Indian Journal of Nuclear Medicine
Home | About IJNM | Search | Current Issue | Past Issues | Instructions | Ahead of Print | Online submissionLogin 
Indian Journal of Nuclear Medicine
  Editorial Board | Subscribe | Advertise | Contact
Users Online: 1742 Print this page  Email this page Small font size Default font size Increase font size


 
 Table of Contents     
INTERESTING IMAGE
Year : 2018  |  Volume : 33  |  Issue : 4  |  Page : 370-373  

F-18 fluorodeoxyglucose positron-emission tomography-computed tomography in a case of extensive multi-organal extranodal lymphoma with cardiac involvement mimicking apical hypertrophic obstructive cardiomyopathy: Staging and response evaluation


1 Department of Nuclear Medicine and PET/CT, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Hemato-Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication9-Oct-2018

Correspondence Address:
Rajender Kumar
Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_67_18

Rights and Permissions
   Abstract 


18F fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) is a standard imaging tool in staging as well as response evaluation for lymphoma. Here, we present a young male with extensive extranodal lymphoma with cardiac involvement which presented as diffuse myocardial lesion mimicking hypertrophic obstructive cardiomyopathy. 18F-FDG PET/CT helped in the staging by revealing multiple systemic involvements. Interim PET after three cycles of chemotherapy showed a complete metabolic response to therapy in all the extranodal sites including the cardiac involvement, thus retrospectively confirming the lymphomatous involvement. Previous literature also conforms to the superior role of 18F-FDG PET/CT in the clinical management of extensive extranodal lymphoma.

Keywords: 18F fluorodeoxyglucose positron-emission tomography-computed tomography, cardiac lymphoma, diffuse large B-cell lymphoma, extranodal lymphoma, hypertrophic obstructive cardiomyopathy, response evaluation


How to cite this article:
Vadi SK, Parihar AS, Mittal BR, Kumar R, Singh H, Malhotra P. F-18 fluorodeoxyglucose positron-emission tomography-computed tomography in a case of extensive multi-organal extranodal lymphoma with cardiac involvement mimicking apical hypertrophic obstructive cardiomyopathy: Staging and response evaluation. Indian J Nucl Med 2018;33:370-3

How to cite this URL:
Vadi SK, Parihar AS, Mittal BR, Kumar R, Singh H, Malhotra P. F-18 fluorodeoxyglucose positron-emission tomography-computed tomography in a case of extensive multi-organal extranodal lymphoma with cardiac involvement mimicking apical hypertrophic obstructive cardiomyopathy: Staging and response evaluation. Indian J Nucl Med [serial online] 2018 [cited 2019 Nov 17];33:370-3. Available from: http://www.ijnm.in/text.asp?2018/33/4/370/242938



A 32-year-old male patient presented with a history of nasal stuffiness 6 months before. On workup, nasal endoscopy showed soft-tissue mass in the nasal cavity and the left maxillary sinus. Endoscopic biopsy from the nasal lesion was confirmative of diffuse large B-cell lymphoma (DLBCL) with immunohistochemistry positive for CD20 and CD45 and negative for CD3. The patient underwent 18F fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) for staging purpose. The study showed abnormal FDG uptake in lesions in multiple systemic organs suggestive of multi-organal extranodal involvement from DLBCL [Figure 1]. There was also abnormal FDG avidity in the myocardium of the left ventricle with marked asymmetric thickening of the left ventricular (LV) myocardium [Figure 2].
Figure 1: 18F fluorodeoxyglucose positron-emission tomography-computed tomography showing abnormal tracer uptake in multiple organs as seen in the maximum intensity projection (a) with tracer avid soft-tissue lesions in the nasal cavity (arrow: b-d), body of pancreas (arrows: e-g), duodenal wall (arrows: h-j), and cortex of the left kidney (dotted arrows: h-j). The maximum intensity projection (a) also shows intense tracer uptake in the myocardium (arrow head)

Click here to view
Figure 2: Diffusely increased fluorodeoxyglucose uptake in the thickened myocardium, predominantly in apex and extending to adjacent anterior, septal, lateral, and inferior walls as shown with arrows in the axial positron emission tomography (a), fused axial positron-emission tomography-computed tomography (b), axial computed tomography (c) and the corresponding coronal (d and e) and sagittal views (f and g)

Click here to view


The patient was planned for chemotherapy. During the prechemotherapy workup, the electrocardiogram showed global T-wave inversion and cardiologist consultation was sought. A 2D-echocardiogram was done which showed asymmetrical hypertrophy of the myocardium suggestive of apical hypertrophic obstructive cardiomyopathy (HOCM). Although the patient was advised endomyocardial biopsy to detect nature of apical thickening of the LV (HOCM vs. lymphoma), patient refused biopsy and started with chemotherapy (R-CHOP regimen along with intrathecal methotrexate). After three cycles of chemotherapy, PET/CT was again done for interim response evaluation which showed complete metabolic response with resolution of the previously seen lesions [Figure 3]. The complete metabolic response of the cardiac lesion post-chemotherapy retrospectively confirmed cardiac infiltration of extranodal DLBCL, thus mimicking as apical pseudo-HOCM. The patient is currently doing well and is on the sixth cycle of chemotherapy at present.
Figure 3: 18F fluorodeoxyglucose positron-emission tomography-computed tomography done for response evaluation showing resolution of the tracer uptake as well as the lesions in the previously seen extranodal organs as seen in the maximum intensity projection (a), axial positron emission tomography (b, e, h and k), axial fused positron-emission tomography-computed tomography (c, f, i and l) and axial computed tomography (d, g, j and m) images indicating a complete metabolic and structural response

