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Lymphoma / Myeloma - Case #4

Patient Presentation

A 46-year-old man who was in his usual state of health until 2000 when he noticed a left axillary lymph node. This was biopsied and confirmed the presence of follicular large cell lymphoma. This was confirmed at the M. D. Anderson Cancer Center Department of Pathology. The patient was treated outside of the M. D. Anderson Cancer Center by a private oncologist with CHOP and, reportedly, he received 8 doses of CHOP, ending in mid 2001 with initial response.

In 12/01, he had progressive disease in the neck and axillary area and was started on FND and received 4 cycles. In 05/02, he was then switched to rituximab maintenance and, by report, he received weekly doses x3 followed by 1 week of rest. Apparently, he received rituximab for a total of approximately 4 months. His last dose was in 09/03. The patient states that initially he had a very good response to rituximab with almost complete resolution of his lymph nodes, but then his lymph nodes started to grow back again in 09/03. He therefore was referred to us for further evaluation and treatment recommendations.

At the present time, he is complaining of night sweats but no fever. He had no significant weight loss. He also had some generalized itching. He also had intermittent abdominal pain, and he takes Vicodin with some improvement. He has also complained of fatigue. Other than that, he has no shortness of breath, cough, nausea, vomiting, back pain, or diarrhea. Review of the rest of the systems is negative.

Image Interpretation

Esophageal Cancer
  • PET/CT demonstrates the extensive FDG avid disease in multiple compartments including the cervical nodal regions, mediastinum, axillae, abdominal and pelvic including groin nodes.
  • This finding indicates nodal involvment on both sides of the diaphragm and therapy implications of combination chemotherapy with rituxan-CHOP (8 cyles).
  • PET/CT demonstrates mediastinal and axillary nodes, note the left sided pleural effusion.
  • PET/CT demonstrates marrow involvement in the left humerus best seen on the multiimage projections (MIP).

Patient Management

  • Having disease on both sides of the diaphragm makes this an advanced stage lymphoma; this affects the type and duration as well as prognosis of this patient.
  • Although this patient becomes a candidate for combination therapy, the extensive disease documented by PET and CT allows subsequent comparison with restaging scans following therapy to determine prognosis.
  • Patients with persistant FDG avid disease after chemotherapy have a poorer prognosis overall.
  • Repeat PET scanning at the end of therapy is necessary to predict outcome.

Case Summary

FDG PET imaging is an integral part of the workup of lymphoma patients. The baseline studies improve the accuracy of staging by identifying the true extent of the disease, i.e. if there is involvement of normal sized nodes, or extranodal components like marrow involvement. This has implications on the type of therapy and duration or extent of therapy, i.e. combination chemotherapy and extent of the field for radiotherapy planning. Finally, this will serve as a baseline to predict if patients will have a good prognosis, as the anatomic response, i.e. diminution of enlarged nodes may be manifested much later than the diminution of metabolic activity as an indicator of response and good prognosis.

References

  1. Young CS, Young BL, Smith SM. "Staging Hodgkin's Disease with 18-FDG PET: Comparison with CT and Surgery." Clin Pos Imag 1998;1:161-164
  2. Naumann R, Vaic A, Beuthien-Baumann B, et al. "Prognostic Value of Positron Emission Tomography in the Evaluation of Post-Treatment Residual Mass in Patients with Hodgkin's Disease and Non-Hodgkin's Lymphoma." Br J Haematol: 2001; 115(4):793-800.
  3. Spaepen K, Stroobants S, Dupont P, Vandenberghe P, Thomas J, de Groot T, Balzarini J, DeWolf-Peeters C, Mortelmans L, Verhoef G. "Early Restaging Positron Emission Tomography with (18)F-Fluorodeoxyglucose Predicts Outcome in Patients with Agressive Non-Hodgkin's Lymphoma." Annals of Oncology 2002;13:1356-1353.
  4. Spaepen K, Stroobants S, Dupont P, et al. "Prognostic Value of Positron Emission Tomography (PET) with Fluorine-18 Fluorodeoxyglucose ([18F]FDG) After First-Line Chemotherapy in Non-Hodgkin's Lymphoma: Is [18F]FDG-PET a Valid Alternative to Conventional Diagnostic Methods?" J Clin Oncol .2001;19(2):414-9.
PET Foundations