FDG PET-CT in the management of primary breast lymphoma

Unusual Presence of Synchronous Primary Ovarian and Thyroid Extranodal Non-Hodgkin Lymphoma Without Lymph Node Involvement

ABSTRACT

Extranodal lymphomas without lymph node involvement are rarely observed and create diagnostic challenges. We present the case of a 33-year-old woman who was admitted with abdominal swelling. Ultrasonography findings suggested bilateral ovarian masses. 18 F-FDG PET/CT revealed intense uptake on the bilateral pelvic mass and thyroid gland. Following excisional surgery and thyroid fine-needle aspiration biopsy, the patient was diagnosed with diffuse large B-cell lymphoma. This case is exceptionally rare, as it presents 2 synchronous extranodal involvements in the ovaries and the thyroid gland independently while not presenting any lymph node activity, which has not been reported before.

Unusual US Findings of Diffuse Large B-Cell Lymphoma of the Breast: A Case Report

Lymphoma is an uncommon type of breast malignancy, with low prevalence. The ultrasonographic findings of breast lymphoma have been described as nonspecific. Breast lymphoma most commonly appears as a solitary hypoechoic mass on US, and usually shows hypervascularity on color Doppler US. Herein, we report an unusual case of breast lymphoma that presented as multiple bilateral hyperechoic nodules on US.

PET-CT in Clinical Adult Oncology: II. Primary Thoracic and Breast Malignancies

Simple Summary

Positron emission tomography (PET), typically combined with computed tomography (CT), has become a critical advanced imaging technique in oncology. With PET-CT, a radioactive molecule (radiotracer) is injected in the bloodstream and localizes to sites of tumor because of specific cellular features of the tumor that accumulate the targeting radiotracer. The CT scan, performed at the same time, provides information to facilitate assessment of the amount of radioactivity from deep or dense structures, and to provide detailed anatomic information. PET-CT has a variety of applications in oncology, including staging, therapeutic response assessment, restaging, and surveillance. This series of six review articles provides an overview of the value, applications, and imaging and interpretive strategies of PET-CT in the more common adult malignancies. The second article in this series addresses the use of PET-CT in breast cancer and other primary thoracic malignancies.

Abstract

Positron emission tomography combined with x-ray computed tomography (PET-CT) is an advanced imaging modality with oncologic applications that include staging, therapy assessment, restaging, and surveillance. This six-part series of review articles provides practical information to providers and imaging professionals regarding the best use of PET-CT for the more common adult malignancies. The second article of this series addresses primary thoracic malignancy and breast cancer. For primary thoracic malignancy, the focus will be on lung cancer, malignant pleural mesothelioma, thymoma, and thymic carcinoma, with an emphasis on the use of FDG PET-CT. For breast cancer, the various histologic subtypes will be addressed, and will include ¹⁸F fluorodeoxyglucose (FDG), recently Food and Drug Administration (FDA)-approved ¹⁸F-fluoroestradiol (FES), and ¹⁸F sodium fluoride (NaF). The pitfalls and nuances of PET-CT in breast and primary thoracic malignancies and the imaging features that distinguish between subcategories of these tumors are addressed. This review will serve as a resource for the appropriate roles and limitations of PET-CT in the clinical management of patients with breast and primary thoracic malignancies for healthcare professionals caring for adult patients with these cancers. It also serves as a practical guide for imaging providers, including radiologists, nuclear medicine physicians, and their trainees.

FDG PET/CT of Primary Breast Lymphoma in a Man

ABSTRACT

Primary lymphoma of the male breast is extremely rare. We describe FDG PET/CT findings in a man with primary breast lymphoma in his right breast. The breast tumor showed intense FDG uptake mimicking breast carcinoma.

Primary Breast Lymphoma Detected by 18F-FDG and 68Ga-DOTA-FAPI-04 PET/CT

ABSTRACT

Primary breast lymphoma is a rare form of extranodal lymphoma. We report 18F-FDG and 68Ga-DOTA-FAPI-04 PET/CT findings of breast lymphoma in a 60-year-old woman. Both breast ultrasound and mammogram showed a mass in the right breast and suggested that the mass might be a malignant tumor. She was referred for an 18F-FDG PET/CT scan and subsequently recruited in our 68Ga-DOTA-FAPI-04 PET/CT trial. Both scans revealed the breast mass with intense tracer uptake. Biopsy and immunohistochemical examinations of the mass confirmed the diagnosis of diffuse large B-cell lymphoma.

