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FDG-PET in Aggressive Lymphoma

FDG-PET in Aggressive Lymphoma. Chen Shih-Wei, SKH. The Role of NM in Lymphoma. Nuclear medicine has a well-established role in the management of malignant lymphomas. 67 Ga-Citrate has been widely used for the evaluation of HD and NHL.

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FDG-PET in Aggressive Lymphoma

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  1. FDG-PET in Aggressive Lymphoma Chen Shih-Wei, SKH

  2. The Role of NM in Lymphoma • Nuclear medicine has a well-established role in the management of malignant lymphomas. • 67Ga-Citrate has been widely used for the evaluation of HD and NHL. • Many studies have proved FDG-PET is superior to Gallium scan for both initial staging and follow-up of lymphoma. J Nucl Med 2006; 47:1326–1334

  3. Case 1 • 36 y/o male • PET for cancer screening on 2004-10-30 • No specific complaint

  4. 2004-10-30

  5. max SUV: 18.1 • 4.2 x 3.5 x 3.4 cm

  6. D/D • Colon cancer ? • Small intestine cancer ? • Gastrointestinal stromal tumor ? • Castleman’s disease • Lymphoma ?

  7. Result • He received operation at NTUH: Mesentery lymphoma, Diffuse large B cell type. • Chemotherapy (Jan to May, 2005)

  8. 2006-8-12

  9. DLBL • Diffuse large B-cell lymphoma (DLBL) is a type of aggressive lymphoma. • It accounts for approximately 40% of lymphomas among adults.

  10. The Role of PET in Lymphoma • Initial Staging • Evaluate response of treatment • Follow-up (detect recurrence)

  11. J of Nucl Med, 2006;47(8): 1326-1334

  12. (29.7%) (24.4%) (27.3%) (7.0%) (4.1%) (1.2%) (2.9%) (1.2%) (0.6%) (0.6%) (0.6%) (0.6%) Blood, 15 May 2003, Vol. 101, No. 10, pp. 3875-3876

  13. Table. Positive rate of FDG-PET in T/NK-cell neoplasms Annals of Oncology 18: 1685 -1690, 2007

  14. The Role of PET in Lymphoma • Many studies revealed overlap between the SUVs of indolent and aggressive lymphomas. • Generally, aggressive disease had a higher FDG uptake than indolent lymphomas. J Nucl Med 2006; 47:1326–1334

  15. Case 2 • 62 y/o female • Right parotid cancer (adenoid cystic carcinoma) s/p operation and radiotherapy in 2001 • PET for follow up examination on 2004-1-15

  16. 2004-1-15

  17. Possibly due to chronic thyroiditis. • Diffusely increased FDG uptake in bilateral thyroid lobes, more intense on the right side.

  18. 2005-7-14

  19. 2005-08-20 Ultrasound: Multinodular goiter • 2006-10-27 Ultrasound: Multinodular goiter

  20. 2007-11-5

  21. max SUV: 4.5 max SUV: 5.8 max SUV: 64.1 2004-1-15 2005-7-14 2007-11-5

  22. D/D • Papillary cancer ? • Medullary cancer ? • Anaplastic cancer ? • Anaplastic cancer ? • Thyroid Lymphoma ?

  23. (2007-11-23)US: MNG, right > left. FNA: Negative for malignancy • (2007-12-10) FNA: Atypical cell present • Malignancy still cannot be ruled out, so she received operation on 96-12-14.

  24. Result • Right total thyroidectomy: - Diffuse large B cell lymphoma - Lymphocytic thyroiditis • Left near total thyroidectomy: - Lymphocytic thyroiditis • Right neck LNs dissection: - Negative for malignancy = Hashimoto’s thyroiditis

  25. Thyroid Lymphoma • Rare: about 2% of extranodal lymphomas & < 5% of all thyroid cancers. • Typically found in older woman. • Almost always B-cell lineage. Large cell type predominance (70–80%). • The main ones are diffuse large B-cell lymphoma and MALT lymphoma. Thyroid Cancer, 2nd Edition, 2007, p615-623 J of Clin Oncol, 2007 ASCO, Vol.25, No.18S

  26. Thyroid Lymphoma • About half limited to the thyroid gland (stage IE). • Pre-existing Hashimoto’s thyroiditis is the only known risk factor (about 60-fold relative risk). • Thyroid gland enlarges rapidly, compressive symptoms. • Diagnosis is made by fine-needle aspiration. Thyroid Cancer, 2nd Edition, 2007, p615-623 J of Clin Oncol, 2007 ASCO, Vol.25, No.18S

  27. Hashimoto’s thyroiditis & Thyroid Lymphoma • The cause has not been adequately explained. • One potential mechanism may be the result of chronic antigenic stimulation in thyroiditis, enhancing the probability of neoplastic transformation.

