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Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, HAL B176D, Baltimore, MD 21287. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received April 17, 2002; revision requested July 16 and received August 22; accepted August 23. Address correspondence to S.S. (e-mail: ssheth@jhmi.edu).

View larger version (152K): [in a new window]   Figure 1.  Normal appearance of the small bowel mesentery in a potential renal donor. Coronal contrast material-enhanced computed tomographic (CT) image shows the mesenteric vessels running through the mesenteric fat. A small node is present (arrow).

View larger version (127K): [in a new window]   Figure 2a.  Desmoid tumor in a 42-year-old man with abdominal pain. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5-cm soft-tissue mass in the mesentery (arrow). The attenuation of the mass is similar to that of the psoas muscles. (b) Coronal reformatted image demonstrates that the mesenteric vessels are displaced but not encased by the mass. Histologic analysis of the surgical specimen yielded the diagnosis of desmoid tumor.

View larger version (162K): [in a new window]   Figure 2b.  Desmoid tumor in a 42-year-old man with abdominal pain. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5-cm soft-tissue mass in the mesentery (arrow). The attenuation of the mass is similar to that of the psoas muscles. (b) Coronal reformatted image demonstrates that the mesenteric vessels are displaced but not encased by the mass. Histologic analysis of the surgical specimen yielded the diagnosis of desmoid tumor.

View larger version (156K): [in a new window]   Figure 3a.  Desmoid tumor in a 29-year-old woman with Gardner syndrome and recent onset of abdominal pain. (a) Axial contrast-enhanced CT image shows a 4 x 7-cm soft-tissue mass involving the left rectus abdominis muscle (arrow). The mass is nearly isoattenuating relative to muscle. (b) Contrast-enhanced axial CT image obtained 11 cm higher shows an intraabdominal soft-tissue mass with a central area of lower attenuation (arrow). Histologic findings confirmed the diagnosis of desmoid tumors.

View larger version (148K): [in a new window]   Figure 3b.  Desmoid tumor in a 29-year-old woman with Gardner syndrome and recent onset of abdominal pain. (a) Axial contrast-enhanced CT image shows a 4 x 7-cm soft-tissue mass involving the left rectus abdominis muscle (arrow). The mass is nearly isoattenuating relative to muscle. (b) Contrast-enhanced axial CT image obtained 11 cm higher shows an intraabdominal soft-tissue mass with a central area of lower attenuation (arrow). Histologic findings confirmed the diagnosis of desmoid tumors.

View larger version (125K): [in a new window]   Figure 4.  Gastrointestinal autonomic nerve tumor in a 48-year-old woman with explosive diarrhea. Axial contrast-enhanced CT image of the midabdomen shows a 6-cm intensely enhancing mesenteric mass (arrows). Tumor enhancement is comparable with the nodular enhancement of a known hepatic giant hemangioma (arrowhead). There is no intestinal wall thickening or beading of the surrounding mesentery. Pathologic evaluation of the surgical specimen revealed a spindle cell tumor with features of a gastrointestinal autonomic nerve tumor.

View larger version (132K): [in a new window]   Figure 5.  Mesenteric panniculitis in an 80-year-old woman with abdominal pain. Axial contrast-enhanced CT image of the midabdomen shows increased attenuation of the fat surrounding the mesenteric vessels (solid arrow). Note the pseudocapsule (open arrow) and the perivascular halo (arrowhead). This appearance is characteristic of mesenteric panniculitis.

View larger version (136K): [in a new window]   Figure 6a.  Sclerosing mesenteritis in a 70-year-old man with recurrent rectal bleeding. (a) Axial contrast-enhanced CT image of the midabdomen shows an 8.5 x 3-cm soft-tissue mass at the root of the mesentery (solid arrows). The lesion contains coarse calcifications (open arrow). Mesenteric varices are present (arrowheads). (b) Axial contrast-enhanced CT image obtained 3 cm above a shows encasement of the superior mesenteric artery (open arrow) and near occlusion of the superior mesenteric vein (solid arrow). Note the mesenteric varices (arrowheads). (c) Coronal oblique reformatted image displays the full extent of the lesion encasing the superior mesenteric artery. Open surgical biopsy of the mass revealed sclerosing mesenteritis.

View larger version (136K): [in a new window]   Figure 6b.  Sclerosing mesenteritis in a 70-year-old man with recurrent rectal bleeding. (a) Axial contrast-enhanced CT image of the midabdomen shows an 8.5 x 3-cm soft-tissue mass at the root of the mesentery (solid arrows). The lesion contains coarse calcifications (open arrow). Mesenteric varices are present (arrowheads). (b) Axial contrast-enhanced CT image obtained 3 cm above a shows encasement of the superior mesenteric artery (open arrow) and near occlusion of the superior mesenteric vein (solid arrow). Note the mesenteric varices (arrowheads). (c) Coronal oblique reformatted image displays the full extent of the lesion encasing the superior mesenteric artery. Open surgical biopsy of the mass revealed sclerosing mesenteritis.

