Dalakta diffüz büyük B hücreli lenfoma

Özet

Dalakta diffüz büyük B hücreli lenfoma, primer splenik kitle biçiminde veya sistemik lenfomanın dalak tutulumu olarak görülebilir. Klinik belirtiler tümörün yeri, büyüme hızı ve dalak fonksiyonundaki bozulmaya bağlıdır; evre I hastaların sağkalımı evre III'e göre daha iyidir. Portal venöz kontrastlı BT, hipoattenüe kitleleri, yaygın infiltrasyonu, nodal zincirleri ve karaciğer gibi ekstranodal bölgeleri anatomik olarak haritalar. DLBCL'de PET/BT hastalık evrelemesinde önemli rol oynar. Büyük nekrotik lezyon, infarkt veya enfeksiyonla karıştırılırsa hastalık yükü ve komplikasyonlar yanlış değerlendirilebilir.

Faz ve pencere

Portal tanısal

Dalak parankimi homojenleştiği için lezyonlar portal venöz fazda çoğunlukla hipoattenüe görünür; tek büyük kitle, çoklu odaklar veya diffüz büyüme biçiminde olabilir. Kitle içinde nekroz görülebilir; aynı faz karın içi nodal ve organ tutulumlarını araştırmaya uygundur.

Önerilen pencereler: Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40).

BT bulguları

• Tek, iyi seçilen büyük solid splenik kitle veya dalak parankimini genişleten infiltratif kitle görünümü.
• Çok sayıda yuvarlak ya da düzensiz hipoattenüe odak; lezyonlar portal fazda normal dokudan ayrılır.
• Diffüz formda belirgin splenomegali ve hafif heterojen parankim; odaksal kitle seçilemeyebilir.
• Büyük kitlelerde santral düşük atenüasyon nekrozla uyumlu olabilir.
• Dalak dışı nodlar, karaciğer lezyonları ve diğer ekstranodal odaklar hastalık dağılımını belirler.
• Dalak dışı bulgu yokluğu BT ile primer splenik kökeni kanıtlamaz; histoloji ve evreleme gerekir.

Ölçütler ve sınıflamalar

Histolojik sınıflama

WHO-HAEM5'te DLBCL ayrı bir histolojik kategori olarak yer alır; dalağın tutulumu tek başına yeni bir histolojik alt tip oluşturmaz.

Evreleme

DLBCL FDG tutan bir lenfomadır; güncel Lugano yaklaşımı başlangıç evrelemede FDG PET/BT'yi tercih eder. Kontrastlı BT anatomik haritalama ve gerektiğinde boyut ölçümü için tamamlayıcıdır.

Normalde

Kontrastlı portal venöz faz BT görüntülerinde sağlıklı dalak parankimi homojen kontrastlanır; hipodens lezyonlar bu faza dayanarak değerlendirilmelidir. Fokal hipoatenüasyonun farklı fazlarda devam edip etmediğini ve ardışık kesitlerde aynı yerde görünüp görünmediğini incele. Tek odaklı görüntüde damar kesitlerini ve dalak yarıklarını kitle sanmamak için ardışık kesitlere bak.

Ayırıcı tanı

Splenik marjinal zon lenfoması

daha çok homojen splenomegaliyle ve daha az belirgin kitle paterniyle karşımıza çıkar.

Splenik metastaz

bilinen primer tümör ve karaciğer/akciğer/periton gibi diğer metastaz alanları destekler.

Splenik apse

sıvı atenüasyonu, çevresel kontrastlanma ve gaz odağı enfeksiyonu düşündürür.

Splenik infarkt

kapsüle taban veren kama biçimli, perfüzyonsuz alan tipiktir.

Primer splenik anjiyosarkom

çok nadir ve agresif bir vasküler tümördür; görüntülemede benign hemanjiyomu taklit edebilir ve spontan ruptür ile hemoperitoneum riski taşır.

Tuzaklar

• Arteriyel fazda normal dalak sinüzoidlerinin yamalı kontrastlanması kitle gibi görünebilir; odak portal fazda kalıcı mı diye kontrol et.
• Diffüz lenfoma belirgin kitle oluşturmadan yalnız organı büyütebilir; normal görünümlü fokal inceleme hastalığı dışlamaz.
• İmmünsüprese hastada çoklu küçük dalak odakları lenfoma kadar fungal mikroapseleri de düşündürür; klinik ve PET/histoloji ayrımda yardımcıdır.

Kendini dene

1. Portal fazda dalakta tek büyük, hipoattenüe solid kitle ve merkezinde düşük atenüasyon görülüyor. En uygun olasılık hangisidir?

   • Splenik diffüz büyük B hücreli lenfoma
   • Dalak infarktı
   • Splenik kist
   • Splenik hemanjiyom
   Cevabı göster

   Splenik diffüz büyük B hücreli lenfoma. Lenfoma tek kitle veya çoklu odak şeklinde olabilir; büyük tümörlerde nekroz bulunabilir. İnfarkt kama biçimli, kist sıvı yoğunluklu ve kontrastlanmayan, hemanjiyom ise vasküler kontrast paternli olmalıdır.

2. Dalakta kitle saptanan hastada evreleme için BT'de hangi ek bölge mutlaka taranmalıdır?

   • Abdominal nodal ve ekstranodal alanlar
   • İzole el bileği eklemi
   • Paranazal sinüs ostiumları
   • Safra kesesi duvarı
   Cevabı göster

   Abdominal nodal ve ekstranodal alanlar. Nodal istasyonlar ve karaciğer dahil ekstranodal alanlar sistemik yayılımı gösterebilir. Abdominal lenf nodları ve karaciğer tutulumu hastalık yayılımını gösterebilir.

İlgili konular

• Lenfomada dalak tutulumu

Kaynaklar

Bu sayfadaki 41 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 7 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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