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British Journal of Radiology (2004) 77, 512-515
© 2004 British Institute of Radiology
doi: 10.1259/bjr/58044417
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Case report

Appearance of uterine cervical lymphoma on MRI: a case report and review of the literature

M S Thyagarajan, MD M J Dobson, FRCP, FRCR and A Biswas, MRCP, FRCR

Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston PR2 9HT, UK

Correspondence: Dr M J Dobson


   Abstract
Top
 Abstract
Introduction
 Case report
 Discussion
 References
 
We present the appearances on CT and MRI of a case of non-Hodgkin's lymphoma (NHL) of uterine cervix. A 41-year-old woman presented with a short history of urinary symptoms and menorrhagia. Previous cervical smears were normal. Clinically, the cervix was replaced by a huge ulcerating mass. Biopsy showed malignant high grade B-cell NHL. T2 weighted MRI of the pelvis showed a 12 cm intermediate signal mass replacing the cervix, with infiltration of the vagina and left parametrium, and bilateral internal iliac lymphadenopathy. Whole body CT imaging showed lymphoma in the kidneys and pancreas, the latter associated with biliary obstruction. The patient is in complete remission 7 months post chemotherapy, radiotherapy and stenting of biliary stricture. The success of the cervical cancer screening programme has lead to a reduction in the number of cases of advanced cervical carcinoma and the presence of an unusually large homogeneous cervical tumour, with relatively scant necrosis should prompt suspicion of a less common histology such as NHL.


   Introduction
Top
 Abstract
 Introduction
Case report
 Discussion
 References
 
Lymphoma of the uterine cervix is uncommon [1–5]. Cervical involvement in multiorgan disease is more common than primary lymphoma [2, 3, 5–7]. Intermittent vaginal bleeding is the most common symptom. As these tumours originate within the cervical stroma, the epithelium is initially preserved and therefore, cytology often normal [8]. Accurate staging is important, though the prognosis is good even for advanced disease [8–14]. We describe the CT and MRI features of a rare case of uterine cervical lymphoma with further disease in the kidneys and pancreas.


   Case report
Top
 Abstract
 Introduction
 Case report
Discussion
 References
 
A 41-year-old woman presented with a short history of urinary symptoms and menorrhagia. Her last cervical smear, performed 3 years previously, was normal. On clinical examination there was a large pelvic mass which completely replaced the cervix. Histology revealed a malignant high grade B-cell non-Hodgkin's lymphoma (NHL). MRI of pelvis showed a 12 cm cervical mass, isointense to muscle on T1 weighted images and mixed intermediate and high signal on T2 weighted images (Figure 1Go). There was breach of the anterior aspect of the left vaginal wall with infiltration of the left parametrium. There was also infiltration of the outer aspect of the bladder wall, though no apparent mucosal involvement. Following diagnosis of high grade NHL, staging was undertaken with thoracoabdominal CT. In addition to the cervical mass, this showed multiple, bilateral, hypodense renal masses, heterogeneity and enlargement of the pancreas, and biliary dilation consistent with lymphoma at these sites (Figure 2Go). Liver function tests showed an obstructive pattern and endoscopic retrograde cholangiopancreatography (ERCP) confirmed a stricture of the lower common bile duct, which was duly stented. Apart from the enlarged pelvic sidewall lymph nodes, there was no other nodal enlargement. Final diagnosis, therefore, was stage 4 high grade NHL. She was treated with 8 cycles of chemotherapy followed by radiotherapy to the pelvis. Follow-up CT scans showed complete remission of the renal and pancreatic disease, with a small residual cervical mass, likely to be fibrotic. The patient remains in remission 7 months post treatment.



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  		Figure 1. (a) Sagittal T2 weighted MR images showing a large, mostly homogeneous, intermediate signal mass (M), and high signal possibly representing areas of necrosis (arrowheads). Bladder (B), rectum (R), endometrium (arrow). (b) Axial T2 weighted MR image through the mass shown in (a) (M). The left anterior vaginal wall is breached (solid arrow), compared with the intact right vaginal wall (arrowheads).

