INTERESTING IMAGE 18
FDG PET/CT Appearance in Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type
Amin Samarghandi, MD,* Alejandro Ariel Gru, MD,† Mona Natwa, MD,* and David W. Barker, MD* Abstract: We report the case of a 70-year-old woman who presented with a small and painless red skin nodule in the right lower leg, which rapidly and significantly increased in size over few weeks and developed a central eschar. Skin biopsy was consistent with primary cutaneous diffuse large B-cell lymphoma, leg type (PCDBCL-LT), an aggressive and rare cutaneous lymphoma. 18F-FDG PET/ CT showed a hypermetabolic soft tissue mass in the right leg with no evidence of systemic involvement of disease. Key Words: primary cutaneous diffuse large B-cell lymphoma, leg type, PCDLBCL-LT, 18F-FDG PET/CT (Clin Nucl Med 2015;40: 506–508)
Received for publication October 15, 2014; revision accepted January 9, 2015. From the *Division of Nuclear Medicine, Department of Radiology, and †Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH. Conflicts of interest and sources of funding: none declared. Reprints: Amin Samarghandi, MD, Division of Nuclear Medicine, Department of Radiology, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Columbus, OH 43210. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4006–0506
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REFERENCES 1. Willemze R, Jaffe ES, Burg G, et al. WHO-EORTC classification for cutaneous lymphomas. Blood. 2005;105:3768–3785. 2. Grange F, Beylot-Barry M, Courville P, et al. Primary cutaneous diffuse large B-cell lymphoma, leg type. Clinicopathologic features and prognostic analysis in 60 cases. Arch Dermatol. 2007;143:1144–1150. 3. Huang CT, Yang WC, Liu YC, et al. Primary cutaneous diff use large B-cell lymphoma, leg type, with unusual clinical presentation of bluish-reddish multicolored rainbow pattern. J Clin Oncol. 2011;29:497–498. 4. Senff NJ, Noordijk EM, Kim YH, et al. European Organization for Research and Treatment of Cancer and International Society for Cutaneous Lymphoma consensus recommendations for the management of cutaneous B-cell lymphomas. Blood. 2008;112:1600–1609. 5. Kodama K, Massone C, Chott A, et al. Primary cutaneous large B-cell lymphomas: clinicopathologic features, classification, and prognostic factors in a large series of patients. Blood. 2005;106:2491–2497. 6. Vermeer MH, Geelen FA, van Haselen CW, et al. Primary cutaneous large B-cell lymphomas of the legs: a distinct type of cutaneous B-cell lymphoma with an intermediate prognosis. Arch Dermatol. 1996;132:1304–1308. 7. Hallermann C, Niermann C, Fischer RJ, et al. New prognostic relevant factors in primary cutaneous diffuse large B-cell lymphomas. J Am Acad Dermatol. 2007; 56:588–597. 8. Paulli M1, Lucioni M, Maffi A, et al. Primary cutaneous diffuse large B-cell lymphoma (PCDLBCL), leg-type and other: an update on morphology and treatment. G Ital Dermatol Venereol. 2012;147:589–602.
Clinical Nuclear Medicine • Volume 40, Number 6, June 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 6, June 2015
18
FDG PET/CT Appearance in B-Cell Lymphoma
FIGURE 1. 18F-FDG PET, 18F-FDG PET/CT, noncontrast CT of lower extremity and 18F-FDG PET MIP image. A 70-year-old woman presented with a small and painless red skin spot involving the right inner leg, which rapidly increased in size and turned into an erythematous nodule measuring approximately 3 4 cm with central eschar and surrounding induration. FDG PET (A) and fused FDG PET/CT (B) show a markedly hypermetabolic soft tissue mass involving the anteromedial aspect of the right leg with SUVmax of 20.2. C, Noncontrast CT reveals a soft tissue mass in right medial leg measuring approximately 4.2 2.6 7.1 cm in anteroposterior, transverse, and longitudinal dimensions, respectively. D, PET MIP demonstrates a focal hypermetabolic lesion in the right leg with no evidence of systemic involvement of disease. The patient subsequently underwent systemic chemotherapy.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
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Clinical Nuclear Medicine • Volume 40, Number 6, June 2015
Samarghandi et al
FIGURE 2. Gross (A) and histopathological (B) features of the tumor. A, Erythematous nodule with central eschar and surrounding induration. Excisional skin biopsy revealed diffuse infiltrate of large lymphoid cells in the dermis. Cells are strongly and diffusely positive for CD20 (B), PAX-5, BCL-2, MUM-1, and CD45 and weakly but diffusely positive for BCL-6 with high degree of Ki67 expression (not shown). Strong expression of MUM1 and partial BCL-6 among the B cells indicate a nongerminal center phenotype (activated B-cell type) according to the Hans algorithm.1 An elevated Ki67 (70-80%) indicates a very high proliferation index, typical of an aggressive B-cell lymphoma. Primary cutaneous diffuse large B-cell lymphoma, leg type (PCDBCL-LT) is an aggressive and rare cutaneous lymphoma, representing approximately 1% to 4% of all cutaneous lymphomas.1–8 The disease particularly affects elderly people and often involves one or both lower legs. It typically has a relatively high relapse rate with a fairly poor prognosis and disease-specific 5-year survival rate of 55%.1
