European Radiology

, Volume 29, Issue 12, pp 6911–6921 | Cite as

Computed tomography textural analysis for the differentiation of chronic lymphocytic leukemia and diffuse large B cell lymphoma of Richter syndrome

  • C.P. ReinertEmail author
  • B. Federmann
  • J. Hofmann
  • H. Bösmüller
  • S. Wirths
  • J. Fritz
  • M. Horger



To test the hypothesis that both indolent and aggressive chronic lymphocytic leukemia (CLL) can be differentiated from diffuse large B cell lymphoma (DLBCL) of Richter syndrome (RS) by CT texture analysis (CTTA) of involved lymph nodes.

Material and methods

We retrospectively included 52 patients with indolent CLL (26/52), aggressive CLL (8/52), and DLBCL of RS (18/52), who underwent standardized contrast-enhanced CT. In main lymphoma tissue, VOIs were generated from which CTTA features including first-, second-, and higher-order textural features were extracted. CTTA features were compared between the entire CLL group, the indolent CLL subtype, the aggressive CLL subtype, and DLBCL using a Kruskal-Wallis test. All p values were adjusted after the Bonferroni correction. ROC analyses for significant CTTA features were performed to determine cut-off values for differentiation between the groups.


Compared with DLBCL of RS, CTTA of the entire CLL group showed significant differences of entropy heterogeneity (p < 0.001), mean intensity (p < 0.001), mean average (p = 0.02), and number non-uniformity gray-level dependence matrix (NGLDM) (p = 0.03). Indolent CLL significantly differed for entropy (p < 0.001), uniformity of heterogeneity (p = 0.02), mean intensity (p < 0.001), and mean average (p = 0.01). Aggressive CLL showed significant differences in mean intensity (p = 0.04). For differentiation between CLL and DLBCL of RS, cut-off values for mean intensity and entropy of heterogeneity were defined (e.g., 6.63 for entropy heterogeneity [aggressive CLL vs. DLBCL]; sensitivity 0.78; specificity 0.63).


CTTA features of ultrastructure and vascularization significantly differ in CLL compared with that in DLBCL of Richter syndrome, allowing complementary to visual features for noninvasive differentiation by contrast-enhanced CT.

Key Points

• Richter transformation of CLL into DLBCL results in structural changes in lymph node architecture and vascularization that can be detected by CTTA.

• First-order CT textural features including intensity and heterogeneity significantly differ between both indolent CLL and aggressive CLL and DLBCL of Richter syndrome.

CT texture analysis allows for noninvasive detection of Richter syndrome which is of prognostic value.


Texture analysis Tomography, X-ray-computed Leukemia, lymphocytic, chronic, B cell Lymphoma, large B cell, diffuse 



Contrast-enhanced CT


Chronic lymphocytic leukemia


CT texture analysis


Diffuse large B cell lymphoma




Lactate dehydrogenase


Region of interest


Richter syndrome


Volume of interest



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Christian Philipp Reinert.

Conflict of interest

Marius Horger received institutional research funds and speaker’s honorarium from Siemens Healthineers and is a scientific advisor of Siemens Healthcare, Germany. Konstantin Nikolaou received institutional research funds and speaker’s honorarium from Siemens Healthineers and is a scientific advisor of Siemens Healthcare, Germany. Jan Fritz received institutional research support from Siemens Healthcare, USA, DePuy, Zimmer, Microsoft, and BTG International; is a scientific advisor of Siemens Healthcare USA, Alexion Pharmaceuticals, and BTG International; received speaker’s honorarium from Siemens Healthcare, USA; and has shared patents with Siemens Healthcare and Johns Hopkins University. The other authors have declared that no competing interests exist.

Statistics and biometry

Dr. Christian Philipp Reinert has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board (project number 467/2018).

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic study

• performed at one institution

Supplementary material

330_2019_6291_MOESM1_ESM.docx (6.3 mb)
ESM 1 (DOCX 6494 kb)


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • C.P. Reinert
    • 1
    Email author
  • B. Federmann
    • 2
  • J. Hofmann
    • 1
  • H. Bösmüller
    • 2
  • S. Wirths
    • 3
  • J. Fritz
    • 4
  • M. Horger
    • 1
  1. 1.Department of Diagnostic and Interventional RadiologyUniversity Hospital TübingenTübingenGermany
  2. 2.Department of Pathology and NeuropathologyUniversity Hospital TübingenTübingenGermany
  3. 3.Department of Hematology and OncologyUniversity Hospital TübingenTübingenGermany
  4. 4.Russell H. Morgan Department of Radiology and RadiologicalJohns Hopkins University School of MedicineBaltimoreUSA

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