.

In our s tu dy , ap prox im ate ly 80% o f p at ie nt s

had no nd issem ina ted tu bercu losis , m ain ly in -

vo lv ing the m esen ter ic , le sse r om en ta l, an te rio r

para rena l, and upp er p araao rtic lym p h nod es.

T he rem ain ing pa tien ts h ad d issem in ated tub er-

cu los is, w hich of ten invo lve d the lo w e r pa raa or-

tic lym ph nodes , un less they w ere affec ted by

no ndisse m in ate d tu bercu losis. H enc e, the an a-



Tube rcu lo s is V e rsus Lym phom as in Abdom in a l L ym ph Nodes

A J R :1 72 , M arch 19 99 62 3

tom ic d istribu tion o f th is d isease close ly para l-

le ls the rou te o f tubercu lou s in fec tion .

P atho lo g ic find ings from surg ica lly o b ta in ed

sp ecim e ns of tub ercu lou s ly m p had eno pa thy in-

d ica ted th at casea tion or liquefac tive subs tan ces

a t th e cen te r o f the en larged lym p h nodes had a

low attenua tion tha t p resum ably resu lted fro minsuffic ien t b lood sup p ly , w hereas periph eral

in flam m atory lym pha tic tissue had a h igher a t-

tenua tion o n en hanced C T tha t resu lted f rom

the prese rved b lo od sup p ly . C T attenua tio n o f

the cen tra l n onenhanc ing tis su es ranged fro m

28 to 84 H , co nsis ten t w ith cen tra l liquefac tiv e

an d casea tion su bstances. T ubercu lous ly m ph

nodes m ea su red less th an 4 .0 cm in dia m e ter,

with a m ean o f 2 .0 cm , co nsis ten t w ith da ta in -

d ica tin g pa tho log ic se lf-lim iting gro w th [15].

T he com b in ation of en largem en t and periph-

e ral, m u ltilo cu lar en han ce m en t oflym ph n od es

m ight be in terpreted as represe n ting a pe rito -

nea l or re tro perito nea l tum or, lead ing to po ten -tially u nne ces sary surg ica l re sec tion .

In m os t p a tien ts w ith un trea ted lym pho m a

(H odgk in ’s d isease, 87 .5% ; non -H o dgk in ’s

lym pho m a, 70% ), the lym ph nod es enhanced

hom o geneous ly . In 12 .5% of pa tien ts w ith

H odgk in ’s d isease and 26% of pa tien ts w ith

no n-H od gk in’s lym ph om a, the lym ph n od es

had a co m bina tion of hom ogen eo us en hance-

m en t and periph era l enhancem ent. O u r find -

ing s on the m orp ho log y of ly m p h n ode s w ere

similar to tho se of p rev io us reports , in w hich

th e en hancem en t p atte rns o f un trea ted lym -

phom as w ere hom o geneous o r, le ss frequen tly ,

necro tic w ith cen tra l hyp odens ity in the neck

andmedias t inum [16-18] . O livereta l. [1 9] re-

ported tha t in 20% o f pa tien ts w ith lym ph om a,

th e en la rged ly m ph nod es had decreased den-

sity and m esen te ric s trand ing afte r trea tm en t.

H o w e ver , o n rela pse o f the d ise ase , th e lym ph

nodes appeared hom og en eo us . Th us , it is im -

po rtan t to k now if pat ien ts w ith lym ph om a

hav e und erg on e th era py th at m ay h av e ca use d

cen tral low attenua tio n w ith in no des, s im ula t-

in g tu be rc ulo us ly mp ha de no pa th y.

