INTERESTING IMAGE
Lymphoma and Tuberculosis Temporal Evolution of Dual Pathology on Sequential
18
F-FDG PET/CT
Anirban Mukherjee, MBBS, Punit Sharma, MD, Sellam Karunanithi, MD, Varun Singh Dhull, MD, and Rakesh Kumar, PhD Abstract: Tuberculosis can often be seen in patients undergoing chemotherapy for lymphoma, especially in endemic countries. As both tuberculosis and lymphoma can lead to hypermetabolic lesions of 18F-FDG PET/CT, a diagnostic dilemma often ensues. We present the sequential 18F-FDG PET/CT images of a 22-year-old female patient with Hodgkin lymphoma who developed tuberculosis and later relapse of lymphoma. These images present the temporal evaluation of the dual pathology on 18F-FDG PET/CT. Key Words: hodgkin lymphoma, tuberculosis,
18
F-FDG, PET/CT
(Clin Nucl Med 2014;39: 736Y737)
Received for publication July 4, 2013; revision accepted December 28, 2013. From the Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India. Conflicts of interest and sources of funding: none declared. Reprints: Rakesh Kumar, MD, PhD, E-81, Ansari Nagar (East) AIIMS Campus, New Delhi-110029, India. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3908Y0736
736
www.nuclearmed.com
REFERENCES 1. Sioka C. The utility of FDG PET in diagnosis and follow-up of lymphoma in childhood. Eur J Pediatr. 2013;172:733Y738. 2. Donaldson SS, Link MP, Weinstein HJ, et al. Final results of a prospective clinical trial with VAMP and low-dose involved-field radiation for children with low-risk Hodgkin’s disease. J Clin Oncol. 2007;25:332Y337. 3. Kung FH, Schwartz CL, Ferree CR, et al. POG 8625: a randomized trial comparing chemotherapy with chemoradiotherapy for children and adolescents with Stages I, IIA, IIIA1 Hodgkin Disease: a report from the Children’s Oncology Group. J Pediatr Hematol Oncol. 2006;28:362Y368. 4. Khan SA, Wingard JR. Infection and mucosal injury in cancer treatment. J Natl Cancer Inst Monogr. 2001;29:31Y36. 5. Kamboj M, Kent AS. The risk of tuberculosis in patients with cancer. Clin Infect Dis. 2006;42:1592Y1595. 6. Ouedraogo M, Ouedraogo SM, Cisse R, et al. Active tuberculosis in a patient with Hodgkin’s disease. A case report. Rev Pneumol Clin. 2000;56:33Y35. 7. Audebert F, Schneidewind A, Hartmann P, et al. Lymph node tuberculosis as primary manifestation of Hodgkin’s disease. Med Klin (Munich). 2006;101: 500Y504. 8. Martinez V, Castilla-Lievre MA, Guillet-Caruba C, et al. (18)F-FDG PET/CT in tuberculosis: an early non-invasive marker of therapeutic response. Int J Tuberc Lung Dis. 2012;16:1180Y1185.
