Neurolymphomatosis as initial manifestation of recurrence

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Rev Esp Med Nucl Imagen Mol. 2014;33(1):50–51
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Neurolymphomatosis as initial manifestation of recurrence in lymphoma夽
Neurolinfomatosis como manifestación inicial de recidiva en linfoma
D. Ramírez Ocaña a,∗ , A.L. Gutiérrez Cardo b , L. González Díaz c , K. Hurst c , M. Espeso de Haro c
a
b
c
Unidad de Gestión Clínica de Medicina Nuclear, Hospital Universitario Carlos Haya, Málaga, Spain
Unidad de Imagen Molecular, Centro de Investigaciones Médico Sanitarias, Málaga, Spain
Unidad de Gestión Clínica de Hematología y Hemoterapia, Hospital Universitario Carlos Haya, Málaga, Spain
a r t i c l e
i n f o
Article history:
Received 11 December 2012
Accepted 12 February 2013
We present the case of a 71-year-old woman diagnosed with
diffuse large B-cell non-Hodgkin lymphoma, stage IV-B, IPI 3, in
complete remission after 6 cycles of rituximab-CHOP.
Five months after completing treatment the patient went to the
Emergency Department for a picture of headache and diplopy of
one month of evolution. During admission she present lumbosciatalgia refractory to pharmacologic treatment. Lumbosacral MR was
performed showing no signs of lymphomatous disease (Fig. 1).
CSF study demonstrated relapse of lymphoma in the CNS and
intrathecal therapy was initiated. At the end of the treatment 18 FFDG/PET-CT showed hypermetabolic foci in axillary, lumbar and
pelvis regions compatible with nervous system tumoral involvement (neurolymphomatosis). In addition, hypermetabolic foci in
the humeral head and sacrum were observed compatible with bone
involvement by lymphoma (Fig. 2).
Lymphatic infiltration of the peripheral nervous system
(neurolymphomatosis) is a rare manifestation of non-Hodgkin
lymphoma. It is usually presented in patients with very
extended non-Hodgkin lymphoma or as the first manifestation of
relapse.1
The onset of symptoms is generally progressive and insidious,
presenting only radicular pain or associated to central or peripheral
sensitivo-motor neuropathy.
Pain is the most common clinical presentation, generally being
intense and described as relentless and, sometimes, burning pain.
Neuropathy may present clinical symptoms similar to the
Guillain-Barré syndrome, cauda equina syndrome (horse-tail)
or quadriparesia, and differential diagnosis should include
chemotherapy-induced neurotoxicity, infections, compression of
a nerve root, radicular neuropathy and vasculitis.2
Definitive diagnosis requires histological confirmation of the
affected nerve, which, on occasions cannot be performed and is
often not diagnostic since the affected zone may not be accessible
to biopsy.
Fig. 1. Sagittal T2-weighted sequence MR images of the lumbosacral spine showing multiple degenerative changes with no evidence of lymphomatous disease.
夽 Please cite this article as: Ramírez Ocaña D, Gutiérrez Cardo AL, González Díaz L,
Hurst K, Espeso de Haro M. Neurolinfomatosis como manifestación inicial de recidiva
en linfoma. Rev Esp Med Nucl Imagen Mol. 2014;33:50–51.
∗ Corresponding author.
E-mail address: d [email protected] (D. Ramírez Ocaña).
2253-8089/$ – see front matter © 2012 Elsevier España, S.L. and SEMNIM. All rights reserved.
Documento descargado de http://www.elsevier.es el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
D. Ramírez Ocaña et al. / Rev Esp Med Nucl Imagen Mol. 2014;33(1):50–51
51
Fig. 2. 18 F-FDG/PET-CT study: (a) MIP showing an increase in the 18 F-FDG uptake in the left humeral head, sacrum and axillary and lumbar plexus. (b) PET, (c) CT and (d)
fusion 18 F-FDG/PET-CT coronal images showing lineal uptake corresponding with the left lumbar plexus suggestive of infiltration by lymphoma.
Fig. 3. Axial 18 F-FDG/PET-CT images showing an increase in the 18 F-FDG uptake in the right brachial plexus suggestive of lymphomatous infiltration.
MR is the imaging test presenting the best performance for the
study of metastasis of the plexus and may show a slight mass
adjacent to the plexus or identify metastatic infiltration. However,
none of these characteristics is specific and, in some circumstances,
the MR may be normal.
18 F-FDG/PET-CT plays an essential role in staging, in the evaluation of response to treatment and in the detection of recurrence of lymphoma. Since the study assesses the entire whole
body, it allows the restaging of the disease and the identification of tumor dissemination patterns which may be atypical.3 The
use of hybrid images achieves precise localization (Fig. 3) and
allows guidance of the biopsy to more accessible sites with greater
metabolic activity in an attempt to reduce the rate of false negative
results.
In our case, 18 F-FDG/PET-CT confirmed the presence of tumor
recurrence, demonstrating an increase in the uptake in the nervous
structures which, together with the symptomatology referred,
allowed the diagnostic suspicion of neurolymphomatosis and identified the site for performing the biopsy.
Conflict of interest
The authors have no conflicts of interest to declare.
References
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