View larger version (117K): [in a new window]   Figure 6c.  Sclerosing mesenteritis in a 70-year-old man with recurrent rectal bleeding. (a) Axial contrast-enhanced CT image of the midabdomen shows an 8.5 x 3-cm soft-tissue mass at the root of the mesentery (solid arrows). The lesion contains coarse calcifications (open arrow). Mesenteric varices are present (arrowheads). (b) Axial contrast-enhanced CT image obtained 3 cm above a shows encasement of the superior mesenteric artery (open arrow) and near occlusion of the superior mesenteric vein (solid arrow). Note the mesenteric varices (arrowheads). (c) Coronal oblique reformatted image displays the full extent of the lesion encasing the superior mesenteric artery. Open surgical biopsy of the mass revealed sclerosing mesenteritis.

View larger version (108K): [in a new window]   Figure 7a.  Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).

View larger version (101K): [in a new window]   Figure 7b.  Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).

View larger version (98K): [in a new window]   Figure 7c.  Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).

View larger version (78K): [in a new window]   Figure 7d.  Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).

View larger version (143K): [in a new window]   Figure 8a.  Carcinoid tumor in a 57-year-old man with persistent diarrhea. (a) Axial contrast-enhanced CT image shows a 6-cm enhancing mass at the root of the mesentery (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm below a shows tethering, angulation, and thickening of small bowel loops (arrows). Note beading of the mesenteric vessels (arrowhead). (c) Coronal reformatted image displays radiating strands of soft tissue extending into the mesenteric fat (arrowheads). Surgical biopsy of the mass revealed metastatic carcinoid tumor.

View larger version (149K): [in a new window]   Figure 8b.  Carcinoid tumor in a 57-year-old man with persistent diarrhea. (a) Axial contrast-enhanced CT image shows a 6-cm enhancing mass at the root of the mesentery (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm below a shows tethering, angulation, and thickening of small bowel loops (arrows). Note beading of the mesenteric vessels (arrowhead). (c) Coronal reformatted image displays radiating strands of soft tissue extending into the mesenteric fat (arrowheads). Surgical biopsy of the mass revealed metastatic carcinoid tumor.

View larger version (130K): [in a new window]   Figure 8c.  Carcinoid tumor in a 57-year-old man with persistent diarrhea. (a) Axial contrast-enhanced CT image shows a 6-cm enhancing mass at the root of the mesentery (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm below a shows tethering, angulation, and thickening of small bowel loops (arrows). Note beading of the mesenteric vessels (arrowhead). (c) Coronal reformatted image displays radiating strands of soft tissue extending into the mesenteric fat (arrowheads). Surgical biopsy of the mass revealed metastatic carcinoid tumor.

View larger version (125K): [in a new window]   Figure 9a.  Carcinoid tumor in a 60-year-old man with abdominal pain and distention. (a) Axial contrast-enhanced CT image shows a small ill-defined mass with a coarse calcification in the mesentery (arrow). Note the dilated fluid-filled small bowel loops (arrowheads). (b) Axial contrast-enhanced CT image obtained 35 mm above a demonstrates a smooth enhancing mass in the ileum (arrow) that proved to be the primary tumor. The ileal mass was not diagnosed prospectively. (c) Contrast-enhanced CT image obtained 2 months later, when the patient returned with recurrent pain, demonstrates that the partial small bowel obstruction has resolved but shows focal thickening of a small bowel loop (arrowheads), indicating probable ischemia. The primary tumor is unchanged (arrow). Findings from surgical exploration confirmed the diagnosis of ileal carcinoid metastatic to the mesentery.

View larger version (133K): [in a new window]   Figure 9b.  Carcinoid tumor in a 60-year-old man with abdominal pain and distention. (a) Axial contrast-enhanced CT image shows a small ill-defined mass with a coarse calcification in the mesentery (arrow). Note the dilated fluid-filled small bowel loops (arrowheads). (b) Axial contrast-enhanced CT image obtained 35 mm above a demonstrates a smooth enhancing mass in the ileum (arrow) that proved to be the primary tumor. The ileal mass was not diagnosed prospectively. (c) Contrast-enhanced CT image obtained 2 months later, when the patient returned with recurrent pain, demonstrates that the partial small bowel obstruction has resolved but shows focal thickening of a small bowel loop (arrowheads), indicating probable ischemia. The primary tumor is unchanged (arrow). Findings from surgical exploration confirmed the diagnosis of ileal carcinoid metastatic to the mesentery.

