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Renal Lymphoma: CT Patterns with Emphasis on Helical CT¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287. Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received February 8, 1999; revision requested March 19 and received April 6; accepted April 6. Address reprint requests to B.A.U.

View larger version (148K): [in a new window]   Figure 1.   Diffuse large cell lymphoma in a 38-year-old woman. Photograph of a gross specimen reveals a large, fleshy yellow tumor arising from the superior pole of the kidney (arrow). Small retroperitoneal and pelvic lymph nodes were also present at surgery. Immunohistochemical analysis of the renal mass demonstrated a staining pattern consistent with a lymphoma of B-cell origin, the most common type of lymphoma involving the kidney.

View larger version (132K): [in a new window]   Figure 2.   Large cell lymphoma in a 63-year-old man. Sagittal renal US image demonstrates lymphoma with a characteristic hypoechoic appearance in the lower pole of the right kidney (arrow).

View larger version (157K): [in a new window]   Figure 3a.   Recurrent large cell lymphoma in the right kidney in a 28-year-old man. The patient had undergone successful treatment of a large anterior mediastinal mass 7 months earlier. (a) Contrast material-enhanced helical CT scan obtained at the time of recurrence illustrates the sensitivity of this modality for the detection of very small lesions (arrowheads). (b) Contrast-enhanced CT scan obtained 6 weeks later shows that one of the lesions has increased markedly in size (arrow).

View larger version (143K): [in a new window]   Figure 3b.   Recurrent large cell lymphoma in the right kidney in a 28-year-old man. The patient had undergone successful treatment of a large anterior mediastinal mass 7 months earlier. (a) Contrast material-enhanced helical CT scan obtained at the time of recurrence illustrates the sensitivity of this modality for the detection of very small lesions (arrowheads). (b) Contrast-enhanced CT scan obtained 6 weeks later shows that one of the lesions has increased markedly in size (arrow).

View larger version (144K): [in a new window]   Figure 4a.   Perirenal lymphoma in a 64-year-old man. Helical CT scans obtained before (a) and after (b) intravenous administration of contrast material show a perirenal soft-tissue mass enveloping the left kidney. The symmetric renal function seen in b reflects the characteristic "soft" nature of lymphomatous tumor.

View larger version (143K): [in a new window]   Figure 4b.   Perirenal lymphoma in a 64-year-old man. Helical CT scans obtained before (a) and after (b) intravenous administration of contrast material show a perirenal soft-tissue mass enveloping the left kidney. The symmetric renal function seen in b reflects the characteristic "soft" nature of lymphomatous tumor.

View larger version (63K): [in a new window]   Figure 5.   Renal lymphoma manifesting as multiple masses. Drawing illustrates the characteristic appearance of multiple masses in renal lymphoma.

View larger version (150K): [in a new window]   Figure 6.   Large cell lymphoma in an 11-year-old boy. The patient presented with a large anterior mediastinal mass and renal lesions. Contrast-enhanced helical CT scan demonstrates small, hypoattenuating masses bilaterally (arrows), a typical finding in renal lymphoma. The patient responded well to treatment, and the renal lesions eventually resolved.

View larger version (162K): [in a new window]   Figure 7.   Large cell lymphoma in a 73-year-old woman. Contrast-enhanced CT scan shows bilateral renal masses with characteristic homogeneous attenuation, smooth borders, and low contrast enhancement. Retroperitoneal adenopathy is also present (A).

View larger version (60K): [in a new window]   Figure 8.   Renal lymphoma manifesting as a solitary mass. Drawing illustrates the characteristic appearance of a dominant lymphomatous renal mass.

View larger version (171K): [in a new window]   Figure 9.   Renal lymphoma in a 69-year-old man. Contrast-enhanced helical CT scan shows a dominant 5-cm mass in the right kidney (arrow). There is no evidence of retroperitoneal adenopathy.

View larger version (165K): [in a new window]   Figure 10.   Follicular, mixed small cleaved and large cell lymphoma in a 74-year-old man. Contrast-enhanced helical CT scan shows a large mass located in the left kidney and extending into the perirenal space. Small nodes are seen in the retroperitoneum (arrow).

View larger version (79K): [in a new window]   Figure 11.   Renal lymphoma manifesting as contiguous retroperitoneal extension. Drawing illustrates the characteristic appearance of a bulky retroperitoneal mass invading the renal hilum and enveloping the renal vessels.

