Enhanced Marrow [18F]Fluorodeoxyglucose Uptake Related to Myeloid Hyperplasia in Hodgkin's Lymphoma Can Simulate Lymphoma Involvement in Marrow

doi:10.3816/CLM.2004.n.012

Clinical Lymphoma

Volume 5, Issue 1, June 2004, Pages 62-64

https://doi.org/10.3816/CLM.2004.n.012 Get rights and content

Abstract

[¹⁸F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) is increasingly used for the clinical staging of lymphomas and for assessment of response to therapy. We report the case of a woman with classic Hodgkin's lymphoma who had marked FDG uptake by tumor and bone marrow suggestive of diffuse marrow involvement by lymphoma. However, iliac crest bone marrow examination showed marked myeloid hyperplasia without evidence of lymphoma involvement. We discuss the implications for interpretation of FDG-PET imaging of bone marrow in lymphomas.

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Of the two present cases who underwent PET, increased FDG activity in multiple vertebral bodies was seen in the case of Hodgkin's lymphoma and DHMH, but not Ewing's sarcoma and FNHMH. The maximum standardized uptake value (SUVmax) values range from 2.2 to 6.2, falling within the range of metastatic lesions described by Shigematsu et al.18 Likewise, Elstrom et al.22 also described a patient with Hodgkin's lymphoma showing markedly increased diffuse uptake throughout the entire skeleton at FDG-PET due to underlying DHMH. The failure of FDG-PET to detect FNHMH demonstrable by MRI in the present patient with Ewing's sarcoma (patient 3) is in accordance with the experience of Marcelo et al.10 Therefore, one cannot rely completely on FDG-PET in the detection and distinction of FNHMH from metastasis.
To report the authors' experience of focal nodular haematopoietic marrow hyperplasia (FNHMH) and diffuse haematopoietic marrow hyperplasia (DHMH) clinically masquerading as skip, distant, or disseminated metastasis in seven patients with underlying malignant neoplasms.
Five patients with FNHMH and two with DHMH mistaken radiologically as skip and disseminated metastasis, respectively, were compared and contrasted with four patients with osteosarcomas and two with chondrosarcomas harbouring skip metastasis, noting the temporal relationship with their haematological profile.
FNHMH and DHMH were undetectable by plain radiography and computed tomography (CT) except one showing subtle sclerosis on CT. They showed either isointense or hyperintense, but not hypointense, attenuation at T1-weighted imaging, and all showed hyperintense attenuation at T2-weighted MRI relative to skeletal muscle. Of the five patients who underwent bone scintigraphy, one showed mildly increased uptake, and one out of two showed markedly increased 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG)-positron-emission tomography (PET) uptake. The rates for sarcoma skip metastasis by plain radiography, CT, MRI, and bone scintigraphy were 40%, 66.7%, 100%, and 66.7%, respectively. At MRI, 60% showed hypointense and 40% isointense attenuation at T1-weighted, 80% hyperintense and 20% hypointense attenuation at T2-weighted imaging. Combined FDG-PET and CT, which was performed in only one patient, failed to show the skip metastasis. Not every patient with FNHMH or DHMH received granulocyte colony-stimulating factor (GCSF), but all had low or falling haemoglobin levels, which may thus be the prime cause for HMH.
Due to overlapping radiological features, FNHMH and DHMH are great radiological mimics of malignancy. In some cases, needle biopsy is required for their definitive differentiation.
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PET-CT correctly diagnosed all clinically significant marrow involvement identifiable by marrow histology; in addition, PET-CT identified focal deposits of DLBCL not detected by iliac crest biopsy. Difficulty in the correct interpretation of diffuse FDG uptake in bone marrow, leading to false-positives and poor specificity previously reported in HL and NHL24,25 was not evident in this study focused on DLBCL, suggesting that experienced reporters using a standardized display and strict reporting criteria are able to differentiate between infiltrating lymphoma and low-level “reactive” marrow FDG uptake. PET-CT failed to detect a low-volume large-cell infiltrate in 2 cases, which were already classified as stage IV due to extranodal disease elsewhere.
We investigated whether positron emission tomography combined with computed tomography (PET-CT) identifies clinically important bone marrow involvement by diffuse large B-cell lymphoma (DLBCL) with sufficient accuracy to replace routine staging bone marrow biopsy. All patients from a single centre diagnosed as DLBCL since 2005 had data extracted from staging PET-CT, marrow biopsy, and treatment records. Of 130 patients, 35 (27%) were judged to have marrow involvement; 33 were identified by PET-CT compared with 14 by marrow histology. PET identified all clinically important marrow lymphoma, while biopsy did not upstage any patient. Sensitivity and specificity were 94% and 100% for PET-CT and 40% and 100% for marrow biopsy. As a secondary aim, we compared the prognosis of marrow involvement, as detected by PET-CT or biopsy. Cases with marrow deposits identified by PET-CT but not biopsy had progression-free survival (PFS) and overall survival similar to stage IV disease without involved marrow. Positive biopsy conferred significantly inferior PFS (P = .003); these cases frequently had other markers of poor-risk disease. These data confirm that in experienced hands PET-CT has a high level of accuracy for identifying marrow disease in DLBCL, and provide new insight into the nature and clinical significance of marrow involvement.
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Case ReportEnhanced Marrow [18F]Fluorodeoxyglucose Uptake Related to Myeloid Hyperplasia in Hodgkin's Lymphoma Can Simulate Lymphoma Involvement in Marrow

Abstract

Ann Oncol

Blood

Blood

Blood

On the origin of cancer cells

Science

Uptake of carbon-11- methionine and fluorodeoxyglucose in non-Hodgkin's lymphoma: a PET study

J Nucl Med

Lymphoma: role of wholebody 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) PET in nodal staging

Radiology

Case Report
Enhanced Marrow [¹⁸F]Fluorodeoxyglucose Uptake Related to Myeloid Hyperplasia in Hodgkin's Lymphoma Can Simulate Lymphoma Involvement in Marrow