View larger version (133K): [in a new window]   Figure 9c.  Carcinoid tumor in a 60-year-old man with abdominal pain and distention. (a) Axial contrast-enhanced CT image shows a small ill-defined mass with a coarse calcification in the mesentery (arrow). Note the dilated fluid-filled small bowel loops (arrowheads). (b) Axial contrast-enhanced CT image obtained 35 mm above a demonstrates a smooth enhancing mass in the ileum (arrow) that proved to be the primary tumor. The ileal mass was not diagnosed prospectively. (c) Contrast-enhanced CT image obtained 2 months later, when the patient returned with recurrent pain, demonstrates that the partial small bowel obstruction has resolved but shows focal thickening of a small bowel loop (arrowheads), indicating probable ischemia. The primary tumor is unchanged (arrow). Findings from surgical exploration confirmed the diagnosis of ileal carcinoid metastatic to the mesentery.

View larger version (139K): [in a new window]   Figure 10a.  Carcinoid tumor in a 65-year-old man with an incidentally found mesenteric mass. (a) Axial CT image obtained in the arterial phase of enhancement shows a 4-cm enhancing mass at the root of the mesentery (arrow). There is a 1.5-cm enhancing mass in the wall of the proximal small intestine near the ligament of Treitz (arrowhead). (b) Coronal reformatted image shows that the mesenteric mass is contiguous with the primary tumor. At pathologic analysis, a jejunal carcinoid tumor was found to be extending through the intestinal wall to invade an adjacent lymph node.

View larger version (112K): [in a new window]   Figure 10b.  Carcinoid tumor in a 65-year-old man with an incidentally found mesenteric mass. (a) Axial CT image obtained in the arterial phase of enhancement shows a 4-cm enhancing mass at the root of the mesentery (arrow). There is a 1.5-cm enhancing mass in the wall of the proximal small intestine near the ligament of Treitz (arrowhead). (b) Coronal reformatted image shows that the mesenteric mass is contiguous with the primary tumor. At pathologic analysis, a jejunal carcinoid tumor was found to be extending through the intestinal wall to invade an adjacent lymph node.

View larger version (123K): [in a new window]   Figure 11a.  Adenocarcinoma of the pancreas in a 57-year-old woman with abdominal pain. (a) Axial CT image obtained in the arterial phase of enhancement shows a subtle soft-tissue mass abutting the superior mesenteric artery (arrow). The mass has lower attenuation than that of normal pancreatic parenchyma. (b) Coronal reformatted image from the arterial phase of enhancement allows better appreciation of the tumor growing along the superior mesenteric artery and encasing the vessel (arrow). (c) Coronal reformatted image from the venous phase of enhancement shows marked narrowing of the superior mesenteric vein (arrow). Coronal reformatted images allow a more confident diagnosis of unresectability. The diagnosis of adenocarcinoma of the pancreas was confirmed by means of percutaneous biopsy.

View larger version (112K): [in a new window]   Figure 11b.  Adenocarcinoma of the pancreas in a 57-year-old woman with abdominal pain. (a) Axial CT image obtained in the arterial phase of enhancement shows a subtle soft-tissue mass abutting the superior mesenteric artery (arrow). The mass has lower attenuation than that of normal pancreatic parenchyma. (b) Coronal reformatted image from the arterial phase of enhancement allows better appreciation of the tumor growing along the superior mesenteric artery and encasing the vessel (arrow). (c) Coronal reformatted image from the venous phase of enhancement shows marked narrowing of the superior mesenteric vein (arrow). Coronal reformatted images allow a more confident diagnosis of unresectability. The diagnosis of adenocarcinoma of the pancreas was confirmed by means of percutaneous biopsy.

View larger version (118K): [in a new window]   Figure 11c.  Adenocarcinoma of the pancreas in a 57-year-old woman with abdominal pain. (a) Axial CT image obtained in the arterial phase of enhancement shows a subtle soft-tissue mass abutting the superior mesenteric artery (arrow). The mass has lower attenuation than that of normal pancreatic parenchyma. (b) Coronal reformatted image from the arterial phase of enhancement allows better appreciation of the tumor growing along the superior mesenteric artery and encasing the vessel (arrow). (c) Coronal reformatted image from the venous phase of enhancement shows marked narrowing of the superior mesenteric vein (arrow). Coronal reformatted images allow a more confident diagnosis of unresectability. The diagnosis of adenocarcinoma of the pancreas was confirmed by means of percutaneous biopsy.

