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Ultrasound Diagnosis of Lymphoma: Case-Based Clinical Insights

By Kvolnuo

January 24, 2026

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Lymphoma is a group of malignant tumors originating from lymph nodes or other lymphoid tissues, which can be classified into two main categories: Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Histologically, neoplastic proliferation of lymphocytes and/or histiocytes can be observed.

Clinical Manifestations

Painless lymphadenopathy is the most typical presentation, often accompanied by hepatosplenomegaly. In advanced stages, symptoms such as cachexia, fever, and anemia may occur. Clinical manifestations vary depending on the location and extent of the lesions. Lymphoma may originate in lymph nodes (nodal lymphoma) or in extranodal lymphoid tissues (extranodal lymphoma).

Ultrasound Findings

Nodal Lymphoma (more common)

- Location: Commonly occurs in the neck, supraclavicular region, axilla, and groin.

- Number: Multiple enlarged lymph nodes in multiple regions are often observed, while solitary enlarged lymph nodes are rare.

- Morphology and Echogenicity: Affected lymph nodes are typically round or oval, with a plump appearance, and may be solitary or fused. The medulla disappears or is deformed and displaced, while the cortex exhibits uneven thickening. At lower gain settings, the nodes may appear anechoic (resembling cystic echoes). The parenchyma may also show a grid-like or septated echo pattern. The hilum is compressed and eccentrically displaced. CDFI often reveals abundant blood flow signals, which may fill the entire lymph node, with hilar or claw-like blood supply patterns being common.

Extranodal Lymphoma

- Common Sites: The spleen is most frequently involved, followed by the liver, gastrointestinal tract, breast, and thyroid.

- Gastrointestinal lymphoma often exhibits a "pseudo-kidney sign," with extremely low echogenicity at sites where the lymphoma erodes the wall.

- In hepatic or splenic lymphoma, patchy hypoechoic areas with ill-defined borders may be observed within the affected organs, accompanied by hepatosplenomegaly.

Differential Diagnosis

Lymphoma must be differentiated from reactive lymphadenopathy, tuberculous lymphadenitis, and metastatic lymph nodes.

- Reactive and Inflammatory Lymphadenopathy: Lymph nodes are enlarged with regular morphology, often oval-shaped, and a longitudinal-to-transverse ratio (L/T) ≥ 2. The cortex and medulla are uniformly thickened, with clear structure in most cases. The hilum is central, and no fusion of lymph nodes is observed. CDFI shows regular, evenly distributed blood flow, often appearing as "seaweed-like" or "regular branching."

- Tuberculous Lymphadenitis: Its sonographic features resemble those of lymphoma and metastatic lymphadenopathy. Characteristic findings include calcifications within lymph nodes, liquefaction due to caseous necrosis, and possible rupture leading to sinus tracts or fistulas. Fusion of lymph nodes is common in tuberculous lymphadenitis. CDFI shows sparse blood flow within lymph nodes, which is valuable for differentiation.

- Metastatic Lymph Nodes: Lymph node enlargement is extremely pronounced, with medullary disappearance being far more common than in lymphoma. Cortical thickening is more significant, and eccentric displacement of the hilum is more frequently observed. Additionally, clinical history is crucial, as metastatic lymph nodes originate from primary tumors in other organs. Examination should include exploration of the primary tumor based on history, physical examination, and related test results to obtain sonographic findings of the primary tumor and enhance diagnostic confidence.

Treatment Measures

Clinicians should make a comprehensive diagnosis based on the patient’s clinical manifestations and pathological examination results, including the pathological type and clinical staging of Hodgkin’s lymphoma. Specific radiotherapy and chemotherapy regimens are determined according to the staging and classification.

Below are ultrasound findings of lymphoma in nine different locations

Typical Case 1: Axillary Lymphoma

Patient: Female, 64 years old
Presentation: Visited the hospital after discovering a painless mass in the right axilla for six months.

P1

Picture 1: An oval heterogeneous hypoechoic nodule is noted in the right axilla. The corticomedullary differentiation is indistinct, with a reticular internal echotexture.

P2

Picture 2: Right axillary heterogeneous hypoechoic nodule with a longitudinal-to-transverse ratio greater than 1.

P3

P4

Picture 3 , 4: Abundant blood flow signals are observed within the nodule.