Clinical Nuclear Medicine
& Volume 39, Number 8, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 8, August 2014
Lymphoma and Tuberculosis
FIGURE 1. A 22-year-old female patient was diagnosed with stage II Hodgkin lymphoma involving bilateral cervical and bilateral axillary lymph nodes. She underwent 4 cycles of chemotherapy and was referred for 18F-FDG PET/CT for restaging. Restaging 18 F-FDG PET/CT (AYD) showed hypermetabolic bilateral axillary lymph nodes (arrows) and minimally 18F-FDG avid left femoral node (arrowhead), suggesting residual disease and partial response to chemotherapy. She then completed her chemotherapy and underwent repeat18F-FDG PET/CT 1 month later. Post-therapy 18F-FDG PET/CT showed complete remission of the disease process in the axillary and femoral lymph nodes (EYH). However, there was appearance of left supraclavicular lymphadenopathy with foci of calcification (G; arrow) and increased 18F-FDG uptake (EYH). Because of presence of calcification along with lack of correlation with patient symptoms, a differential diagnosis of lymphoma versus infective pathology was given on PET/CT. To solve the dilemma, the treating physician advised a biopsy from the supraclavicular lymph node which showed caseating granulomatous lesion, suggestive of tuberculosis. The patient then underwent a full course of anti-tubercular treatment for 6 months. Because 18F-FDG PET/CT allows an easy evaluation of therapeutic response in patients with tuberculosis, particularly extrapulmonary tuberculosis, the patient was again referred for 18F-FDG PET/CT. PET/CT showed disappearance of the supraclavicular lymph node (IYL). Surprisingly, a large 18 F-FDG avid left femoral lymph node was noted on PET/CT (IYL, arrowhead), corresponding to the node seen on initial restaging PET/CT (AYD, arrowhead). This again led to a diagnostic dilemma. Fine-needle aspiration cytology was done from the left femoral lymph node which revealed presence of Reed-Sternberg cells, confirming a diagnosis of relapsed Hodgkin lymphoma. The patient is currently undergoing second-line chemotherapy. 18F-FDG PET/CT can be employed for accurate staging, treatment planning, and response assessment in patients with Hodgkin lymphoma. 18F-FDG PET has higher sensitivity than other imaging modalities to detect nodular or diffuse lesions and higher sensitivity than bone marrow biopsy to detect bone marrow infiltration.1 These patients generally respond well to chemotherapy with or without adjuvant radiotherapy and are usually cured.2,3 However, weakening of immune system due to anticancer therapy toxicity makes them prone to secondary infections.4 Reactivation of tuberculosis is a relatively common occurrence after chemotherapy in endemic countries.5 Because both tuberculosis and lymphoma can lead to hypermetabolic lesions on 18F-FDG PET/CT, differentiation is often not possible.6,7 Hence, in case of any discrepancy cytological or histopathological verification is warranted, as in the present case. 18F-FDG PET/CT allows an easy evaluation of early therapeutic response in patients with tuberculosis, particularly extrapulmonary lesions.8 The present case describes a unique clinical scenario where there was differential evolution of lymphoma and tuberculosis over time as documented by 18F-FDG PET/CT. * 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
737
Lymphoma and Tuberculosis Temporal Evolution of Dual Pathology on Sequential
18
F-FDG PET/CT
Anirban Mukherjee, MBBS, Punit Sharma, MD, Sellam Karunanithi, MD, Varun Singh Dhull, MD, and Rakesh Kumar, PhD Abstract: Tuberculosis can often be seen in patients undergoing chemotherapy for lymphoma, especially in endemic countries. As both tuberculosis and lymphoma can lead to hypermetabolic lesions of 18F-FDG PET/CT, a diagnostic dilemma often ensues. We present the sequential 18F-FDG PET/CT images of a 22-year-old female patient with Hodgkin lymphoma who developed tuberculosis and later relapse of lymphoma. These images present the temporal evaluation of the dual pathology on 18F-FDG PET/CT. Key Words: hodgkin lymphoma, tuberculosis,
18
F-FDG, PET/CT
(Clin Nucl Med 2014;39: 736Y737)
Received for publication July 4, 2013; revision accepted December 28, 2013. From the Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India. Conflicts of interest and sources of funding: none declared. Reprints: Rakesh Kumar, MD, PhD, E-81, Ansari Nagar (East) AIIMS Campus, New Delhi-110029, India. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3908Y0736
736
www.nuclearmed.com
REFERENCES 1. Sioka C. The utility of FDG PET in diagnosis and follow-up of lymphoma in childhood. Eur J Pediatr. 2013;172:733Y738. 2. Donaldson SS, Link MP, Weinstein HJ, et al. Final results of a prospective clinical trial with VAMP and low-dose involved-field radiation for children with low-risk Hodgkin’s disease. J Clin Oncol. 2007;25:332Y337. 3. Kung FH, Schwartz CL, Ferree CR, et al. POG 8625: a randomized trial comparing chemotherapy with chemoradiotherapy for children and adolescents with Stages I, IIA, IIIA1 Hodgkin Disease: a report from the Children’s Oncology Group. J Pediatr Hematol Oncol. 2006;28:362Y368. 4. Khan SA, Wingard JR. Infection and mucosal injury in cancer treatment. J Natl Cancer Inst Monogr. 2001;29:31Y36. 5. Kamboj M, Kent AS. The risk of tuberculosis in patients with cancer. Clin Infect Dis. 2006;42:1592Y1595. 6. Ouedraogo M, Ouedraogo SM, Cisse R, et al. Active tuberculosis in a patient with Hodgkin’s disease. A case report. Rev Pneumol Clin. 2000;56:33Y35. 7. Audebert F, Schneidewind A, Hartmann P, et al. Lymph node tuberculosis as primary manifestation of Hodgkin’s disease. Med Klin (Munich). 2006;101: 500Y504. 8. Martinez V, Castilla-Lievre MA, Guillet-Caruba C, et al. (18)F-FDG PET/CT in tuberculosis: an early non-invasive marker of therapeutic response. Int J Tuberc Lung Dis. 2012;16:1180Y1185.
