A central role for imaging in the workup of

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1 A central role for imaging in the workup of Marlys S. Fassett, PhD, HMS IV 17 September

2 Pruritis the itch 2

3 Pruritis ddx Skin inflammation (contact dermatitis, eczema, urticaria, eosinophilia) Skin infection (primary varicella, tinea, scabies) Xerosis Systemic disease (10-50%) Renal/Uremic Cholestatic Hematologic (polycythemia vera) Endocrine (hyper- and hypothyroid) Malignancy almost any but especially Hodgkin s lymphoma Idiopathic generalized pruritus, Psychogenic pruritis 3

4 Talk Outline Index case presentation: pruritis & unilateral LE edema Role of imaging in diagnostic work-up of suspected lymphoma Abdominal CT : pelvic mass CT-guided needle biopsy (IR) Hodgkin lymphoma basics Ongoing role for nuclear medicine PET-CT staging & follow-up Alternative imaging modalities 4

5 Index case: patient MS CC: pruritis and new R leg swelling HPI: 82-yo M p/w repeat complaint of worsening generalized pruritis x 3 yrs and new, progressive RLE swelling x two mos. Pruritis symptoms persist despite stopping all medications. Interferes with sleep. WBC 13, Chem 7 wnl, LFTs wnl. Negative LENI. ROS: No fevers, chills, or nightsweats. No dyspnea or orthopnea. No abdominal pain. No GI/GU complaints. No calf pain. Physical Exam: Afebrile, no LAD, 2+ pitting edema RLE OMR, BIDMC 5

6 Ddx for patient MS Problem 1: acquired generalized pruritis x3 years infectious (untreated) inflammatory/allergic (eczema, contact dermatitis) medication-induced (antibiotics, many others) malignancy-associated (lymphoma, leukemia) Problem 2: RLE edema x 2 months obstruction of draining veins or lymphatics Lumenal DVT Within vessel wall External compression Any mass: hematoma/abcess/malignancy/lad myositis compartment syndrome 6

7 Workup for suspected lymphoma Labs Imaging CBC ESR LDH Alk Phos CT chest/abd/pelvis Dessain, S.K. et al., Hodgkin Disease accessed 16 Sept

8 Talk Outline Index case presentation: pruritis & unilateral LE edema Role of imaging in diagnostic work-up of suspected lymphoma Abdominal CT : pelvic mass CT-guided needle biopsy (IR) Hodgkin lymphoma basics Ongoing role for nuclear medicine staging PET-CT surveillance follow-up PET-CTs Alternative imaging modalities 8

9 Initial Imaging: Abdomen/Pelvis CT R abdominal adenopathy R external iliac artery R external iliac vein L external iliac artery L external iliac vein Major findings: external iliac and retrocaval lymphadenopathy PACS, BIDMC 9

10 CT-guided FNA vs. LN biopsy CT-guided FNA vs. Open surgical LN biopsy Recovery time minimal short Anaesthesia less more Admission status outpatient outpatient Pathology often sufficient preferable - more tissue - more special stains psbl - intact LN architecture Practical matters Ideal for superficial targets with uninterrupted path from skin lesion Better for deeper targets or targets with difficult access through essential structures 10

11 CT-guided FNA Reasons for IR procedure in patient MS: High suspicion of lymphoma Uninterrupted path from skin mass Desire to minimize post-procedure morbidity in an elderly patient FNA pathology: Hodgkin s lymphoma PACS, BIDMC 11

12 Talk Outline Index case presentation: pruritis & unilateral LE edema Role of imaging in diagnostic work-up of suspected lymphoma Abdominal CT : pelvic mass CT-guided needle biopsy (IR): Hodgkin s lymphoma Hodgkin s lymphoma basics Ongoing role for nuclear medicine staging PET-CT surveillance follow-up PET-CTs Alternative imaging modalities 12

13 FNA: Hodgkin lymphoma Reed-Sternberg cells (GC B cells) EBV-associated Contiguous spread Typical presentations: Mediastinal LAD, often identified incidentally on CXR or CT Abdominal pain; bowel or bladder obstruction; new LE edema More rare: Generalized pruritis (can precede LAD by 5 years) Dessain, S.K. et al., Hodgkin Disease accessed 16 Sept 2010 Lichtman, MA et al. Lichtman s Atlas of Hematology. accessed via 13

14 Patient 2: typical presentation HL LAD mediastinal mass multiple round, well-circumscribed pulmonary nodules Pulmonary mets in HL seed via mediastinal LN lymphatics PACS, BIDMC Sharma A et al. Radiographics 2004;24: Guermazi, A. et al. Radiographics 2003;23:

15 Distribution of HL involvement Toma et al. Radiographics 2007; 27:

16 Talk Outline Index case presentation: pruritis & unilateral LE edema Role of imaging in diagnostic work-up of suspected lymphoma Abdominal CT : pelvic mass CT-guided needle biopsy (IR) Hodgkin lymphoma basics Ongoing role for nuclear medicine staging PET-CT surveillance follow-up PET-CTs Alternative imaging modalities 16

