A JH
DIAGNOSTIC IMAGING IN HEMATOLOGY
AJH Educational Material
False-negative FDG-PET in histologically proven extensive large cell bone marrow involvement in diffuse large B-cell lymphoma Hugo J.A. Adams,1* John M.H. de Klerk,2 Rob Fijnheer,3 Stefan V. Dubois,4 Rutger A.J. Nievelstein,1 and Thomas C. Kwee1
Image. 1. Coronal (A), oblique (B), and sagittal (C) 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) maximum intensity projections (MIPs) showing right axillary and right cervical lymphadenopathy, but no involvement of the bone marrow. Axial FDGPET (D) with concomitant CT (E) of the posterior iliac crest showing no signs of bone marrow involvement. Hematoxylin and eosin (HE) (F,G,H, original magnifications 253/2003/6303, respectively) and CD20 (I,J, original magnifications 253/2003, respectively) stained bone marrow biopsy specimens showing extensive large cell (concordant) bone marrow involvement, estimated at 50% by the DLBCL. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
A 69-year-old man presented with right axillary lymph node enlargement and B-symptoms (fever, night sweats, and weight loss). 18F-fluoro-2-deoxyD-glucose (FDG) positron emission tomography (PET) showed confluent right axillary and right cervical lymphadenopathy (Image 1A–C, arrows). Excisional right axillary lymph node biopsy revealed diffuse large B-cell lymphoma (DLBCL). Importantly, FDG-PET did not show any signs of lymphomatous disease in other locations, including the bone marrow. Axial FDG-PET with concomitant CT at the level of the posterior iliac crest was also negative for bone marrow involvement (Image 1D,E). Right posterior iliac crest bone marrow biopsy (BMB) was performed. Remarkably, despite the negative bone marrow FDG-PET findings, the bone trephine showed extensive bone marrow involvement, estimated at 50%, by the DLBCL (Image 1F–H [HE, original magnifications 325/3200/3630, respectively] and Image 1I,J [CD20, original magnifications 325/3200, respectively]). Recently updated guidelines on the Role of Imaging in the Staging and Response Assessment of Lymphoma consider FDG-PET more sensitive than BMB for the detection of bone marrow involvement, and that FDG-PET may only miss low-volume diffuse involvement of 10–20% of the marrow [1,2]. In addition, these guidelines mention that BMB is only needed for DLBCL if FDG-PET is negative and identifying a small cell (discordant) bone marrow involvement is important for patient management [1,2]. However, the presented case shows that FDG-PET can miss rather extensive large cell (concordant) bone marrow involvement in DLBCL. Therefore, BMB remains to play an important role in the evaluation of the bone marrow in DLBCL.
䊏 References 1. Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: Consensus of the international conference on malignant lymphomas
imaging working group. J Clin Oncol 2014;32: 3048–3058.
response assessment of hodgkin and non-Hodgkin lymphoma: The lugano classification. J Clin Oncol 2014;32:3059–3068.
2. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and
1
Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; 2Department of Nuclear Medicine, Meander Medical Center, Amersfoort, The Netherlands; 3Department of Hematology, Meander Medical Center, Amersfoort, The Netherlands; 4Department of Pathology, Meander Medical Center, Amersfoort, The Netherlands
Conflicts of interest: Nothing to report. *Correspondence to: Hugo J.A. Adams MD, Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. E-mail: [email protected] Contract grant sponsor: Alpe d’HuZes/Dutch Cancer Society Bas Mulder Award; Contract grant number: 5409. Received for publication: 18 January 2015; Accepted: 22 January 2015 Am. J. Hematol. 90:681, 2015. Published online: 19 February 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ajh.23986 C 2015 Wiley Periodicals, Inc. V
doi:10.1002/ajh.23986
American Journal of Hematology, Vol. 90, No. 7, July 2015
681
DIAGNOSTIC IMAGING IN HEMATOLOGY
AJH Educational Material
False-negative FDG-PET in histologically proven extensive large cell bone marrow involvement in diffuse large B-cell lymphoma Hugo J.A. Adams,1* John M.H. de Klerk,2 Rob Fijnheer,3 Stefan V. Dubois,4 Rutger A.J. Nievelstein,1 and Thomas C. Kwee1
Image. 1. Coronal (A), oblique (B), and sagittal (C) 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) maximum intensity projections (MIPs) showing right axillary and right cervical lymphadenopathy, but no involvement of the bone marrow. Axial FDGPET (D) with concomitant CT (E) of the posterior iliac crest showing no signs of bone marrow involvement. Hematoxylin and eosin (HE) (F,G,H, original magnifications 253/2003/6303, respectively) and CD20 (I,J, original magnifications 253/2003, respectively) stained bone marrow biopsy specimens showing extensive large cell (concordant) bone marrow involvement, estimated at 50% by the DLBCL. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
A 69-year-old man presented with right axillary lymph node enlargement and B-symptoms (fever, night sweats, and weight loss). 18F-fluoro-2-deoxyD-glucose (FDG) positron emission tomography (PET) showed confluent right axillary and right cervical lymphadenopathy (Image 1A–C, arrows). Excisional right axillary lymph node biopsy revealed diffuse large B-cell lymphoma (DLBCL). Importantly, FDG-PET did not show any signs of lymphomatous disease in other locations, including the bone marrow. Axial FDG-PET with concomitant CT at the level of the posterior iliac crest was also negative for bone marrow involvement (Image 1D,E). Right posterior iliac crest bone marrow biopsy (BMB) was performed. Remarkably, despite the negative bone marrow FDG-PET findings, the bone trephine showed extensive bone marrow involvement, estimated at 50%, by the DLBCL (Image 1F–H [HE, original magnifications 325/3200/3630, respectively] and Image 1I,J [CD20, original magnifications 325/3200, respectively]). Recently updated guidelines on the Role of Imaging in the Staging and Response Assessment of Lymphoma consider FDG-PET more sensitive than BMB for the detection of bone marrow involvement, and that FDG-PET may only miss low-volume diffuse involvement of 10–20% of the marrow [1,2]. In addition, these guidelines mention that BMB is only needed for DLBCL if FDG-PET is negative and identifying a small cell (discordant) bone marrow involvement is important for patient management [1,2]. However, the presented case shows that FDG-PET can miss rather extensive large cell (concordant) bone marrow involvement in DLBCL. Therefore, BMB remains to play an important role in the evaluation of the bone marrow in DLBCL.
䊏 References 1. Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: Consensus of the international conference on malignant lymphomas
imaging working group. J Clin Oncol 2014;32: 3048–3058.
response assessment of hodgkin and non-Hodgkin lymphoma: The lugano classification. J Clin Oncol 2014;32:3059–3068.
2. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and
1
Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; 2Department of Nuclear Medicine, Meander Medical Center, Amersfoort, The Netherlands; 3Department of Hematology, Meander Medical Center, Amersfoort, The Netherlands; 4Department of Pathology, Meander Medical Center, Amersfoort, The Netherlands
Conflicts of interest: Nothing to report. *Correspondence to: Hugo J.A. Adams MD, Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. E-mail: [email protected] Contract grant sponsor: Alpe d’HuZes/Dutch Cancer Society Bas Mulder Award; Contract grant number: 5409. Received for publication: 18 January 2015; Accepted: 22 January 2015 Am. J. Hematol. 90:681, 2015. Published online: 19 February 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ajh.23986 C 2015 Wiley Periodicals, Inc. V
doi:10.1002/ajh.23986
American Journal of Hematology, Vol. 90, No. 7, July 2015
681