Clinical Nuclear Medicine
& Volume 39, Number 8, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 8, August 2014
Lymphoma and Tuberculosis
FIGURE 1. A 22-year-old female patient was diagnosed with stage II Hodgkin lymphoma involving bilateral cervical and bilateral axillary lymph nodes. She underwent 4 cycles of chemotherapy and was referred for 18F-FDG PET/CT for restaging. Restaging 18 F-FDG PET/CT (AYD) showed hypermetabolic bilateral axillary lymph nodes (arrows) and minimally 18F-FDG avid left femoral node (arrowhead), suggesting residual disease and partial response to chemotherapy. She then completed her chemotherapy and underwent repeat18F-FDG PET/CT 1 month later. Post-therapy 18F-FDG PET/CT showed complete remission of the disease process in the axillary and femoral lymph nodes (EYH). However, there was appearance of left supraclavicular lymphadenopathy with foci of calcification (G; arrow) and increased 18F-FDG uptake (EYH). Because of presence of calcification along with lack of correlation with patient symptoms, a differential diagnosis of lymphoma versus infective pathology was given on PET/CT. To solve the dilemma, the treating physician advised a biopsy from the supraclavicular lymph node which showed caseating granulomatous lesion, suggestive of tuberculosis. The patient then underwent a full course of anti-tubercular treatment for 6 months. Because 18F-FDG PET/CT allows an easy evaluation of therapeutic response in patients with tuberculosis, particularly extrapulmonary tuberculosis, the patient was again referred for 18F-FDG PET/CT. PET/CT showed disappearance of the supraclavicular lymph node (IYL). Surprisingly, a large 18 F-FDG avid left femoral lymph node was noted on PET/CT (IYL, arrowhead), corresponding to the node seen on initial restaging PET/CT (AYD, arrowhead). This again led to a diagnostic dilemma. Fine-needle aspiration cytology was done from the left femoral lymph node which revealed presence of Reed-Sternberg cells, confirming a diagnosis of relapsed Hodgkin lymphoma. The patient is currently undergoing second-line chemotherapy. 18F-FDG PET/CT can be employed for accurate staging, treatment planning, and response assessment in patients with Hodgkin lymphoma. 18F-FDG PET has higher sensitivity than other imaging modalities to detect nodular or diffuse lesions and higher sensitivity than bone marrow biopsy to detect bone marrow infiltration.1 These patients generally respond well to chemotherapy with or without adjuvant radiotherapy and are usually cured.2,3 However, weakening of immune system due to anticancer therapy toxicity makes them prone to secondary infections.4 Reactivation of tuberculosis is a relatively common occurrence after chemotherapy in endemic countries.5 Because both tuberculosis and lymphoma can lead to hypermetabolic lesions on 18F-FDG PET/CT, differentiation is often not possible.6,7 Hence, in case of any discrepancy cytological or histopathological verification is warranted, as in the present case. 18F-FDG PET/CT allows an easy evaluation of early therapeutic response in patients with tuberculosis, particularly extrapulmonary lesions.8 The present case describes a unique clinical scenario where there was differential evolution of lymphoma and tuberculosis over time as documented by 18F-FDG PET/CT. * 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
737
