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Indian Journal of Medical and Paediatric Oncology
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CASE REPORT
Year : 2013  |  Volume : 34  |  Issue : 2  |  Page : 101-103  

Four rare extranodal sites seen on FDG PET/CT in a single patient of disseminated lymphoma


Department of Nuclear Medicine and Molecular Imaging,Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India

Date of Web Publication6-Aug-2013

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Dr. E Borges Marg, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-5851.116189

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  Abstract 

Extranodal disease refers to lymphomatous infiltration of anatomic sites other than lymph nodes. With the advent of FDG PET/CT for staging, rare sites of extranodal disease have been documented. We report a case of Non- Hodgkin's lymphoma with four rare extranodal sites, namely adrenal, peripheral nerves, pancreas and prostate, in the same patient, detected on FDG PET/CT imaging.

Keywords: Extranodal, pancreas, peripheral nerves, prostate


How to cite this article:
Puranik AD, Agrawal A, Purandare NC, Shah S, Rangarajan V. Four rare extranodal sites seen on FDG PET/CT in a single patient of disseminated lymphoma. Indian J Med Paediatr Oncol 2013;34:101-3

How to cite this URL:
Puranik AD, Agrawal A, Purandare NC, Shah S, Rangarajan V. Four rare extranodal sites seen on FDG PET/CT in a single patient of disseminated lymphoma. Indian J Med Paediatr Oncol [serial online] 2013 [cited 2019 Nov 21];34:101-3. Available from: http://www.ijmpo.org/text.asp?2013/34/2/101/116189


  Introduction Top


FDG PET/CT is commonly used for staging and treatment response assessment in lymphomas, as in helps in picking up primary sites, nodes and extranodal sites in a single study. This also leads to uncovering of rare sites of lymphomatous involvement. Our case similarly shows four rare extranodal sites in a case of Non Hodgkin's lymphoma on PET/CT.


  Case Report Top


A 25-year-old gentleman, on anti-retroviral treatment for immunopositivity for HIV, since two years, presented to our institution 4 months back, with history of unexplained fever, weight loss and bilateral axillary swellings. On examination he had palpable bilateral axillary nodes. Recent CD4 count was 550 cells/mm 3 . A biopsy from the left axillary node confirmed it to be Non-Hodgkin's lymphoma (NHL) B cell type. Patient was then referred for a baseline whole body 18-F Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) study. Maximum intensity projection (MIP) images [Figure 1]a revealed multiple foci of increased tracer uptake in bilateral cervical, axillary, mediastinal and retroperitoneal regions. In addition, there were foci of intense uptake on the left side of abdomen (arrow) and in the pelvis (arrow head), which appeared to be due to physiological tracer excretion into the urinary bladder. Axial fused PET/CT images revealed multiple enlarged FDG avid bilateral axillary and mediastinal nodes. In addition, FDG uptake was seen in enlarged bilateral adrenal glands, left being more than right [Figure 1]b, arrows. There was focal FDG uptake seen in the body of pancreas on axial-fused PET/CT images [Figure 1]c, arrow]. FDG uptake in the retroperitoneal region corresponded on CT and fused PET/CT images to exiting nerve roots from lumbar vertebrae [Figure 2]a and b, arrow. Also, the FDG uptake in the pelvis which appeared to be excreted tracer in bladder, was in fact seen in the enlarged prostate gland on CT and fused PET/CT images [Figure 2]c and d, arrow. Patient received two cycles of intravenous bolus chemotherapy regimen, R-EPOCH (Rituximab with etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone) with methotrexate, after which he was referred for a FDG PET/CT study for treatment response assessment. Post-treatment FDG PET/CT study revealed no abnormal focus of FDG uptake in the entire body, suggestive of complete metabolic and morphological response to treatment [Figure 3], MIP image.
Figure 1: (a) MIP image showing abnormal tracer foci in abdomen (arrow) and pelvis (arrowhead) (b) Axial fused image showing intense tracer uptake in bilateral adrenal glands (arrows) (c) Axial fused image showing tracer uptake in body of pancreas (arrow)