Clinical and Pathological Findings: Lymphoma is considered.

Typical Case 2: Axillary and Inguinal Lymphoma

Patient: Female, 74 years old
Clinical Presentation: Admitted for examination due to chest and back pain for 10 days, occurring over three months after chemotherapy for T-cell lymphoma.

P5

Picture 5: An ovoid lymph node is observed in the right axilla, with an indistinct corticomedullary differentiation and an irregular anechoic area within.

P6

Picture 6: Partial lymph node confluence is observed in the left inguinal region.

P7

Picture 7: An enlarged lymph node is observed in the left inguinal region, showing decreased parenchymal echogenicity with a visible hilum.

Pathology: Lymph node biopsy: T-cell lymphoma.

Typical Case 3: Retroperitoneal Lymphoma with Multiple Metastases

Patient: Male, 64 years old
Clinical Presentation: Admitted for examination due to a progressively enlarging neck mass over 7 years, masses in the axilla and inguinal region for 5 years, and shortness of breath for over 10 days.

P8

Picture 8: In the subxiphoid view, an irregular heterogeneous hypoechoic mass is observed, containing irregular patchy hyperechoic areas, and the mass envelops the retroperitoneal vessels.

P9

Picture 9: Internal blood flow signals within the subxiphoid heterogeneous mass.

P10

Picture 10: In the first hepatic portal region, a heterogeneous hypoechoic mass is observed encircling the portal vein.

P11

Picture 11: Blood flow signals within the portal vein in the first hepatic portal region, along with scattered punctate blood flow signals distributed within the mass.

Involvement of the intrahepatic portal vein.

P12

P13

Picture 12, 13: Involvement of the intrahepatic portal vein.

P14

Picture 14: Splenomegaly with heterogeneous echogenicity of the spleen and patchy areas of slightly increased echogenicity within.

Enlarged lymph nodes are observed bilaterally in the neck.

P15

P16

P17

Picture 15, 16, 17: Enlarged lymph nodes are observed bilaterally in the neck. Some exhibit irregular morphology with indistinct corticomedullary differentiation. Their internal echogenicity is heterogeneous, presenting a grid-like pattern, along with irregular hypoechoic areas and punctate calcifications. Abundant blood flow is noted within the lymph nodes.

P18

Picture 18: Multiple enlarged lymph nodes are observed in the right axilla, exhibiting very low internal echogenicity with clear borders.

CT Findings: Enlargement of both hila and enlarged lymph nodes in the mediastinum, bilateral axillae, and supraclavicular fossae. Consideration: Lymphoma with pleural invasion.

Pathology: Retroperitoneal lymphoma with multi-site metastases throughout the body.

Typical Case 4: Intestinal Lymphoma Causing Intussusception

Patient: 8-year-old child
Clinical Presentation: Admitted due to "intermittent abdominal pain for 4 days and one episode of bloody stool." The child developed abdominal pain four days prior to admission and passed one currant jelly stool. An ultrasound performed on the day of admission suggested intussusception, which was successfully reduced via air enema. Two days after admission, the abdominal pain recurred. Repeat ultrasound revealed: a solid, hypervascular mass in the mid-upper abdomen, originating from the intestine (nature to be determined); a target sign was observed in the hepatic flexure of the colon, with the mass partially intussuscepting into the intestinal lumen, suggesting an intestinal tumor secondary to intussusception.

P19

Picture 19: Transverse section of the hepatic flexure of the colon shows a target sign, with a hypoechoic mass visible within it.

P20

Picture 20: The longitudinal section displays a sleeve sign, with a hypoechoic mass visible inside it and blood flow signals detected within the mass.

Postoperative Pathology: (Terminal ileum, cecum, ascending colon) Consistent with diffuse large B-cell lymphoma, Stage III, R3 group.

Summary: Intussusception can be secondary to intestinal polyps, Meckel's diverticulum, Henoch-Schönlein purpura, lymphoma, enteric duplication cysts, parasites, foreign bodies, etc. When encountering intussusception, it is essential to be vigilant and investigate potential underlying causes.

Typical Case 5: Eyelid Subcutaneous Lymphoma

Patient: Female, 72 years old
Clinical Presentation: Visited the hospital after noticing a mass in the left eyelid for one year, with slight recent enlargement. No impact on vision. Physical examination revealed a nodular mass in the left eyelid, with moderately firm consistency, slightly reduced mobility, and no tenderness.