  28. FDG-PET in Thyroid Cancer • Well-differentiated cancers can trap radioiodine, but not FDG. Poorly differentiated cancers show avid uptake of FDG, but they do not tend to trap iodine. • When showing focal high FDG uptake should be regarded as a possible malignancy that needs further assessment. Thyroid Cancer, 2nd Edition, 2007, p639 In Vivo. 2008 Jan-Feb;22(1):109-14

  29. Bilateral Thyroid FDG Uptake • Bilateral thyroidal uptake of FDG could be normal variants and subjects with various thyroid disorders • Diffuse intense uptake and higher SUV levels are a clue to a diagnosis of chronic thyroiditis, especially for those with hypothyroidism. • Focally intense uptake suggests the possibility of a thyroid carcinoma. Nucl Med Commun; 2007; 28:117–122

  30. Case 3 • 26 y/o female. • Right shoulder mass with swelling. • Biopsy on 2006-7-15: - Shoulder: Lymphoma, diffuse large type - iliac crest: Negative for malignancy • PET scan on 2006-7-26.

  31. 2006-7-26

  32. S/P chemotherapy with CHOP x 6 courses. • Follow-up PET on 2006-12-21 .

  33. 2006-12-21

  34. Bone Marrow Involve • Bone marrow involvement in patients with lymphoma is considered a sign of less favorable prognosis. • Bone marrow biopsy (BMB) represents the standard diagnostic procedure. However, BMB has a high rate of false-negative, which may lead to errors in management.

  35. 7 57 10 4 78 8 patients were confirmed and2 cases remained unresolved. PET in Detecting Bone Marrow Involvement • 78 patients (NHL= 39, HD= 39) • Sensitivity=81%, Specificity=100% for detecting bone marrow disease, with only 4 cases not being seen on PET. J of ClinOncol, 1998; 16: 603-609

  36. Total 7 77 5 16 105 PET vs. BMB Blood, 15 May 2003, Vol. 101, No. 10, pp. 3875-3876

  37. 50 449 35 53 587 76.2% High Grade 30.2% Low Grade PET vs. BMB 13 studies, 587 patients Sensitivity Specificity HD (191) 76% 92% NHL (191) 43% 88% Both/not separable (121) 52% 97% Total 51% 91% J of Nucl Med, 2005;46(6): 958-963

  38. 5 33 5 2 45 High grade lymphoma Low grade lymphoma SKH, from 2001 to 2008

  39. 2004-9-14 2004-9-14 Ga Scan Bone Scan 2004-8-11 2004-9-15 Hodgkin lymphoma; bone involve & biopsy(-)

  40. 83y, F, Diffuse large B Cell Lymphoma; bone involve & biopsy(-)

  41. 2008-5-26 2008-5-30 77y, M, Diffuse large B Cell Lymphoma; bone involve & biopsy(-)

  42. PET vs. BMB • PET has good, but not excellent for the detection of bone marrow infiltration of lymphoma. • PET may complement the results of BMB. • Its performance may vary according to the type of lymphoma.

  43. Post-C/T Marrow Hyperplasia • Marrow hyperplasia as a consequence of recovery from a chemotherapeutic insult may also cause a generalized increase in FDG uptake in marrow. • This increased uptake generally returns to baseline levels by 1 mo (usually within 3 wk), suggesting that clinicians should wait at least 1 mo after completion of therapy before obtaining a PET scan. J of Nucl Med, 2006;47(8): 1326-1334

  44. FIGURE 1.  Pretherapy (A) and posttherapy (B) PET scans of patient with Burkitt's lymphoma involving multiple vertebrae (arrows). Follow-up scan demonstrates diffuse bone marrow uptake secondary to administration of growth factor, with decreased uptake seen in areas of previous bone marrow involvement. J of Nucl Med, 2006;47(8): 1326-1334

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