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Heterogeneous bone marrow uptake on interim 18F-fluorodeoxyglucose positron emission tomography for lymphoma mimicking disease progression: a case report.

Cherk MH, Patil S, Beech P, Kalff V - J Med Case Rep (2014)

Bottom Line: Evaluation of lymphomatous bone marrow infiltration on 18F-FDG PET can usually distinguish between normal regenerating marrow following chemotherapy by a characteristic pattern of uptake.Here we report the case of a 51-year-old Caucasian woman with mixed low- and high-grade lymphoma with biopsy confirmed marrow infiltration.Subsequent investigations were performed including bone marrow biopsies, repeat 18F-FDG PET scanning and a white cell scan.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Nuclear Medicine, The Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia. m.cherk@alfred.org.au.

ABSTRACT

Introduction: The use of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scanning for baseline staging and assessment of treatment response for higher grade lymphomas is considered to be the standard of care. Evaluation of lymphomatous bone marrow infiltration on 18F-FDG PET can usually distinguish between normal regenerating marrow following chemotherapy by a characteristic pattern of uptake.

Case presentation: Here we report the case of a 51-year-old Caucasian woman with mixed low- and high-grade lymphoma with biopsy confirmed marrow infiltration. An interim post-three cycle chemotherapy 18F-FDG PET scan revealed apparent progression of marrow disease. Subsequent investigations were performed including bone marrow biopsies, repeat 18F-FDG PET scanning and a white cell scan. These revealed the interim 18F-FDG PET scan appearance was due to a highly unusual pattern of scattered islands of regenerating normal marrow, rather than progressive lymphoma.

Conclusions: Our case report highlights that apparent severe bone marrow abnormalities on 18F-FDG PET scans in lymphoma patients treated with chemotherapy are not always due to disease. Clinicians should retain a high index of suspicion for benign causes when 18F-FDG PET scan results appear incongruent with clinical response.

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Three-dimensional maximal intensity projection 18F-fluorodexoyglucose positron emission tomography scan images. Baseline prior to treatment (A), after three cycles of chemotherapy (B) and at completion of six cycles of chemotherapy (C).
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Figure 1: Three-dimensional maximal intensity projection 18F-fluorodexoyglucose positron emission tomography scan images. Baseline prior to treatment (A), after three cycles of chemotherapy (B) and at completion of six cycles of chemotherapy (C).

Mentions: Further staging included a whole body 18F-FDG PET scan which demonstrated moderate to markedly FDG-avid right upper and bilateral lower thoracic para-spinal, lower lumbar para-spinal and presacral soft tissue masses with extension into several right lower lumbar and sacral neural foramen. Heterogeneous increased FDG uptake was also seen in a right external iliac node and throughout the skeleton, most marked and intense in the trochanteric region of the right femur and right ilium, consistent with marrow infiltration (FigureĀ 1A). A bone marrow aspirate and trephine of the right ilium at a site of increased FDG uptake on the PET scan confirmed a marrow packed with lymphoma, with a combination of small and larger cells, the latter of which were CD20 positive. Due to sacral and lumbar neural foramen invasion, CT and magnetic resonance imaging (MRI) brain scans along with a lumbar puncture were performed to exclude leptomeningeal disease. These were found to be negative.


Heterogeneous bone marrow uptake on interim 18F-fluorodeoxyglucose positron emission tomography for lymphoma mimicking disease progression: a case report.

Cherk MH, Patil S, Beech P, Kalff V - J Med Case Rep (2014)

Three-dimensional maximal intensity projection 18F-fluorodexoyglucose positron emission tomography scan images. Baseline prior to treatment (A), after three cycles of chemotherapy (B) and at completion of six cycles of chemotherapy (C).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4228820&req=5

Figure 1: Three-dimensional maximal intensity projection 18F-fluorodexoyglucose positron emission tomography scan images. Baseline prior to treatment (A), after three cycles of chemotherapy (B) and at completion of six cycles of chemotherapy (C).
Mentions: Further staging included a whole body 18F-FDG PET scan which demonstrated moderate to markedly FDG-avid right upper and bilateral lower thoracic para-spinal, lower lumbar para-spinal and presacral soft tissue masses with extension into several right lower lumbar and sacral neural foramen. Heterogeneous increased FDG uptake was also seen in a right external iliac node and throughout the skeleton, most marked and intense in the trochanteric region of the right femur and right ilium, consistent with marrow infiltration (FigureĀ 1A). A bone marrow aspirate and trephine of the right ilium at a site of increased FDG uptake on the PET scan confirmed a marrow packed with lymphoma, with a combination of small and larger cells, the latter of which were CD20 positive. Due to sacral and lumbar neural foramen invasion, CT and magnetic resonance imaging (MRI) brain scans along with a lumbar puncture were performed to exclude leptomeningeal disease. These were found to be negative.

Bottom Line: Evaluation of lymphomatous bone marrow infiltration on 18F-FDG PET can usually distinguish between normal regenerating marrow following chemotherapy by a characteristic pattern of uptake.Here we report the case of a 51-year-old Caucasian woman with mixed low- and high-grade lymphoma with biopsy confirmed marrow infiltration.Subsequent investigations were performed including bone marrow biopsies, repeat 18F-FDG PET scanning and a white cell scan.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Nuclear Medicine, The Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia. m.cherk@alfred.org.au.

ABSTRACT

Introduction: The use of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scanning for baseline staging and assessment of treatment response for higher grade lymphomas is considered to be the standard of care. Evaluation of lymphomatous bone marrow infiltration on 18F-FDG PET can usually distinguish between normal regenerating marrow following chemotherapy by a characteristic pattern of uptake.

Case presentation: Here we report the case of a 51-year-old Caucasian woman with mixed low- and high-grade lymphoma with biopsy confirmed marrow infiltration. An interim post-three cycle chemotherapy 18F-FDG PET scan revealed apparent progression of marrow disease. Subsequent investigations were performed including bone marrow biopsies, repeat 18F-FDG PET scanning and a white cell scan. These revealed the interim 18F-FDG PET scan appearance was due to a highly unusual pattern of scattered islands of regenerating normal marrow, rather than progressive lymphoma.

Conclusions: Our case report highlights that apparent severe bone marrow abnormalities on 18F-FDG PET scans in lymphoma patients treated with chemotherapy are not always due to disease. Clinicians should retain a high index of suspicion for benign causes when 18F-FDG PET scan results appear incongruent with clinical response.

Show MeSH
Related in: MedlinePlus