PMC9803627_01
Timeline of patient's disease and imaging course
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F1
A 64-year-old male with a history of stage IV-A primary cutaneous diffuse large B-cell lymphoma of the left leg in remission for seven months after treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) and focal radiotherapy presented with eight months of progressive facial and lower extremity weakness and loss of sensation (Figure 1).
18F-FDG PET/CT whole-body maximum intensity projection image (A) shows linear abnormal uptake along the left brachial plexus (broken arrow), and in the bilateral sciatic nerves (arrows). Fused 18F-FDG PET/CT images demonstrate extension into the left tibial nerve (B arrow), involvement of the left cervicothoracic nerve roots and brachial plexus (C, dashed arrows), and osseus infiltration of the tibiae (D, broken arrows) and nearby neurovascular bundles (D, arrows). Follow-up 18F-FDG PET/CT performed 4 months later demonstrated near complete resolution at these sites (E). Asymmetric muscle uptake may be due to asymmetric muscular strain
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F2
Pathologic specimens demonstrating left tibial nerve involvement by diffuse large B-cell lymphoma. A. The nerve was densely and diffusely infiltrated by large, atypical cells with irregular nuclei, vesicular chromatin, and prominent nucleoli. Scattered mitotic figures are present (arrow). B. Immunohistochemistry showed that the neoplastic cells were strongly positive for CD20, a marker of mature B lymphocytes. C. Trichrome stain highlights the damaged myelin nerve fibers in light blue (arrow)
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F3
Left sural and tibial nerve biopsies showed infiltration of diffuse large B-cell lymphoma having immunophenotype and morphology compatible with relapse of the patient's prior lymphoma (Figure 3).