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FDG-PET in Indolent Lymphomas 2009/3/21 2009/3/21 新光醫院 核醫科 葉力豪.

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Presentation on theme: "FDG-PET in Indolent Lymphomas 2009/3/21 2009/3/21 新光醫院 核醫科 葉力豪."— Presentation transcript:

1 FDG-PET in Indolent Lymphomas 2009/3/ /3/21 新光醫院 核醫科 葉力豪

2 Case 1 66 y/o male 66 y/o male CC: progressive ptosis with poor visual acuity(os) for 2 years. 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): suspicious left orbital tumor

3 Cranial CT for orbital study (2007/11/10)

4 FDG-PET (2007/12/7)

5 maxSUV:3.6 maxSUV:3.9 maxSUV:3.3 maxSUV:1.7 Orbitl tumor maxSUV:2.8, Delayed maxSUV:4.5 maxSUV:1.8 FDG-PET (2007/12/7) maxSUV:2.4 maxSUV:2.1 maxSUV:7.4

6 Left Orbital Lesion maxSUV:2.8 Delayed maxSUV:4.5

7 Left cevical LN 1.0x0.7cm maxSUV:2.4

8 Pretracheal LN 2.5x1.1 cm maxSUV:3.3 Right axillary LN 1.2x0.8cm maxSUV:1.7

9 Gastric wall maxSUV:7.4

10 Gastric wall Delayed image Focal mild FDG uptake maxSUV: 3.4

11 Right inguinal LN 1.5x0.8cm maxSUV:1.8

12 PES (2007/11/11) Ulcers at fundus HP test (+) PES (2007/11/11) Ulcers at fundus HP test (+)

13 Pathology 1. Partial excision of Left Orbital tumor: Marginal zone lymphoma, most likely Marginal zone lymphoma, most likely MALT lymphoma (Extra-nodal Marginal MALT lymphoma (Extra-nodal Marginal zone lymphoma, Indolent lymphoma) zone lymphoma, Indolent lymphoma) 2. Left inguinal LN biopsy: lymphoid hyperplasia lymphoid hyperplasia 3. PES with biopsy : 3. PES with biopsy : ulcer at gastric antrum ulcer at gastric antrum

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15 Orbital MALT lymphoma

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17 Lymphoid Hyperplasia of inguinal LN

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19 Clinical Stage: IIIEB at least Orbital Lesion

20 Treatment & Follow-up Chemotherapy as low grade (indolent) lymphoma with Cyclophosphamide : 2008/1/11~4/18 Chemotherapy as low grade (indolent) lymphoma with Cyclophosphamide : 2008/1/11~4/18  Partial Remission

21 Follow-up Orbital CT (2008/5/19)

22 Suspcious recurrence since 2008/8/8: 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

23 2009/1/ /1/ /12/7

24 Left orbital lesion maxSUV:2.8 lesion subsided

25 Left cevical LN 1.0x0.7cm maxSUV: x0.5cm maxSUV:1.9

26 Pretracheal LN 2.5x1.1 cm maxSUV: x0.9 cm maxSUV:3.1

27 Right axillary LN 1.2x0.8cm maxSUV: x0.5cm maxSUV:1.0

28 Right inguinal LN 1.5x0.8cm maxSUV: x0.6cm maxSUV:0.9

29 Case 2 56 y/o male 56 y/o male PH: PH: C-spine and L-spine DJD Gastritis Smoking: (+), social Drinking: rare Drinking: rare Underwent FDG-PET for physical check-up Underwent FDG-PET for physical check-up

30 Left lingular lobe lesion

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32 2005/12/31 maxSUV: /1/16 maxSUV:3.0

33 Underwent left lung surgery in NTUH Underwent left lung surgery in NTUH Pathology: Pulmonary Extra-nodal marginal zone lymphoma (MALT lymphoma) Pathology: Pulmonary Extra-nodal marginal zone lymphoma (MALT lymphoma)

34 Discussion

35 Marginal zone B-cell lymphoma The marginal zone lymphomas are so named because of their involvement of the marginal zone surrounding normal lymphoid follicles. The marginal zone lymphomas are so named because of their involvement of the marginal zone surrounding normal lymphoid follicles. Indolent lymphoma Indolent lymphoma Three subtypes: 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

36 MALT lymphoma Extranodal marginal zone B-cell 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 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. May present as a new mass, found on routine imaging studies, or be associated with local symptoms.