Multimodality imaging features of primary breast lymphoma - A rare entity

Primary lymphoma of breast is very rare which has no tell-tale imaging characteristics. Multimodality imaging helps not only in suggesting the possibility of lymphoma but also in its management. We present here one such case which was extensively worked up with various imaging modalities and was histologically proven as primary breast lymphoma.

FDG PET/CT Showing a Primary Lymphoma of the Sternoclavicular Joint

ABSTRACT

We presented a case of primary lymphoma of the sternoclavicular joint. A 67-year-old woman with a history of swelling at the sternoclavicular joint region was considered as osteoarthritis initially. Chest CT found a soft tissue mass around the sternoclavicular joint. Biopsy demonstrated diffuse large B-cell lymphoma. The subsequent FDG PET/CT revealed FDG-avid articular destruction with surrounding soft tissue mass without any other abnormal findings, suggesting a primary extranodal lymphoma of sternoclavicular joint.

Primary Breast Extranodal Marginal Zone Lymphoma in Primary Sjögren Syndrome: Case Presentation and Relevant Literature

The association between autoimmune diseases, mostly rheumatoid arthritis, systemic lupus erythematosus, celiac disease and Sjögren syndrome, and lymphoma, has been widely demonstrated by several epidemiologic studies. By a mechanism which has not yet been entirely elucidated, chronic activation/stimulation of the immune system, along with the administration of specific treatments, may lead to the onset of different types of lymphoma in such patients. Specifically, patients affected by Sjögren syndrome may develop lymphomas many years after the original diagnosis. Several epidemiologic, hematologic, and histological features may anticipate the progression from Sjögren syndrome into lymphoma but, to the best of our knowledge, a definite pathogenetic mechanism for such progression is still missing. In fact, while the association between Sjögren syndrome and non-Hodgkin lymphoma, mostly extranodal marginal zone lymphomas and, less often, diffuse large B-cell, is well established, many other variables, such as time of onset, gender predilection, sites of occurrence, subtype of lymphoma, and predictive factors, still remain unclear. We report on a rare case of primary breast lymphoma occurring three years after the diagnosis of Sjögren syndrome in a 57-year-old patient. The diagnostic work-up, including radiograms, core needle biopsy, and histological examination, is discussed, along with emerging data from the recent literature, thus highlighting the usefulness of breast surveillance in Sjögren syndrome patients.

[Imaging findings of intramammary malignant lymphoproliferative disease]

Intramammary manifestation of lymphoproliferative disease is rare. The radiological evaluation follows in most cases the clinical suspicion and therefore the radiologist takes an important place in diagnostics. The aim of this work is to demonstrate typical radiological patterns of this rare entity with multimodal cases and to sensitize for it. The differential diagnosis to other breast tumors, especially primary breast carcinoma, can be radiologically difficult, so the suspicious lesion must be histologically verified by biopsy.

Spectrum of the Breast Lesions With Increased 18F-FDG Uptake on PET/CT

Interpretation of ¹⁸F-FDG PET/CT studies in breast is challenging owing to nonspecific FDG uptake in various benign and malignant conditions. Benign conditions include breast changes in pregnancy and lactation, gynecomastia, mastitis, fat necrosis, fibroadenoma, intraductal papilloma, and atypical ductal hyperplasia. Among malignancies, invasive ductal carcinoma and invasive lobular carcinoma are common histological types of breast carcinoma. Rarely, other unusual histological types of breast carcinomas (eg, intraductal papillary carcinoma, invasive micropapillary carcinoma, medullary carcinoma, mucinous carcinoma, and metaplastic carcinoma), lymphoma, and metastasis can be the causes. Knowledge of a wide spectrum of hypermetabolic breast lesions on FDG PET/CT is essential in accurate reading of FDG PET/CT. The purpose of this atlas article is to demonstrate features of various breast lesions encountered at our institution, both benign and malignant, which can result in hypermetabolism on FDG PET/CT imaging.

Role of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in evaluating breast mucosa-associated lymphoid tissue lymphoma: A case series

Mucosa-associated lymphatic tissue (MALT) lymphoma of the breast is an extremely rare disease; its pathogenesis is not clear because of the rarity of disease, and the best diagnostic method has yet to be established. The metabolic behavior of this lymphoma is not still clear because only a few case reports are present in literature describing the possible role of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in this field. This report presents 4 cases of women with histologically proven breast MALT lymphoma who underwent 7 18F-FDG PET/CT throughout the course of disease. All patients underwent staging PET/CT showing in all cases an FDG avid lesion corresponding to breast lymphoma; 3 patients underwent 18F-FDG PET/CT also after chemotherapy. Our results suggest that breast MALT lymphomas are 18F-FDG-avid lymphomas. Positron emission tomography/computed tomography showed heterogeneous but high FDG uptake (mean maximum standardized uptake value 7.9), suggesting that it could be part of diagnostic workup and restaging process.

