The use of whole-body fluorine-18-fluorodeoxyglucose positron emission tomography integrated with computed tomography for accurate staging and surveillance in the case of mucosa-associated lymphoid tissue

摘要

We present the case of a 79-year-old male, who was initially treated for mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) of the right eyelid, and later for disease relapse in the stomach. During follow up, he was noted to have developed left arm nodules just medial to the proximal biceps muscle, which were found to be multiply enlarged lymph nodes on subsequent ultrasound imaging. Excisional biopsy of these nodes revealed MALT lymphoma. He was initially referred for consideration of radiation, but a restaging F-18 fluorodeoxyglucose positron emission tomography integrated with computed tomography (F-18 FDG PET/CT) further identified a focus of suspicious uptake in left calf, which was later also biopsy proven to be MALT lymphoma. His disease was upstaged as the result of this later finding, and the overall recommendation for treatment changed to favor systemic treatment with Rituximab. Keywords: Extranodal marginal zone B-cell lymphoma, mucosa-associated lymphatic tissue (MALT) lymphoma, Marginal zone lymphoma of MALT, field of view, PET/CTCASE REPORTOur patient is a 79-year-old male with a past medical history significant for rheumatoid arthritis and a known diagnosis of MALT lymphoma. He initially presented 10 years ago to his primary care physician with a one-month history of right eyelid swelling. He underwent a CT scan of the orbit with contrast enhancement, which showed a 2.7 cm infiltrating mass in the right upper eyelid extending posteriorly into the extraconal orbital roof. He underwent orbital exploration with biopsy of the mass, which yielded pathology consistent with a diagnosis of MALT lymphoma. Flow cytometry showed lambda monotypic B cells which represented about 6% of the total leukocytes. For disease staging, he underwent a F-18 FDG PET/CT scan from eyes to thighs. Notably, there was a focus of asymmetric increase in FDG activity with maximum standardized uptake value (SUVmax) of 4.2 in the region of the right orbit, likely related to the biopsied mass. No other focus of FDG activity was noted (Figure 1). His disease was staged as IE per Ann Arbor classification, and he proceeded to undergo external beam radiation therapy at his local radiation center, receiving 3060 cGy in 17 daily fractions to his right orbit. Open in a separate windowFigure 1 70-year-old male with mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) of the right eyelidWhen this patient was 70 years old, he presented with a newly diagnosed with MALT lymphoma of the right orbit.FINDINGS: CT scan of the orbit with contrast enhancement demonstrated a 2.7 × 2.3 × 1.8 cm infiltrative mass in the right upper eyelid, extending posteriorly into the extraconal orbit along the orbit roof (Figure 1a, axial view; Figure 1b, sagittal view, arrow); on a staging PET/CT scan from eyes to thigh that was obtained shortly after biopsy, there was a focus of asymmetric increase in FDG activity with a SUVmax of 4.2 in the region of the right orbit, likely related to the biopsied mass. (Figure 1c, axial view; Figure 1d, sagittal view, arrow).TECHNIQUE: Figure 1a, b: Axial CT scans with 67 mAs, 120 kV in 2 mm slice thickness and coronal reformations without and with 100ml IV nonionic iodinated contrast material. Figure 1c, d: Initial non-contrast whole body CT axial scan with 71 mAs, 130 kV in 3 mm slice thickness was performed for attenuation correction purposes. Patient is then injected intravenously with 15.3 mCi of F-18 fluorodeoxyglucose followed by a delayed PET scan 60 minutes afterwards from the skull base through the mid thigh. Blood glucose 95 mg/dL.