A heterogeneous hypoechoic mass with clear boundaries is observed in the subcutaneous tissue of the left eyelid

P21

P22

Picture 21, 22: A heterogeneous hypoechoic mass with clear boundaries is observed in the subcutaneous tissue of the left eyelid. Figure 2 shows a comparison between the left and right eyes, as well as the left and right eyelids.

P23

Picture 23: Linear blood flow signals are observed within the heterogeneous hypoechoic mass at the left eyelid.

Pathology: Mucosa-associated marginal zone B-cell lymphoma.

Typical Case 6: Testicular Lymphoma

Patient: Male, 38 years old
Clinical Presentation: Visited the hospital due to scrotal discomfort.

P24

P25

Picture 24, 25: The left testis exhibits irregular morphology with coarsened parenchymal echotexture and heterogeneous echogenicity, containing irregular patchy hyperechoic areas.

P26

Picture 26: Abundant blood flow signals and spectral waveform manifestations are observed within the left testis.

P27

Picture 27: Sonographic Appearance of the Right Testis (Normal)

Pathology: Diffuse Large B-Cell Lymphoma

Summary: The hyperechoic structures within the left testis actually represent islands of normal testicular tissue, while the surrounding hypoechoic areas correspond to zones of lymphoma infiltration.

In this article

Clinical Manifestations

Ultrasound Findings

Extranodal Lymphoma

Differential Diagnosis

Treatment Measures

Ultrasound findings of lymphoma in nine different locations

Typical Case 1: Axillary Lymphoma

Typical Case 2: Axillary and Inguinal Lymphoma

Typical Case 3: Retroperitoneal Lymphoma with Multiple Metastases

Typical Case 4: Intestinal Lymphoma Causing Intussusception

Typical Case 5: Eyelid Subcutaneous Lymphoma

Typical Case 6: Testicular Lymphoma

Typical Case 7: Breast Lymphoma

Typical Case 8: Renal Lymphoma

Typical Case 9: Hepatic Lymphoma

Typical Case 7: Breast Lymphoma

Patient: Female, 47 years old
Clinical Presentation: Presenting with a right breast mass for evaluation.

P28

Picture 28: A heterogeneous echo mass measuring approximately 29×21 mm is observed at the 7-8 o'clock position in the right breast, with unclear borders, irregular shape, and containing mixed high and low echoes inside.

P29

Picture 29: Abundant blood flow signals are observed within the mass.

Pathology: Non-Hodgkin's lymphoma.

Typical Case 8: Renal Lymphoma

Patient: Male, 44 years old
Clinical Presentation: Visited the hospital due to left lumbar pain persisting for three months, with no gross hematuria, chills, or fever. Ultrasound Findings:

P30

P31

Picture 30, 31: A heterogeneous hypoechoic mass is observed in the left kidney, exhibiting an irregular shape with multiple notches and heterogeneous internal echogenicity, formed by the fusion of multiple hypoechoic masses.

P32

P33

Picture 32, 33: Abundant blood flow signals and flow spectrum within the mass.

Pathology: Non-Hodgkin's lymphoma.

Typical Case 9: Hepatic Lymphoma

The patient presented with a self-reported sensation of abdominal discomfort, without other obvious abnormalities, and denied a history of hepatitis. Multiple ultrasound examination results were available.

P34

P35

Picture 34, 35: The liver is enlarged with an uneven surface and markedly heterogeneous internal echogenicity, showing multiple heterogeneous hypoechoic nodules.

At that time, the ultrasound findings were considered suggestive of nodular cirrhosis or schistosomal cirrhosis, although the patient's medical history did not strongly support these diagnoses. Subsequently, the patient underwent an MRI examination, which raised suspicion for a malignant liver tumor.

Following this, the patient underwent an ultrasound-guided needle biopsy. The pathology results confirmed primary hepatic lymphoma, with immunohistochemistry showing CD20 positivity, ultimately leading to a diagnosis of diffuse large B-cell lymphoma.

Once the diagnosis was confirmed, the patient promptly received chemotherapy, which yielded excellent results. Follow-up ultrasound examinations revealed that the original hypoechoic nodules gradually became hyperechoic with blurred borders. Additionally, the patient's laboratory test results progressively normalized.