Ultrafest sandwich sign

1. Classical Sandwich Sign In Mesenteric Lymphoma on Ultrasound Shekhar khanpara 1 st year resident Mp shah medical college Under guidance of dr. n.u bahri

2. A 14 year female presented with the complains of fever and night sweats since 2 months. No complain of cough, expectoration, abdominal pain, weight loss, anorexia, nausea, vomiting, diarrhea.

3. Ultrasonography Multiple conglomerated lymph nodes are noted along portal, mesentery, para-aortic, paracolic areas. Few of them appear conglomerated, largest of size (3.2x2.5)cm . Few vessels are noted at the center of the conglomerated lymph node mass situated in paracolic area (arrow).

4. Colour Doppler Study On Colour Doppler study, we can appreciate the blood vessels coursing through the center of the conglomerated lymph node mass, giving rise to classic “sandwich sign”, suggestive of possibility of mesenteric lymphoma .

5. Liver Liver and spleen appeared enlarged with liver measuring 16 cm and spleen measuring 13 cm along their respective axis suggestive of hepatosplenomegaly . Spleen

6. Spleen A heterogeneously hypoechoic lesion of (1.5x0.6) cm size is noted in lower pole of spleen, suggesting possibility of lymphomatous infiltration.

7. Blood investigations Hb- 6.4 RBC-3.09 millions/cumm TLC- 11200 with no premature WBC PLATELETS-52000 LDH- 396 Multiple monotonous cells which have fine chromatin and lack of nucleoli. Possibility of Lymphoblastic Lymphoma likely. Histopathology

8. D iscussion A ppearance of mesenteric fat and vessels "sandwiched" between two nodular layers of mesenteric lymphadenopathy. Highly suggestive of mesenteric lymphoma Usually non-Hodgkin's variety (NHL) Mesenteric masses occur in 30-50% of patients with NHL. Frequently associated with retroperitoneal adenopathy as well. Sandwich sign may also be seen in patients with post-transplantation lymphoproliferative disorder.

9. Another case of a 12 year old female diagnosed as lymphoblastic lymphoma.

10. References 1. Hardy SM. The sandwich sign. Radiology. 2003;226 (3): 651-2. doi:10.1148/radiol.2263020109 2. Haaga JR, Boll D. CT and MRI of the whole body. Mosby. (2009) ISBN:0323053750.  3. Rubensin SE, Gilchrist AM, Bronner M, et al. Non-Hodgkin lymphoma of the small intestine. RadioGraphics 1990; 10:985-998. 4. Swinnen LJ. Treatment of organ transplant-related lymphoma. Hematol Oncol Clin North Am 1997; 11:963-973 . 5. Brant WE. Mesenteric small bowel. In: Brant WE, Helms CA, eds. Fundamentals of diagnostic radiology. 2nd ed. Philadelphia, Pa: Williams & Wilkins, 1999; 740. 6. Maccioni F, Rossi P, Gourtsoyiannis N, Bezzi M, Di Nardo L, Broglia L. US and CT findings of small bowel neoplasms. Eur Radiol 1997; 7:1398-1409.