Case of the Quarter - 2015 Q1

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Clinical History

66-year-old female with a history of flu from November to December 2014, which failed to resolve despite two courses of antibiotics. A diagnostic CT scan demonstrated a left hilar mass. The patient was subsequently referred to the Respiratory Team and a PET-CT was requested for staging of a possible lung cancer.

Findings

An FDG scan was acquired from skull base to below knees together with a low dose CT scan for attenuation correction and image fusion.

There is high-grade increased tracer uptake (SUVmax = 9.1) associated with a 3.7 cm left upper lobe lung mass, which extends into the mediastinum. There is no separate discrete high-grade uptake related to the left hilum. There is very low-grade increased tracer uptake associated with an ill-defined nodule seen superior to the mass (axial slice 232).

There is low-grade uptake within a 8mm left parotid mass (axial slice 282). Tracer distribution is otherwise unremarkable.

On low dose CT note is made of minor bibasal atelectasis and a right duplex kidney.

Interpretation

Appearances are in keeping with a primary bronchogenic malignancy invading the mediastinum. There is no definite evidence of metabolically active nodal disease or distant metastases identified on this study.

The small left parotid mass may represent an intraparotid node or a small pleomorphic adenoma.

Follow-up

The patient subsequently underwent a CT guided biopsy, which demonstrated a Follicular Lymphoma (Low grade 1/2, CD20+, BCL2+) with no involvement of the bone marrow. The patient was discussed at the Multidisciplinary Team Meeting with a plan for radiotherapy on the basis of Stage I disease.

Key Teaching points and Discussion

References

Ferraro P, Trastek VF, Adlakha H, Deschamps C, Allen MS, Pairolero PC. Primary non-Hodgkin's lymphoma of the lung. Ann Thorac Surg. 2000 Apr;69(4):993-7

Ooi GC, Chim CS, Lie AK, Tsang KW. Computed tomography features of primary pulmonary non-Hodgkin's lymphoma. Clin Radiol. 1999 Jul;54(7):438-43.

Kim JH, Lee SH, Park J, Kim HY, Lee SI, et al. Primary pulmonary non-Hodgkin's lymphoma. Jpn J Clin Oncol. 2004 Sep;34(9):510-4.

Evidence-based Indications for the use of PET-CT in the United Kingdom 2013 - Lymphoma

Published by the RCP London, Glasgow, Edinburgh, RCR, BNMS, and ARSAC

www.rcplondon.ac.uk/rersources/evidence-based-indications-use-pet-ct-uk-2013