View larger version (166K): [in a new window]   Figure 12.   Diffuse lymphocytic lymphoma in a 65-year-old woman. Contrast-enhanced helical CT scan shows a large, homogeneous mass enveloping the retroperitoneum and invading the right kidney. Note how flow is maintained in the renal arteries (straight arrows) and left renal vein (curved arrow) despite the massive tumor burden. These findings are characteristic of retroperitoneal lymphoma.

View larger version (142K): [in a new window]   Figure 13.   Large cell lymphoma in a 51-year-old woman. Contrast-enhanced helical CT scan shows a large tumor mass invading and displacing the left kidney. The tumor also involves the right side of the retroperitoneum.

View larger version (60K): [in a new window]   Figure 14.   Renal lymphoma manifesting as perirenal disease. Drawing illustrates the characteristic appearance of isolated perirenal lymphoma, which surrounds but does not destroy the underlying kidney.

View larger version (147K): [in a new window]   Figure 15.   Perirenal lymphoma in the same patient as in Figure 4. Sagittal multiplanar reconstruction image from a contrast-enhanced helical CT scan reveals a perirenal soft-tissue mass (arrows) enveloping the left kidney (K). Sp = spleen, St = stomach.

View larger version (137K): [in a new window]   Figure 16.   Large cell lymphoma in a 34-year-old man. Contrast-enhanced helical CT scan demonstrates perirenal masses bilaterally, especially on the right side. The resulting marked compression and deformity of the right kidney are somewhat unusual for perirenal involvement.

View larger version (68K): [in a new window]   Figure 17.   Renal lymphoma manifesting as infiltrative disease. Drawing illustrates the characteristic appearance of infiltrative lymphoma within the interstitium of the renal parenchyma.

View larger version (161K): [in a new window]   Figure 18.   Infiltrative renal lymphoma in an 80-year-old man. Contrast-enhanced CT scan shows minimal renal enlargement bilaterally, a finding that suggests subtle involvement by lymphoma.

View larger version (109K): [in a new window]   Figure 19a.   High-grade large cell lymphoma in a 35-year-old man. (a) Contrast-enhanced CT scan demonstrates patchy tumor infiltration within the kidneys. The kidneys have retained their normal contour, a finding that is characteristic of infiltrative lymphoma. (b) On an unenhanced CT scan, the infiltration is undetectable, which underscores the importance of contrast-enhanced CT for diagnosis.

View larger version (105K): [in a new window]   Figure 19b.   High-grade large cell lymphoma in a 35-year-old man. (a) Contrast-enhanced CT scan demonstrates patchy tumor infiltration within the kidneys. The kidneys have retained their normal contour, a finding that is characteristic of infiltrative lymphoma. (b) On an unenhanced CT scan, the infiltration is undetectable, which underscores the importance of contrast-enhanced CT for diagnosis.

View larger version (132K): [in a new window]   Figure 20.   Infiltrative renal lymphoma in a 44-year-old woman. Contrast-enhanced CT scan shows the kidneys as diffusely enlarged and replaced by tumor. The lobulated appearance of the tumor reflects the transition to a more focal expansile mass as it compresses and destroys renal parenchyma.

View larger version (161K): [in a new window]   Figure 21.   Non-Hodgkin lymphoma in a 51-year-old man. Contrast-enhanced CT scan shows a cystic retroperitoneal mass (M) invading the left kidney, resulting in hydronephrosis. The attenuation of the mass is similar to that of the dilated collecting system (C).

View larger version (149K): [in a new window]   Figure 22a.   Large cell lymphoma in a 63-year-old man. Contrast-enhanced helical CT scans demonstrate a cystic mass in the right kidney (arrow in a) and cystic or necrotic nodes in the retroperitoneum (arrow in b). These CT findings are highly unusual for lymphoma and are more common in necrotic tumors such as adenocarcinoma or testicular cancer or in infectious diseases such as tuberculosis.

View larger version (148K): [in a new window]   Figure 22b.   Large cell lymphoma in a 63-year-old man. Contrast-enhanced helical CT scans demonstrate a cystic mass in the right kidney (arrow in a) and cystic or necrotic nodes in the retroperitoneum (arrow in b). These CT findings are highly unusual for lymphoma and are more common in necrotic tumors such as adenocarcinoma or testicular cancer or in infectious diseases such as tuberculosis.