Primary Breast Lymphoma: Analysis of 55 Cases of the Spanish Lymphoma Oncology Group

INTRODUCTION

Primary breast lymphoma is a rare form of localized extranodal lymphoma, which affects the mammary glands unilaterally or bilaterally, and can also affect the regional lymph nodes.

MATERIALS AND METHODS

We reviewed 55 patients, with disease stages IE and IIE, diagnosed in 16 Spanish institutions between 1989 and 2016. A serial of clinical variables and treatment were collected, and overall survival (OS) and progression-free survival (PFS) were calculated.

RESULTS

Of the 55 patients, 96.4% were women with an average age of 69 years. A total of 53 patients corresponded to non-Hodgkin lymphoma (NHL), of whom 36.3% had lymph node involvement upon diagnosis. Of the patients, 58.2% were stage IE, and 41.8% were stage IIE. Treatments received included radiotherapy (36.3%), chemotherapy (85.5%), and rituximab (in 38 of the 45 patients with NHL treated with chemotherapy). In all, 82.2% of complete responses were achieved. OS and progression-free survival at 5 years in NHL patients was 76% and 73%, respectively.

CONCLUSION

Current treatments (chemotherapy, immunotherapy, and radiotherapy) achieve good control of the disease, with an OS of 5 years in 80% of the patients, although there is no consensus in treatment, given the scarce incidence of these lymphomas.

Non-Hodgkin lymphoma dominated by multiple organ extranodal disease revealed on FDG PET/CT

The definition of primary extranodal lymphoma is rather controversial and often complicated by the variety of lymphoma types. Here we describe FDG PET/CT findings in 3 pediatric patients with diffuse large B-cell non-Hodgkin lymphomas dominated by extranodal lesions involving multiple organs. Lymphomas arising primarily in extranodal sites can present significant diagnostic challenges due to their morphological diversity and lack of uniformity in histopathological classification.

The features of breast lymphoma on MRI

OBJECTIVE

To investigate the morphological features of breast lymphoma (BL) on MRI.

METHODS

MRI features of 20 patients with BL (12 primary and 8 secondary) were reviewed according to Breast Imaging-Reporting and Data System categories.

RESULTS

19 cases were unilateral and 1 was bilateral. According to the enhanced images, of the 20 cases, BL presented as a mass in 11 (55%), as an enhancement with no mass effect in 7 (35%) and as a mass and mixed enhancement with no mass effect in 2 (10%). There were 38 masses and 44 lesions with no mass effect in our study. All lesions showed mild heterogeneous internal enhancement. For lesions with mass effect, the margins were smooth in 32% (12/38) and irregular in 68% (26/38); and the shape was oval in 87% (32/38). Kinetic curve assessment (13 cases, 38 lesions) revealed that the average initial rise rate was 104%. The type II enhancement curve appeared in 55% (21/38) of lesions. No significant differences between the primary and secondary BL were observed for any of the MRI features.

CONCLUSION

BL mostly appeared oval with irregular margins showing mild heterogeneous internal enhancement and/or as enhanced lesions with no mass effect with mild heterogeneous internal enhancement.

ADVANCES IN KNOWLEDGE

Some special features on MRI are useful for the diagnosis of BL.

Primary diffuse large B-cell lymphoma of the breast: looking at pathogenesis, clinical issues and therapeutic options

Primary breast lymphoma is a rare form of non-Hodgkin lymphoma with some distinct clinical features. The most common histopathological type is diffuse large B-cell lymphoma (DLBCL), but other less frequent subtypes are also encountered. In this review, we describe the characteristics of primary breast DLBCL, with emphasis on pathogenesis, staging, risk stratification and prognosis. In addition, key issues regarding therapy and various available therapeutic modalities are addressed, as well as the role of rituximab in therapy and whether central nervous system prophylaxis is still routinely required. There are very few prospective clinical studies addressing therapy, and available data rely mostly on retrospective case series involving small numbers of patients. Our conclusions and proposed recommendations are therefore not offered as formal guidelines. This review attempts to represent an unbiased analysis of the published data and is intended as a useful aid for clinicians treating this uncommon type of extra nodal lymphoma.

Efficient construction of PET/fluorescence probe based on sarcophagine cage: an opportunity to integrate diagnosis with treatment

PURPOSE

Due to the shortage of established platforms/methods for multimodality probe construction, in this study, we developed a heterofunctional chelator, BaAn(Boc)Sar, from sarcophagine cage as a general platform for dual-modality probe construction.

