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ANALYTICAL REPORT
Year : 2012  |  Volume : 8  |  Issue : 1  |  Page : 106-108

F-18 flourodeoxyglucose positron emission tomography/computed tomography findings in a case of hepatosplenic T-cell lymphoma


1 Department of Nuclear Medicine and PET-CT, Jaslok Hospital and Research Centre, Worli, Mumbai, India
2 Department of Oncology, Jaslok Hospital and Research Centre, Worli, Mumbai, India
3 Department of Radiodiagnosis, Jaslok Hospital and Research Centre, Worli, Mumbai, India
4 Department of Pathology, Jaslok Hospital and Research Centre, Worli, Mumbai, India

Date of Web Publication19-Apr-2012

Correspondence Address:
Prathamesh V Joshi
Department of Nuclear Medicine and PET-CT, Jaslok Hospital and Research Centre, Worli, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.95184

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 > Abstract 

T-cell lymphoma (TCL) is a biologically diverse and uncommon group of lymphoid malignant diseases. Compared with its B-cell counterparts, TCL is notably more difficult to diagnose and manage owing to its rarity and biologic heterogeneity. Hepatosplenic TCL is an extremely rare subtype of TCL. A 37-year-old Indian male presented to his physician with swelling and pain in left hypochondrium. Clinical examination revealed pallor, icterus and massive splenomegaly. His blood examination revealed pancytopenia. His bone marrow biopsy was suggestive of lymphoma. Whole body F-18 flourodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scan revealed diffuse increased metabolic activity in massively enlarged spleen, liver and bone marrow. There was no evidence of metabolically active lymphadenopathy anywhere in the body. Guided by the FDG PET/CT findings, a liver biopsy was advised. Liver histopathology revealed the presence of hepatosplenic TCL. A final diagnosis of hepatosplenic TCL with liver, spleen and bone marrow involvement was made. Even though rare, hepatosplenic TCL should be considered as a possible diagnosis in patients presenting with similar clinical picture and FDG PET/CT scan findings.

Keywords: Flourodeoxyglucose (FDG), hepatosplenic T-cell lymphoma, positron emission tomography/computed tomography (PET/CT)


How to cite this article:
Joshi PV, Lele VR, Bhat GM, Garg S, Chitale A. F-18 flourodeoxyglucose positron emission tomography/computed tomography findings in a case of hepatosplenic T-cell lymphoma. J Can Res Ther 2012;8:106-8

How to cite this URL:
Joshi PV, Lele VR, Bhat GM, Garg S, Chitale A. F-18 flourodeoxyglucose positron emission tomography/computed tomography findings in a case of hepatosplenic T-cell lymphoma. J Can Res Ther [serial online] 2012 [cited 2019 Sep 16];8:106-8. Available from: http://www.cancerjournal.net/text.asp?2012/8/1/106/95184


 > Introduction Top


T-cell lymphoma (TCL) is a biologically diverse and uncommon group of lymphoid malignant diseases. [1] Compared with its B-cell counterparts, TCL is notably more difficult to diagnose and manage owing to its rarity and biologic heterogeneity. [2] Hepatosplenic TCL is an extremely rare subtype of TCL. [3] We present a case of hepatosplenic TCL where FDG PET/CT played a vital role in accurate diagnosis of this disease.


 > Case Report Top


A 37-year-old Indian male presented to his physician with swelling and pain in left hypochondrium. Clinical examination revealed pallor, icterus and massive splenomegaly. His blood examination revealed pancytopenia. There was no history of any overt bleeding, surgery or blood transfusion. He was given packed cell transfusion (irradiated) and he underwent bone marrow biopsy which was morphologically suggestive of lymphoma.

The patient was referred to our center for whole body FDG PET/CT scan for evaluation of whole body status and staging. The scan [[Figure 1]a- coronal images of FDG PET] revealed diffuse increased metabolic activity in massively enlarged spleen (arrows), liver (block arrow) and bone marrow (notched arrow). The maximum standardized uptake value (SUVmax) of liver was -1.8 cm 2 /ml, spleen -1.9 cm 2 /ml and bone marrow -2.0 cm 2 /ml. CT demonstrated [[Figure 1]b-coronal image and [Figure 1]c sagittal image] enlarged liver that measured 24.8 cm in craniocaudal extent. There was massive splenomegaly (arrows) measuring 31.8 cm in craniocaudal extent. No evidence of abnormal metabolic activity or CT demonstrable lesion was noted in rest of the body. There was no evidence of metabolically active lymphadenopathy. The absence of metabolically active lymphadenopathy pointed toward presence of extranodal lymphoma. A possibility of lymphoid malignancy involving spleen, liver and bone marrow was raised in the report. A liver biopsy was performed, which revealed presence of hepatosplenic T-cell lymphoma.
Figure 1: (a) Coronal images of FDG PET revealed diffuse increased metabolic activity in massively enlarged spleen (arrows), liver (block arrow) and bone marrow (notched arrow). CT demonstrated (b) coronal
image and (c) sagittal image) enlarged liver that measured 24.8 cm in craniocaudal extent. There was massive splenomegaly (arrows) measuring 31.8 cm in craniocaudal extent. A possibility of lymphoid
malignancy involving spleen, liver and bone marrow was raised in the report


