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Year : 2004  |  Volume : 14  |  Issue : 2  |  Page : 225-226
Abdominal visceral involvement in non-endemic Burkitt's lymphoma


Department of Radiodiagnosis, K.G. Hospital, 5 Govt. Arts College Road, Coimbatore, Tamil Nadu, India

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How to cite this article:
Vijay S, Dahiya N, Karthikeyan D, Sudha G. Abdominal visceral involvement in non-endemic Burkitt's lymphoma. Indian J Radiol Imaging 2004;14:225-6

How to cite this URL:
Vijay S, Dahiya N, Karthikeyan D, Sudha G. Abdominal visceral involvement in non-endemic Burkitt's lymphoma. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Nov 13];14:225-6. Available from: http://www.ijri.org/text.asp?2004/14/2/225/28592
Sir,

Dr. NP Tara et al [1] had presented a classical case of Burkitt's lymphoma in the February 2003 issue of the journal. As reported by the authors, painful swelling of the jaw with a lytic mandibular lesion and 'floating teeth' are classical in the African form. In non-endemic areas, abdominal presentation is the most frequent, in contrast to the typical jaw presentation seen in West African children with the endemic form [2]. We rarely see facial involvement in Burkitt's lymphoma in our country. Abdominal visceral involvement is more common here. We present here a case of Burkitt's lymphoma without facial bony involvement but with a rather unusual form of abdominal visceral involvement.

A 10-year-old boy was admitted with history of fever and acute severe abdominal pain. Ultrasonogram of abdomen revealed bilateral enlarged kidneys with multiple well-defined hypoechoic parenchymal masses [Figure - 1]A. A similar hypoechoic mass was also noted in the region of pancreatic head [Figure - 1]A. No lymph nodes were seen. The liver and spleen were normal in size with no focal lesions. CT scan of the abdomen was done. CT showed multiple well-defined, non-enhancing hypodense masses of varying sizes in the renal parenchyma on both sides. The uninvolved parts of the cortex and medulla showed normal contrast enhancement with normal excretion of contrast into the collecting system [Figure - 1]B. An ill-defined, non-enhancing hypodense mass was also noted in the region of pancreatic head with some peripancreatic fat stranding [Figure - 1]B. No other mass lesion was seen in the abdomen. No lymphnodal involvement was evident. No obvious bowel involvement was seen. Ultrasound-guided renal biopsy was done. Histopathological examination revealed a classical picture of Burkitt's lymphoma. CT scans of the brain and chest were normal. The patient received combination chemotherapy and showed good clinical improvement. Ultrasonogram was repeated a month later (during chemotherapy). It showed normal-sized kidneys with complete resolution of the parenchymal deposits [Figure2]. The pancreatic deposit had considerably reduced in size and was isoechoic to normal pancreatic parenchyma [Figure - 2]. Renal involvement in Burkitt's lymphoma is quite common. However, pancreatic involvement as seen in this patient without involvement of lymph nodes, bowel or other abdominal viscera is unusual.

Burkitt's lymphoma is a type of non-Hodgkin's lymphoma first described by Burkitt in 1958. It has subsequently been subdivided into endemic (African) and non-endemic forms. More recently, a group of Burkitt-like NHL has been recognized [2]. Although they are extremely aggressive, they are potentially curable. Extranodal disease is extremely common and presentation is with rapidly growing masses. In the African form, involvement of the maxilla and mandible is usual, producing the ''floating tooth'' sign on plain radiography. [2] The nonendemic and Burkitt-like forms have a predilection for the bowel, particularly in the ileocaecal region; thus patients often present with intussusception and other acute abdominal emergencies. In a recent series, 50% had disease confined to the abdomen at presentation [2]. The retroperitoneal organs are commonly involved, as is the peritoneum [2].

Renal involvement will be seen in about 3% of patients with lymphoma [2]. Primary lymphoma of the kidney is rare [3]. Renal lymphoma is usually of the non-Hodgkin's type - Burkitt's lymphoma is most common - and is associated with disease arising outside the urinary tract [3]. Early in the disease, tumour involves primarily the interstitium, sparing the nephrons, and gross renal morphology is usually preserved. Bilateral, focal masses that distort the collecting system and renal contours are more common in lymphoma [3]. CT is superior to ultrasonography for detecting renal involvement with lymphoma in children [2],[3]. At ultrasonography, the involved portions of the kidneys appear slightly hypoechoic, with diminished or absent corticomedullary differentiation [3]. The commonest disease pattern is multiple masses, which are hypoechoic on ultrasound with little posterior acoustic enhancement [2]. At CT, the masses are commonly isodense or hyperdense prior to intravenous injection of contrast medium and hypodense afterwards (i.e., non-enhancing) - the so-called ''density reversal pattern'' [2]. Pancreatic neoplasms are rare in childhood. They are usually of epithelial origin and rarely of mesenchymal origin. The most common nonepithelial tumor of the pancreas in children is non-Hodgkin's lymphoma. The CT appearance of non-Hodgkin's lymphoma includes the presence of a focal intrapancreatic mass or diffuse gland enlargement (30).

Burkitt's lymphoma is the most rapidly dividing lymphoma. This is reflected in the presentation and complications, with renal failure and CNS involvement being quite common [4]. Specific protocols comprising high doses of cyclophosphamide and methotrexate, together with an anthracycline, vincristine, cytosine arabinoside and an epipodophyllotoxin have resulted in greatly improved survival, with overall cure rates of 80-90% [4]. CNS prophylaxis is essential [4].

 
   References Top

1.NP Tara, RB Dubey, SM Desai. Case Report: Burkitt's Lymphoma - Classical Presentation of a Rare tumor. Ind J Radiol Imag 2003;13:1:17-18  Back to cited text no. 1    
2.S J Vinnicombe, R H Reznek. Extranodal manifestations of lymphoma. Imaging 1999; 11: 240-268.  Back to cited text no. 2    
3.CJ Sivit. Pediatric Pancreas. JM Serin. Pediatric Kidneys and Adrenal Glands. In: JR Haaga, CF Lanzieri, RC Gilkeson. CT and MR Imaging of the Whole Body. 4th Edition. Missouri, Mosby. 2003: 2037-38, 2048-49.  Back to cited text no. 3    
4.JM Foran, AZS Rohatiner. Lymphoma - Principles of diagnosis, staging and management. Imaging 1999;11:214-229.  Back to cited text no. 4    

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Correspondence Address:
S Vijay
Department of Radiodiagnosis, K.G. Hospital, 5 Govt. Arts College Road, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


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