INTERESTING IMAGE 18
F-FDG Hepatic Superscan in a Patient With Chronic Myeloid Leukemia
Bulin Du, MD,* Xuena Li, MD,* Na Li, MD,* Yaming Li, MD,* and Bailing Hsu, PhD*Þ Abstract: A 62-year-old man with a history of breakpoint cluster region-ABLY positive chronic myeloid leukemia treated with hydroxyurea and interferon alfa for 4 years presented a lesion in the left lateral lobe of the liver. Besides an FDGavid lesion, his 18F-FDG PET/CT study showed intense and diffuse FDG uptake (reminiscent of a hepatic superscan) throughout the rest of the left lobe and the right anterior lobe of the liver. This interesting superscan indicated that patients with chronic myeloid leukemia may show hepatic involvement by leukemia cells. Key Words: chronic myeloid leukemia, hepatic involvement
18
F-FDG, PET/CT, superscan,
(Clin Nucl Med 2014;39: 835Y836) Received for publication October 6, 2013; revision accepted January 22, 2014. From the *Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang, China; and †Nuclear Science and Engineering Institute, University of Missouri-Columbia, Columbia, MO. Conflicts of interest and sources of funding: none declared. Reprints: Yaming Li, MD, Department of Nuclear Medicine, The First Hospital of China Medical University, No. 155, Nanjing North St, Heping District, Shenyang City, China, 110001. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3909Y0835
Clinical Nuclear Medicine
REFERENCES 1. Lyall A, Ulaner GA. False-positive FDG PET/CT due to liver parenchymal injury caused by a surgical retractor. Clin Nucl Med. 2012;37:910Y911. 2. Wong JJ, Anthony MP, Lan Khong P. Hepatic radiation injury in distal esophageal carcinoma: a case report. Clin Nucl Med. 2012;37:709Y711. 3. Jo I, Won KS, Choi BW, et al. Eosinophilic infiltration in the colon and liver mimicking primary colon cancer with hepatic metastases on (18)F-FDG PET/CT. Clin Nucl Med. 2013;38:471Y473. 4. Lin E. Reactive lymphoid hyperplasia of the liver identified by FDG PET. Clin Nucl Med. 2008;33:419Y420. 5. Taneja S, Achong DM. Hepatic superscan on PET/CT due to Richter’s transformation of chronic lymphocytic leukemia. Clin Nucl Med. 2010;35: 644Y645. 6. Tichelaar V, Gemmel F, de Rhoter W, et al. FDG hepatic superscan caused by massive breast cancer invasion. Clin Nucl Med. 2009;34:716Y718. 7. Basu S, Nair N. Unusually elevated liver radioactivity on F-18 FDG PET in Hodgkin’s disease: hepatic ‘superscan’. Clin Nucl Med. 2004;29:626Y628. 8. Cervantes F, Rozman M, Nicola´s JM, et al. Extramedullary blast crisis in chronic myeloid leukemia. Sangre (Barc). 1989;34:96Y98. 9. Inverardi D, Lazzarino M, Morra E, et al. Extramedullary disease in Ph’-positive chronic myelogenous leukemia: frequency, clinical features and prognostic significance. Haematologica. 1990;75:146Y148. 10. Prabhash K, Loknath D, Babu KG, et al. Chronic myeloid leukemia with osteolytic bone involvement. J Assoc Physicians India. 2003;51:740Y741.
