Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 3, 2010, pp. 403-404

Journal of Cancer Research and Therapeutics, Vol. 6, No. 3, July-September, 2010, pp. 403-404

Letter to the Editor

Sandwich sign in mesenteric lymphoma

Noushif Medappil, R Reghukumar

Department of General Surgery, Thiruvananthapuram Medical College, Kerala, India

Correspondence Address:Noushif Medappil, 'Grace', Thenhipalam, Malappuram, Kerala, India, noushif@gmail.com

Code Number: cr10104

PMID: 21119294

DOI: 10.4103/0973-1482.73333

Sir,

Mesenteric lymphomas are asymptomatic in the early stage and present late in the course of disease. They have typical imaging findings among which ′sandwich sign′ is the most specific.

A 31-year-old female presented with self detected upper abdominal lump of one week duration. There was no associated pain, bowel symptoms, fever, weight loss or night sweats. Clinical examination revealed a firm irregular mobile 10 × 8 cm intra abdominal mass in epigastrium and umbilical region. Laboratory parameters were within normal limits. CT scan of abdomen showed multiple large rounded and ovoid, homogenous soft tissue density mass lesions involving the small bowel mesentery measuring up to 5 cm in size, some of which were confluent, with no evidence of calcification or central necrosis. The lesions were encasing the mesenteric vessels without significant luminal narrowing (sandwich sign). Para aortic, inter aortico caval and para caval lymphnodes were enlarged [Figure - 1]. Mesenteric lymph node biopsy was suggestive of follicular lymphoma [Figure - 2].

Mesenteric lymphadenopathy can result from lymphoma, sarcoma, acquired immunodeficiency syndrome (AIDS), tuberculosis, Whipple′s disease and post transplant lymphoproliferative disorder (PTLD), of which non Hodgkin′s lymphoma is the most common cause. ^[1] Mesenteric lymphomas grow to a large size and cause bulky adenopathy encasing mesenteric vessels without producing clinical symptoms. On CT or ultrasound imaging, the confluent mesenteric nodes resemble two halves of a sandwich and the tubular mesenteric vessels and perivascular fat resemble the sandwich filling. ^[1],[2] This sign is also seen in PTLD, which should be considered in patients who have undergone transplantation. PTLD is characterized by gastrointestinal involvement and the absence of superficial nodal disease. Other causes of mesenteric adenopathy have typical clinical symptoms and do not produce the large bulky adenopathy that results in the sandwich sign. ^[1],[3] Mesenteric lymphomas can also show retroperitoneal adenopathy and increased attenuation of the mesentery (misty mesentery). ^[1],[2]

In our case, the absence of symptoms, imaging findings of mesenteric soft-tissue nodules producing sandwich sign and retroperitoneal lymph nodes made lymphoma the most likely diagnosis. The sandwich sign is specific for mesenteric lymphoma (typically non-Hodgkin′s) unless the patient has had a transplant.

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