(Circulation. 1998;97:2577-2578.)
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Metabolic Imaging Identifies Non-Hodgkin's Lymphoma Infiltrating Heart
Wolfgang Römer, MD;
Manfred Garbrecht, MD;
Christoph Fuchs, MD;
; Markus Schwaiger, MD
From the Nuklearmedizinische Klinik rechts der Isar, Technische
Universität München, and IV. Medizinische Abteilung, Krankenhaus
München Neuperlach, Germany.
Correspondence to Dr Wolfgang Römer, Nuklearmedizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany.
A67-year-old
man was diagnosed with a lymphoblastic non-Hodgkin's lymphoma and was
found to have tumor infiltrating the right atrium, the
ventricular septum, and the left ventricle. The tumor was
imaged by TEE and MRT, and the diagnosis was confirmed by biopsy. After
completion of six courses chemotherapy with CHOEP, no residual wall
motion abnormalities or contrast changes were detectable by TEE. A
follow-up MRT was not possible after pacemaker implantation became
necessary because of AV conduction abnormalities. A CT scan was
performed but could not be evaluated because of metal artifacts. A PET
scan with FDG was performed to exclude residual tumor mass.
Non-Hodgkin's lymphomas exhibit an enhanced FDG uptake, as do most
malignant tumors.1 In contrast to myocardial
tissue, tumor FDG uptake is independent of plasma substrate levels and
insulin stimulation, allowing identification of tumor infiltration.
Therefore, the patient was fasted >12 hours before the FDG study to
minimize glucose uptake in normal myocardium. Before the
FDG study, a flow study with [13N]ammonia was
performed to document myocardial perfusion.
The images (Figure
, A) show the ammonia and FDG studies after six
courses of CHOEP. The perfusion study demonstrated a
homogeneous perfusion of the left ventricle, but the FDG
study revealed evidence of viable tumor in the lateral wall of the left
ventricle. There was focally enhanced tracer accumulation in the
mediastinum representing involved lymph nodes. The FDG
uptake was documented as the SUV, which is the maximum radioactivity
concentration in a region of interest divided by the injected dose
normalized to the patient's weight at 30 to 60 minutes after
injection. On the basis of these results, the patient received
radiotherapy.
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Figure 1. A, Transaxial PET images of ammonia (upper row) and FDG
(lower row) studies after completion of chemotherapy showing normal
perfusion of left ventricle and intense focal FDG uptake in lateral
wall of left ventricle and beyond atrium in mediastinum. B, Transaxial
FDG-PET images of same region 4 months later (2 weeks after
radiotherapy) revealing diffuse enhanced FDG uptake in lower
mediastinum, heart, perihilar lymphatic tissue, and left lower lobe
with continued normal perfusion of left ventricle.
|
|
Two weeks after completion of radiotherapy, the PET study
(Figure
, B) was repeated. Progress of the tumor with extensive tumor
masses in the lower mediastinum infiltrating the heart, perihilar
lymphatic tissue, and left lower lobe was demonstrated. The SUV in the
known lesion in the left ventricle had decreased 19% from 7.9 to 6.4,
which represented partial tumor devitalization by
radiotherapy. In the mediastinum, the SUV increased 72% as a marker of
tumor progress. The perfusion of the left ventricle was again normal.
Two weeks after this study, the patient died of cerebral infarction;
the tumor extension shown by the PET study was confirmed
histologically at autopsy.
Selected Abbreviations and Acronyms
| CHOEP |
= |
cyclophosphamide, doxorubicin, vincristine, etoposide, and prednisone |
| FDG |
= |
18F-fluorodeoxyglucose |
| MRT |
= |
magnetic resonance tomography |
| SUV |
= |
standardized uptake value |
| TEE |
= |
transesophageal
echocardiography |
|
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.
References
1.
Lapela M, Leskinen S, Minn HR, Lindholm P, Klemi PJ,
Söderström KO, Bergman J, Haaparanta M, Ruotsalainen U,
Solin O, Joensuu H. Increased glucose metabolism in
untreated non-Hodgkin's lymphoma: a study with positron emission
tomography and fluorine-18-fluorodeoxyglucose. Blood. 1995;86:3522–3527.[Abstract/Free Full Text]
