Pancreatic involvement in acute lymphoblastic leukaemia is rare [1, 2, 3] and obstructive jaundice secondary to a pancreatic mass as a primary presentation of acute lymphoblastic leukaemia has not been reported in the surgical literature. Acute lymphoblastic leukaemia typically presents with symptoms of bone marrow failure such as fatigue, lethargy, infections, bruising or bleeding. Approximately half the patients will have lymphadenopathy, splenomegaly or hepatomegaly at presentation. Full blood count may reveal cytopenias or (as in this case) a raised white cell count due to circulating blast cells. Although long term survival in adults is less good than children, acute lymphoblastic leukaemia is an important diagnosis to make because it is highly chemo-sensitive, with 91% of adults achieving complete remission following induction therapy in the recent UK ALL XII trial [4]. If suspected, a haematological referral is required since the diagnostic procedure of choice is a bone marrow aspirate and trephine.

http://www.blogger.com/www.joplink.net/prev/201001/19.html

A four-year-old boy with sacrococcygeal endodermal sinus tumour. Blood culture grew Peiciliomyces lilacinus. (a) CT lungs showed tiny nodular lesions, presumed involvement of lungs by fungus. (b) After two weeks of anti-fungal therapy, CT showed the lung lesions had increased in size and number. (c) CT lungs after two months of continuous anti-fungal therapy showed more and larger lesions, which were likely to be metastases.

http://www.blogger.com/www.biij.org/2006/2/e21/

Fungal abscesses in intrabdominal organs. (a) A two-year-old girl with leukaemia and Aspergillus sepsis. CT showed multiple hypodense lesions in both kidneys. (b) A six-year-old girl with leukemia and presumed fungal sepsis. CT revealed multiple hypodense lesions in the liver and spleen. Fungal elements were isolated from liver biopsy, but the species could not be identified. (c) A three-year-old boy with leukemia with presumed fungal sepsis. CT abdomen showed multiple hypodense splenic lesions No fungi were isolated from biopsy.

http://www.blogger.com/www.biij.org/2006/2/e21/

Fungal sinusitis of a four-year-old girl with myeloid leukaemia. CT of the sinuses revealed opacification of the maxillary sinuses with bone destruction of the medial wall. Mucor species was isolated from maxillary sinus washout.

http://www.blogger.com/www.biij.org/2006/2/e21/

A 10-year-old girl with leukemia and biopsy proven Aspergillus infection of the lung. She later developed a mycotic aneurysm in the chest. (a) CT showed a cavity with a “crescent sign” in keeping with an Aspergilloma. The lesion was excised. (b) Chest radiograph two months later showed a round opacity in the right lung. (c) CT revealed an aneurysm of the lower lobe branch of the right pulmonary artery.

http://www.blogger.com/www.biij.org/2006/2/e21/

An 18-month-old girl with leukaemia and Aspergillus isolated from the lung. (a) Chest radiograph showed a round opacity behind the heart. (b) CT revealed a cavitating nodule in the left lower lobe.

http://www.blogger.com/www.biij.org/2006/2/e21/

Neck CT scan demonstrating large thyroid lymphoma

http://www.google.com.eg/imgres?imgurl=http://www.ispub.com/ispub/ijorl/volume_8_number_1_7/non_hodgkin_s_lymphoma_of_the_neck_an_important_lesson_in_early_diagnosis/lymphoma-fig1.jpg&imgrefurl=http://www.ispub.com/journal/the_internet_journal_of_otorhinolaryngology/volume_8_number_1_7/article_printable/non_hodgkin_s_lymphoma_of_the_neck_an_important_lesson_in_early_diagnosis.html&usg=__XWpv3tJWMhvLAMqTruQS-s4Vu0Y=&h=531&w=528&sz=30&hl=en&start=17&itbs=1&tbnid=UB6bVtT8GfYHQM:&tbnh=132&tbnw=131&prev=/images%3Fq%3Dlymphoma,ct%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1

Marked FDG uptake throughout the mediastinum and in the right axilla/supraclavicular area corresponding to bulky adenopathy on the CT portion of the exam compatible with malignancy.

