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PET Scans Demonstrate Both Tumor
and Infectious Activity
PET/CT for Restaging of Hodgkin’s Disease
MC is a 50-year-old female who presented originally in August of
2004 to her physician for appearance of a mass in her left neck.
Subsequent evaluation led to a biopsy of a lymph node, revealing
Hodgkin's disease lymphoma with subsequent treatment. The patient
received nine cycles of ABVD combination chemotherapy with mild
nausea, alopecia, but no other serious toxicities. The patient only
had a partial response to treatment. The patient was referred to us
for evaluation in consideration for high-dose therapy and stem cell
support.
PAST MEDICAL HISTORY:
Past medical history is significant for bilateral mastectomy without
any malignant disease: The patient had bilateral mastectomies and
reconstruction in 1990 because she had multiple benign lesions and
dense breasts that will have made the follow up extremely difficult
and family history of breast cancer. Also had a submandibular gland
removed in 1998, had hysterectomy, oophorectomy, and appendectomy
also for benign disease originally felt to be endometriosis. The
patient does not recall specifically the diagnosis but was told that
there was no malignancy. Also, in 2004, the patient had lysis of
adhesions for intestinal obstruction probably related to previous
extensive abdominopelvic surgery.
FAMILY HISTORY:
Family history is significant for breast cancer, in family history
mother alive at age 73, father alive at age 76, one sister age 51,
one brother age 54. Cancer history in the family: The patient's
grandmother died at age 36 of Hodgkin's disease. The patient's
maternal aunt with Hodgkin's disease at age 36, alive, has breast
cancer diagnosed at age 56 and thyroid cancer diagnosed at age 67.
Maternal grandfather had esophageal and gastric cancer. Maternal
great aunt died from lymphoma. Maternal great aunt died from breast
cancer. Maternal aunt had lymphoma with subsequent development of
secondary to leukemia. The patient's mother had breast cancer at age
47, had bilateral mastectomy. Maternal first cousin at age 21 had
Hodgkin's disease. Maternal first cousin had breast cancer at age
49. Paternal aunt had breast cancer at age 69.
WHOLE BODY PET CT EXAMINATION
01-14-06
CLINICAL INDICATION: Restaging of lymphoma.
RADIOPHARMACEUTICAL: 16.8 mCi F-18 FDG via right forearm vein.
COMMENT: The patient’s blood sugar at the time of injection was 90
mg/dl. Patient height is 5 feet 6 inches and patient weight is 115
pounds.
PROCEDURE: Following injection of radioisotope, imaging was
performed from top of head to hips 90 minutes following injection of
radioisotope. Emission and transmission imaging was performed with
attenuation correction. Correction was also performed for random
events. Iterative reconstructions were performed with axial, coronal
and sagittal reconstructions, as well as with 30 volume rendering.
Emission imaging of the lower extremities was performed from hips to
toes, also with axial, coronal and sagittal reconstructions with 3D
imaging.
REVIEW OF PREVIOUS EXAMINATIONS: Previous PET CT scan performed
12-22-05 demonstrated active disease in the left lower neck
anteriorly, as well as in the left paraclavicular regions, also with
bony involvement at T1. Too numerous to count pulmonary nodules were
present with capsules and central cavitation suggestive of
infection, i.e. probable fungal infection. A prevascular node was
seen, also with bilateral hilar uptake, in the hilar regions for
infection versus tumor.
CURRENT PET CT SCAN FINDINGS
The current examination reveals no apparent changes in the
appearance of the patient’s known tumor in the left neck base and
paraclavicular region, or at the level of T1 or in the prevascular
area. These regions are all essentially stable.
The disease in the left neck base measures 2.8 cm in diameter with
SUV (Standard Update Value) value of 4.2. Previously this region had an SUV value of 4.7
with maximum dimension of 2.6 cm.
The paraclavicular disease is essentially stable measuring 9 cm
transverse by 2 cm AP and longitudinal with SUV value of 3.6,
previously having an SUV value of 4.1 and by my measurements
essentially being unchanged in terms of size.
The anterior mediastinal prevascular node previously measured 1.6 cm
with SUV of 3.4. This region now measures 1.6 cm with SUV of 2.3.
The extensive cavitary lung nodules are again noted, essentially
unchanged with typical measurements being subcentimeter up to 1.5 cm
with capsule thickness of about 0.2 cm and SUV values measuring
between 1 and 1.2 by lean body mass, up to a maximum of 1.5 by body
weight.
Involvement is again seen in the T1 vertebral body, SUV of 3.7,
previously with SUV value of 4.6.
The remainder of the study is otherwise stable.
IMPRESSION:
1. ESSENTIALLY UNCHANGED EXAMINATION IN TERMS OF BOTH TUMOR
INVOLVEMENT, STAGE 4 WITH NODAL AND EXTRANODAL (SKELETAL) DISEASE,
ASSUMING THAT THE T1 LESION IS TUMOR AND NOT INFECTION, AND WITH
PERSISTENT MULTIPLE CAVITARY LUNG NODULES PRESUMABLY DUE TO FUNGAL
INFECTION, OF COURSE THIS IS NONSPECIFIC.
ASSESSMENT AND PLAN:
Difficult situation in a 50-year-old female with chemosensitive
Hodgkin disease; however, with rapid relapses after multiple
interventions. The decision is to proceed with rituximab at a high
dose of 1 g per m2 days one, four, eight, and 11,without steroid
premedication and PET scan followup on the day before
the second or the third dose. The patient is to have her
immunoglobulins and creatinine clearance monitored and to have
laboratory testing, including counts and chemistries, on the
rituximab
days to rule out the rare event of tumor lysis.
BACK
© 2006 Nuclear Education Online
- Images courtesy of University
of Arkansas for Medical Sciences Dept of Nuclear Medicine.
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