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| LETTER TO EDITOR |
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| Year : 2014 | Volume
: 62
| Issue : 1 | Page : 83-85 |
Peripheral nerves and muscles involvement by non-Hodgkin's lymphoma seen on FDG PET/CT scan
Hina J Shah1, Vikram R Lele1, Abhishek R Keraliya2, Parag S Aland1
1 Department of Nuclear Medicine and PET/CT, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of CT and MRI, ESIC hospital, Mumbai, Maharashtra, India
| Date of Submission | 11-Dec-2013 |
| Date of Decision | 22-Dec-2013 |
| Date of Acceptance | 26-Jan-2014 |
| Date of Web Publication | 7-Mar-2014 |
Correspondence Address:
Hina J Shah
Department of Nuclear Medicine and PET/CT, Jaslok Hospital and Research Centre, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.128341
How to cite this article:
Shah HJ, Lele VR, Keraliya AR, Aland PS. Peripheral nerves and muscles involvement by non-Hodgkin's lymphoma seen on FDG PET/CT scan. Neurol India 2014;62:83-5 |
Sir,
Neuromuscular involvement by lymphoma is rare and unique entity. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is useful diagnostic modality in its evaluation. Here, we present a case of non-Hodgkin's lymphoma involving muscles and peripheral nerves.
A 60-year-old female had non-Hodgkin's lymphoma of sacral nerve roots. She had received chemotherapy and radiotherapy for the same. Later, she presented with foot drop and recurrence was suspected. She underwent whole body FDG PET/CT for evaluation of her disease status. Whole body maximum intensity projection PET image [Figure 1] shows increased FDG uptake in subcutaneous soft-tissue density lesions in the right axillary region, pericardial soft-tissue deposit, enlarged sciatic nerves; the fused PET/CT image shows increased FDG uptake in fusiform enlargement of sciatic nerves [Figure 2] and [Figure 3]. Increased FDG uptake is also seen in left tibial and peroneal nerves, left soleus [Figure 4] and plantar muscles [Figure 5]. These findings, in view of known history of lymphoma, are suggestive of recurrence of the disease with predominant neuromuscular involvement. | Figure 1: Maximum intensity projection fl uorodeoxyglucose (FDG) positron emission tomography image showing increased FDG uptake in right axillary soft-tissue (small arrow), paracardiac soft-tissue deposit (long arrow) and in fusiform enlargement of bilateral sciatic nerves (block arrows)
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 | Figure 2: Coronal images showing fusiform enlargement of sciatic nerves bilaterally on computed tomography (CT) (a), positron emission tomography (PET) (b) and fused PET/CT (C) images showing increased fluorodeoxyglucose uptake in it
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 | Figure 3: Axial images – positron emission tomography (PET) (a), computed tomography (CT) (b) and fused PET/CT (c) showing increased fl uorodeoxyglucose uptake in enlarged sciatic nerves
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 | Figure 4: Coronal (upper row) and axial (lower row) images – positron emission tomography (PET) (a and d), computed tomography (CT) (b and e) and fused PET/CT (c and f) showing increased fluorodeoxyglucose uptake in right bulky soleus muscle and in left tibial and peroneal nerves
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 | Figure 5: Coronal (upper row) and axial (lower row) images – positron emission tomography (PET) scan (a and d), computed tomography (CT) scan (b and e) and fused PET/CT (c and f) showing increased fluorodeoxyglucose uptake in bulky right plantar muscles
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Involvement of peripheral nervous system by lymphoma is termed as "Neurolymphomatosis", the term coined by Lhermitte and Trelles. [1] According to International Primary Central Nervous System (CNS) Lymphoma Collaborative Group who retrospectively analyzed 50 patients, the affected neural structures included peripheral nerves in 60%, spinal nerve roots in 48%, cranial nerves in 46% and plexus in 40% and multiple site involvement in 58%. [2] Nerve involvement in lymphoma is due to direct infiltration of peripheral nerves by lymphomatous cells and neurological complications occur due to direct axonal damage. [3] Four different clinical presentations have been mentioned - painful infiltration of nerves or roots, painful or painless cranial neuropathy, painless involvement of peripheral nerves and painful or painless involvement of a single peripheral nerve. [4] Peripheral neuropathy can also occur as paraneoplastic symptom in some form of lymphoma due to various antibodies. [5],[6]
FDG PET/CT is a well-accepted modality in the evaluation of lymphoma. FDG PET/CT provides a whole body evaluation of anatomical and functional disease status. A single scan can be used to know the location of disease, metabolic activity in abnormal areas and assess response to therapy. Usually FDG PET/CT is acquired until mid-thigh. However, as this patient had foot drop, whole body, that is, additional lower limb acquisition was done. Thus, it is important to note history and individualize scan acquisition protocol.
FDG PET/CT or magnetic resonance imaging (MRI) can be used to evaluate nerve involvement in lymphoma. In FDG PET/CT, diffuse increased uptake is seen along the involved nerves. [7] On MRI, diffuse enlargement with contrast enhancement is seen in the involved nerves. [4]
According to International Primary CNS Lymphoma Collaborative Group report, FDG PET-CT appears to be a highly sensitive diagnostic method facilitating identification of neurolymphomatosis. [2] According to Rosso et al., FDG PET may have clinical value in diagnosis of neurolymphomatosis, when lymphomatous infiltration in large peripheral nerves or plexus is suspected and when histological biopsy is not possible or is negative. [8]
FDG PET/CT can be used as a single modality to evaluate neurolymphomatosis - to demonstrate multiplicity, activity of the disease, staging and response assessment.
| » References | |  |
| 1. | Lhermitte J, Trelles LO. Neurolymphomatose peripherique humaine. Press Med 1934;42:289-92. 
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| 2. | Grisariu S, Avni B, Batchelor TT, van den Bent MJ, Bokstein F, Schiff D, et al. Neurolymphomatosis: An International Primary CNS Lymphoma Collaborative Group report. Blood 2010;115:5005-11.
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| 3. | Kelly JJ, Karcher DS. Lymphoma and peripheral neuropathy: A clinical review. Muscle Nerve 2005;31:301-13.
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| 4. | Baehring JM, Damek D, Martin EC, Betensky RA, Hochberg FH. Neurolymphomatosis. Neuro Oncol 2003;5:104-15.
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| 5. | Vallat JM, De Mascarel HA, Bordessoule D, Jauberteau MO, Tabaraud F, Gelot A, et al. Non-Hodgkin malignant lymphomas and peripheral neuropathies - 13 cases. Brain 1995;118:1233-45.
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| 6. | Dalmau J, Rosenfeld MR. Paraneoplastic neurologic syndromes. Harrison′s Principle of Internal Medicine. 17 th ed., Ch. 97. 2008. p. 623-8.
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| 7. | Durán C, Infante JR, Serrano J, Rayo JI, García L, Domínguez ML, et al. Neurolymphomatosis: Diagnosis of extension and assessment of response to treatment with PET-CT. Rev Esp Med Nucl 2009;28:295-8.
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| 8. | Rosso SM, de Bruin HG, Wu KL, van den Bent MJ. Diagnosis of neurolymphomatosis with FDG PET. Neurology 2006;67:722-3.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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