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© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
FDG PET/CT Appearance in Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type
Amin Samarghandi, MD,* Alejandro Ariel Gru, MD,† Mona Natwa, MD,* and David W. Barker, MD* Abstract: We report the case of a 70-year-old woman who presented with a small and painless red skin nodule in the right lower leg, which rapidly and significantly increased in size over few weeks and developed a central eschar. Skin biopsy was consistent with primary cutaneous diffuse large B-cell lymphoma, leg type (PCDBCL-LT), an aggressive and rare cutaneous lymphoma. 18F-FDG PET/ CT showed a hypermetabolic soft tissue mass in the right leg with no evidence of systemic involvement of disease. Key Words: primary cutaneous diffuse large B-cell lymphoma, leg type, PCDLBCL-LT, 18F-FDG PET/CT (Clin Nucl Med 2015;40: 506–508)
Received for publication October 15, 2014; revision accepted January 9, 2015. From the *Division of Nuclear Medicine, Department of Radiology, and †Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH. Conflicts of interest and sources of funding: none declared. Reprints: Amin Samarghandi, MD, Division of Nuclear Medicine, Department of Radiology, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Columbus, OH 43210. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4006–0506
506
www.nuclearmed.com
REFERENCES 1. Willemze R, Jaffe ES, Burg G, et al. WHO-EORTC classification for cutaneous lymphomas. Blood. 2005;105:3768–3785. 2. Grange F, Beylot-Barry M, Courville P, et al. Primary cutaneous diffuse large B-cell lymphoma, leg type. Clinicopathologic features and prognostic analysis in 60 cases. Arch Dermatol. 2007;143:1144–1150. 3. Huang CT, Yang WC, Liu YC, et al. Primary cutaneous diff use large B-cell lymphoma, leg type, with unusual clinical presentation of bluish-reddish multicolored rainbow pattern. J Clin Oncol. 2011;29:497–498. 4. Senff NJ, Noordijk EM, Kim YH, et al. European Organization for Research and Treatment of Cancer and International Society for Cutaneous Lymphoma consensus recommendations for the management of cutaneous B-cell lymphomas. Blood. 2008;112:1600–1609. 5. Kodama K, Massone C, Chott A, et al. Primary cutaneous large B-cell lymphomas: clinicopathologic features, classification, and prognostic factors in a large series of patients. Blood. 2005;106:2491–2497. 6. Vermeer MH, Geelen FA, van Haselen CW, et al. Primary cutaneous large B-cell lymphomas of the legs: a distinct type of cutaneous B-cell lymphoma with an intermediate prognosis. Arch Dermatol. 1996;132:1304–1308. 7. Hallermann C, Niermann C, Fischer RJ, et al. New prognostic relevant factors in primary cutaneous diffuse large B-cell lymphomas. J Am Acad Dermatol. 2007; 56:588–597. 8. Paulli M1, Lucioni M, Maffi A, et al. Primary cutaneous diffuse large B-cell lymphoma (PCDLBCL), leg-type and other: an update on morphology and treatment. G Ital Dermatol Venereol. 2012;147:589–602.
Clinical Nuclear Medicine • Volume 40, Number 6, June 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 6, June 2015
18
FDG PET/CT Appearance in B-Cell Lymphoma
FIGURE 1. 18F-FDG PET, 18F-FDG PET/CT, noncontrast CT of lower extremity and 18F-FDG PET MIP image. A 70-year-old woman presented with a small and painless red skin spot involving the right inner leg, which rapidly increased in size and turned into an erythematous nodule measuring approximately 3 4 cm with central eschar and surrounding induration. FDG PET (A) and fused FDG PET/CT (B) show a markedly hypermetabolic soft tissue mass involving the anteromedial aspect of the right leg with SUVmax of 20.2. C, Noncontrast CT reveals a soft tissue mass in right medial leg measuring approximately 4.2 2.6 7.1 cm in anteroposterior, transverse, and longitudinal dimensions, respectively. D, PET MIP demonstrates a focal hypermetabolic lesion in the right leg with no evidence of systemic involvement of disease. The patient subsequently underwent systemic chemotherapy.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
507
Clinical Nuclear Medicine • Volume 40, Number 6, June 2015
Samarghandi et al
FIGURE 2. Gross (A) and histopathological (B) features of the tumor. A, Erythematous nodule with central eschar and surrounding induration. Excisional skin biopsy revealed diffuse infiltrate of large lymphoid cells in the dermis. Cells are strongly and diffusely positive for CD20 (B), PAX-5, BCL-2, MUM-1, and CD45 and weakly but diffusely positive for BCL-6 with high degree of Ki67 expression (not shown). Strong expression of MUM1 and partial BCL-6 among the B cells indicate a nongerminal center phenotype (activated B-cell type) according to the Hans algorithm.1 An elevated Ki67 (70-80%) indicates a very high proliferation index, typical of an aggressive B-cell lymphoma. Primary cutaneous diffuse large B-cell lymphoma, leg type (PCDBCL-LT) is an aggressive and rare cutaneous lymphoma, representing approximately 1% to 4% of all cutaneous lymphomas.1–8 The disease particularly affects elderly people and often involves one or both lower legs. It typically has a relatively high relapse rate with a fairly poor prognosis and disease-specific 5-year survival rate of 55%.1
508
www.nuclearmed.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
