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INTERESTING IMAGE
Year : 2019  |  Volume : 34  |  Issue : 4  |  Page : 326-328  

Diffuse skeletal uptake on 18F-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography scan in a patient with acute lymphoblastic leukemia: A typical superscan pattern resembling naf positron emission tomography scan


1 Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Nuclear Medicine, Taleghani Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Web Publication23-Sep-2019

Correspondence Address:
Dr. Mohsen Qutbi
Department of Nuclear Medicine, Taleghani Hospital, Yaman Street, Velenjak, Tehran 1985711151
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_106_19

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   Abstract 


A 65-year-old patient with acute lymphoblastic leukemia presented for an 18fluoro-2-deoxy-d-glucose positron emission tomography computed tomography (18FDG PET) after several courses of chemotherapy for metastatic evaluation. Unexpectedly, on 18FDG PET scan, no discernible uptake was observed in the visceral organs, but instead, the skeleton/bone marrow showed homogenously intense metabolic activity. The distribution of 18FDG observed on the scan was remarkably similar to that on the NaF PET scan, indicating a superscan appearance.

Keywords: 18 fluoro-2-deoxy-d-glucose positron emission tomography computed tomography, acute lymphoblastic leukemia, bone marrow, diffuse uptake, skeleton, superscan


How to cite this article:
Yousefi-Koma A, Shiravand Y, Qutbi M. Diffuse skeletal uptake on 18F-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography scan in a patient with acute lymphoblastic leukemia: A typical superscan pattern resembling naf positron emission tomography scan. Indian J Nucl Med 2019;34:326-8

How to cite this URL:
Yousefi-Koma A, Shiravand Y, Qutbi M. Diffuse skeletal uptake on 18F-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography scan in a patient with acute lymphoblastic leukemia: A typical superscan pattern resembling naf positron emission tomography scan. Indian J Nucl Med [serial online] 2019 [cited 2019 Oct 22];34:326-8. Available from: http://www.ijnm.in/text.asp?2019/34/4/326/267500



A 65-year-old man with a history of acute lymphoblastic leukemia (L3 subtype) was referred for an 18F fluoro-2-deoxy-d-glucose positron emission tomography computed tomography (18 FDG PET/CT) for possible metastatic assessment. After obtaining an informed consent, an 18 FDG PET/CT scan was performed. The diagnosis was established by a bone marrow biopsy following a pancytopenia developed 2 years ago, and then, the chemotherapy was instituted shortly thereafter. After completion of 8 cycles of chemotherapy, the bone marrow biopsy examination revealed no leukemic involvement, but mild erythroid hyperplasia. Subsequently, a CT scan of the thorax was performed, on which, a few small nodules were detected in the lungs. Two months later, the patient underwent an 18 FDG PET/CT [Figure 1]a, on which, a massive redistribution of the tracer from internal organs to the skeleton/bone marrow was noticed. Except mild physiological uptake in the brain, the visceral organs and soft tissue background activity were barely discernible. The most conspicuous finding on the maximum intensity projection image was the intense, homogeneous uptake in the axial and appendicular skeleton, suggesting diffuse bone marrow involvement. In addition, uptake irregularity of the renal parenchyma suspicious for tumoral involvement was evident. In [Figure 1]b, on enhancement of the brightness of the image in part “a” of [Figure 1], the liver and spleen demonstrated faint uptake, and the background activity is still suppressed. As can be seen in [Figure 2], the CT, PET, and fused PET/CT images from thorax (a), upper abdomen (b), and pelvis (c) demonstrate intense hypermetabolic pulmonary nodules in the right lung and substantial uptake in the bones as compared to faint uptake in the parenchyma of the liver and spleen. Two months later, despite the initiation of a new regimen of chemotherapy, the patient expired. “Superscan” appearance is an interesting terminology that has long been in use in nuclear medicine.[1],[2] Initially, by definition, this terminology applied to a pattern on bone scintigraphy that assumes a condition in which the99 mTc-mthylene-diphosphonate is perfectly taken up in the skeletal system, and no background activity is noticed. Owing to the homogeneous distribution, this appearance resembles a normal scan but with much higher quality and is associated with varieties of metabolic disorders and rarely, widespread metastatic involvement of the skeleton.[1],[2],[3] Later, the application of this term is generalized to similar features in other scans or any dominant uptake limited to a specific organ, for example, liver,[4],[5] suppressing uptake elsewhere, although some misuses have been occurred. Diffuse 18 FDG uptake in the skeleton and bone marrow as superscan pattern on PET scan has been reported in multiple malignant disorders, including lymphoma and leukemia,[6],[7] multiple myeloma,[8] and metastasis like prostate cancer[9],[10] as well as other hematologic conditions, for example, following administration of granulocyte colony-stimulating factor.[11] This finding is also observed in metabolic disorders such as renal osteodystrophy[12] and parathyroid carcinoma.[13] In this case, although some uptake in the brain and excretion via the urinary system are present, the uptake in the skeleton is sufficiently high and homogeneous that conforms, to a large extent, to the definition of superscan and bears a striking resemblance to an NaF PET scan, an exceptionally rare finding. In such conditions, because of less tracer available to accumulate in other organs, the detection of lesions may be compromised and more importantly, as in our patient, the prognosis is considerably poorer in patients without such finding.
Figure 1: Maximum intensity projections of 18FDG PET scan without (a) and with (b) brightness enhancement

