Imaging of extranodal lymphoma with PET/CT. Clin Nucl Med. 2011;36:e127-e138. [PMID: 21892025 DOI: 10.1097/rlu.0b013e31821c99cd]

MALT Lymphoma in Histologic Transformation: FDG-Avid but Pentixafor-Negative

ABSTRACT

An 81-year-old woman experienced compression symptoms due to diffuse enlargement of the thyroid gland. The cytopathological results of thyroid fine-needle suggested malignancy. Therefore, she underwent bilateral thyroidectomy. Postoperative pathology indicated mucosa-associated lymphoid tissue (MALT) lymphoma. Three months later, she found a progressively enlarged mass in her neck. The biopsy showed MALT lymphoma with highly aggressive B-cell lymphoma transformation. 18F-FDG PET/CT showed increased metabolism in multiple lymph nodes. However, some of these lymph nodes were negative in 68Ga-pentxafor PET/CT. Our case demonstrated that 68Ga-pentixafor may have limited value in evaluating MALT lymphoma transformation.

Thyromegaly: Not The Usual Cause

Non-Hodgkin lymphoma (NHL) of the thyroid is a very rare condition. Swelling of the neck is the usual presentation among patients. Of all thyroid malignancies, only a very small portion accounts for NHL of the thyroid. Here, we present two cases of diffuse large B-cell NHL of the thyroid. Preoperative diagnosis helps in the management of patients with chemotherapy, but in rare cases, surgical removal of the thyroid is done to reduce obstructive symptoms. The diagnosis is usually made based on fine-needle aspiration cytology and biopsy with immunohistochemistry. In these two cases, the patients presented with a history of a rapidly growing mass in the neck for three to four months, but the treatment modalities differed. In one of the cases, the patient received six cycles of chemotherapy, and in the other case, the patient underwent a total thyroidectomy, followed by six cycles of chemotherapy, though chemotherapy is the standard treatment option over surgical removal of the thyroid.

Prognostic value of metabolic tumor volume of extranodal involvement in diffuse large B cell lymphoma

Extranodal involvement predicts poor outcomes of diffuse large B cell lymphoma (DLBCL), but the impact of the metabolic tumor burden (MTV) of extranodal sites using positron emission tomography has not been clarified. This study aimed to assess the impact of extranodal MTV on overall survival (OS). We retrospectively analyzed 145 newly diagnosed DLBCL patients and verified the prognostic impact of each extranodal and nodal MTV. Multivariate Cox hazards modelling using both extranodal and nodal MTV as covariables identified extranodal MTV as a significant factor for OS (hazard ratio [HR] 1.072, 95% confidence interval [CI] 1.019-1.129, P = 0.008), but not nodal MTV. Multivariate Cox modelling using restricted cubic splines demonstrated that the impact of total MTV depends on the MTV of extranodal sites, not of nodal sites. When both the number and MTV of extranodal involvements were used as covariables, extranodal MTV remained a significant predictor of OS (HR 1.070, 95%CI 1.017-1.127, P = 0.009), but the number of extranodal sites did not. Extranodal MTV potentially had a more significant role on prognosis than nodal MTV. When considering prognostic impacts, the MTV of extranodal involvement is significantly more important than the number.

Prostate lymphoma with renal obstruction; reflections on diagnosis and treatment: Two case reports

BACKGROUND

Prostate lymphoma has no characteristic clinical symptomatology, is often misdiagnosed, and currently, clinical case reports of this disease are relatively rare. The disease develops rapidly and is not sensitive to conventional treatment. A delay in the treatment of hydronephrosis may lead to renal function injury, often causing physical discomfort and rapid deterioration with the disease. This paper presents two patients with lymphoma of prostate origin, followed by a summary of the literature concerning the identification and treatment of such patients.

CASE SUMMARY

This paper reports on the cases of two patients with prostate lymphoma admitted to the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, one of whom died of the disease 2 mo after diagnosis, while the other was treated promptly, and his tumor was significantly reduced at the 6-mo follow-up.

CONCLUSION

The literature shows that prostate lymphoma is often seen as a benign prostate disease during its pathogenesis, even though primary prostate lymphoma enlarges rapidly and diffusely with the invasion of surrounding tissues and organs. In addition, prostate-specific antigen levels are not elevated and are not specific. There are no significant features in single imaging either, but during dynamic observation of imaging, it can be found that the lymphoma is diffusely enlarged locally and that systemic symptoms metastasize rapidly. The two cases of rare prostate lymphoma reported herein provide a reference for clinical decision making, and the authors conclude that early nephrostomy to relieve the obstruction plus chemotherapy is the most convenient and effective treatment option for the patient.

Advanced Ann Arbor stage and age over 60 years as prognostic predictors in patients with primary cervical lymphoma: a retrospective cohort study and systematic review

OBJECTIVE

To evaluate the overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) for primary cervical lymphoma (PCL), an extremely rare disease without treatment consensus.

METHODS

We conducted a retrospective study included 177 patients, including 169 cases identified from literature review. The Kaplan-Meier methods and Cox regression were used to determine the OS, DSS, RFS, and relevant risk factors.