Click here to view


Extranodal involvement occurs in ~25%–40% of non-Hodgkin's lymphoma cases.[1] However, extensive systemic multi-organ involvement like in the index case is rarely described.[2],[3],[4] The involvement of nasal cavity with extra-nodular manifestation initially raised the suspicion of extranodal NK/T-cell lymphomas (ENKL and nasal type). However, the IHC was positive for the pan B-cell marker CD20. In IHC, NK/T-cell lymphomas are negative for CD20 (pan B-cell marker) and positive for expression of T-lineage antigens including CD2, CD7, and CD8 and NK lineage markers (such as CD56). In addition, evidence of the Epstein–Barr Virus (EBV) involvement by in situ hybridization staining for EBV-encoded small nuclear RNA-1 within transformed cells is critical to the diagnosis of ENKL (nasal and nonnasal).[5] Although frequently missed, cardiac involvement from lymphoma is ~18% in autopsy studies.[6] Despite the potentially lethal nature, most patients remain asymptomatic as in the index case. Cardiac involvement in lymphoma poses a diagnostic challenge with lesions mimicking many other benign heart conditions like infarct,[7] or as HOCM[8] as in this case. Functional imaging like FDG PET/CT has shown superiority over CT in the evaluation of extra-nodal involvement and PET/CT has been reported to reveal previously unsuspected cardiac involvement.[9],[10],[11],[12],[13] Assessment of response with a serial PET has been suggested to be more accurate than magnetic resonance imaging and echocardiography for assessing cardiac lymphoma regression. PET/CT proved useful in this patient in bringing out the extra-nodal sites as well as showing the response to therapy and in proving the cardiac involvement retrospectively.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
   References Top

1.
Freeman C, Berg JW, Cutler SJ. Occurrence and prognosis of extranodal lymphomas. Cancer 1972;29:252-60.  Back to cited text no. 1
    
2.
Dhull VS, Sharma P, Singla S, Faizi NA, Thulkar S, Bal C, et al. Extensive extranodal involvement of rare sites in non Hodgkin's lymphoma detected on (18)F- FDG PET-CT: A case report. Nucl Med Mol Imaging 2013;47:125-9.  Back to cited text no. 2
    
3.
Bai X, Codreanu I, Kaplan SL, Servaes S, Zhuang H. Non-Hodgkin lymphoma dominated by multiple organ extranodal disease revealed on FDG PET/CT. Clin Nucl Med 2015;40:360-3.  Back to cited text no. 3
    
4.
Paes FM, Kalkanis DG, Sideras PA, Serafini AN. FDG PET/CT of extranodal involvement in non-Hodgkin lymphoma and Hodgkin disease. Radiographics 2010;30:269-91.  Back to cited text no. 4
    
5.
Kohrt H, Advani R. Extranodal natural killer/T-cell lymphoma: Current concepts in biology and treatment. Leuk Lymphoma 2009;50:1773-84.  Back to cited text no. 5
    
6.
Petersen CD, Robinson WA, Kurnick JE. Involvement of the heart and pericardium in the malignant lymphomas. Am J Med Sci 1976;272:161-5.  Back to cited text no. 6
    
7.
Sankaranarayanan R, Prasanna K. A case of primary cardiac lymphoma mimicking acute myocardial infarction. Clin Cardiol 2009;32:E52-4.  Back to cited text no. 7
    
8.
Kim DH, Kim YH, Song WH, Ahn JC. Primary cardiac lymphoma presenting as an atypical type of hypertrophic cardiomyopathy. Echocardiography 2014;31:E115-9.  Back to cited text no. 8
    
9.
O'Mahony D, Peikarz RL, Bandettini WP, Arai AE, Wilson WH, Bates SE, et al. Cardiac involvement with lymphoma: A review of the literature. Clin Lymphoma Myeloma 2008;8:249-52.  Back to cited text no. 9
    
10.
Nguyen JD, Carrasquillo JA, Little RF, Ryan QC, Wilson W, Chen CC, et al. Fluorodeoxyglucose positron emission tomography in the presence of cardiac metastases. Clin Nucl Med 2003;28:979-80.  Back to cited text no. 10
    
11.
Agrawal K, Mittal BR, Manohar K, Kashyap R, Bhattacharya A, Varma S, et al. FDG PET/CT in detection of metastatic involvement of heart and treatment monitoring in non-Hodgkin's lymphoma. World J Nucl Med 2012;11:33-4.  Back to cited text no. 11
  [Full text]  
12.
Ilica AT, Kocacelebi K, Savas R, Ayan A. Imaging of extranodal lymphoma with PET/CT. Clin Nucl Med 2011;36:e127-38.  Back to cited text no. 12
    
13.
Römer W, Garbrecht M, Fuchs C, Schwaiger M. Images in cardiovascular medicine. Metabolic imaging identifies non-Hodgkin's lymphoma infiltrating heart. Circulation 1998;97:2577-8.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    References
    Article Figures

 Article Access Statistics
    Viewed244    
    Printed3    
    Emailed0    
    PDF Downloaded49    
    Comments [Add]    

Recommend this journal