A JH
DIAGNOSTIC IMAGING IN HEMATOLOGY
AJH Educational Material
Paget’s disease of the bone mimicking lymphomatous bone marrow involvement at FDG-PET Hugo J.A. Adams,1* John M.H. de Klerk,2 Rob Fijnheer,3 Stefan V. Dubois,4 Rutger A.J. Nievelstein,1 and Thomas C. Kwee1
Image 1. Coronal (A), oblique (B), and sagittal (C) 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (FDG-PET) maximum intensity projections (MIPs) showing multiple FDG-avid lesions throughout the skeleton. FDG-PET (D), CT (E), and biopsy results (F, G, H) of retroperitoneal mass showing a CD20 positive proliferation of atypical B-cells, consistent with follicular lymphoma grade 3A. FDG-PET (I), CT (J), and bone marrow biopsy (K, L, M) of right iliac crest showing Paget’s disease.
1
Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; 2Department of Nuclear Medicine, Meander Medical Center, Amersfoort, The Netherlands; 3Department of Hematology, Meander Medical Center, Amersfoort, The Netherlands; 4Department of Pathology, Meander Medical Center, Amersfoort, The Netherlands
Conflict of interest: Nothing to report. *Correspondence to: Hugo J.A. Adams, Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, The Netherlands. E-mail: [email protected] Contract grant sponsor: Alpe d’HuZes/Dutch Cancer Society Bas Mulder Award; Contract grant number: 5409. Received for publication: 2 December 2014; Accepted: 11 December 2014 Am. J. Hematol. 90:269–270, 2015. Published online: 19 December 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ajh.23921 C 2014 Wiley Periodicals, Inc. V
doi:10.1002/ajh.23921
American Journal of Hematology, Vol. 90, No. 3, March 2015
269
Adams et al.
A 76-year-old man presented with pain in both upper legs and anorexia. Laboratory findings showed increased erythrocyte sedimentation rate (24 mm/hr), elevated C-reactive protein (34 mg/L), elevated alkaline phosphatase (173 IU/L), and elevated lactate dehydrogenase (540 IU/L). Technetium-99m methylene diphosphonate whole-body bone scan (not shown) demonstrated multiple foci of increased radiotracer uptake in the axial and proximal appendicular skeleton. Subsequent 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (FDG-PET) showed multiple FDG-avid lesions in both proximal humeri, both scapulae, multiple ribs, multiple vertebrae, pelvic bone, and both proximal femora (Image 1A–C). There was also an FDG-avid retroperitoneal mass along the right internal iliac vessels (Image D,E, arrows), which was biopsied. Overview/ detail (original magnification 325/3100) of this lymph node biopsy demonstrated loss of architecture and extensive proliferation of atypical B-cells, consistent with B-cell non-Hodgkin’s lymphoma (Image 1F,G). The B-cell marker CD20 is shown. Further immuno-
270
American Journal of Hematology, Vol. 90, No. 3, March 2015
DIAGNOSTIC IMAGING IN HEMATOLOGY histochemistry showed a non-diffuse pattern of follicular lymphoma (Grade 3A) (Image 1H). In addition, one FDG-avid lesion in the right posterior iliac crest (Image 1I, dashed arrow) was directly biopsied. Also note no visible changes of the bone (marrow) at concomitant CT (Image 1J). Overview/detail (original magnification 325/3100/3200) of this bone marrow biopsy demonstrates extensive fibrosis and irregularly branching trabecular bone with apposition of new woven bone and rows of osteoblasts, consistent with Paget’s disease (Image 1K–M). However, the bone marrow biopsy did not show any signs of lymphomatous involvement. Although rare, Paget’s disease of the bone is known to potentially exhibit markedly increased FDG uptake. The presented case demonstrates that FDG-avid foci in the bone marrow of a patient with lymphoma do not always represent lymphomatous bone marrow involvement, and that bone marrow biopsy is necessary to rule out benign diseases (such as Paget’s disease of the bone) or metastatic disease from other malignancies than lymphoma.
