PMC4746845_01
Baseline 18F-flouro deoxyglucose positron emission tomography/computed tomography (a) shows multiple enlarged hypermetabolic lymph nodes on both sides of the diaphragm involving left lower cervical (b), left supraclavicular, abdominal (c and d) and bilateral iliac regions. Diffuse hypermetabolic omental thickening (e) and low grade hypermetabolic perihepatic surface deposits (c) are also seen. In addition, there are metabolically inactive thin walled cysts in bilateral adnexae with a metabolically active soft tissue density lesion in the right adnexa with free fluid in the pouch of Douglas (f)
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F1
Images also revealed diffuse bone marrow (BM) hypermetabolism in the axial and appendicular skeleton with few focal areas of relatively increased FDG uptake in the posterior column of left acetabulum, left ischium as well as metadiaphyseal and intramedullary regions of left femur [Figure 1].
Haematoxylin and eosin staining of cervical lymph node shows Reed-Sternberg-like cells (a). Immunohistochemistry shows CD30 membrane and Golgi positivity (b), PAX-5 negativity (c), focal membranous and cytoplasmic CD4 positivity (d), epithelial membrane antigen membranous positivity (e) in Reed-Sternberg-like cells. Haematoxylin and eosin staining of bone marrow shows normal haematopoietic elements without Reed-Sternberg-like cell infiltration (f)
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F2
However, in view of the metabolically active soft tissue density lesion in the right adnexa with free fluid in the pouch of Douglas, a second possibility of ovarian malignancy was also considered. Histopathology was reviewed with additional IHC markers that showed negativity for PAX-5 and positivity for CD4, confirming the diagnosis as ALK-1 negative anaplastic large T-cell lymphoma [Figure 2a-e]. BM biopsy (by H and E staining) from the left iliac crest did not reveal any evidence of lymphoma infiltration [Figure 2f].
Interim 18F-flouro deoxyglucose positron emission tomography/computed tomography (a) performed after 3 cycles of chemotherapy shows almost complete resolution of multiple enlarged hypermetabolic lymph nodes on both sides of the diaphragm (b-d), diffuse hypermetabolic omental thickening (e) and perihepatic (c) surface deposits and significant reduction in the size of bilateral adnex al cysts with resolution of hypermetabolic soft tissue density lesion in the right adnexa as well as free fluid in the pouch of Douglas (f)
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F3
Interim PET/CT after two cycles of chemotherapy showed a very good partial response to therapy [Figure 3].