PROCEDURES

A dual-modality probe for positron-emission tomography (PET) and fluorescence imaging was synthesized using the developed BaAn(Boc)Sar chelator. The c(RGDyK)(2) peptide (denoted as RGD(2)) and fluorescence dye Cy5.5 were conjugated with BaAn(Boc)Sar to form BaAnSar-RGD(2)-Cy5.5. Then, BaAnSar-RGD(2)-Cy5.5 was labeled with (64)Cu in ammonium acetate buffer. PET and fluorescent imaging were carried out to evaluate (64)Cu-BaAnSar-RGD(2)-Cy5.5 in nude mice bearing U87MG glioblastoma xenograft.

RESULTS

The BaAnSar-RGD(2)-Cy5.5 was labeled with (64)Cu very efficiently in 0.1 M NH(4)OAc buffer within 10 min at 37 °C in the yield of 86.7 ± 4.4 % (n = 3). The specific activity of (64)Cu-BaBaSar-RGD(2) was controlled at 50-200 mCi/μmol for the consideration of both PET and optical imaging. MicroPET quantification analysis shows that the U87MG tumor uptake is 6.41 ± 0.28, 6.51 ± 1.45, and 5.92 ± 1.57 %ID/g at 1, 4, and 20 h postinjection, respectively. Good correlation was obtained between the tumor to muscle ratios measured by the radioactivity and fluorescence intensity. As a proof of concept, an animal surgery study demonstrated that this dual-modality probe would greatly benefit the patients because the PET moiety could be used for tumor detection, and the fluorescent moiety would allow image-guided surgery.

CONCLUSIONS

Our findings demonstrated the effectiveness and feasibility of preparing dual-modality imaging probes based on the sarcophagine scaffold. The resulting PET and fluorescent imaging probe also holds a great potential for clinical translation.

Positron emission mammography in breast cancer presurgical planning: comparisons with magnetic resonance imaging

PURPOSE

The objective of this study was to compare the performance characteristics of (18)F-fluorodeoxyglucose (FDG) positron emission mammography (PEM) with breast magnetic resonance imaging (MRI) as a presurgical imaging and planning option for index and ipsilateral lesions in patients with newly diagnosed, biopsy-proven breast cancer.

METHODS

Two hundred and eight women >25 years of age (median age = 59.7 ± 14.1 years) with biopsy-proven primary breast cancer enrolled in this prospective, single-site study. MRI, PEM, and whole-body positron emission tomography (WBPET) were conducted on each patient within 7 business days. PEM and WBPET images were acquired on the same day after intravenous administration of 370 MBq of FDG (median = 432.9 MBq). PEM and MRI images were blindly evaluated, compared with final surgical histopathology, and the sensitivity determined. Substudy analysis compared the sensitivity of PEM versus MRI in patients with different menopausal status, breast density, and use of hormone replacement therapy (HRT) as well as determination of performance characteristics for additional ipsilateral lesion detection.

RESULTS

Two hundred and eight patients enrolled in the study of which 87% (182/208) were analyzable. Of these analyzable patients, 26.4% (48/182), 7.1% (13/182), and 64.2% (120/182) were pre-, peri-, and postmenopausal, respectively, and 48.4% (88/182) had extremely or heterogeneously dense breast tissue, while 33.5% (61/182) had a history of HRT use. Ninety-two percent (167/182) underwent core biopsy for index lesion diagnosis. Invasive cancer was found in 77.5% (141/182), while ductal carcinoma in situ (DCIS) and/or Paget's disease were found in 22.5% (41/182) of patients. Both PEM and MRI had index lesion depiction sensitivity of 92.8% and both were significantly better than WBPET (67.9%, p < 0.001, McNemar's test). For index lesions, PEM and MRI had equivalent sensitivity of various tumors, categorized by tumor stage as well as similar invasive tumor size predictions with Spearman's correlation coefficient of 0.61 for both PEM and MRI compared to surgical pathology. Menopausal status, breast density, and HRT did not influence the sensitivity of PEM or MRI. For 67 additional unsuspected ipsilateral lesions or multifocal lesions, PEM had sensitivity of 85% (34/40) and specificity of 74%, (20/27) compared to MRI's sensitivity of 98% (39/40) and specificity of 48% (13/27) [p = 0.074, for sensitivity; p = 0.096 for specificity]

CONCLUSION

PEM is a good alternative to MRI as a presurgical breast imaging option and its performance characteristics are not affected by patient menopausal/hormonal status or breast density.