17 What does FDG-PET detect? Beta-emission from 18-FDG wherever glucose metabolism occurs. Metabolically-active regions include: Inflammation Malignancy Brown fat Cardiac myocytes Brain Kidneys Bowel wall Any muscle activity (teeth grinding, tensing) Insulin effect PACS, BIDMC 17

18 Next step after diagnosis: staging PET-CT Advantages of pre-therapy PET-CT for lymphoma: - establish a baseline - identify small but active sites Why PET-CT? MarlysFassett, HMSIV - FDG-PET provides metabolic information - CT allows localization ***Prednisone dampens FDG-PET signal*** Juweid, M.E. et al. J Clin Onc 2007; 25: PACS, BIDMC 18

19 Staging PET-CT for patient MS FDG-PET CT fusion FDG-avid lesions in R pelvis R pelvic adenopathy FDG-avidity localizes to pelvic LAD & R iliac crest PACS, BIDMC 19

20 Follow-up PET-CT patient MS FDG-PET CT fusion initial 4 mo follow-up prominent retroperitoneal and right iliac/obturator lymph nodes, FDG-negative small right iliac focus (image 144) shows new FDG avidity (SUVmax 5.90) Chemo: 4 rounds MOPP (mechlorethamine, vincristine, procarbazine, prednisone) PACS, BIDMC. 20

21 Follow-up PET-CT recommendations weeks after completion of chemotherapy weeks after completion of radiotherapy 3. Definition of positive scan includes any FDG+ mass, even if diminished in size or normal 1 cm LN 4. PET-CT during therapy only in clinical trials Juweid, M.E. et al. J Clin Onc 2007; 25: PACS, BIDMC 21

22 Talk Outline Index case presentation: pruritis & unilateral LE edema Role of imaging in diagnostic work-up of suspected lymphoma Abdominal CT : pelvic mass CT-guided needle biopsy (IR): Hodgkin s lymphoma Hodgkin s lymphoma basics Ongoing role for nuclear medicine staging PET-CT surveillance follow-up PET-CTs Alternative imaging modalities 22

23 Alternative imaging methods Lymphography MR 23

24 Older technology: Lymphography Older technology, now rarely done Pro: visualize lymphatic drainage network, small/non-pathologic lymph nodes, sub-lymph node architecture. Con: procedural difficulty, time Guermazi, A. et al. Radiographics 2003; 23:

25 Lymphography technique interdigital methylene blue injxn lymphatic mapping/cannulation Images courtesy of Melvin Clouse, MD 25

26 Gallery of HL by lymphography Images courtest of Melvin Clouse, MD 26

27 Alternative staging by MRI Ionizing radiation-free whole-body imaging. Used here to stage HL during advanced pregnancy. Vermoolen, M.A. et al. Am J Hematol2010; 85:

28 Take-home points Unexplained pruritis deserves a full malignancy workup including abdominal and chest imaging. Lymphoma is a can t miss differential diagnosis for new generalized pruritis PET/CT has a central role to play in therapeutic planning and follow-up of Hodgkin lymphoma Recommendations re: follow-up PET/CT frequency are controversial & dynamic 28

29 References Dessain, S.K. et al., Hodgkin Disease accessed 16 Sept 2010 Guermazi, A. et al. Lymphography: An Old Technique Retains Its Usefulness. Radiographics 2003; 23: Juweid, M.E. et al. Use of positron emission tomography fro response assessment of lymphoma: consensus of the imaging subcommittee of international harmonization project in lymphoma. J Clin Onc 2007; 25: Lee, A.I. et al. Surveillance Imaging of Hodgkin lymphoma patients in first remission. Cancer 2010; 116: Lichtman, MA et al. Lichtman s Atlas of Hematology. accessed via Paes, F. M. et al. FDG PET/CT of extranodal involvement in non-hodgkin lymphoma and Hodgkin disease. Radiographics 2010; 30: Petrausch, U. et al. Hodgkin s lymphoma in remission after first-line therapy: which patients need FDG-PET for follow-up. Ann Onc 2010; 21: Poulos, L.S et al. FDG PET scan strategries and long-term outcomes after first-line therapy in Hodgkin s Disease. Eur J Rad 2009; 499:506 Sharma A et al. Patterns of lymphadenopathy in thoracic malignancies. Radiographics 2004; 24: Vermoolen, M.A. et al. Whole-body MRI for staging Hodgkin lymphoma in a pregnant patient. Am J Hematol 2010; 85:443. Toma et al. Multimodality imaging of Hodgkin Disease and Non-Hodgkin Lymphomas in Children. Radiographics 2007; 27:

30 Acknowledgments BIDMC Radiology Kevin Donahoe, MD Anthony Parker, MD PhD Melvin Clouse, MD Sachin Pandey, MD (PGY-2) HMS BIDMC Radiology Core Clerkship, Course Director Emily Hansen, Educational Coordinator Larry Barbaras, Webmaster 30

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