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FDG-PET in Indolent Lymphomas. 2009/3/21 新光醫院 核醫科 葉力豪. Case 1. 66 y/o male CC: progressive ptosis with poor visual acuity(os) for 2 years. Cranial CT for orbital study (2007/11/10): suspicious left orbital tumor. Cranial CT for orbital study (2007/11/10). FDG-PET (2007/12/7).

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fdg pet in indolent lymphomas

FDG-PET in Indolent Lymphomas

2009/3/21

新光醫院 核醫科

葉力豪

case 1
Case 1
  • 66 y/o male
  • CC: progressive ptosis with poor visual acuity(os) for 2 years.
  • Cranial CT for orbital study (2007/11/10): suspicious left orbital tumor
slide5

FDG-PET (2007/12/7)

Orbitl tumor

maxSUV:2.8 , Delayed maxSUV:4.5

maxSUV:2.4

maxSUV:2.1

maxSUV:1.7

maxSUV:3.3

maxSUV:3.6

maxSUV:3.9

maxSUV:7.4

maxSUV:1.8

slide6

Left Orbital Lesion

maxSUV:2.8

Delayed maxSUV:4.5

slide7

Left cevical LN

1.0x0.7cm

maxSUV:2.4

slide8

Pretracheal LN

2.5x1.1 cm

maxSUV:3.3

Right axillary LN

1.2x0.8cm

maxSUV:1.7

slide9

Gastric wall

maxSUV:7.4

slide10

Gastric wall

Delayed image

Focal mild FDG uptake

maxSUV: 3.4

slide11

Right inguinal LN

1.5x0.8cm

maxSUV:1.8

pathology
Pathology

1. Partial excision of Left Orbital tumor:

Marginal zone lymphoma, most likely

MALT lymphoma (Extra-nodalMarginal

zone lymphoma, Indolent lymphoma)

2. Left inguinal LN biopsy:

lymphoid hyperplasia

3. PES with biopsy :

ulcer at gastric antrum

treatment follow up
Treatment & Follow-up
  • Chemotherapy as low grade (indolent) lymphoma with Cyclophosphamide : 2008/1/11~4/18
  • Partial Remission
slide22
Suspcious recurrence since 2008/8/8:

A new nodule at left lower eyelid, a LN at suboccipital area

Tx with Cyclophosphamide

Partial Remission

F/U FDG-PET on 2009/1/19

2009 1 19
2009/1/19

2007/12/7

slide24

Left orbital lesion

maxSUV:2.8

lesion subsided

slide25

Left cevical LN

1.0x0.7cm

maxSUV:2.4

0.9x0.5cm

maxSUV:1.9

slide26

Pretracheal LN

2.5x1.1 cm

maxSUV:3.3

2.3x0.9 cm

maxSUV:3.1

slide27

Right axillary LN

1.2x0.8cm

maxSUV:1.7

0.9x0.5cm

maxSUV:1.0

slide28

Right inguinal LN

1.5x0.8cm

maxSUV:1.8

0.9x0.6cm

maxSUV:0.9

case 2
Case 2
  • 56 y/o male
  • PH:

C-spine and L-spine DJD

Gastritis

Smoking: (+) , social

Drinking: rare

  • Underwent FDG-PET for physical check-up
slide32

2005/12/31

maxSUV:2.4

2007/1/16

maxSUV:3.0

slide33
Underwent left lung surgery in NTUH
  • Pathology: Pulmonary Extra-nodal marginal zone lymphoma (MALT lymphoma)
marginal zone b cell lymphoma
Marginal zone B-cell lymphoma
  • The marginal zone lymphomas are so named because of their involvement of the marginal zone surrounding normal lymphoid follicles.
  • Indolent lymphoma
  • Three subtypes:

1. Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) or MALT lymphoma (or Maltoma)