Chemotherapy (CHOP). Follow-up PET/CT ordered following 1 cycle.

Complete resolution of abnormal FDG activity compatible with a good response to therapy. Focal apparent FDG activity in the left supraclavicular area was not present on the uncorrected images compatible with an attenuation correction artifact. Bulky adenopathy is still present, but no increased FDG activity is present.

Discussion:

This case demonstrates the power of PET/CT to assess response to therapy soon after initiation. The strength of the modality is in the ability to assess an early response to therapy by assessing the metabolic changes. As shown in the second set of images, there is still considerable soft tissue abnormality present, but no increased FDG activity. Evidence suggests that for non-Hodgkin’s lymphoma, patients are to be categorized as responders (better overall survival) only if there is minimal or no residual FDG activity on follow up exams after therapy initiation. The metabolic changes can be assessed after one cycle of chemotherapy, whereas the soft tissue component will take much longer to regress and may remain indefinitely.

http://www.google.com.eg/imgres?imgurl=http://www.babradiology.com/Assets/Images/MRI/CS2_Lymphoma_2.jpg&imgrefurl=http://www.babradiology.com/index.cfm/fuseaction/Doctors.Lymphoma/Doctors-Lymphoma.htm&usg=__zlHsFFrm_2Ru8gdRmI3g6wW-7Zc=&h=313&w=419&sz=106&hl=en&start=15&itbs=1&tbnid=ZS44MmId3CXiJM:&tbnh=93&tbnw=125&prev=/images%3Fq%3Dlymphoma,ct%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1

Esophageal involvement by mediastinal lymphoma. CT scan in a patient with large cell lymphoma of the mediastinum shows extensive mediastinal adenopathy compressing the esophagus (arrowhead) and superior vena cava (arrow). (Courtesy of Duane G. Mezwa, MD, Royal Oak, MI.)

http://www.google.com.eg/imgres?imgurl=http://download.imaging.consult.com/ic/images/S1933033206705420/gr11-midi.jpg&imgrefurl=http://imaging.consult.com/image/topic/dx/Gastrointestinal%3Ftitle%3DEsophagus,%2520Other%2520Malignant%2520Tumors%26image%3Dfig11%26locator%3Dgr11%26pii%3DS1933-0332(06)70542-0&usg=__uTZTDQZoEVoHH4U-pWmSd-gqSmo=&h=194&w=200&sz=6&hl=en&start=16&itbs=1&tbnid=krD-8l90xPz2yM:&tbnh=101&tbnw=104&prev=/images%3Fq%3Dlymphoma,ct%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1

CT non contrast
ADC MAP

DWI

Axial flair

MR perfusion CBV map

findings:Multiple enhancing mass lesions with increased choline and restricted diffusion and minimally decreased perfusion.

D.D.:Metastases, abscesses, lymphoma, demyelination

Discusion:Lymphoma with high cellularity may show restricted diffusion and iso or slightly decreased perfusion.

home.comcast.net/~dshibata2/brain3.html

CT showed lymphadenopathy above and below the diaphragm and a lesion in L-3 vertebra consistent with a compressed or pathological fracture. The final diagnosis of lymphoma was made after biopsy of enlarged right inguinal lymph nodes and by bone marrow biopsy. There are areas of increased pathological activity in the left supra and infraclavicular region, the upper and mid-mediastinum, the right pulmonary hilus, D-8, D-12, L-2, L-3, L-4 vertebrae and the left inguinal region.

http://www.blogger.com/www.gehealthcare.com/.../products/lymphoma.html

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.

radiographics.rsna.org/.../1/197/F38.expansion

orbital lymphoma

This is 68 year old man with bilateral propotosis and lymphadenopathy. CT images are characterstic of orbital lymphoma.

sumerdoc.blogspot.com/2009/11/orbital-lymphom...