RESULTS

The 5-year OS and 5-year DSS rates were 85.8 and 87.2%, respectively, while the 5-year RFS rate was 85.5%. Diffuse large B-cell lymphoma (DLBCL) was the predominant subtype that comprised 63.8% (113 cases) in this cohort. Multivariate analysis in the DLBCL subgroup revealed that age ≥ 60 years (Odds ratio [OR]: 26.324, 95% Confidence Interval [CI]: 5.090-136.144, P < 0.001) or stage IIIE-IVE (advanced stage) (OR: 4.219, 95%CI: 1.314-13.551, P = 0.016) were the risk factors for OS, while patients with age ≥ 60 years (OR:23.015, 95%CI: 3.857-137.324, P = 0.001), and stage IIIE-IVE (OR: 4.056, 95% CI: 1.137-14.469, P = 0.031) suffered a poor DSS. Chemotherapy and/or radiotherapy improved the OS (P = 0.008), DSS (P = 0.049), and RFS (P = 0.003). However, cancer-directed surgery did not improve the OS, DSS, and RFS. The risk factor was unavailable in other subtypes of PCL due to limited cases.

CONCLUSION

The survival outcomes in patients with PCL at early stage were satisfactory, while the advanced disease stage and age ≥ 60 years were the two major factors predicting poor prognosis in DLBCL subtype.

Primary non-Hodgkin’s lymphoma of the orbit: treatment outcomes from India

Background:

Primary non-Hodgkin’s lymphoma (NHL) of the orbit is rare. Orbital NHLs show good response to both radiotherapy (RT) and chemotherapy, and hence, the emphasis should be to ensure maximum cure rate with minimum morbidity. In this study, we present the clinical profile and treatment outcomes of patients with NHL who had initial presentation in the orbit.

Materials and methods:

In this retrospective analysis, case records of patients with a diagnosis of NHL of the orbit were analysed from January 2005 to January 2015. Patients were worked up and staged according to the Ann Arbor system. Patients with large tumours were initially given chemotherapy with CHOP regimen (cyclophosphamide, vincristine, adriamycin and prednisolone) three weekly for 4–6 cycles. Patients with residual disease were given RT 20–30 Gy at 2 Gy per fraction. RT when given as a primary treatment consisted of 36–45 Gy at 1·8–2 Gy per fraction on either Cobalt 60 machine or linear accelerator.

Results:

A total of 52 patients with diagnosis of orbital NHL were included in this study. Median age at presentation was 57 years (range 13–71). Left, right and bilateral orbit was involved in 21 (40%), 28(54%) and 3(6%) patients, respectively. Low- and high-grade pathology was seen in 39(75%) and 13(25%) patients, respectively. On immunohistochemistry, 23(44%) tumors were CD 20 positive. After staging, 33 (63%) patients had stage I disease. Median tumour size was 4·0 × 3·2 × 1·5 cm (1·7 × 1·7 × 1·4 cm to 5·8 × 4·0 × 4·7 cm). Primary RT was given to 7(13%) patients. Upfront chemotherapy was given in 45(86·5%) patients, out of which 24 had stage I disease. RT consolidation was done in 26 (50%) patients for residual disease after chemotherapy. Median follow-up was 88 months (range 29–183 months). Relapse occurred in 6(9·6%) patients; 2 local; 2 local + distant and in 2 distant alone. These patients were successfully salvaged with systemic chemotherapy and local RT. One patient died due to neutropenia. Overall survival in this series was 96%.

Conclusions:

Excellent local control was achieved with initial chemotherapy followed by RT for primary orbital NHL with minimal toxicity. We recommend a dose of 36–40 Gy for definitive RT and 30 Gy for lymphoma following chemotherapy using 2 Gy/fraction for Indian patients who present with bulky tumours. RT should be incorporated in treatment of orbital NHL whenever possible as it is safe, effective and is associated with minimal complications.

FDG PET/CT Showing a Primary Vaginal NK/T Cell Lymphoma

ABSTRACT

A 28-year-old woman with vaginal discharge was admitted to the hospital. Colposcopy examination found several ulcers with pus in the vagina. Biopsy demonstrated extranodal natural killer/T-cell lymphoma. PET/CT scan was subsequently performed for staging. It revealed intense FDG uptake in the vagina. No FDG-avid lesion was seen in the rest of the body. A primary vaginal extranodal natural killer/T-cell lymphoma was diagnosed.

FDG PET/CT Showing a Primary Lymphoma of the Sternoclavicular Joint

ABSTRACT

We presented a case of primary lymphoma of the sternoclavicular joint. A 67-year-old woman with a history of swelling at the sternoclavicular joint region was considered as osteoarthritis initially. Chest CT found a soft tissue mass around the sternoclavicular joint. Biopsy demonstrated diffuse large B-cell lymphoma. The subsequent FDG PET/CT revealed FDG-avid articular destruction with surrounding soft tissue mass without any other abnormal findings, suggesting a primary extranodal lymphoma of sternoclavicular joint.