2. Splenic marginal zone B-cell lymphoma

3. Nodal marginal zone B-cell lymphoma

malt lymphoma
MALT lymphoma
  • Extranodal marginal zone B-cell lymphoma
  • May occur in the stomach (most often),orbit, intestine, lung, thyroid, salivary gland, skin, soft tissues, bladder, kidney, and CNS.
  • May present as a new mass, found on routine imaging studies, or be associated with local symptoms.
malt lymphoma1
MALT lymphoma
  • Pathology pattern: infiltration of small lymphocyte that are monoclonal B cell and CD5(-).
  • The majority present with localized stage I or II extranodal disease, involving glandular epithelial tissues of various sites.
  • In some cases, transformation todiffuse large B cell lymphoma (aggressive lymphoma, worse prognosis) occurs, and both diagnoses may be made in the same biopsy.
malt lymphoma2
MALT lymphoma
  • These lymphomas can disseminate to other MALT sites, lymph nodes, or marrow in about 30 percent of cases.
  • In a series of 36 pts presenting with non-GI MALT lymphoma, 12 (33%) were found to have gastric involvement at the time of initial workup.
  • Some suggest that routine evaluation of the stomach should be a part of the initial staging workup, and at relapse, of non-GI MALT lymphomas

Clinical manifestations, pathologic features, and diagnosis of extranodal (MALT) and nodal marginal zone lymphomas. UpToDate

malt lymphoma3
MALT lymphoma
  • They often arise within tissues involved by chronic inflammatory disorders of autoimmune or infectious etiology:

1. Sjogren syndrome (salivary gland MALT)

2. Helicobacter gastritis (gastric MALT)

3. Chlamydophilapsittaci conjunctivitis (ocular

MALT)

4. Borelia skin infection (cutaneous MALT)

★ This neoplasm may lie on a continuum between reactive lymphoid hyperplasia and full-blown B-cell lymphoma.

treatment of malt lymphoma
Treatment of MALT Lymphoma
  • Localized disease:

Local therapy such as radiation or surgery

  • More extensive disease:

Single-agent chemotherapy

  • Coexistent diffuse large B cell lymphoma:

Combination chemotherapy

fdg uptake varies among different types of lymphoma
FDG Uptake Varies Among Different Types of Lymphoma

★ Intensity of FDG uptake determined by:

  • Histology
  • Grade
  • Viable tumor cell fraction
  • Tumor cell proliferation
  • Up-regulation of glucose meyabolism
  • Local perfusion
  • Presence of hypoxia

PET Imaging for Response Assessment in Lymphoma: Potential and Limitation. Radio Clin N Am 46(2008) 225-241

fdg uptake varies among different types of lymphoma1
FDG Uptake Varies Among Different Types of Lymphoma
  • Indolent lymphoma exhibit lower glucosemetabolic activity and hence FDG uptake than the more aggressive ones.
  • Using an SUV of 10 as a cutoff, FDG-PET seperated aggressive from indolent lymphoma with a sensitivity of 71% and a specificity of 81%.
  • There is (sometimes large) heterogeneity between lesions of the same histologic entitiy and sometimes overlap between tumor grades.

The Impact of Fluorodeoxyglucose-Positron Emmision Tomography in Primary Staging and Patient management in Lymphoma Patients. Radiol Clin N Am 46(2008) 199-211

slide44

The Impact of Fluorodeoxyglucose-Positron Emmision Tomography in Primary Staging and Patient management in Lymphoma Patients. Radiol Clin N Am 46(2008) 199-211

FDG Uptake Varies Among Different Types of Lymphoma

Aggressive

Indolent

Indolent

Indolent

diagnostic accuracy of fdg pet in patients with malt lymphoma
Diagnostic accuracy of FDG-PET in patients with MALT lymphoma
  • Overall disease detection sensitivity:

In 5 studies (132 pts),

54.4%(18/33) to 81%(21/26, 34/42)