& Volume 39, Number 9, September 2014
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
835
Clinical Nuclear Medicine
Du et al
& Volume 39, Number 9, September 2014
FIGURE 1. A previously asymptomatic 62-year-old man with stable breakpoint cluster region-ABLYpositive chronic myeloid leukemia was continuously treated with hydroxyurea and interferon alfa for 4 years. Because of a 10-day history of increasing fatigue, physical checkup was performed, and a tender enlarged liver and abdominal fullness in the flanks were found. A follow-up contrast-enhanced CT for further examination was executed and revealed a hepatic lesion partially protruding from the surface of the left lateral lobe (small arrows), and a low attenuation area was identified as focal fatty infiltration in the rest of the left lobe (large arrow) in plain scan (A), arterial phase (B), and portal phase (C). The pertinent laboratory test found dramatically increased white blood cell counts (35.87 109/L; reference range [RR], 3.5Y9.5 109/L), serum lactate dehydrogenase level (586 U/L; RR, 135Y225 U/L), and serum aspartate aminotransferase level (205 U/L; RR, 15Y40 U/L). The levels for serum tumor marker carcino embryonie antigen was 24.12 ng/mL (RR, 0Y4.3 ng/mL) and greater than 1000 ng/mL for CA199 (RR, 0Y27 ng/mL). To further differentiate whether the hepatic lesion was benign or malignant, 18F-FDG PET/CT scan was performed. PET/CT images confirmed a hypermetabolic lesion in the left lateral lobe with a maximum cross-sectional area of 4.7 4.0 cm and an SUVmax of 7.8 (small arrows, DYF). Incidentally, intense and diffuse 18F-FDG uptake (reminiscent of hepatic superscan) throughout the rest part of the left lobe and right anterior lobe was found with an SUVmax of 24.3 (large arrows, D, F, and G). Diffuse high 18F-FDG uptake in the bone marrow (SUVmax, 3.4) was also showed in maximum intensity projection image (G). Based on the 18F-FDG PET/CT findings and deteriorated liver function, intensive medication with albumin and virus inactivated plasma were implemented to this patient but persistently ineffective. He died 1 month after the discharged from the intensive care unit. Focal elevated FDG uptake is common in malignant tumor, which also could be seen in benign lesion caused by etiology such as surgical retractor injury, radiation injury, reactive lymphoid hyperplasia, and eosinophilic infiltration in liver.1Y4 Hepatic superscan is relatively infrequent, which was reported in the Richter’s transformation of chronic lymphocytic leukemia, metastatic breast cancer, and Hodgkin disease.5Y7 To chronic myeloid leukemia, the common extramedullary involved organs are the bone, lymph nodes, skin, soft tissues, and the central nervous system,8,9 and hepatic involvement is rare. In this case, hepatic superscan, the unique 18F-FDG PET/CT finding, indicates that substantial leukemia cells are accumulated in the liver.10
836
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
F-FDG Hepatic Superscan in a Patient With Chronic Myeloid Leukemia
Bulin Du, MD,* Xuena Li, MD,* Na Li, MD,* Yaming Li, MD,* and Bailing Hsu, PhD*Þ Abstract: A 62-year-old man with a history of breakpoint cluster region-ABLY positive chronic myeloid leukemia treated with hydroxyurea and interferon alfa for 4 years presented a lesion in the left lateral lobe of the liver. Besides an FDGavid lesion, his 18F-FDG PET/CT study showed intense and diffuse FDG uptake (reminiscent of a hepatic superscan) throughout the rest of the left lobe and the right anterior lobe of the liver. This interesting superscan indicated that patients with chronic myeloid leukemia may show hepatic involvement by leukemia cells. Key Words: chronic myeloid leukemia, hepatic involvement
18
F-FDG, PET/CT, superscan,
(Clin Nucl Med 2014;39: 835Y836) Received for publication October 6, 2013; revision accepted January 22, 2014. From the *Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang, China; and †Nuclear Science and Engineering Institute, University of Missouri-Columbia, Columbia, MO. Conflicts of interest and sources of funding: none declared. Reprints: Yaming Li, MD, Department of Nuclear Medicine, The First Hospital of China Medical University, No. 155, Nanjing North St, Heping District, Shenyang City, China, 110001. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3909Y0835
Clinical Nuclear Medicine