A Case of Primary Sacral Lymphoma Evaluated by 18F-FDG PET/CT

Primary sacral lymphoma is an unusual bone malignant tumor that poses a diagnostic challenge. Herein, we report a rare case of primary sacral lymphoma, which was initially assessed as suspicious bone metastasis. The subsequent histology and immunohistochemistry of the sacral biopsy confirmed the diagnosis of diffuse large B-cell lymphoma.

Diagnostic challenge of soft tissue extranodal Hodgkin lymphoma in core-needle biopsy: case report

Hodgkin lymphoma (HL) is an uncommon malignancy usually limited to the lymph nodes and lymphatic system while extranodal involvement is much less common than in non-Hodgkin lymphoma. The current report presents an unusual case of primary classical HL (cHL), nodular sclerosis type with mixed cellularity in buttock soft tissue of 78-year old man. Primary lymphoma of the gluteal muscle is a rare disease and primary cHL is even rarer. In addition, to this unusual extranodal presentation, the present case highlight a diagnostic challenge in fine-needle biopsy masquerading a low grade sarcoma, primarily myxoinflammatory fibrosarcoma or an inflammatory lesion. However, surgical biopsy and immunohistochemistry guided correct diagnosis that was of major interest for further successful treatment.

Imaging features of extranodal involvement in paediatric Hodgkin lymphoma

Detecting extranodal disease in paediatric Hodgkin lymphoma is of great importance for both treatment and prognosis. Different imaging techniques can be used to identify these extranodal sites. This pictorial essay provides an overview of imaging features of extranodal disease manifestation in paediatric Hodgkin lymphoma.

Richter Syndrome Presenting With Colon Localization

A 75-year-old man, who had been diagnosed with small lymphocytic lymphoma with cervical localization, underwent F-FDG PET/CT with iodinated contrast medium due to the appearance of cervical swelling suspected of illness relapse. PET/CT revealed intense F-FDG uptake in multiple cervical and subdiaphragmatic lymph nodes and in the left parotid. Moreover, diffuse uptake and wall thickening of the colon were evident; endoscopy with biopsy revealed a diffuse large B-cell lymphoma. Transformation into a more aggressive lymphoma occurs in 2% to 8% of small lymphocytic lymphoma, the so-called Richter syndrome. Extranodal localization in the sigmoid colon is an extremely rare site for transformed lymphoma.

F-18 Fluorodeoxyglucose Positron-Emission Tomography-Computed Tomography in a Case of Extensive Multi-Organal Extranodal Lymphoma with Cardiac Involvement Mimicking Apical Hypertrophic Obstructive Cardiomyopathy: Staging and Response Evaluation

18F fluorodeoxyglucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) is a standard imaging tool in staging as well as response evaluation for lymphoma. Here, we present a young male with extensive extranodal lymphoma with cardiac involvement which presented as diffuse myocardial lesion mimicking hypertrophic obstructive cardiomyopathy. ¹⁸F-FDG PET/CT helped in the staging by revealing multiple systemic involvements. Interim PET after three cycles of chemotherapy showed a complete metabolic response to therapy in all the extranodal sites including the cardiac involvement, thus retrospectively confirming the lymphomatous involvement. Previous literature also conforms to the superior role of ¹⁸F-FDG PET/CT in the clinical management of extensive extranodal lymphoma.

The size and depth of lesions measured by endoscopic ultrasonography are novel prognostic factors of primary gastric diffuse large B-cell lymphoma

Diffuse large B cell lymphoma is one of the predominant histological subtypes of primary gastric lymphomas. Factors that contribute to precise stratification and guide the treatment of this disease are still not well understood. We analyzed 73 primary gastric diffuse large B cell lymphoma patients retrospectively, and found that patients characterized by late stage, multiple localization, B symptoms, lower serum albumin level and elevated LDH level had a shorter overall survival through Univariate Cox regression analysis. Multivariate Cox regression analysis demonstrated that ALB ≤ 35g/L, staging ≥ IIE and multiple sites localization were independent adverse prognostic factors. Significantly, in 35 patients who received endoscopy at diagnosis, Kaplan-Meier analyses indicated that patients with large (≥3 cm) and deep lesions (≥11 mm) had an inferior OS (p = .01 and .039). These findings implicated that tumor size and depth are two indicators of prognosis under ultrasonography. Further randomized studies with large number of cases are needed.

18F-FDG PET/CT Findings of Non-Hodgkin Lymphoma Involving the Whole Genitourinary System

A sixty-two-year-old male patient underwent orchiectomy and was diagnosed with diffuse large B-cell lymphoma in the testicle and spermatic cord. ¹⁸F-FDG positron emission tomography/computed tomography (PET/CT) scanning was performed for initial staging. ¹⁸F-FDG PET/CT scan revealed multiple hyper-metabolic lymphadenopathies, lung lesions and mass lesions in the adrenal glands and kidneys. In addition, diffuse increased ¹⁸F-FDG uptake suggesting lymphomatous infiltration on the right testicle, prostate and left testicular veins were detected. The genitourinary system involvement is extremely rare in extra-nodal lymphomas and to the best of our knowledge this is the first case in the literature having ¹⁸F-FDG accumulating lesions in all genitourinary system structures.

