PMC5778714_01
(a) Maximal intensity projection of the staging 18F-fluorodeoxyglucose positron emission tomography/computed tomography showing areas of intense abnormal tracer uptake in the right suprarenal location and along the midline; (b and c) Transaxial fused positron emission tomography/computed tomography images localized the intense tracer uptake to a large suprarenal mass and to a few enlarged retroperitoneal lymph nodes; (d-f) maximal intensity projection and fused positron emission tomography/computed tomography images of interim positron emission tomography/computed tomography (following four cycles of chemotherapy) showing significant resolution in size and fluorodeoxyglucose avidity of the right suprarenal mass and retroperitoneal lymph nodes. (g-i) End of treatment positron emission tomography/computed tomography images (after two more cycles of chemotherapy) revealing disease relapse in the form of a right renal lesion and a few retroperitoneal lymph nodes
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F1
A whole-body 18F-FDG PET/CT was performed for further characterization, which revealed intense FDG uptake (maximum standardized uptake value [SUVmax] 20.0; ~9.8 cm x 7.0 cm x 7.8 cm) in the soft-tissue mass involving the right adrenal gland [Figure 1a and b]. A few intensely FDG avid (SUVmax 16.7) enlarged retroperitoneal (largest measuring ~3.6 cm x 2.4 cm), and cervical lymph nodes are also noted [Figure 1c]. The patient then received four cycles of R-CHOP regimen, and interim 18F-FDG PET/CT revealed faint FDG avidity (SUVmax 2 vs. 20 previously) of the right adrenal mass lesion and resolution of FDG avidity of the retroperitoneal and cervical lymphadenopathy suggesting a favorable response to therapy [Figure 1d-f]. FDG avidity in the right adrenal mass and appearance of renal lesions (SUVmax 18.3) and paracaval lymph nodes suggesting disease progression [Figure 1g-i]. Rapid cytopenia developed in the patient following chemotherapy, and the patient was changed to alternate chemotherapy regimen (R-ICE). Further deterioration in thrombocytopenia was noted in the patient after the first cycle, which lead to discontinuation of therapy and was followed by symptomatic treatment.
Photomicrographs showing (a) sheets of atypical lymphoid cells with large nuclei and moderate cytoplasm (H and E, x400); (b) membrane positivity of tumor cells for CD20; (c) atypical lymphoid cells showing positivity for CD79a; (d) CD3 immunostaining highlighting reactive cells (b-d: Immunoperoxidase, x400) confirming a diagnosis of diffuse large B-cell lymphoma
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B-cell lymphoma (DLBCL) through immunotyping [Figure 2a-d]. Bone marrow aspiration was negative for lymphomatous infiltration, and the patient was staged as Ann Arbor Stage IIIE.