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[Figure 2]a shows photomicrograph of the liver biopsy (H&E stained, 10×). It shows infiltrate of medium sized lymphoid cells in the liver sinusoids (marked with arrows). [Figure 2]b shows photomicrograph of the immunohistochemistry slides of liver biopsy. The lymphoid cells (arrows) express CD3, CD2 and CD8 (dim) and are immunonegative for CD 20 and CD 4.
Figure 2: (a) shows photomicrograph of the liver biopsy (H&E stain, 10×). It shows infi ltrate of medium sized lymphoid cells in the liver sinusoids (marked with arrows). (b) shows photomicrograph of the immunohistochemistry slides of liver biopsy. The lymphoid cells (arrows) express CD3, CD2 and CD8 (dim) and are immunonegative for CD 20 and CD 4

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Considering the FDG PET/CT findings and histopathological reports of bone marrow and liver biopsy, a final diagnosis of hepatosplenic T-cell lymphoma with liver, spleen and bone marrow involvement was made. Patient was given treatment with six cycles of chemotherapy with CHOP protocol. There is marked clinical improvement as evident by significant reduction in splenomegaly (approximately 50% of original), resolution of abdominal pain and improved blood counts. At present, one year after the diagnosis, patient is stable, asymptomatic and has been kept on maintenance therapy with dexamethasone.


 > Discussion Top


In general, TCL can be divided into peripheral and leukemic types, and peripheral TCL is subdivided into primary nodal disease and primary systemic (extranodal) disease. Hepatosplenic TCL is a rare form of extranodal disease. In hepatosplenic TCL, the median age at diagnosis is 35 years, and the initial findings are marked hepatosplenomegaly, cytopenia, and B symptoms in the absence of lymphadenopathy. [3] Our case has a compatible clinical history.

CT is the imaging technique most commonly used for pretreatment staging and for restaging of TCL. CT is used to assess for lymphadenopathy and organ involvement. In hepatosplenic TCL, hepatosplenomegaly is seen at CT and is typically the only imaging finding. [4],[5] The described case had similar findings on CT.

FDG PET and PET/CT are established tools in the evaluation of Hodgkin's and B cell lymphoma; however, the role of PET/CT in TCL is evolving, partly because of the rarity of the disease and because of the heterogeneity in clinical behavior. [4],[6]

Use of FDG PET/CT in cutaneous and subcutaneous panniculitis-like TCL suggests that it outperforms physical examination in evaluation for subcutaneous lesions. In addition, PET/CT can be used to monitor the response to therapy of lymph nodes that are FDG-avid but do not meet the size criteria for staging (< 1 cm). [6],[7] In extranodal NK/TCL, which is an aggressive malignancy, inflammation and lymphomatous involvement can be differentiated at PET/CT, which aids in planning of radiation therapy. [8] FDG PET is more sensitive than CT in the detection of enteropathy-type TCL in patients with celiac disease. [9] Promising evidence shows that the diagnostic value of FDG PET is greater than that of CT for local and distant disease. Evidence also shows that FDG PET has particular value in the assessment of tumor burden and treatment response, facilitating rapid optimization of appropriate treatment regimens. [6],[7],[8],[9],[10],[11] In our case, absence of metabolically active lymphadenopathy was a vital finding. Because after revelation of lymphomatous pathology in the bone marrow biopsy, it was the FDG PET/CT findings that prompted the presence of extranodal disease. Also in such cases a baseline FDG PET/CT will be certainly valuable to assess response to the administered therapy.