Functional Parameters of 18F-FDG PET/CT in Patients with Primary Testicular Diffuse Large B-Cell Lymphoma

Fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) positron-emission tomography/computed tomography (PET/CT), a hybrid imaging technique that simultaneously provides functional and anatomical information, has been reported to be useful in lymphoma. The present study was to evaluate the functional parameters of ¹⁸F-FDG PET/CT in patients with testicular diffuse large B-cell lymphoma (DLBCL). We retrospectively reviewed medical records of 5095 patients with lymphoma who treated at West China Hospital between March 2003 and January 2017, and selected patients with ¹⁸F-FDG PET/CT findings and subsequently biopsy confirmed the invasion of testis with DLBCL. Maximum standardized uptake values (SUV_max), peak standardized uptake values (SUV_peak), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the patients were measured. We evaluated the characteristics of ¹⁸F-FDG PET/CT in this population. Six patients ranged in age from 37 to 73 years (median age, 58 years) were included in the analysis. The mean SUV_max was 11.09 and varied between 7.20 and 19.75; mean SUV_peak was 9.56 and ranged between 6.79 and 14.39. In addition, mean MTV 42% was 18.4 and varied between 1.3 and 61.6; mean MTV 2.5 was 34.7 and varied significantly between 1.6 and 141.9. With regard to TLG, mean TLG 42% was 168.906 and ranged from 7.514 to 687.004, while mean TLG 2.5 was 253.972 and ranged from 8.400 to 1127.802. In conclusion, ¹⁸F-FDG PET/CT scan is a useful tool in patients with testicular DLBCL. SUV, MTV, and TLG may vary a lot in different patients. SUV_max of testicular DLBCL lesion is relatively higher than that of normal testis. Also, we provided a set of MTV and TLG data and firstly showed their significant correlation with overall survival, which indicated a potential prognostic value of MTV and TLG. However, studies with larger population are needed to confirm these findings.

2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography in primary extranodal lymphomas: treatment response evaluation and prognosis

BACKGROUND

We evaluated the role of [18F]FDG PET/CT in tumor response assessment and prognosis of primary extranodal lymphoma (PEL) patients.

METHODS

We examined retrospectively, 56 PEL patients: 31 with aggressive diffuse large B cell lymphoma (DLBCL) and 25 with indolent lymphoma (20 mucosa-associated lymphoid tissue lymphoma and five follicular lymphoma). All patients had undergone [18F]FDG PET/CT at diagnosis (PET-I) and 50 of them also after therapy (PET-II). Moreover, 52 patients were subjected to a mean follow-up period of 76 months.

RESULTS

PET-I was positive in 50 (89%) patients (mean SUVmax 10.3±6.7). In the assessment of tumor response, according to Lugano classification, 45 patients showed complete metabolic response (CMR), four patients had partial metabolic response (PMR) and one had progressive metabolic disease (PMD). Based on 66% ΔSUVmax cut-off, among CMR patients, 41 showed a ΔSUVmax>66% whereas among non-responders, four patients showed a ΔSUVmax<66%. At follow-up, univariate analysis showed that age, performance status, prognostic index, ΔSUVmax and Lugano classification predicted progression-free survival (PFS) (P<0.05), while, performance status, prognostic index, ΔSUVmax and Lugano classification predicted overall survival (OS) (P<0.05). At multivariate analysis only Lugano classification was retained in the model for prediction of both PFS (P<0.05) and OS (P<0.05). By Kaplan-Meier analysis and log-rank testing both PFS and OS were significantly better in patients in CMR as compared to patients in PMR or PMD according to Lugano classification (P<0.01).

CONCLUSIONS

[18F]FDG PET/CT represents a useful tool in the detection of disease response and in the evaluation of outcome in PEL patients.

18F-fluorodeoxyglucose positron emission tomography/computed tomography comparison of gastric lymphoma and gastric carcinoma

AIM

To compare ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) features in gastric lymphoma and gastric carcinoma.

METHODS

Patients with newly diagnosed gastric lymphoma or gastric carcinoma who underwent ¹⁸F-FDG PET/CT prior to treatment were included in this study. We reviewed and analyzed the PET/CT features of gastric wall lesions, including FDG avidity, pattern (focal/diffuse), and intensity [maximal standard uptake value: (SUVmax)]. The correlation of SUVmax with gastric clinicopathological variables was investigated by χ² test, and receiver-operating characteristic (ROC) curve analysis was performed to determine the differential diagnostic value of SUVmax-associated parameters in gastric lymphoma and gastric carcinoma.