REFERENCES 1. Lyall A, Ulaner GA. False-positive FDG PET/CT due to liver parenchymal injury caused by a surgical retractor. Clin Nucl Med. 2012;37:910Y911. 2. Wong JJ, Anthony MP, Lan Khong P. Hepatic radiation injury in distal esophageal carcinoma: a case report. Clin Nucl Med. 2012;37:709Y711. 3. Jo I, Won KS, Choi BW, et al. Eosinophilic infiltration in the colon and liver mimicking primary colon cancer with hepatic metastases on (18)F-FDG PET/CT. Clin Nucl Med. 2013;38:471Y473. 4. Lin E. Reactive lymphoid hyperplasia of the liver identified by FDG PET. Clin Nucl Med. 2008;33:419Y420. 5. Taneja S, Achong DM. Hepatic superscan on PET/CT due to Richter’s transformation of chronic lymphocytic leukemia. Clin Nucl Med. 2010;35: 644Y645. 6. Tichelaar V, Gemmel F, de Rhoter W, et al. FDG hepatic superscan caused by massive breast cancer invasion. Clin Nucl Med. 2009;34:716Y718. 7. Basu S, Nair N. Unusually elevated liver radioactivity on F-18 FDG PET in Hodgkin’s disease: hepatic ‘superscan’. Clin Nucl Med. 2004;29:626Y628. 8. Cervantes F, Rozman M, Nicola´s JM, et al. Extramedullary blast crisis in chronic myeloid leukemia. Sangre (Barc). 1989;34:96Y98. 9. Inverardi D, Lazzarino M, Morra E, et al. Extramedullary disease in Ph’-positive chronic myelogenous leukemia: frequency, clinical features and prognostic significance. Haematologica. 1990;75:146Y148. 10. Prabhash K, Loknath D, Babu KG, et al. Chronic myeloid leukemia with osteolytic bone involvement. J Assoc Physicians India. 2003;51:740Y741.
& Volume 39, Number 9, September 2014
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
835
Clinical Nuclear Medicine
Du et al
& Volume 39, Number 9, September 2014
FIGURE 1. A previously asymptomatic 62-year-old man with stable breakpoint cluster region-ABLYpositive chronic myeloid leukemia was continuously treated with hydroxyurea and interferon alfa for 4 years. Because of a 10-day history of increasing fatigue, physical checkup was performed, and a tender enlarged liver and abdominal fullness in the flanks were found. A follow-up contrast-enhanced CT for further examination was executed and revealed a hepatic lesion partially protruding from the surface of the left lateral lobe (small arrows), and a low attenuation area was identified as focal fatty infiltration in the rest of the left lobe (large arrow) in plain scan (A), arterial phase (B), and portal phase (C). The pertinent laboratory test found dramatically increased white blood cell counts (35.87 109/L; reference range [RR], 3.5Y9.5 109/L), serum lactate dehydrogenase level (586 U/L; RR, 135Y225 U/L), and serum aspartate aminotransferase level (205 U/L; RR, 15Y40 U/L). The levels for serum tumor marker carcino embryonie antigen was 24.12 ng/mL (RR, 0Y4.3 ng/mL) and greater than 1000 ng/mL for CA199 (RR, 0Y27 ng/mL). To further differentiate whether the hepatic lesion was benign or malignant, 18F-FDG PET/CT scan was performed. PET/CT images confirmed a hypermetabolic lesion in the left lateral lobe with a maximum cross-sectional area of 4.7 4.0 cm and an SUVmax of 7.8 (small arrows, DYF). Incidentally, intense and diffuse 18F-FDG uptake (reminiscent of hepatic superscan) throughout the rest part of the left lobe and right anterior lobe was found with an SUVmax of 24.3 (large arrows, D, F, and G). Diffuse high 18F-FDG uptake in the bone marrow (SUVmax, 3.4) was also showed in maximum intensity projection image (G). Based on the 18F-FDG PET/CT findings and deteriorated liver function, intensive medication with albumin and virus inactivated plasma were implemented to this patient but persistently ineffective. He died 1 month after the discharged from the intensive care unit. Focal elevated FDG uptake is common in malignant tumor, which also could be seen in benign lesion caused by etiology such as surgical retractor injury, radiation injury, reactive lymphoid hyperplasia, and eosinophilic infiltration in liver.1Y4 Hepatic superscan is relatively infrequent, which was reported in the Richter’s transformation of chronic lymphocytic leukemia, metastatic breast cancer, and Hodgkin disease.5Y7 To chronic myeloid leukemia, the common extramedullary involved organs are the bone, lymph nodes, skin, soft tissues, and the central nervous system,8,9 and hepatic involvement is rare. In this case, hepatic superscan, the unique 18F-FDG PET/CT finding, indicates that substantial leukemia cells are accumulated in the liver.10
836
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