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Figure 2: CT (left), PET (middle) and fused PET/CT (right) slices of 18FDG PET scan from thorax (a), upper abdomen (b) and pelvis (c)

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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.
Osmond JD 3rd, Pendergrass HP, Potsaid MS. Accuracy of 99mTC-diphosphonate bone scans and roentgenograms in the detection of prostate, breast and lung carcinoma metastases. Am J Roentgenol Radium Ther Nucl Med 1975;125:972-77.  Back to cited text no. 1
    
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Sy WM, Patel D, Faunce H. Significance of absent or faint kidney sign on bone scan. J Nucl Med 1975;16:454-6.  Back to cited text no. 2
    
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Buckley O, O'Keeffe S, Geoghegan T, Lyburn ID, Munk PL, Worsley D, et al. 99mTc bone scintigraphy superscans: A review. Nucl Med Commun 2007;28:521-7.  Back to cited text no. 3
    
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Tichelaar V, Gemmel F, de Rhoter W, Bronkhorst C, de Graaf H. FDG hepatic superscan caused by massive breast cancer invasion. Clin Nucl Med 2009;34:716-8.  Back to cited text no. 4
    
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Du B, Li X, Li N, Li Y, Hsu B. 18F-FDG hepatic superscan in a patient with chronic myeloid leukemia. Clin Nucl Med 2014;39:835-6.  Back to cited text no. 5
    
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Chiang SB, Rebenstock A, Guan L, Alavi A, Zhuang H. Diffuse bone marrow involvement of Hodgkin lymphoma mimics hematopoietic cytokine-mediated FDG uptake on FDG PET imaging. Clin Nucl Med 2003;28:674-6.  Back to cited text no. 6
    
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Acevedo-Báñez I, De-Bonilla-Damiá Á, Fernández-López R. 18F-FDG PET/CT “superscan” in a patient with immunoblastic lymphoma. Rev Esp Med Nucl Imagen Mol 2018. pii: S2253-654X(18)30055-6.  Back to cited text no. 7
    
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Fu Z, Chen X, Yang X, Li Q. Skeletal superscan on 18F-FDG PET/CT in a patient with multiple myeloma. Clin Nucl Med 2019;44:169-70.  Back to cited text no. 8
    
9.
Su HY, Liu RS, Liao SQ, Wang SJ. F-18 FDG PET superscan. Clin Nucl Med 2006;31:28-9.  Back to cited text no. 9
    
10.
Bailly M, Besse H, Kerdraon R, Metrard G, Gauvain S. 18F-FDG PET/CT superscan in prostate cancer. Clin Nucl Med 2014;39:912-4.  Back to cited text no. 10
    
11.
Knopp MV, Bischoff H, Rimac A, Oberdorfer F, van Kaick G. Bone marrow uptake of fluorine-18-fluorodeoxyglucose following treatment with hematopoietic growth factors: Initial evaluation. Nucl Med Biol 1996;23:845-9.  Back to cited text no. 11
    
12.
Ghesani N, Jung J, Patel S, Ramchand T. Superscan caused by renal osteodystrophy: Observed on 18F FDG PET/CT scan. Indian J Nucl Med 2013;28:251-2.  Back to cited text no. 12
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13.
Güney İB, Paydaş S, Ballı HT. Super scan caused by parathyroid carcinoma observed both in F-FDG PET/CT scan and tc-99m MDP bone scintigraphy. Mol Imaging Radionucl Ther 2017;26:116-9.  Back to cited text no. 13
    


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