View larger version (114K): [in a new window]   Figure 12a.  Follicular mixed lymphoma in a 68-year-old woman. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5.5-cm soft-tissue mass in the mesentery (arrow). (b) Axial contrast-enhanced CT image obtained at the level of the superior mesenteric artery demonstrates an ill-defined, infiltrating retroperitoneal mass (arrows) encasing the superior mesenteric artery, aorta, inferior vena cava, and right renal artery.

View larger version (126K): [in a new window]   Figure 12b.  Follicular mixed lymphoma in a 68-year-old woman. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5.5-cm soft-tissue mass in the mesentery (arrow). (b) Axial contrast-enhanced CT image obtained at the level of the superior mesenteric artery demonstrates an ill-defined, infiltrating retroperitoneal mass (arrows) encasing the superior mesenteric artery, aorta, inferior vena cava, and right renal artery.

View larger version (132K): [in a new window]   Figure 13a.  Mesenteric lymphoma in a 77-year-old man who presented with a palpable abdominal mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows a large soft-tissue mass in the mesentery (arrows) that displaces the small intestine. The mass has low attenuation, indicating extensive necrosis. (b) Axial contrast-enhanced CT image of the midabdomen shows the mass is encasing the superior mesenteric vein (arrowhead). Large retroperitoneal nodes are also present (open arrow). Percutaneous biopsy of the mass yielded B-cell lymphoma.

View larger version (136K): [in a new window]   Figure 13b.  Mesenteric lymphoma in a 77-year-old man who presented with a palpable abdominal mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows a large soft-tissue mass in the mesentery (arrows) that displaces the small intestine. The mass has low attenuation, indicating extensive necrosis. (b) Axial contrast-enhanced CT image of the midabdomen shows the mass is encasing the superior mesenteric vein (arrowhead). Large retroperitoneal nodes are also present (open arrow). Percutaneous biopsy of the mass yielded B-cell lymphoma.

View larger version (168K): [in a new window]   Figure 14.  Non-Hodgkin lymphoma in clinical remission in a 56-year-old man after chemotherapy. Axial contrast-enhanced CT image of the midabdomen shows insignificant adenopathy except for a small left paraaortic node, consistent with remission. Note the very subtle increase in the attenuation of the mesenteric fat (arrow) surrounding the mesenteric vessels. Pretreatment CT images (not shown) had shown extensive mesenteric lymphadenopathy.

View larger version (116K): [in a new window]   Figure 15.  Recurrent disease in a 56-year-old man with a history of lung cancer and lymphoma. Axial contrast-enhanced CT image of the midabdomen shows bulky mesenteric adenopathy surrounding the mesenteric vessels (arrows). There is thickening of the wall of the descending colon (arrowheads). Although this appearance is very suggestive of lymphoma, percutaneous biopsy of the mesenteric nodes revealed metastatic lung cancer.

View larger version (143K): [in a new window]   Figure 16.  M avium-intracellulare infection in a 37-year-old man infected with HIV (human immunodeficiency virus). Axial contrast-enhanced CT image of the midabdomen shows multiple enlarged nodes (arrows) surrounding the mesenteric vessels. Some of the nodes contain low-attenuation areas and demonstrate rim enhancement (arrowhead). M avium-intracellulare was cultured from the patient’s stool.

View larger version (121K): [in a new window]   Figure 17.  Known Whipple disease in a 43-year-old woman. Axial contrast-enhanced CT image of the lower abdomen shows a conglomerate of low-attenuation nodes with rim enhancement in the mesentery (arrow).

View larger version (149K): [in a new window]   Figure 18a.  Mesenteric varices in a 55-year-old man with hepatocellular carcinoma and portal vein thrombosis. (a) Axial CT image of the midabdomen obtained in the arterial phase of enhancement shows multiple round soft masses in the mesentery (arrow). (b) On an axial CT image obtained in the venous phase of enhancement, these "masses" (arrow) are enhancing to the same degree as the superior mesenteric vein and are shown to represent mesenteric varices.

View larger version (152K): [in a new window]   Figure 18b.  Mesenteric varices in a 55-year-old man with hepatocellular carcinoma and portal vein thrombosis. (a) Axial CT image of the midabdomen obtained in the arterial phase of enhancement shows multiple round soft masses in the mesentery (arrow). (b) On an axial CT image obtained in the venous phase of enhancement, these "masses" (arrow) are enhancing to the same degree as the superior mesenteric vein and are shown to represent mesenteric varices.