In past FDG PET/CT findings in a case of hepatosplenic TCL have been described only in a case report. [12] In this case report of T-cell lymphoma-associated hemophagocytic syndrome, "periportal low attenuation" and edematous gall-bladder wall thickening have been described. FDG PET/CT showed diffuse intense FDG uptake in the enlarged liver and spleen, with systemic FDG-avid lymphadenopathy including the hepatic hilar nodes. The authors proposed that FDG PET/CT is useful for detecting hepatic involvement of lymphoma and secondary-activated histiocytes causing a hemophagocytic syndrome, and that periportal low attenuation and an edematous gallbladder wall can be an indirect sign of lymphatic obstruction caused by FDG-avid hepatic hilar lymphadenopathy. Our case adds to the scarce data available regarding FDG PET/CT findings in hepatosplenic TCL. In our case, no such finding was observed; probably indicating the absence of this associated syndrome.

Evidence on the utility of PET/CT is promising, showing high diagnostic value in the evaluation of occult disease and treatment response, but the current role of PET/CT in TCL is evolving. [4] Our case highlights a significant role played by this exquisitely sensitive modality in management of hepatosplenic TCL.

To conclude, our case demonstrates a valuable role played by FDG PET/CT in diagnosis and staging of this rare disease. It suggests in a suspected case of lymphoma, when metabolically active lymphadenopathy is absent; attention should be paid to the extranodal sites in order to correctly identify primary systemic (extranodal) forms of this disease. Even though rare, hepatosplenic TCL should be considered as a possible diagnosis in patients presenting with similar clinical picture and FDG PET/CT scan findings.

 
 > References Top

1.Rizvi MA, Evens AM, Tallman MS, Nelson BP, Rosen ST. T-cell non-Hodgkin lymphoma. Blood 2006;107:1255-64.  Back to cited text no. 1
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2.Detailed guide: lymphoma, non-Hodgkin type. American Cancer Society. Available from: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=32. [Last accessed on 2009 Apr 27].  Back to cited text no. 2
    
3.Panwalkar AW, Armitage JO. T-cell/NK-cell lymphomas: A review. Cancer Lett 2007;253:1-13.  Back to cited text no. 3
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4.Otero HJ, Jagannathan JP, Prevedello LM, Johnston CJ, Ramaiya NH, Van den Abbeele AD, et al. CT and PET/CT findings of T-cell lymphoma. AJR Am J Roentgenol 2009;193:349-58.  Back to cited text no. 4
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5.Lee HJ, Im JG, Goo JM, Kim KW, Choi BI, Chang KH, et al. Peripheral T-cell lymphoma: Spectrum of imaging findings with clinical and pathologic features. Radio Graphics 2003;23:7-26; discussion 26-8.  Back to cited text no. 5
    
6.Kuo PH, McClennan BL, Carlson K, Wilson LD, Edelson RL, Heald PW, et al. FDG PET/CT in the evaluation of cutaneous T-cell lymphoma. Mol Imaging Biol 2008;10:74-81.  Back to cited text no. 6
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7.Meijer JW, Mulder CJ, Goerres MG, Boot H, Schweizer JJ. Coeliac disease and (extra) intestinal T-cell lymphomas: Definition, diagnosis and treatment. Scand J Gastroenterol Suppl 2004;241:78-84.  Back to cited text no. 7
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8.Khong PL, Pang CB, Liang R, Kwong YL, Au WY. Fluorine-18 fluorodeoxyglucose positron emission tomography in mature T-cell and natural killer cell malignancies. Ann Hematol 2008;87:613-21.  Back to cited text no. 8
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9.Hadithi M, Mallant M, Oudejans J, van Waesberghe JH, Mulder CJ, Comans EF. 18 F-FDG PET versus CT for the detection of enteropathy-associated T-cell lymphoma in refractory celiac disease. J Nucl Med 2006;47:1622-7.  Back to cited text no. 9
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10.Kako S, Izutsu K, Ota Y, Mainatani Y, Sugaya M, Momose T, et al. FDG-PET in T-cell and NK-cell neoplasms. Ann Oncol 2007;18:1685-90.  Back to cited text no. 10
    
11.Kumar R, Xiu Y, Zhuang HM, Alavi A. 18F-fluorodeoxyglucose-positron emission tomography in evaluation of primary cutaneous lymphoma. Br J Dermatol 2006;155:357-63.   Back to cited text no. 11
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12.Suga K, Kawakami Y, Hiyama A, Matsunaga N, Imoto S, Fukuda N, et al. F-18 FDG PET/CT findings in a case of T-cell lymphoma-associated hemophagocytic syndrome with liver involvement. Clin Nucl Med 2010;35:116-20.  Back to cited text no. 12
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    Figures

  [Figure 1], [Figure 2]


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