 


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  		Figure 2. (a) Axial CT image after one course of chemotherapy showing a hypodense mass occupying the cervix (C). The left ovary contained benign cysts (asterix). Bladder (B), rectum (R). (b) CT image showing diffuse bulkiness of the pancreas (P) and dilatation of the distal common bile duct (arrow). Aorta (a), inferior vena cava (IVC), thoracic vertebra (TV), liver (L). (c) CT image caudal to that shown in (b), showing an ill-defined mass in the pancreatic head (P). There are multiple, hypodense bilateral renal masses typical of lymphoma (M). Thoracic vertebra (TV).

 

   Discussion
Top
 Abstract
 Introduction
 Case report
 Discussion
References
 
Cervical lymphoma is rare, comprising less than 1% of cervical malignancies [6, 14], although it is the most common site of lymphoma (primary or secondary) in the female genital tract [15]. The age at presentation ranges from 20 years to 80 years [5, 8], with the median age varying from 40 years to 59 years [8, 11]. The prognosis of cervical lymphoma is good, even when locally advanced at presentation [3, 8–10, 12, 16, 17]. Intermittent vaginal bleeding or spotting is the usual presentation [8, 9, 18], although symptomatic pelvic mass and/or urinary symptoms [3, 12] can be other modes of presentation.

Cervical cytology is often normal as these tumours arise from cervical stroma, and squamous epithelial lining is preserved initially [2, 3, 18, 19]. A deep cervical biopsy is essential for diagnosis [9, 10, 20]. Diffuse cervical enlargement, averaging 4 cm in diameter is the most common appearance [8, 10, 14]. Less commonly, there may be a polypoidal or multinodular mass or a submucosal mass mimicking leiomyoma [10, 14, 21].

Cross-sectional imaging (CT, MRI) is required for staging the extent of disease. In patients with multiorgan disease the pattern of change may be typical of lymphoma, allowing a confident pre-biopsy diagnosis, although, for treatment and prognostic purposes, biopsy is mandatory to determine the precise histological subtype. MRI is superior to CT as an adjunct to clinical evaluation of invasive cervical cancer, providing more complete assessment of morphological risk factors and staging, important in patient prognosis and treatment planning [23, 24]. Both techniques are comparable in terms of assessing lymph node size, though lymph node specific iron oxide contrast agents promise an improvement in lymph node characterization on MR imaging [25–27]. CT is currently the more accurate technique for assessing pulmonary involvement.

There have been few reports of MRI and CT of uterine lymphoma, some predominantly involving only uterine body and/or cervix [1, 3, 4, 16, 20, 28, 30]. Micketic et al [5] reported that CT features of cervical lymphoma are similar to those of other primary pelvic neoplasms with diffuse uterine enlargement and lobular contour alteration, often mimicking fibroids. It has been reported that cervical lymphoma is best defined on T2 weighted images or contrast-enhanced T1 weighted images [3, 13, 17]. Uterine lymphoma on MRI is usually homogeneous in signal, lacks clear margination and shows moderate, uniform enhancement unlike degenerative leiomyoma, endometrial carcinoma or large cervical tumours [17, 20, 28]. Architectural preservation and an intact endometrium have been reported to be characteristic features of uterine lymphoma [3, 16, 20, 29]. Also, high signal for suggesting necrosis are infrequent or scant as in our case [7].

On MRI, the findings of a large cervical mass, invasion of vagina and parametrium and pelvic lymph adenopathy are not uncommon in cancer cervix. However, as stated above, our findings of a predominantly homogeneous, huge mass replacing the cervix, with only scanty necrosis, should suggest lymphoma [7]. The subsequent features on CT, especially the renal changes, are almost pathognomonic.

In line with previous reports, our patient responded well to a combination of chemotherapy and pelvic irradiation. MRI is useful in the follow up of cervical lymphoma [6, 30], and this would probably also be the case for multiorgan disease in the absence of pulmonary changes. Due to resource limitation, however, CT is more often the modality of choice for follow up and in our case, has clearly demonstrated a sustained response to therapy.

In summary, we have described cross-sectional features which may help to distinguish uterine cervical lymphoma from carcinoma, a distinction which carries marked differences in terms of prognosis and management.


   Acknowledgments
 
The authors acknowledge Emma Jane Ormrod for her secretarial support.


   Footnotes
 
Address correspondence to Dr M J Dobson. Back

Received for publication March 26, 2003. Revision received July 16, 2003. Accepted for publication September 10, 2003.


   References
Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 

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This Article
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Right arrow Articles by Thyagarajan, M S
Right arrow Articles by Biswas, A

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