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LETTER TO THE EDITOR
Year : 2019  |  Volume : 34  |  Issue : 2  |  Page : 178-179  

Utility of F-18 fluorodeoxyglucose positron emission tomography-computed tomography in a patient presenting with acute paraparesis in detecting isolated relapse of non-Hodgkin's lymphoma infiltrating the spinal cord


1 Department of Nuclear Medicine, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Internal Medicine, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Radiodiagnosis, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication8-Apr-2019

Correspondence Address:
Dr. Ashwani Sood
Department of Nuclear Medicine, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_23_19

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How to cite this article:
Jain TK, Sood A, Sood A, Basher RK, Prakash G, Prakash M, Mittal BR. Utility of F-18 fluorodeoxyglucose positron emission tomography-computed tomography in a patient presenting with acute paraparesis in detecting isolated relapse of non-Hodgkin's lymphoma infiltrating the spinal cord. Indian J Nucl Med 2019;34:178-9

How to cite this URL:
Jain TK, Sood A, Sood A, Basher RK, Prakash G, Prakash M, Mittal BR. Utility of F-18 fluorodeoxyglucose positron emission tomography-computed tomography in a patient presenting with acute paraparesis in detecting isolated relapse of non-Hodgkin's lymphoma infiltrating the spinal cord. Indian J Nucl Med [serial online] 2019 [cited 2019 Aug 19];34:178-9. Available from: http://www.ijnm.in/text.asp?2019/34/2/178/255614



Sir,

We report the case of a 62-year-old woman – a diagnosed case of diffuse large B-cell lymphoma (DLBCL) Term Stage IV BX, involving multiple lymph nodes on both sides of the diaphragm along with liver and skin lesions – who achieved remission with six courses of Rituximab, Vincristine, Cyclophosphomide, Doxorubicin, Prednisone (R-CHOP). Two years later, she complained of continuous low backache radiating along the back of both the thigh. The pain was associated with progressively increasing bilateral lower-limb weakness. Examination revealed normal higher mental functions, normal power of the upper limbs (5/5), and decreased power of the bilateral lower limbs (3/5). Bilateral knee and ankle reflexes were brisk and mute, respectively. Biochemical and hematological parameters were normal except leukocytosis (15,300; normal: 4000–11,000/cm 3). Magnetic resonance imaging (MRI) lumbosacral spine T1-weighted [Figure 1]a and T2-weighted images [Figure 1]b showed altered signal in the lumbar thecal sac with clumping of the caudal nerve roots in almost whole of the lumbar spine, partially encasing the conus part of the cord and complete cerebrospinal fluid (CSF) effacement in the lumbar thecal sac [Figure 1]a and [Figure 1]b. CSF cytology from the subarachnoid space revealed lymphomatous cells. In view of the clinical suspicion of disease recurrence, 18F fluorodeoxyglucose positron emission tomography and computed tomography (18 F-FDG PET/CT) was done, which showed midline, linear increased FDG uptake in the spinal column of the dorso-lumbar region in maximum intensity projection image [Figure 2]a. The corresponding sagittal and transaxial contrast-enhanced computed tomography and fused images [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e revealed linear intense tracer avidity (maximum standard uptake value 16.8) in the lobular dorso-lumbar spinal cord extending below the conus till the level of L4 vertebra. The patient was put on steroids and received radiotherapy, and she showed immediate symptomatic improvement.
Figure 1: T1- (a) and T2-weighted (b) magnetic resonance imaging images showing altered signal in the lumbar thecal sac with clumping of the caudal nerve roots in almost whole of the lumbar spine, partially encasing the conus part of the cord and complete cerebrospinal fluid effacement in the lumbar thecal sac

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Figure 2: 18F fluorodeoxyglucose positron emission tomography and computed tomography maximum intensity projection (a), sagittal computed tomography (b), sagittal fused positron emission tomography/computed tomography (c), axial fused positron emission tomography/computed tomography (d), and axial computed tomography (e) images showing midline linear increased tracer uptake in the spinal column of the dorso-lumbar region (arrow a). The increased fluorodeoxyglucose uptake corresponded to the uptake in lobular dorso-lumbar spinal cord extending below the conus till the level of L4 vertebra (c, arrow)

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DLBCL frequently presents as disseminated disease at the time of diagnosis though the standard treatment of R-CHOP therapy has improved the outcome significantly.[1] Following first-line therapy, 50%–60% of the patients achieve complete remission, whereas the remaining 10% and 30%–40% have refractory disease and relapse, respectively.[2]

Unfortunately, in the first 2–3 years, patients with DLBCL relapse after treatment, with the extranodal sites being more frequently involved than the nodal sites. Imaging studies help in the identification of the location of relapse. Various unusual sites of relapse of lymphoma such as trachea, orbit, meninges, and terminal ileum have been described in literature.[3]

Secondary involvement of the spinal cord in DLBCL is extremely rare. In Mayo Clinic patient database of 14 years, only seven patients of non-Hodgkin's lymphoma (NHL) with a median age of 61 years and subacute presentation were found to have secondary intramedullary spinal cord involvement on CSF cytology, FDG PET, and MRI. Majority of them had myelopathy following the diagnosis of NHL with favorable survival posttreatment. These patients usually have early neurological morbidity. MRI spine,18 F-FDG PET/CT, and CSF cytology help in the identification of disease and its management.[4] Whole-body 18 F-FDG PET/CT assists in the identification of the other sites of lymphomatous involvement for staging of the disease and response evaluation after intervention. Patients in whom CSF sampling is difficult/unsafe to obtain or unable to undergo MRI scan for various reasons may be benefitted from 18F-FDG PET/CT which can help in detection of spinal cord involvement and timely treatment with favourable survival outcome.

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.
Rodenburg EM, Maartense E, Posthuma EF. Improved survival for patients with large B-cell lymphoma after introduction of rituximab. Neth J Med 2009;67:355-8.  Back to cited text no. 1
    
2.
Perry AR, Goldstone AH. High-dose therapy for diffuse large-cell lymphoma in first remission. Ann Oncol 1998;9 Suppl 1:S9-14.  Back to cited text no. 2
    
3.
Adams HJ, de Klerk JM, Fijnheer R, Heggelman BG, Dubois SV, Nievelstein RA, et al. Where does diffuse large B-cell lymphoma relapse? J Comput Assist Tomogr 2016;40:531-6.  Back to cited text no. 3
    
4.
Flanagan EP, O'Neill BP, Habermann TM, Porter AB, Keegan BM. Secondary intramedullary spinal cord non-Hodgkin's lymphoma. J Neurooncol 2012;107:575-80.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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