RESULTS

Fifty-two patients with gastric lymphoma and 73 with gastric carcinoma were included in this study. Abnormal gastric FDG accumulation was found in 49 patients (94.23%) with gastric lymphoma and 65 patients (89.04%) with gastric carcinoma. Gastric lymphoma patients predominantly presented with type I and type II lesions, whereas gastric carcinoma patients mainly had type III lesions. The SUVmax (13.39 ± 9.24 vs 8.35 ± 5.80, P < 0.001) and SUVmax/THKmax (maximal thickness) (7.96 ± 4.02 vs 4.88 ± 3.32, P < 0.001) were both higher in patients with gastric lymphoma compared with gastric carcinoma. ROC curve analysis suggested a better performance of SUVmax/THKmax in the evaluation of gastric lesions between gastric lymphoma and gastric carcinoma in comparison with that of SUVmax alone.

CONCLUSION

PET/CT features differ between gastric lymphoma and carcinoma, which can improve PET/CT evaluation of gastric wall lesions and help differentiate gastric lymphoma from gastric carcinoma.

Primary extranodal head and neck classical Hodgkin lymphoma: A rare clinical case report

The subcutaneous soft tissue of the forehead is a rare anatomic site for Hodgkin lymphoma (HL), and no such case has previously been reported in the literature, to the best of our knowledge. HLs commonly present in the nodal regions in the majority of patients, rarely occurring in extranodal sites, whereas primary extranodal lymphoma is less common and is more typical in cases of non-HL. The present study reports a novel case of extranodal head and neck classical HL (cHL), initially diagnosed as frontal fibroma. The present study describes an unusual case of subcutaneous soft tissue involvement of HL, aiming to enhance current levels of awareness for patients with extranodal symptoms. A 25-year-old male, who inadvertently detected a hard painless mass above the right superciliary arch 2 months prior to admission in April 2013 was eventually diagnosed with mixed cellularity cHL. Subsequent to six cycles of doxorubicin (Adriamycin), bleomycin, vindesine and dacarbazine chemotherapy, followed by four cycles of ifosfamide, gemcitabine, vinorelbine and prednisone chemotherapy, a satisfactory curative effect was obtained. In conclusion, it is proposed that lymphoma should be considered in the differential diagnosis of a mass involving the subcutaneous soft tissue.

Spectrum of Physiologic and Pathologic Skeletal Muscle (18)F-FDG Uptake on PET/CT

OBJECTIVE

Skeletal muscle (18)F-FDG uptake on PET/CT can be either physiologic or related to a variety of different pathologic conditions. FDG PET/CT can be used for assessment of primary and metastatic tumors and infective or inflammatory conditions affecting the musculature.

CONCLUSION

In this article, we describe the various causes and patterns of skeletal muscle FDG uptake. Familiarity with these patterns is essential for proper interpretation of clinical FDG PET/CT images.

Fluorine-18 fluorodeoxyglucose PET-CT for extranodal staging of non-Hodgkin and Hodgkin lymphoma

PURPOSE

We aimed to evaluate the role of fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) involving care-dose unenhanced CT to detect extranodal involvement in patients with non-Hodgkin and Hodgkin lymphoma.

MATERIALS AND METHODS

Lymphoma patients (35 Hodgkin lymphoma, 75 non-Hodgkin lymphoma) who were referred for 18F-FDG PET-CT imaging, following a diagnostic contrast-enhanced CT (CE-CT) performed within the last month, were included in our study. A total of 129 PET-CT images, and all radiologic, clinical, and pathological records of these patients were retrospectively reviewed.

RESULTS

In total, 137 hypermetabolic extranodal infiltration sites were detected by 18F-FDG PET-CT in 62 of 110 patients. There were no positive findings by CE-CT that reflected organ involvement in 40 of 137 18F-FDG-positive sites. The κ statistics revealed fair agreement between PET-CT and CE-CT for the detection of extranodal involvement (κ=0.60). The organs showing a disagreement between the two modalities were the spleen, bone marrow, bone, and thyroid and prostate glands. In all lesions that were negative at CE-CT, there was a diffuse 18F-FDG uptake pattern in the PET-CT images. The frequency of extranodal involvement was 51% and 58% in Hodgkin and non-Hodgkin lymphoma patients, respectively. There was a high positive correlation between the maximum standardized uptake values of the highest 18F-FDG-accumulating lymph nodes and extranodal sites (r=0.67) in patients with nodal and extranodal involvement.

CONCLUSION

18F-FDG PET-CT is a more effective technique than CE-CT for the evaluation of extranodal involvement in Hodgkin and non-Hodgkin lymphoma patients. PET-CT has a significant advantage for the diagnosis of diffusely infiltrating organs without mass lesions or contrast enhancement compared to CE-CT.

A Case Report of Primary Extranodal Non-hodgkin Lymphoma First Presentation as a Soft Tissue Swelling Around the Wrist

Introduction:

Primary musculoskeletal extranodal non-Hodgkin lymphoma is a rare presentation and account for 5% of all primary extranodal non-Hodgkin lymphomas. Treatment uses a combination of chemotherapy and radiotherapy with good prognosis in unifocal manifestation. We report an unusual case of primary musculoskeletal extranodal lymphoma presenting as a soft tissue swelling around the wrist.