View larger version (131K): [in a new window]   Figure 19.  Metastatic melanoma in a 50-year-old man presenting with vomiting. Axial contrast-enhanced CT image of the lower abdomen shows several enhancing masses in the small bowel mesentery (solid arrows) due to metastatic melanoma. An ileoileal intussusception is present in the right lower quadrant (open arrow) and is causing partial small bowel obstruction. Melanoma implants are also seen in dilated loops of small intestine (arrowheads).

View larger version (118K): [in a new window]   Figure 20a.  Malignant gastrointestinal stromal tumor in a 30-year-old man. (a) Axial contrast-enhanced CT image of the lower abdomen shows two small low-attenuation mesenteric masses adjacent to nondilated loops of small intestine (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm cephalad shows a large heterogeneous low-attenuation omental mass (arrow). Metastases from gastrointestinal stromal tumor are typically low attenuation.

View larger version (122K): [in a new window]   Figure 20b.  Malignant gastrointestinal stromal tumor in a 30-year-old man. (a) Axial contrast-enhanced CT image of the lower abdomen shows two small low-attenuation mesenteric masses adjacent to nondilated loops of small intestine (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm cephalad shows a large heterogeneous low-attenuation omental mass (arrow). Metastases from gastrointestinal stromal tumor are typically low attenuation.

View larger version (121K): [in a new window]   Figure 21a.  Metastatic ovarian carcinoma in a 73-year-old woman with a pelvic mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows several calcified masses in the mesentery and omentum (arrows). (b) Coronal reformatted image depicts the extent of the intraperitoneal spread of this ovarian cancer. The primary tumor appears as a large calcified pelvic mass (arrows). Surgical resection revealed a high-grade serous carcinoma of the ovary with extensive psammoma bodies.

View larger version (123K): [in a new window]   Figure 21b.  Metastatic ovarian carcinoma in a 73-year-old woman with a pelvic mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows several calcified masses in the mesentery and omentum (arrows). (b) Coronal reformatted image depicts the extent of the intraperitoneal spread of this ovarian cancer. The primary tumor appears as a large calcified pelvic mass (arrows). Surgical resection revealed a high-grade serous carcinoma of the ovary with extensive psammoma bodies.

View larger version (137K): [in a new window]   Figure 22.  Metastatic breast cancer in a 57-year-old woman with a palpable abdominal mass and a history of breast cancer. Axial contrast-enhanced CT image of the midabdomen shows an ill-defined soft-tissue mass infiltrating the root of the mesentery and encasing the mesenteric vessels (arrows). Surgical biopsy revealed metastatic lobular breast carcinoma.

View larger version (123K): [in a new window]   Figure 23.  Peritoneal lymphomatosis in a 40-year-old man with a right lower quadrant mass. Axial contrast-enhanced CT image of the midabdomen shows extensive and diffuse soft-tissue infiltration of the mesenteric fat (arrows). Omental caking is also present (arrowheads). Percutaneous biopsy of the omental mass yielded high-grade lymphoma similar to Burkitt lymphoma.

View larger version (145K): [in a new window]   Figure 24.  Peritoneal mesothelioma in a 35-year-old man with abdominal distention. Axial contrast-enhanced CT image of the midabdomen shows ascites and peritoneal implants of tumor (arrowheads). Linear bands of soft-tissue attenuation run through the mesenteric fat, indicating tumor infiltration (arrow). Percutaneous biopsy of a focal peritoneal mass revealed malignant mesothelioma.

View larger version (146K): [in a new window]   Figure 25a.  Peritoneal tuberculosis in a 45-year-old woman with abdominal distention. (a) Axial contrast-enhanced CT image of the lower abdomen shows a moderate amount of ascites. There is enhancement of the peritoneal lining (arrowhead) and nodularity in the mesenteric fat (arrow). (b) Axial contrast-enhanced CT image of the pelvis shows ascites without a discrete ovarian mass. The patient underwent exploratory laparotomy for presumed ovarian cancer. Histologic findings from peritoneal biopsies yielded caseating granulomas consistent for peritoneal tuberculosis.

View larger version (124K): [in a new window]   Figure 25b.  Peritoneal tuberculosis in a 45-year-old woman with abdominal distention. (a) Axial contrast-enhanced CT image of the lower abdomen shows a moderate amount of ascites. There is enhancement of the peritoneal lining (arrowhead) and nodularity in the mesenteric fat (arrow). (b) Axial contrast-enhanced CT image of the pelvis shows ascites without a discrete ovarian mass. The patient underwent exploratory laparotomy for presumed ovarian cancer. Histologic findings from peritoneal biopsies yielded caseating granulomas consistent for peritoneal tuberculosis.