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Figure 2: (a) Axial CT image showing enlarged exiting nerve root with loss of surrounding fat planes (arrow) (b) Axial fused image showing intense uptake in exiting nerve root (arrow) (c) Axial CT image showing enlarged prostate gland (arrow) (d) Axial fused image showing uptake in the prostate gland (arrow)

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Figure 3: Post-treatment MIP image showing no abnormal tracer uptake

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  Discussion Top


Rare sites of extranodal involvement like skin, stomach, small intestine, kidney, bone, ovary, adrenal, peripheral nerves and prostate have been documented in the existing literature [1] Non-Hodgkin's lymphoma can involve adrenal in almost 25% of cases, either with nodal involvement or as primary adrenal lymphoma. [2] Neurolymphomatosis (NL) is an uncommon syndrome of cranial or peripheral nerve root dysfunction secondary to infiltration by B cell Non-Hodgkin's lymphoma and is an extremely rare manifestation of lymphoma. [3] Although CT and MRI have been used for detection and guiding biopsy in NL, recent reports have demonstrated the value of FDG PET/CT in NL. [4],[5] There has been only one case report showing involvement of lumbar plexus on FDG PET/CT, [6] with this being the second one. Similarly, prostatic involvement is rarely encountered, with primary prostatic lymphomas representing approximately 0.2-0.8% of extranodal lymphomas, with urinary tract obstruction being the commonest presentation. [7] Secondary pancreatic involvement has been reported in only 0.2-2% of patients with NHL, out of which only two cases had B cell lymphoma, ours being the third case. [8] All the reports in literature give one rare site of extranodal involvement or a rare site of primary origin of lymphoma. There are no studies which document four rare extranodal sites in the same patient. Uncovering such rare sites in one single patient once again highlights the role of FDG PET/CT in staging of lymphomas. Lymphomas, both Hodgkins and Non-Hodgkins type, can have varied presentations and hence a whole body metabolic imaging with CT fusion is essential to pick up all the sites of lymphomatous involvement to design appropriate treatment regimens. Also, it serves as a baseline, which can be compared to the post-treatment study for assessing response, as in this case, wherein a post-treatment PET/CT study shows complete metabolic response to treatment.

 
  References Top

1.Paes FM, Kalkanis DG, Sideras PA, Serafini AN. FDG PET/CT in extranodal involvement of non Hodgkin's lymphoma and Hodgkin's disease. Radiographics 2010;30:269-91.  Back to cited text no. 1
    
2.Kumar R, Xiu Y, Mavi A, El-Haddad G, Zhuang H, Alavi A. FDG-PET imaging in primary bilateral adrenal lymphoma: A case report and review of the literature. Clin Nucl Med 2005;30:222-30.  Back to cited text no. 2
    
3.Baehring JM, Damek D, Martin EC, Betensky RA, Hochberg FH. Neurolymphomatosis. Neuro Oncol 2003;5:104-15.  Back to cited text no. 3
    
4.Kanter P, Ziedman A, Streifler J, Marmelstein V, Even Sapir E, Mester U, et al. PET-CT imaging of combined brachial and lumbosacral neurolymphomatosis. Eur J Haematol 2005;74:66-9.  Back to cited text no. 4
    
5.Trojan A, Jermann M, Taverna C, Hany TF. Fusion PET CT imaging of neurolyphomaosis. Ann Oncol 2002;13:802-5.  Back to cited text no. 5
    
6.Strobel K, Pestalozzi B, Ciernik I, Schaefer NG, Koma AY, Hany TF. Changing PET/CT manifestation of neurolyphomatosis. Eur J Nucl Med Mol Imaging 2006;33:1244.  Back to cited text no. 6
    
7.Patel DR, Gomez GA, Henderson ES, Gamarra M. Primary prostatic involvement in non Hodgkin lymphoma. Urology 1988;32:96-8.  Back to cited text no. 7
    
8.Saif MW, Khubchandani S, Walczak M. Secondary pancreatic involvement by a diffuse large B-cell lymphoma presenting as acute pancreatitis. World J Gastroenterol 2007;13:4909-11.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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