PET/CT for staging of Hodgkin's lymphoma. CT showed involvement only in right neck. PET/CT (A: coronal views; B: transverse views; MIP = maximum-intensity projection) showed that normal-size (9-mm) upper mediastinal lymph node was clearly metabolically active, changing stage from I to II. This finding is relevant if consolidative radiation after chemotherapy is planned. Incidental normal scalene muscle uptake was noted on coronal PET.

http://jnm.snmjournals.org/cgi/content-nw/full/48/1_suppl/19S/FIG1

Primary right atrial lymphoma. Magnetic Resonance Imaging # Description : Magnetic Resonance Imaging of primary right atrial lymphoma

Primary right atrial lymphoma. CT scan of jugular veins # Description : Contrast CT scan showing extension of the primary right atrial lymphoma through the superior vena cava up to the right jugular vein that is occluded while the contra-lateral jugular vein is opened.

http://www.google.com.eg/imgres?imgurl=http://www.escardio.org/communities/EAE/CasePortal/EAECasePictures/029787ae-5c46-4350-b4ce-0e7b42e936cf/CTJugular-169-5.jpg&imgrefurl=http://www.escardio.org/communities/EAE/CasePortal/Pages/Case169.aspx&usg=___kI2LbT_YeLEcTKy8g-6AT89IeQ=&h=526&w=609&sz=43&hl=en&start=5&itbs=1&tbnid=V2Dwckr9VGW4iM:&tbnh=117&tbnw=136&prev=/images%3Fq%3Dlymphoma,ct%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1

Figure 1. 55-year-old man with recurrent mantle cell lymphoma. CT shows symmetric circumferential thickening of the distal trachea (arrows).

Figure 2. 55-year-old man with recurrent mantle cell lymphoma. Axial PET/CT shows intense activity in the suspected area around the distal trachea.

Figure 3. 55-year-old man with recurrent mantle cell lymphoma. Full body coronal reformatted PET scan shows abnormal intense tracheal uptake and other areas of expected uptake.

http://www.google.com.eg/imgres?imgurl=http://radiology.casereports.net/index.php/rcr/article/viewFile/194/457/2885&imgrefurl=http://radiology.casereports.net/index.php/rcr/article/viewArticle/194/457&usg=__zLXw7ESbta9p_uSKaSTQl7kFkT8=&h=311&w=400&sz=21&hl=en&start=3&itbs=1&tbnid=D7omNl00vprLIM:&tbnh=96&tbnw=124&prev=/images%3Fq%3Dlymphoma,ct%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1

The baseline CT's showed lypmhadenopathy in the left inguinal node and the left iliac fossa. The PET Scan showed increased metabolism in both of these lesions, however the Gallium scan only showed uptake in the inguinal lesion. The Bone scan was normal.

http://www.google.com.eg/imgres?imgurl=http://www.rad.kumc.edu/nucmed/images/pet/lymphoma_ct_chest_0304.jpg&imgrefurl=http://www.rad.kumc.edu/nucmed/clinical/pet_lymphoma_cts.htm&usg=__LVcDBlJY5SirJYEwvrKgRjTF1uo=&h=512&w=512&sz=39&hl=en&start=2&itbs=1&tbnid=VmxothN7GHc01M:&tbnh=131&tbnw=131&prev=/images%3Fq%3Dlymphoma,ct%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1

This abdominal CT scan shows tumor masses (malignant lymphomas) in the area behind the peritoneal cavity (retroperitoneal space).

http://www.google.com.eg/imgres?imgurl=http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1186.jpg&imgrefurl=http://www.nlm.nih.gov/medlineplus/ency/imagepages/1186.htm&usg=__lqPUL516fpMAxCSOyYehx0pJHlA=&h=226&w=306&sz=11&hl=en&start=1&itbs=1&tbnid=DULemepbc2NL4M:&tbnh=86&tbnw=117&prev=/images%3Fq%3Dlymphoma,ct%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1