doi:10.1002/ajh.23921
DIAGNOSTIC IMAGING IN HEMATOLOGY
AJH Educational Material
Paget’s disease of the bone mimicking lymphomatous bone marrow involvement at FDG-PET Hugo J.A. Adams,1* John M.H. de Klerk,2 Rob Fijnheer,3 Stefan V. Dubois,4 Rutger A.J. Nievelstein,1 and Thomas C. Kwee1
Image 1. Coronal (A), oblique (B), and sagittal (C) 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (FDG-PET) maximum intensity projections (MIPs) showing multiple FDG-avid lesions throughout the skeleton. FDG-PET (D), CT (E), and biopsy results (F, G, H) of retroperitoneal mass showing a CD20 positive proliferation of atypical B-cells, consistent with follicular lymphoma grade 3A. FDG-PET (I), CT (J), and bone marrow biopsy (K, L, M) of right iliac crest showing Paget’s disease.
1
Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; 2Department of Nuclear Medicine, Meander Medical Center, Amersfoort, The Netherlands; 3Department of Hematology, Meander Medical Center, Amersfoort, The Netherlands; 4Department of Pathology, Meander Medical Center, Amersfoort, The Netherlands
Conflict of interest: Nothing to report. *Correspondence to: Hugo J.A. Adams, Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, The Netherlands. E-mail: [email protected] Contract grant sponsor: Alpe d’HuZes/Dutch Cancer Society Bas Mulder Award; Contract grant number: 5409. Received for publication: 2 December 2014; Accepted: 11 December 2014 Am. J. Hematol. 90:269–270, 2015. Published online: 19 December 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ajh.23921 C 2014 Wiley Periodicals, Inc. V
doi:10.1002/ajh.23921
American Journal of Hematology, Vol. 90, No. 3, March 2015
269
Adams et al.
A 76-year-old man presented with pain in both upper legs and anorexia. Laboratory findings showed increased erythrocyte sedimentation rate (24 mm/hr), elevated C-reactive protein (34 mg/L), elevated alkaline phosphatase (173 IU/L), and elevated lactate dehydrogenase (540 IU/L). Technetium-99m methylene diphosphonate whole-body bone scan (not shown) demonstrated multiple foci of increased radiotracer uptake in the axial and proximal appendicular skeleton. Subsequent 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (FDG-PET) showed multiple FDG-avid lesions in both proximal humeri, both scapulae, multiple ribs, multiple vertebrae, pelvic bone, and both proximal femora (Image 1A–C). There was also an FDG-avid retroperitoneal mass along the right internal iliac vessels (Image D,E, arrows), which was biopsied. Overview/ detail (original magnification 325/3100) of this lymph node biopsy demonstrated loss of architecture and extensive proliferation of atypical B-cells, consistent with B-cell non-Hodgkin’s lymphoma (Image 1F,G). The B-cell marker CD20 is shown. Further immuno-
270
American Journal of Hematology, Vol. 90, No. 3, March 2015
DIAGNOSTIC IMAGING IN HEMATOLOGY histochemistry showed a non-diffuse pattern of follicular lymphoma (Grade 3A) (Image 1H). In addition, one FDG-avid lesion in the right posterior iliac crest (Image 1I, dashed arrow) was directly biopsied. Also note no visible changes of the bone (marrow) at concomitant CT (Image 1J). Overview/detail (original magnification 325/3100/3200) of this bone marrow biopsy demonstrates extensive fibrosis and irregularly branching trabecular bone with apposition of new woven bone and rows of osteoblasts, consistent with Paget’s disease (Image 1K–M). However, the bone marrow biopsy did not show any signs of lymphomatous involvement. Although rare, Paget’s disease of the bone is known to potentially exhibit markedly increased FDG uptake. The presented case demonstrates that FDG-avid foci in the bone marrow of a patient with lymphoma do not always represent lymphomatous bone marrow involvement, and that bone marrow biopsy is necessary to rule out benign diseases (such as Paget’s disease of the bone) or metastatic disease from other malignancies than lymphoma.
doi:10.1002/ajh.23921