View larger version (160K): [in a new window]   Figure 23a.   Diffuse large cell lymphoma in a 56-year-old man who presented with acute abdominal pain. Contrast-enhanced helical CT scans demonstrate retroperitoneal hemorrhage displacing the left kidney anteriorly. Interruption of the enhancing cortical rim (arrow in b) suggests an underlying renal mass as the cause of bleeding. These findings are typical in renal cell carcinoma but very unusual in lymphoma.

View larger version (161K): [in a new window]   Figure 23b.   Diffuse large cell lymphoma in a 56-year-old man who presented with acute abdominal pain. Contrast-enhanced helical CT scans demonstrate retroperitoneal hemorrhage displacing the left kidney anteriorly. Interruption of the enhancing cortical rim (arrow in b) suggests an underlying renal mass as the cause of bleeding. These findings are typical in renal cell carcinoma but very unusual in lymphoma.

View larger version (157K): [in a new window]   Figure 24.   Diffuse large cell lymphoma in a 56-year-old man who presented with a mass in the left kidney and multiple splenic nodules. Contrast-enhanced helical CT scan shows multiple hypoattenuating lesions in the spleen (arrowheads), which is probably the most common site of extranodal lymphoma.

View larger version (161K): [in a new window]   Figure 25.   Diffuse large cell lymphoma in a 76-year-old woman. A contrast-enhanced CT scan obtained earlier (not shown) demonstrated a large retroperitoneal mass infiltrating the right kidney. Subsequent contrast-enhanced CT scan reveals a separate lymphomatous mass (arrow) inferior to the retroperitoneal mass and encasing several small bowel loops in the right lower quadrant.

View larger version (149K): [in a new window]   Figure 26.   Burkitt lymphoma in a 17-year-old boy. Contrast-enhanced CT scan demonstrates masses in the right kidney (straight arrow) and small intestine (curved arrow). The small bowel mass has caused intussusception and bowel obstruction.

View larger version (127K): [in a new window]   Figure 27.   Recurrent diffuse histiocytic lymphoma in a 50-year-old man who presented with bilateral renal masses and lung nodules. Contrast-enhanced CT scan shows multiple pulmonary nodules bilaterally. Parenchymal lung involvement is usually seen only in patients with recurrent disease.

View larger version (135K): [in a new window]   Figure 28.   Burkitt lymphoma in a 48-year-old woman. The patient had undergone renal transplantation 3 years earlier and was undergoing immunosuppressive steroid and cyclosporin therapy. Contrast-enhanced CT scan shows lymphomatous nodules in the transplanted kidney (arrows). Tumor was also noted within the central nervous system at lumbar puncture.

View larger version (142K): [in a new window]   Figure 29a.   Large cell lymphoma in the same patient as in Figure 16, who tested positive for HIV infection. Multiple sites of involvement included the kidneys and heart. Contrast-enhanced helical CT scans show soft-tissue masses in the perirenal space (a) and within the septum and myocardium of both ventricles (arrows in b). The patient died of acquired immunodeficiency syndrome. Histologic cardiac involvement is common in acquired immunodeficiency syndrome, but bulky lesions as seen in this case are relatively rare.

View larger version (122K): [in a new window]   Figure 29b.   Large cell lymphoma in the same patient as in Figure 16, who tested positive for HIV infection. Multiple sites of involvement included the kidneys and heart. Contrast-enhanced helical CT scans show soft-tissue masses in the perirenal space (a) and within the septum and myocardium of both ventricles (arrows in b). The patient died of acquired immunodeficiency syndrome. Histologic cardiac involvement is common in acquired immunodeficiency syndrome, but bulky lesions as seen in this case are relatively rare.

View larger version (157K): [in a new window]   Figure 30.   Metastatic lung cancer in a 75-year-old woman. Contrast-enhanced helical CT scan shows bilateral renal masses that are indistinguishable from lymphoma.

View larger version (167K): [in a new window]   Figure 31.   Transitional cell carcinoma in a 72-year-old man. Contrast-enhanced helical CT scan shows a mass infiltrating the left renal hilum. The tumor does not result in vascular occlusion or hydronephrosis. Although these are classic findings in lymphoma, biopsy revealed transitional cell carcinoma.

View larger version (162K): [in a new window]   Figure 32.   Adenocarcinoma of unknown primary origin in a 63-year-old man. Contrast-enhanced helical CT scan demonstrates a markedly enlarged, conglomerate nodal mass with homogeneous attenuation enveloping the retroperitoneum. Lymphoma was the most likely diagnosis, but biopsy revealed adenocarcinoma.