Transverse CT image in a 9-year-old girl with myelogenous leukemia and typhlitis demonstrates marked wall thickening in cecum (arrow) and terminal ileum (arrowhead).

radiology.rsna.org/content/240/3/623.full

Leukaemia

Leukaemia.
Leukaemia is a process involving the uncontrolled proliferation of the blood forming cells. The name of the particular leukaemia comes from the type of white cells that proliferate. Theories of its generation involve the idea of delayed maturation. That is if an ancestor cell in the bone marrow goes thorugh a few more cell divisions before forming the recognisable precursor adult cell then the number of those cells will increase. Research into the multiple factors in cell genetics is proceeding so fast that it is more appropriate to recommend the nearest search engine to enquiring minds.
The visible evidence of Leukamia usually follows an aggressive or a long standing abnormality. The radiologic expression of the disease is of an enlargement of the soft tissue mass of the bone marrow with loss of bone, particularly at the metaphyses where bone turnover is a little higher. The bone cortex amy also be eroded from below, giving a scalloped appearance. There may be other clues, such as splenic anlargement, visible on a radiograph of the pelvis. Lytic areas, chloromas, are rare, but are due to local masses of leukaemic cells.
The stem cell theory suggests that some cases of myelofibrosis might be included in this document, but the condition is commoner in polycythaemia.

Figure 1:This view is taken from an intravenous urogram. It shows a large, bounded, soft tissue density in the left hypochondrium which extends down to the left iliac crest. The density in the right hypochrondium, the liver density, also extends lower than is usual. Both kidneys are also lower in the abdomen than is usual, but appear grossly normal. There is no change in the visible bone structure and the patient has not lived abroad.
D=leukaemia with splenomegally

Figure 2:Clinical presentation:55 year old man with acute myloid leukaemia and recent neck pain.
The neck is flexed in both views. The first view shows some increase in the thickness of the anterior paravertebral soft tissue in a patient who isn't swallowing. There is some bone-destruction of the anterior inferior margin of the 5th cervical vertebra, indicated by the absence of a similar osteophyte to that of the upper margin of the 6th cervical vertebra.
The later view shows local angulation of the cervical spine, secondary to further bone destruction in C5 and loss of the C5/C6 disc-space. The anterior soft tissue swelling is increased.
D=Pyogenic discitis&osteomyelitis

Figure 3:Clinical presentation:Adult male with anaemia.
The particular feature is the low density of pubis and sacrum with relative sparing of ilia and femora. Patchy bone loss can be seen in both ischia and the proximal metaphyses of both femora, coarsening the visible bone architecture. There is a fairly well-defined area of patchy bone loss in the upper part of each pubic bone centred around the mid-line. Some cortical scalloping of the cortex of pubic bones is present. The density of the ilia is probably normal, except adjacent to the sacro-iliac joint margins where some more extensive destruction is seen on the right side. The density of Sacrum and vertebrae is reduced by what appears to be a patchy destructive process.
The appearance is of a patchy lytic bone process that is predominatly mid-line. This might suggest a process that affects active bone marrow, which is often restricted in the adult to the axial skeleton and the medulla of adjacent parts of long bones.
D=lk inf

Figure 4:Clinical presentation:A 13 year old boy with anaemia.
There is a patchy destructive process, prodominantly in the medulla of the distal metaphyses of the left radius and ulna. The process is more marked in the distal metaphysis of the left ulna. More proximally, there is a visible reaction over the diaphyses The bone cortex is elevated and thickened. This takes the form of a thick line, separated from the cortex of the diaphysis of the right radius. A similar appearance is seen over the distal metaphyses of both humeri.
D=lk infitration

Figure 5:Clinical presentation:A 45 year old man with anaemia.
There is a patchy destructive process, prodominantly in the medulla of the distal metaphysis of the right humerus. The process undermines and thins the cortex
D=lk infiltration