T he focus of th is stu dy w as d iffe re ntia tio n

of tub ercu lo sis fro m untrea ted lym p hom as u s-

ing con tras t-en hanced C T . In p atien ts w ith

non-H od gk in ’s lym phom a, ana tom ic d is trib u -

tio n w as s im ila r to tha t in pa tien ts w ith d issem -

ina ted tub ercu lo sis; ho w ever, in pa tien ts w ith

H odg k in ’s d isease , the d is tribu tion w as d iffe r-

en t-m esen te ric lym ph n odes w ere inv o lved

less o ften . W hen c lin ica l sy m ptom ato logy is

a lso cons id ered , d issem ina ted tubercu los is

shou ld rarely be confused in clin ica l p ractice

w ith the tw o types of lym p hom a. N o nd issem i-

na ted tu bercu losis usua lly invo lved the lym p h

nodes of the m esen te ry , le sser om en tum , an te -

rio r para rena l space, and upper paraaortic re -

gio n bu t rare ly inv o lv ed the low er paraao rtic

reg ion . T h is las t characte ris tic m ay be u sefu l in

d iffe ren tia ting no nd issem in a ted tu bercu losis

from lym pho m as . O ther d iffe ren tia ting ch ar-ac te ris tic s o f non d issem ina ted tubercu los is a re

the grea te r frequency of m esen tenc lym ph

nod e invo lvem en t than in H o dgk in ’s d isease

and th e g reate r frequen cy of p er ip hera l (ra the r

than hom og en eo us) , m u ltilocu la r enhance-

m en t than in m ost un trea ted lym pho m as .

O n e lim itation of the s tudy is the re la tive ly

few cases o f hem atogeno usly d issem ina ted tu -

bercu los is w ith abd om ina l ly m phadenop ath y .

A ltho ugh the d istribu tion and enhancem ent pa t-

terns o f noda l d isease w ith d issem ina ted tuber-

cu los is d iffe r from the o ther d iseases stud ied , a

la rger p opu la tion w o uld h av e been va luab le .

E n larged ly m p h n od es w it h a l ow -a tte nu ati oncen ter can a lso be seen in o ther d iseases,

namely metasta t ic m alignancy , pyog en ic in fec-

tio n , and W h ip p le ’s d isease . In genera l, m os t

m e tas ta tic m a lig nan cie s are ea sily d iagn osed

because the pr im ary m alignancy is know n. T he

appearance of m etas tatic m alignancy on

co ntra st-enh anc ed C T m a y b e rela ted to its cell

type and the therapy u sed fo r th e p rim ary m a-

lign an cy , w hereas the an a to m ic d is tribu tion re -

la tes to the drain ing co urse of th e lym pha tics .

In ano ther s tudy , w e w ill com pare the C T find-

ing s oftu be rcu losis w ith tho se o f m etasta tic ally

m align an t abd om ina l lym ph nodes .

In conc lus ion , ou r find in gs in d ic ate tha t co n-

trast-enhanced C T can be u sefu l in d iffe ren tia tin g

tubercu lous abd om ina l ly m phadenop a th y from

lym pho m atou s abdom ina l lym p hadenop athy on

the b as is o f th e ana tom ic d is tribu tion and en-

hancem ent p atte rns o f en larged lym ph no des .

D issem ina ted and n ond issem ina ted tub ercu losis

involved predom inan tly lesse r o m en ta l, m esen-

teric, anterior para rena l , and upper paraaortic

ly m ph nod es . L ow er paraaortic lymph nodes

w ere involved i n o nl y 5 of pa tien ts w ith non-

d issem ina ted tu bercu los is . In contrast , in pa t ien ts

w ith ly m pho m as, t he l ow er paraaortic lymph

nodes w ere th os e p re do min an tly in vo lve d . A d is-

t inc t differencein ch arac te ristic noda l enhance-

m e n t pat terns was also seen-per iphera l an d

f re qu en tl y m u lt il oc ul ar in tu be rcu lou s lym pha de-

nopathy , and ho m o gen eo us in lymphoma

Acknow ledgments

We thank the Committee of the National

N atura l Sc iences F oun da tion of C hina fo r

sup porting th is w ork financ ia lly . W e a lso

t hank Z hong R o ng C hen fo r h elp in g w ith o ur

E ng lish m an us crip t.

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tbc or lymphoma

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