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The Limit of Ultrasonographic Examination in Abdominal Masses Diagnosis

Prișcă R¹ , Patraulea F ¹, Derzsi Z¹ , Gozar H²

¹Emergency Clinical County Hospital of Târgu-Mureș, Departament of Pediatric Surgery and Orthopedics, Târgu-Mureș, Romania

²University of Medicine and Pharmacy Târgu-Mureș, Departament Of Pediatric Surgery and Orthopedics, Târgu-Mureș, Romania

 

Correspondence:

Prișcă Radu-Alexandru

Departament of Pediatric Surgery and Orthopedics

Emergency Clinical County Hospital of Târgu-Mureș

Gheorghe Marinescu 50

Târgu-Mureș, Mureș, Romania

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Burkitt lymphoma is an aggressive form of non-Hodgkin cell B lymphoma, which most commonly occurs in children and young adults. It presents with nonspecific symptoms in cases with abdominal localization, and it can simulate various diseases. The aim of this paper is to demonstrate the limits of ultrasonography in diagnosis of abdominal masses, exemplifying with the case of an 8 years old child, with symptoms of an acute abdominal condition, in which numerous ultrasounds performed during hospitalization were not able to lead the diagnosis to a tumor disease, and even more, they delayed the diagnosis.

Keywords: Burkitt lymphoma, appendicitis, ultrasonography, computer tomography

 

Introduction

Burkitt lymphoma is described as an aggressive form of non-Hodgkin cell B lymphoma, which most commonly occurs in children and young adults [1]. It is responsible for about 25% of lymphomas diagnosed in childhood. The extranodal localization of lymphoma is usually the small intestine, with a tendency to occur in the ileocecal region [2]. It disclose nonspecific clinical symptoms, including abdominal pain, vomiting, gastrointestinal bleeding, and acute abdomen syndrome can simulate acute appendicitis or intussusception. At ultrasound examination, Burkitt's lymphoma can occur in various ways, depending on the location of the lesion [3]. It originates from lymph follicles of the terminal ileum submucosa spreads along the wall, which on US examination is manifested by fragmentary thickening with low echogenicity and a blurred layered structure [4]. The aim of this presentation is to emphasize the limitation of ultrasonography in abdominal Burkitt lymphoma diagnosis.

Case presentation

A 8 years old male patient was presented to our emergency service, accusing colicative abdominal pain with right iliac fossa irradiation, nausea, vomiting and anorexia, started a day before, according to mother's statement. Clinical examination reveals a right iliac sensitive, immobile and irregular tumor, with a size about 8/6 cm. Laboratory findings were suggestive for an infectious process, with a count of leukocytes of 15.98 103/µl. Taking into account the data collected, the suspicion of periapendicular inflammatory mass was raised, and an abdominal ultrasonography was requested. The result confirms the presumed diagnosis of periappendicular mass (Fig. 1), and the patient was hospitalized in our service for specific treatment.

Figure 1: Ultra sonographic image revealing the intraabdominal mass

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Standard protocol for complicated acute appendicitis was applied, consisting of conservative management, electrolyte rebalance, broad-spectrum antibiotherapy, anti-inflammatory, analgesic and antipyretic medication. During hospitalization, the tumor mass was followed by serial ultrasound that revealed slight size reduction, patient's general condition has improved and the leukocytes reached the value of 9.78 103/µl. The ultrasound examinations were done by four distinct examinators. He was discharged after 15 days, on home antibiotic treatment and weekly follow-up.

Since weekly clinical examination revealed no regressive character of the tumor, a computer tomography examination was done. It described a seemingly expansive process located at enteral level with dilated lumen and thicken walls with a cranio-caudal diameter of 77 millimeters (Fig. 2). CT imaging details could not detect relevant signs of periapendicular inflammatory mass.

Figure 2: CT scan image - the tumor appears as incorporating an intestinal loop, not being able to appreciate its relationship with adjacent organs

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Considering the CT scan results, the patient was referred to the pediatric oncology department. After a multidisciplinary consult between pediatric oncologists, pediatric surgeons and pathologists, surgery was decided for therapeutic and diagnostic purposes. Median supraombilico-pubic celiotomy was performed. Intraperitoneally, a solid mass which totally incorporated an ileal loop on a length of about 8 cm and the wall of the sigmoid colon for approximately 5 cm was detected (Fig. 3). The ureter, posterior bladder wall and posterior peritoneum were affected by the peritumoral inflammatory process. A biopsy was taken and sent to histopathology for extemporaneous examination, which revealed a malignant tumor. The right ureter and bladder wall were released by blunt dissection. The tumor, the ileal loop and the sigmoid were resected en-bloc. Entero-enteral anastomosis and left side colostomy were performed.

Figure 3: Intraoperative aspect of the tumor

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Postoperative, the patient was transferred to the pediatric oncology service for specific treatment. Final histopathologic diagnoses result was Burkitt's lymphoma and confirmed the safety limits of oncological surgical resection. Standard oncological therapy according to protocols in use was performed, opting for aggressive chemotherapy because the patient had a value of LDH> 500 U/ l.

Discussions

Burkitt’s lymphoma is an aggressive disease and urgent imaging is required to assess initial tumour bulk, compromise of vital organs, and for follow-up of patients during therapy. Ultrasound is used initially if the patient presents an abdominal or pelvic mass. CT scan would often follow to allow a more global assessment for bowel and visceral involvement as well as tumor staging. However, tissue biopsy diagnosis is definitive [5]. The distal small bowel, caecum, and appendix are common sites of involvement of non-Hodgkin’s lymphoma including Burkitt lymphoma, on the other side the involvement of the proximal gastrointestinal tract occurs rarely. Abdominal and pelvic disease is seen at presentation with the ileocaecal region as the most common site [6]. Terminal ileum is commonly affected because of increased lymphoid tissue [7]. Focal mass or diffuse bowel wall thickening is seen commonly on imaging, with cavitations/abscess formation being uncommon [5,6]. Our case showed similar features with no proximal obstruction despite significant luminal compromise. Because of its disposition and clinical features, it can often be confused with an acute inflammatory process as complicated appendicitis.

Marjerrison et al. demonstrated that US provides more accurate staging of Burkitt lymphoma than clinical examination, and abdominal involvement is very common for this condition [8], but perhaps they didn’t take into account the examinator’s experience. In our case, the patient was examined by four distinct examinators, but none raised the suspicion of an abdominal tumor.

A particularity of this case was that, especially because of the location of the tumor in the right iliac fossa, it’s behavior was like a classical complicated appendicitis, which imposed the conservative management, and delayed diagnosis. In unexperienced hands, abdominal ultrasonography has a very limited role in abdominal masses diagnosis. Every abdominal mass detected by clinical examination should be considered for CT scan.

 

 

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