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Year : 2020  |  Volume : 35  |  Issue : 4  |  Page : 355-357  

Extramedullary infiltration in multiple organs in a relapsed case of acute lymphoblastic leukemia on 18F-fluorodeoxyglucose positron emission tomography


Department of Nuclear Medicine and PET-CT, All India Institute of Medical Sciences, New Delhi, India

Date of Submission15-Mar-2020
Date of Decision09-Apr-2020
Date of Acceptance22-Apr-2020
Date of Web Publication21-Oct-2020

Correspondence Address:
Dr. Shamim Ahmed Shamim
Department of Nuclear Medicine and PET.CT, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_47_20

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   Abstract 


T-cell acute lymphoblastic leukemia (ALL) is hematological malignancy with a propensity to involve extramedullary organs. We present the case of a 7-year-old child who was diagnosed with disease free from ALL for 1 year and then developed fever. 18F-fluorodeoxyglucose positron emission tomography/computed tomography revealed extramedullary infiltration of ALL in lungs, pancreas, kidneys, bone, muscles, and subcutaneous tissues.

Keywords: Acute lymphoblastic leukemia, extramedullary, fluorodeoxyglucose, positron emission tomography/computed tomography


How to cite this article:
Tripathy S, Arun Raj ST, Prakash S, Sagar S, Arora G, Shamim SA. Extramedullary infiltration in multiple organs in a relapsed case of acute lymphoblastic leukemia on 18F-fluorodeoxyglucose positron emission tomography. Indian J Nucl Med 2020;35:355-7

How to cite this URL:
Tripathy S, Arun Raj ST, Prakash S, Sagar S, Arora G, Shamim SA. Extramedullary infiltration in multiple organs in a relapsed case of acute lymphoblastic leukemia on 18F-fluorodeoxyglucose positron emission tomography. Indian J Nucl Med [serial online] 2020 [cited 2020 Nov 30];35:355-7. Available from: https://www.ijnm.in/text.asp?2020/35/4/355/298747



A 7-year-old male child who has been diagnosed disease free from acute lymphoblastic leukemia (ALL) for the past 1 year presented with a history of fever for 3 weeks to medicine outpatient department. He was started on oral antibiotics for 1 month, which was upgraded to a higher dose following the persistence of fever. On suspicion of disease relapse,18 F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET-CT) was advised by the referring physician.18 F-FDG PET-CT findings revealed subcentimetric parenchymal nodules in the bilateral lung fields [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, solid black arrows] in addition to paratracheal and paraesophageal lymph nodes. Also seen were focal FDG uptake in the left 10th rib [Figure 1]f and [Figure 1]g, FDG avid hypodense lesions in the tail and head of the pancreas [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, and bilateral enlarged kidneys with diffuse increased homogenous FDG uptake (>liver) with multiple interspersed focal areas of intense FDG uptake in the bilateral renal parenchyma [Figure 2]e and [Figure 2]f. FDG avid hepatic subcapsular [Figure 3]a and [Figure 3]b and subcutaneous deposit in the left posterior lumbar region [Figure 3]c and [Figure 3]d with hypodense lesion showing FDG uptake seen in the right gluteus maximus muscle [Figure 3]e and [Figure 3]f were also seen. Histopathology from the subcutaneous deposit in the left posterior lumbar region revealed lymphoblastic cell infiltration.
Figure 1: (a) Maximum intensity projection image of fluorodeoxyglucose positron emission tomography-computed tomography scan showing multiple focal areas of fluorodeoxyglucose uptake in the right axillary, abdomen, and pelvic region. (b and d) Axial computed tomography chest section showing subcentimetric nodule in the posterior segment of the right upper lobe showing mild fluorodeoxyglucose uptake in fused positron emission tomography-computed tomography image (c and e). (f) Axial computed tomography section showing subtle sclerotic changes in the left 10th rib showing intense fluorodeoxyglucose uptake in the fused positron emission tomography-computed tomography image (g)