  • Site dependent:

gastric MALT : 38.9%1 & 60%2

non-gastric MALT : 75%1 & 88%2

  • Grade dependent:

early stage disease (I-II): 42.3%1 & 79%2

advanced disease (stage III-IV): 100% 1,2

  • Diagnostic accuracy of PET/CT in patients with extranodal marginal zone MALT lymphoma .Eur J Haematol. 2007 Sep; 79(3):205-9. Epub 2007 Jul 27
  • FDG-PET scanning for detection and staging of extranodal marginal zone lymphomas of the MALT type: a report of 42 cases. Annals of Oncology 16: 473–480, 2005
diagnostic accuracy of fdg pet in patients with malt lymphoma1
Diagnostic accuracy of FDG-PET in patients with MALT lymphoma
  • Large cell transformation3:

Non-transformed SUV: 3.7 (SD 1.4)

Transfromed SUV: 11.3 (SD 5.5)

3. Role of Fluorine-18 Fluoro-Deoxyglucose Positron Emission Tomography Scan in the Evaluation and Follow-Up of Patients With Low-Grade Lymphomas. CANCER July 1, 2006 / Volume 107 / Number 1

usefulness of fdg pet in low grade lymphomas
Usefulness of FDG-PET in low grade lymphomas

Role of Fluorine-18 Fluoro-Deoxyglucose Positron Emission Tomography Scan in the Evaluation and Follow-Up of Patients With Low-Grade Lymphomas. CANCER July 1, 2006 / Volume 107 / Number 1

large cell transformation lct
Large cell transformation (LCT)
  • Some of indolent lymphomas (about 3% per year) will undergo large cell transformation (histologic transformation) during the course of the disease, an event that dictates a different management strategy and alters survival signicantly.
  • Although LCT can be suspected on clinical grounds alone, it may also go unnoticed or may be difficult to prove.

Role of Fluorine-18 Fluoro-Deoxyglucose Positron Emission Tomography Scan in the Evaluation and Follow-Up of Patients With Low-Grade Lymphomas. CANCER July 1, 2006 / Volume 107 / Number 1

large cell transformation lct1
Large cell transformation (LCT)
  • Significant difference between FDG uptake of nontransformed and transformed lymphomas.
  • When during the course of an otherwise indolent disease, there are FDG avid foci with much higher uptake than noted on the baseline study, suspicion should be raised regarding LCT.

Role of Fluorine-18 Fluoro-Deoxyglucose Positron Emission Tomography Scan in the Evaluation and Follow-Up of Patients With Low-Grade Lymphomas. CANCER July 1, 2006 / Volume 107 / Number 1

fdg pet v s bone marrow biopsy

5

33

5

2

45

High grade lymphoma

Low grade lymphoma

FDG-PET v.s. Bone Marrow Biopsy

Patients of Lymphoma in SKH

conclusion
Conclusion
  • PET usefulness in staging low-grade(indolent) lymphomas varies depending on histology.
  • PET sensitivity is excellent in follicular lymphoma and moderate in marginal zone lymphoma.
  • Detectability of extra-nodal marginzal zone lymphoma (MALT lymphoma) is site and grade dependent:

★Non-gastric > Gastric

★Advanced > Early

conclusion1
Conclusion
  • PET is more specific than CT for follow-up in follicular lymphoma, marginal zone lymphoma, and B-cell small-cell lymphocytic lymphoma (SLL/CLL) .
  • PET has limited usefulness for B-cell small-cell lymphocytic lymphoma (SLL/CLL) staging.
conclusion2
Conclusion
  • In low-grade lymphomas, the emergence of foci of intense uptake should raise suspicion of conversion to high-grade disease.
  • FDG-PET scan may become the test of choice for early detection of LCT and/or selection of the optimal biopsy site when transformation is suspected.
conclusion3
Conclusion
  • FDG-PET cannnot substitute for bone marrow biopsy, and is less sensitive in detecting bone marrow involvement of low grade(indolent) lymphoma.