Case Report:

A 75 year old lady was referred to the Orthopaedic Outpatients Department with a painless, slowly growing mass on the dorsum of the right wrist. Clinical examination revealed a 6 X 9 cm round painless mass on the dorsum of the distal radius adherent to both the underlying structures and skin. MRI of the wrist showed a large mass causing extensive osteolysis of the distal radius and extending proximally with abnormal replacement of the marrow. The patient was brought to theatre for biopsy and subsequent histopathological examination confirmed a B-cell non-Hodgkin lymphoma. The patient was referred to the Haematology Service for further treatment and follow-up. She received chemotherapy and radiotherapy with satisfactory results.

Conclusion:

Lymphoma presenting as a soft tissue mass is relatively uncommon and can easily be confused with a wide variety of inflammatory conditions, more common neoplasias as well as infectious diseases (tuberculosis). Though rare, extranodal lymphoma should be regularly included in the differential diagnosis of mass lesions.

Extranodal lymphoma originating in the gluteal muscle with adjacent bone involvement and mimicking a soft tissue sarcoma

Introduction

Extranodal lymphoma (ENL) in the muscles is a rare manifestation of non-Hodgkin lymphoma (NHL). The aim of this case report is to describe and evaluate the clinical presentation and important radiologic features of ENL affecting the musculoskeletal system.

Presentation of case

We present a 52-year-old female with a 3-week history of left gluteal pain. Computed tomography (CT) showed a non-uniformly early enhancing mass in the left gluteal muscle, the tumor demonstrating central necrosis and adjacent bone involvement. Fluorine-18 fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET)/CT showed areas of increased ¹⁸F-FDG uptake in the left gluteal musculature, pelvic bones, para-aortic and mediastinal lymph nodes and both lungs. Histopathological examination showed a diffuse large B cell lymphoma (DLBCL). After 8 cycles of R-CHOP chemotherapy, the mass in the left gluteal muscle has completely disappeared

Discussion

Although destructive tumor originating in the gluteal muscle with adjacent bone involvement is more common in soft tissue sarcoma, lymphoma should be regularly included in the differential diagnosis. While CT is a useful modality for assessing soft tissue masses, disruption and injury of the surrounding tissues, PET/CT fusion is superior for the detection of unexpected extranodal sites of disease, or for exclusion of disease in the presence of nonspecific extranodal CT findings.

Conclusion

A rapid growth pattern and destructive masses that invade adjacent structures on CT are key findings of DLBCL, and ¹⁸F-FDG PET/CT is a useful imaging modality to accurately determine the disease stage and disease aggressiveness of NHL.

Breast implant-associated anaplastic large cell lymphoma: sensitivity, specificity, and findings of imaging studies in 44 patients

Breast implant-associated anaplastic large cell lymphoma (BIA ALCL) is a newly described clinicopathologic entity. The purpose of this study is to describe the imaging findings of patients with BIA ALCL and determine their sensitivity and specificity in the detection of the presence of an effusion or a mass related to BIA ALCL. A retrospective search was performed of our files as well as of the world literature for patients with pathologically proven BIA ALCL who had been assessed by any imaging study including ultrasound (US), computerized tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT, as well as mammography. The sensitivity and specificity of each imaging modality in the detection of an effusion or a mass around breast implants was determined. We identified 44 patients who had BIA ALCL and imaging studies performed between 1997 and 2013. The sensitivity for detecting an effusion was 84, 55, 82, and 38 %, and for detecting a mass was 46, 50, 50, and 64 %, by US, CT, MRI, and PET, respectively. The sensitivity of mammography in the detection of an abnormality without distinction of effusion or mass was 73 %, and specificity 50 %. Progression-free survival was worse in patients with an implant-associated mass (p = 0.001).

CONCLUSIONS

Current imaging with US, CT, MR, and PET appears suboptimal in the detection of an imaging abnormality associated with BIA ALCL. This under diagnosis may reflect a lack of awareness of this rare entity suggesting the need for better understanding of the spectrum of imaging findings associated with BIA ALCL by breast imagers.

Thyroid lymphoma on a background of Hashimoto's thyroiditis: PET/CT appearances

Primary thyroid lymphoma is a rare thyroid tumor accounting for only 5% of all thyroid malignancies. It is more common in patients with a background history of chronic thyroiditis. PET/CT is helpful in the initial staging and for follow up to assess treatment response.