37 MALT lymphoma Pathology pattern: infiltration of small lymphocyte that are monoclonal B cell and CD5(-). 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. The majority present with localized stage I or II extranodal disease, involving glandular epithelial tissues of various sites. In some cases, transformation to diffuse large B cell lymphoma (aggressive lymphoma, worse prognosis) occurs, and both diagnoses may be made in the same biopsy. In some cases, transformation to diffuse large B cell lymphoma (aggressive lymphoma, worse prognosis) occurs, and both diagnoses may be made in the same biopsy.

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39 MALT lymphoma These lymphomas can disseminate to other MALT sites, lymph nodes, or marrow in about 30 percent of cases. 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. 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 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

40 MALT lymphoma They often arise within tissues involved by chronic inflammatory disorders of autoimmune or infectious etiology: 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. Chlamydophila psittaci conjunctivitis (ocular MALT) MALT) 4. Borelia skin infection (cutaneous MALT) ★ This neoplasm may lie on a continuum between reactive lymphoid hyperplasia and full-blown B- cell lymphoma.

41 Treatment of MALT Lymphoma Localized disease: Localized disease: Local therapy such as radiation or surgery More extensive disease: More extensive disease: Single-agent chemotherapy Coexistent diffuse large B cell lymphoma: Coexistent diffuse large B cell lymphoma: Combination chemotherapy

42 FDG Uptake Varies Among Different Types of Lymphoma ★ Intensity of FDG uptake determined by: Histology Histology Grade Grade Viable tumor cell fraction Viable tumor cell fraction Tumor cell proliferation Tumor cell proliferation Up-regulation of glucose meyabolism Up-regulation of glucose meyabolism Local perfusion Local perfusion Presence of hypoxia Presence of hypoxia PET Imaging for Response Assessment in Lymphoma: Potential and Limitation. Radio Clin N Am 46(2008)

43 FDG Uptake Varies Among Different Types of Lymphoma Indolent lymphoma exhibit lower glucose metabolic activity and hence FDG uptake than the more aggressive ones. Indolent lymphoma exhibit lower glucose metabolic 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%. 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. 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)

44 FDG Uptake Varies Among Different Types of Lymphoma Indolent Aggressive

45 Diagnostic accuracy of FDG-PET in patients with MALT lymphoma Overall disease detection sensitivity: Overall disease detection sensitivity: In 5 studies (132 pts), 54.4%(18/33) to 81%(21/26, 34/42) Site dependent: Site dependent: gastric MALT : 38.9% 1 & 60% 2 non-gastric MALT : 75% 1 & 88% 2 Grade dependent: Grade dependent: early stage disease (I-II): 42.3% 1 & 79% 2 advanced disease (stage III-IV): 100% 1,2 1.Diagnostic accuracy of PET/CT in patients with extranodal marginal zone MALT lymphoma.Eur J Haematol Sep; 79(3): Epub 2007 Jul 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

46 Diagnostic accuracy of FDG-PET in patients with MALT lymphoma Large cell transformation 3 : Large cell transformation 3 : Non-transformed SUV: 3.7 Non-transformed SUV: 3.7 (SD 1.4) Transfromed SUV: 11.3 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

47 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

48 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

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50 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

51 Low grade lymphomaHigh grade lymphoma FDG-PET v.s. Bone Marrow Biopsy Patients of Lymphoma in SKH

52 67y,M, Malignant lymphoma, small lymphocytic type, PET bone-

53 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

54 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.

55 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. 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.

56 Conclusion FDG-PET cannnot substitute for bone marrow biopsy, and is less sensitive in detecting bone marrow involvement of low grade(indolent) lymphoma. FDG-PET cannnot substitute for bone marrow biopsy, and is less sensitive in detecting bone marrow involvement of low grade(indolent) lymphoma.

57 Thank You.


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