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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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Comparison of 18F-fluorodexoyglucose positron emission tomography scan uptake in spine with sites of normal bone marrow activity on whole body white cell scan post six cycles of chemotherapy. White cell scan anterior planar view (A), White cell scan posterior planar view (C) three-dimensional maximal intensity projection (MIP) 18F-FDG PET scan images (B). The overall pattern of FDG uptake on PET scan is similar to the white cell scan uptake in keeping with sites of normal regenerating marrow rather than lymphoma. Arrows highlight similarities in FDG and white cell uptake in the thoracic and lumbar spine.
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Figure 3: Comparison of 18F-fluorodexoyglucose positron emission tomography scan uptake in spine with sites of normal bone marrow activity on whole body white cell scan post six cycles of chemotherapy. White cell scan anterior planar view (A), White cell scan posterior planar view (C) three-dimensional maximal intensity projection (MIP) 18F-FDG PET scan images (B). The overall pattern of FDG uptake on PET scan is similar to the white cell scan uptake in keeping with sites of normal regenerating marrow rather than lymphoma. Arrows highlight similarities in FDG and white cell uptake in the thoracic and lumbar spine.

Mentions: As residual lymphoma was not confirmed on both bone marrow biopsies, treatment was not changed and she completed a further three cycles of CHOP-R chemotherapy, at which point another 18F-FDG PET scan was performed (Figures 1C and 2C). This scan again demonstrated a similar heterogeneous pattern of increased FDG uptake throughout the marrow of the skeleton in a similar distribution to the post third cycle interim PET scan however, overall intensity of uptake had decreased significantly and was not typical for disease progression.Due to the apparent improvement in PET scan appearances, a whole body radiolabelled white cell scan was performed to evaluate normal skeletal bone marrow activity. This demonstrated areas of normal marrow activity throughout the skeleton in a similar highly heterogeneous distribution to the interim and post-six cycle PET/CT scans. This suggested that the apparent ‘abnormal’ bone marrow appearance on the interim and, to a lesser extent, post-six cycle chemotherapy PET scans actually represented FDG uptake in scattered residual islands of regenerating and pegfilgrastim-stimulated normal bone marrow, rather than sites of progressive lymphoma (Figure 3).


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)

Comparison of 18F-fluorodexoyglucose positron emission tomography scan uptake in spine with sites of normal bone marrow activity on whole body white cell scan post six cycles of chemotherapy. White cell scan anterior planar view (A), White cell scan posterior planar view (C) three-dimensional maximal intensity projection (MIP) 18F-FDG PET scan images (B). The overall pattern of FDG uptake on PET scan is similar to the white cell scan uptake in keeping with sites of normal regenerating marrow rather than lymphoma. Arrows highlight similarities in FDG and white cell uptake in the thoracic and lumbar spine.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: Comparison of 18F-fluorodexoyglucose positron emission tomography scan uptake in spine with sites of normal bone marrow activity on whole body white cell scan post six cycles of chemotherapy. White cell scan anterior planar view (A), White cell scan posterior planar view (C) three-dimensional maximal intensity projection (MIP) 18F-FDG PET scan images (B). The overall pattern of FDG uptake on PET scan is similar to the white cell scan uptake in keeping with sites of normal regenerating marrow rather than lymphoma. Arrows highlight similarities in FDG and white cell uptake in the thoracic and lumbar spine.
Mentions: As residual lymphoma was not confirmed on both bone marrow biopsies, treatment was not changed and she completed a further three cycles of CHOP-R chemotherapy, at which point another 18F-FDG PET scan was performed (Figures 1C and 2C). This scan again demonstrated a similar heterogeneous pattern of increased FDG uptake throughout the marrow of the skeleton in a similar distribution to the post third cycle interim PET scan however, overall intensity of uptake had decreased significantly and was not typical for disease progression.Due to the apparent improvement in PET scan appearances, a whole body radiolabelled white cell scan was performed to evaluate normal skeletal bone marrow activity. This demonstrated areas of normal marrow activity throughout the skeleton in a similar highly heterogeneous distribution to the interim and post-six cycle PET/CT scans. This suggested that the apparent ‘abnormal’ bone marrow appearance on the interim and, to a lesser extent, post-six cycle chemotherapy PET scans actually represented FDG uptake in scattered residual islands of regenerating and pegfilgrastim-stimulated normal bone marrow, rather than sites of progressive lymphoma (Figure 3).

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