Molecular imaging of urogenital diseases

There is an expanding and exciting repertoire of PET imaging radiotracers for urogenital diseases, particularly in prostate cancer, renal cell cancer, and renal function. Prostate cancer is the most commonly diagnosed cancer in men. With growing therapeutic options for the treatment of metastatic and advanced prostate cancer, improved functional imaging of prostate cancer beyond the limitations of conventional CT and bone scan is becoming increasingly important for both clinical management and drug development. PET radiotracers, apart from ¹⁸F-FDG, for prostate cancer are ¹⁸F-sodium fluoride, ¹¹C-choline, and ¹⁸F-fluorocholine, and (¹¹C-acetate. Other emerging and promising PET radiotracers include a synthetic l-leucine amino acid analogue (anti-¹⁸F-fluorocyclobutane-1-carboxylic acid), dihydrotestosterone analogue (¹⁸F-fluoro-5α-dihydrotestosterone), and prostate-specific membrane antigen-based PET radiotracers (eg, N-[N-[(S)-1,3-dicarboxypropyl]carbamoyl]-4-¹⁸F-fluorobenzyl-l-cysteine, ⁸⁹Zr-DFO-J591, and ⁶⁸Ga [HBED-CC]). Larger prospective and comparison trials of these PET radiotracers are needed to establish the role of PET/CT in prostate cancer. Although renal cell cancer imaging with FDG-PET/CT is available, it can be limited, especially for detection of the primary tumor. Improved renal cell cancer detection with carbonic anhydrase IX (CAIX)-based antibody (¹²⁴I-girentuximab) and radioimmunotherapy targeting with ¹⁷⁷Lu-cG250 appear promising. Evaluation of renal injury by imaging renal perfusion and function with novel PET radiotracers include p-¹⁸F-fluorohippurate, hippurate m-cyano-p-¹⁸F-fluorohippurate, and rubidium-82 chloride (typically used for myocardial perfusion imaging). Renal receptor imaging of the renal renin-angiotensin system with a variety of selective PET radioligands is also becoming available for clinical translation.

Primary and secondary hepatic lymphomas diagnosed by image-guided fine-needle aspiration: a retrospective study of clinical and cytomorphologic findings

OBJECTIVES

To explore the diagnosis of hematolymphoid malignancies of the liver (hepatic lymphoma [HeL]) by image-guided fine-needle aspiration (FNA), which can often be difficult due to a low index of suspicion and nonspecific patient presentations, especially in the rare cases where the liver is the only site of disease (primary HeL [PHeL]). Understanding the clinical setting in which such lesions arise, as well as the cytomorphologic findings, may assist cytopathologists in making an accurate diagnosis and triaging samples for ancillary studies.

METHODS

In this retrospective study of 32 patients with HeL, the largest such study to our knowledge, we review the clinical and diagnostic features of HeL.

RESULTS

HeL and especially PHeL most commonly show a diffuse large B-cell lymphoma phenotype and have a poor prognosis (median survival of seven months). PHeL is strongly associated with human immunodeficiency virus infection (12/16 patients).

CONCLUSIONS

Image-guided FNA with immediate evaluation is a reliable means to obtain diagnostic material and triage for ancillary tests.

Fluorodeoxyglucose uptake in absence of CT abnormality on PET-CT: What is it?

The purpose of this article is to provide a pictorial review of the findings and interpretative pitfalls about focal fluorodeoxyglucose (FDG) uptake in the absence of corresponding computer tomography (CT) lesion or abnormality on an integrated positron emission tomography (PET)-CT. The integrated CT images in the PET-CT scanner allow correct co-registration and fused imaging of anatomical and functional data. On FDG PET-CT imaging, a real pathologic process often demonstrates abnormal uptake associated with a visible corresponding CT lesion or abnormality. When focal uptake is seen on PET imaging but no corresponding anatomic abnormality is visualized on the integrated CT, one should always be aware of possible mis-registration or mismatch of the PET and CT images due to the patient’s respiratory or body motion. While most of the hot spots in the absence of corresponding anatomic abnormalities are artefactual or secondary to benign etiologies, some may represent small sized or early staged neoplasm or metastases, especially in the gastrointestinal tract and skeletons. Caution should be exercised to simply diagnose a pathology based on the presence of the uptake only, or exclude the disease based on the absence of anatomic abnormality.

FDG PET/CT findings in 3 cases of pulmonary peripheral T-cell lymphoma

Pulmonary involvement of peripheral T-cell lymphoma is rare. It is difficult to make a clinical and radiologic diagnosis of pulmonary lymphomatous involvement, yet the diagnosis is often critical in determining treatment. We present 3 cases of pulmonary peripheral T-cell lymphoma with FDG PET/CT findings. In these 3 cases, FDG PET/CT images revealed multiple bilateral FDG-avid nodules, masses, or mass-like consolidations with or without air bronchogram. Familiarity with these imaging features may be helpful for the diagnosis and differential diagnosis.

Oral lesions associated with human immunodeficiency virus disease

Human immunodeficiency virus (HIV)-associated oral disease among people living with HIV infection includes oral candidiasis, oral hairy leukoplakia, Kaposi sarcoma, oral warts, herpes simplex virus ulcers, major aphthous ulcers or ulcers not otherwise specified, HIV salivary gland disease, and atypical gingival and periodontal diseases. Diagnosis of some oral lesions is based on clinical appearance and behavior, whereas others require biopsy, culture, or imaging for definitive diagnosis. Management strategies including pharmacologic and nonpharmacologic approaches are discussed in this article. Dentists also need to be cognizant of the potential oral side effects of HIV antiretroviral medications.