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Figure 2: (a) Axial computed tomography abdomen image showing a hypodense lesion in the tail of pancreas showing intense fluorodeoxyglucose uptake in the fused positron emission tomography-computed tomography image (b). (c) Axial computed tomography abdomen image showing a hypodense lesion in the head of the pancreas showing intense fluorodeoxyglucose uptake in the fused positron emission tomography-computed tomography image (d). (e) Coronal computed tomography image showing bilateral enlarged kidneys showing increased fluorodeoxyglucose uptake (>liver) in the fused positron emission tomography-computed tomography image (f)

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Figure 3: (a) Axial computed tomography abdomen image showing subcapsular hepatic deposit showing increased fluorodeoxyglucose uptake in the fused positron emission tomography-computed tomography image (b). (c) Axial computed tomography lower abdomen showing subcutaneous deposit in the left posterior lumbar region showing increased fluorodeoxyglucose uptake in the fused tomography image (d). (e) Axial computed tomography pelvis showing a hypodense lesion in the right gluteus maximus muscle showing increased fluorodeoxyglucose uptake in the fused positron emission tomography-computed tomography image (f)

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Extramedullary acute leukemia lesions occur at an anatomical location other than bone marrow, which is considered to be an uncommon presentation of acute leukemia, with the most common sites being central nervous system, mediastinum, liver, lung, kidney, and testicle.[1],[2] Concurrent and isolated extramedullary infiltration of rare sites such as liver, pancreas, kidneys, bones, optic nerve, and stomach presenting in the initial stage and relapse of ALL with utility of 18 F-FDG PET-CT in unmasking and accurately localizing these lesions have been previously described in the literature.[3],[4],[5],[6],[7],[8] Authors through this case want to underscore the significance of 18 F-FDG PET-CT in the restaging of cases of ALL where it can be aptly utilized to localize the extramedullary infiltration of rare sites as described above in a scenario of clinical dilemma.

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.
Zhou WL, Wu HB, Wang LJ, Tian Y, Dong Y, Wang QS. Usefulness and pitfalls of F-18-FDG PET/CT for diagnosing extramedullary acute leukemia. Eur J Radiol 2016;85:205-10.  Back to cited text no. 1
    
2.
Choi EK, Byun JH, Lee SJ, Jung SE, Park MS, Park SH, et al. Imaging findings of leukemic involvement of the pancreaticobiliary system in adults. AJR Am J Roentgenol 2007;188:1589-95.  Back to cited text no. 2
    
3.
Zhang S, Wang W, Kan Y, Liu J, Yang J. Extramedullary infiltration of acute lymphoblastic leukemia in multiple organs on FDG PET/CT. Clin Nucl Med 2018;43:217-9.  Back to cited text no. 3
    
4.
Amer R, David R, Dotan S. Bilateral leukemic optic nerve infiltration as the first manifestation of extramedullary relapse in T-cell acute lymphoblastic leukemia. Harefuah 2013;152:112-4, 21.  Back to cited text no. 4
    
5.
Sato A, Imaizumi M, Chikaoka S, Niizuma H, Hoshi Y, Takeyama J, et al. Acute renal failure due to leukemic cell infiltration followed by relapse at multiple extramedullary sites in a child with acute lymphoblastic leukemia. Leuk Lymphoma 2004;45:825-8.  Back to cited text no. 5
    
6.
Li D, Liu Q, Feng Z, Zhang Q, Feng S. Nephrogenic diabetes insipidus in initial stage of acute lymphoblastic leukemia and relapse after haploidentical hematopoietic stem-cell transplantation: A case report. Medicine (Baltimore) 2018;97:e11157.  Back to cited text no. 6
    
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Kiziloglu O, Mestanoglu M, Gedar OM, Adiguzel C, Toygar O. Recurrence of acute lymphoblastic leukemia manifesting as serous retinal detachments and optic disc swelling. Int Ophthalmol 2018;38:1791-5.  Back to cited text no. 7
    
8.
Min M, Bi Y, Liu Y, Xu Y. Extramedullary gastric relapse of acute lymphoblastic leukemia in an adolescent. Gastrointest Endosc 2017;86:565-7.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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