Page 57 - ARNM-2-1

Advances in Radiotherapy
& Nuclear Medicine Symmetrical bilateral extranodal recurrence in FL

2. Case presentation A B

A 55-year-old woman was admitted to our university
hospital in August 2020 for evaluation of cervical and
axillary lymphadenopathies. Abdominal ultrasound
revealed multiple enlarged lymph nodes, alongside an
unexpected retroperitoneal mass encircling the left kidney,
accompanied by hydronephrosis and left pleural effusion.
Subsequent computed tomography (CT) scan of the
abdomen and pelvis validated ultrasound findings, revealing Figure 1. Axial plane (A) and coronal plane (B) reconstruction computed
a 15 × 21 cm abdominal mass and multiple enlarged lymph tomography scan. The scan illustrates focal and bilateral enlargement of
nodes spanning from the abdominal aorta to the origin of external oblique muscles without distinct margins (white arrow).
the internal iliac arteries. In addition, an excisional axillary A B
lymph node biopsy unveiled a localization of grade 2 FL.
The flow cytometry demonstrated a substantial population
of CD20-CD19-positive cells coexpressing CD10.
Fluorescence in situ hybridization exhibited positivity for
BCL2 translocation, coupled with a Ki-67 proliferation
index of 35%. Staging positron emission tomography
(PET) with 2-deoxy-2-[fluorine-18] fluoro-D-glucose
18
( F-FDG) manifested intense and pathological glucose
metabolism in multiple supra- and subdiaphragmatic
lymph nodes and left pleural effusion, devoid of extranodal
disease evidence. Subsequently, based on the stage and Figure 2. Axial plain (A) and coronal plain (B) reconstruction fused
FL International Prognostic Index 2 (FLIPI 2) score, the 18 F-FDG PET/CT scan. The scan illustrates intense F-FDG uptake in the
18
patient underwent first-line treatment with seven cycles pathological tissue superimposed on the focal and bilateral enlargement
of R-CHOP (cyclophosphamide, doxorubicin, vincristine, of the external oblique muscles (white arrow).
prednisone, and rituximab) from September 2020 to
February 2021, resulting in a metabolic complete response
according to F-FDG-PET. Subsequently, the patient
18
underwent clinical and radiological surveillance during
the rituximab maintenance therapy, exhibiting minimal
clinical symptoms except for asthenia and mild weight
loss. After 2 years, a follow-up total-body CT scan revealed
bilateral enlargement of the lumbar region contiguous
to the external oblique muscles, displaying no notable
disparities in density or contrast enhancement compared
to surrounding muscular tissues (Figure 1) and absence of
pathological lymph nodes or signs of disease recurrence.
Figure 3. Ultrasound revealing hypoechoic polylobulate lesions distinctly
Further diagnostic evaluation encompassed an delineated in a “nodular focal” pattern with vascularization signal on the
18 F-FDG-PET examination, demonstrating intense FDG color-Doppler module.
uptake bilaterally in the lumbar regions adjoining the
external oblique muscles, consistent with CT findings
(Figure 2).
Subsequently, a percutaneous ultrasound-guided biopsy
The metabolic data aligned with suspected disease was performed under local anesthesia (2% lidocaine) to
recurrences predicated on the focal pattern and intensity procure samples from the hypoechoic areas of both regions
of F-FDG uptake. Consequently, an ultrasound scan within the external oblique muscle. The biopsy confirmed
18
was conducted to characterize the tissue and anatomical the suspected diagnosis of FL, grade 3B (CD20+, CD10+,
location and guide a biopsy. Soft tissue ultrasound PAX5+, BCL2+, and Ki-67 20%), in both muscle samples.
unveiled hypoechoic polylobulate lesions conspicuously Following the confirmation of the diagnosis with symptoms
demarcated with vascularization signals on color Doppler including night sweats and unintentional weight loss, the
imaging within the muscle (Figure 3). patient underwent autotransplantation.

Volume 2 Issue 1 (2024) 2 https://doi.org/10.36922/arnm.2828