Value of positron emission tomography/computed tomography in diagnosis and staging of primary ocular and orbital tumors

Accurate and reliable staging methods are crucial for optimal care of patients with ocular and orbital malignancies. Positron emission tomography/computed tomography (PET/CT) has recently emerged as a staging tool in the field of ophthalmic oncology. For detecting primary ocular or orbital lesions, PET/CT does not seem to provide an advantage over clinical ophthalmologic examination or conventional imaging studies such as CT or magnetic resonance imaging of the orbit. However, PET/CT may detect distant metastatic lesions that conventional imaging studies miss. For orbital and ocular adnexal lymphoma, use of PET/CT has been proven to be feasible and is now accepted both as a standard part of the initial staging work-up and for the assessment of response to therapy. For other ophthalmic tumors, PET/CT seems most appropriate for advanced metastatic tumors of the orbit, eyelid, and eye, for which the detection of distant metastasis with 1 comprehensive study may be preferable to performing multiple CT scans with contrast.

Thyroid nodule as a first manifestation of Hodgkin lymphoma-report of two cases and literature review

Lymphomas account for less than 5% of thyroid malignant lesions. Vast majority of them are B-cell non-Hodgkin lymphomas (NHL), while Hodgkin lymphoma (HL) is extremely rare. Here we present two cases of HL, at baseline manifesting as a thyroid lesion. First patient, 29-year-old pregnant female, initially suspected for metastatic medullary thyroid cancer, was eventually diagnosed with mixed cellularity type of thyroid HL. Second patient, 22-year-old woman with suspicion of advanced thyroid cancer, was in the end diagnosed with an extra-lymphatic classical HL of the thyroid. In both cases, despite repeated fine-needle aspiration biopsy, cytological examination gave inconclusive or misleading results. On histopathological examination, thyroid tumor cells were positive for CD15 and CD30 antigen, which is typical for Reed-Sternberg cells. In the report authors also discuss difficulties in management as well as potential importance of novel methods such as FISH, PCR and other molecular techniques in diagnostics of thyroid lymphomas.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2896947559559648.

The use and importance of liposomes in positron emission tomography

Among different imaging modalities, Positron Emission Tomography (PET) gained importance in routine hospital practice depending on ability to diagnose diseases in early stages and tracing of therapy by obtaining metabolic information. The combination of PET with Computed Tomography (CT) forms hybrid imaging modality that gives chance to obtain better images having higher resolution by fusing both functional and anatomical images in the same imaging modality at the same time. Therefore, better contrast agents are essentially needed. The advance in research about developing drug delivery systems as specific nanosized targeted systems gained an additional importance for obtaining better diagnosis and therapy of different diseases. Liposomes appear to be more attractive drug delivery systems in delivering either drugs or imaging ligands to target tissue or organ of diseases with higher accumulation by producing in nano-scale, long circulating by stealth effect and specific targeting by modifying with specific ligands or markers. The combination of positron emitting radionuclides with liposomes are commonly in research level nowadays and there is no commercially available liposome formulation for PET imaging. However by conjugating positron emitter radionuclide with liposomes can form promising diagnostic agents for improved diagnosis and following up treatments by increasing image signal/contrast in the target tissue in lower concentrations by specific targeting as the most important advantage of liposomes. More accurate and earlier diagnosis of several diseases can be obtained even in molecular level with the use of stable and effectively radiolabeled molecular target specific nano sized liposomes with longer half-lived positron emitting radionuclides.

A rare case of Hodkin's lymphoma of the mediastinum imitating retrosternal goiter--retrospective analysis of the diagnostic process

Primary extranodal sites of development of lymphoid neoplasms are rare and concern about 5% of patients with Hodgkin's lymphoma. Extranodal development is more common in non Hodgkin's lymphoma and may reach 33%. A 27-year-old woman was diagnosed by a cardiologist for a short breath. On the physical examination no other abnormalities were observed. Echocardiography, performed by cardiologist, revealed a large tumor, overlaying the right ventricle and compressing the pulmonary trunk. Chest X-ray, ultrasound and CT-scan confirmed diagnosis. In fine needle aspiration clear, lucid fluid was obtained. Scintygraphy of the neck and thorax showed accumulation of the marker in the properly placed but enlarged thyroid gland. Patient was qualified for surgical treatment - cervicotomy and sternothomy were performed. The histopatological exam of the tumor revealed Hodgkin's lymphoma of the mediastinum (classical subtype NS-1). Following the surgery, adjuvant therapy was instituted. After the treatment PET-CT-scan did not show any kind of non-physiological radiomarker's accumulation in the monitored regions of the body and in in three-years follow-up the patient shows no signs of recurrence.

Clinicopathological features and treatment of primary small intestinal lymphoma: recent advances

Primary small intestinal lymphoma (PSIL) is an extra-nodal lymphoma whose clinical and histological presentations are usually heterogeneous depending on the site of the lesion. Proper staging criteria are important for clinicopathological diagnosis. Although there is no consensus regarding the role of surgery and chemotherapy in the treatment of PSIL, surgery followed by chemotherapy and radiotherapy is still the main treatment. This review summarizes the clinicopathological features, diagnosis, therapy and prognosis of PSIL.