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LETTER TO EDITOR
Year : 2013  |  Volume : 28  |  Issue : 2  |  Page : 124-125  

Multicentric Castleman's disease: Closest mimic of lymphoma on FDG PET/CT


Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India

Date of Web Publication16-Sep-2013

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai- 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.118259

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How to cite this article:
Puranik AD, Purandare NC, Shah S, Agrawal A, Rangarajan V. Multicentric Castleman's disease: Closest mimic of lymphoma on FDG PET/CT. Indian J Nucl Med 2013;28:124-5

How to cite this URL:
Puranik AD, Purandare NC, Shah S, Agrawal A, Rangarajan V. Multicentric Castleman's disease: Closest mimic of lymphoma on FDG PET/CT. Indian J Nucl Med [serial online] 2013 [cited 2019 Dec 9];28:124-5. Available from: http://www.ijnm.in/text.asp?2013/28/2/124/118259

Sir,

Intense lymph nodal concentration of tracer on 18 F- Fluoro-deoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) is a characteristic of high grade lymphomas. However, a similar imaging pattern is seen in Castleman's disease (CD). We report one such case of a 43-year-old lady, presenting with fever and significant weight loss since 3 months. Patient was seronegative for HIV (Human Immuno-deficiency Virus and HHV-6 (human herpes virus-6). Ultrasonography (USG) of abdomen showed enlarged retroperitoneal nodes. With a high suspicion of neoplastic etiology, whole body FDG PET/CT was carried out. Maximum intensity projection (MIP) image revealed intense tracer concentration in the retroperitoneal, pelvic, and right inguinal nodal chain [Figure 1]a - arrow heads], with discrete foci in mediastinum [Figure 1]a - arrow] and pelvic bones. Axial fused PET/CT images confirmed showed hypermetabolic conglomerate enlarged retroperitoneal [Figure 1]b - arrow], right pelvic [Figure 1]c - arrow] and inguinal nodes [Figure 1]e - arrow], extending from renal hilum upto aortic bifurcation. Also seen was tracer uptake in bone marrow at D6 [Figure 1]d - arrow], L2 and L5 vertebra, and in right pelvic bones [Figure 1]d - arrowhead]. Post-contrast CT images show mild enhancement in retroperitoneal [Figure 2]a - arrow], pelvic [Figure 2]b and 2c - arrow] and inguinal [Figure 2]d - arrow] nodes, which show hypermetabolism on PET images. Discrete hypermetabolic focus was seen in right pelvic subcutaneous region. Scan features and uptake pattern was strongly suggestive of stage IV lymphoma. Bone marrow biopsy showed plasma cell aggregates with no malignant cells. However, histopathological examination of retroperitoneal nodal specimen revealed plasma cell variant of CD, with numerous atrophic germinal centers. Patient was treated with steroids and follow-up study carried out 3 months later showed significant metabolic and morphological regression [Figure 3] - arrow and arrow heads].
Figure 1: MIP image (a) showing intense tracer uptake in retroperitoneal and pelvic nodal chain (arrow-heads) and focal uptake in mediastinum (arrow). Axial fused PET/CT showing hypermetabolic retroperitoneal nodes (b - arrow) with (FDG) avid right pelvic (c - arrow) nodes. FDG uptake seen in the right iliac (d - arrow head), D6 vertebra (d - arrow). Also seen is hypermetabolic right inguinal node (e - arrow)

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Figure 2: Axial post contrast CT images show mild enhancement in nodes in retroperitoneal (a - arrow), pelvic (b and c - arrow) and right inguinal (d - arrow) regions, which on axial PET images show FDG uptake

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Figure 3: MIP image of FDG PET/CT carried out after 3 months of steroid therapy shows significant metabolic and morphological regression of disease (compared to Figure 1a)

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CD was first described by Benjamin Castleman in 1956. [1] It is of unknown etiology; most popular hypothesis labeling it as chronic low grade inflammation with Interleukin-6 overproduction. [2] It commonly involves the lymphatics, with extra-lymphatic involvement seen in lungs, bones, meninges, and muscles. [3] Its association with inflammatory cells is the most likely explanation of FDG uptake in CD. FDG is known to concentrate in many non-specific infections and inflammations, seen as hypermetabolic adenopathy. [4] Hypermetabolic nodes are also seen in granulomatous diseases. [5] All these are commonest false positives for FDG uptake in lymph nodes in cancer patients. In these cases, distinction can be made from lymphoma, by the intensity of nodal FDG concentration and morphology of nodes. However, CD, though a benign lymphoproliferative disorder; the pattern of lymphatic involvement, extranodal sites; and FDG avidity of these lesions, makes it to appear similar to lymphoma. Thus, FDG PET/CT offers little help in distinguishing between the two; making CD the closest imaging mimic of lymphoma on FDG PET/CT. However, whole body metabolic - morphological fusion imaging helps in picking up sites of involvement, separating unicentric from multicentric disease. This can have an impact on disease management, since localized disease is amenable to surgery. [6] Thus, on a positive note, PET/CT can be used for mapping the extent of disease involvement by uncovering sites of disease and can also be used for assessing treatment response, which are otherwise difficult to document.

 
   References Top

1.Castleman B, Towne VW. Case records of the Massachusetts General Hospital Weekly Clinicopathological Exercises: Case 40011. N Engl J Med 1954;250:26-30.  Back to cited text no. 1
    
2.Kanda J, Kawabata H, Yamaji Y, Ichinohe T, Ishikawa T, Tamura T, et al. Reversible cardiomyopathy associated with Multicentric Castleman disease: Successful treatment with tocilizumab, an anti-interleukin 6 receptor antibody. Int J Hematol 2007;85:207-11.  Back to cited text no. 2
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3.Bonekamp D, Horton KM, Hruban RH, Fishman EK. Castleman disease: The great mimic. Radiographics 2011;31:1793-807.  Back to cited text no. 3
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4.Long NM, Smith CS. Causes and imaging features of false positives and false negatives on F-PET/CT in oncologic imaging. Insights Imaging 2011;2:679-98.  Back to cited text no. 4
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5.Kumar A, Dutta R, Kannan U, Kumar R, Khilnani GC, Gupta SD. Evaluation of mediastinal lymph nodes using F-FDG PET-CT scan and its histopathologic correlation. Ann Thorac Med 2011;6:11-6.  Back to cited text no. 5
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6.Enomoto K, Nakamichi I, Hamada K, Inoue A, Higuchi I, Sekimoto M, et al. Unicentric and multicentric Castleman's disease. Br J Radiol 2007;80:e24-6.  Back to cited text no. 6
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