|
 |
| INTERESTING IMAGE |
|
|
|
| Year : 2023 | Volume
: 38
| Issue : 1 | Page : 65-66 |
|
|
Intense fluorodeoxyglucose uptake in aggressive systemic mastocytosis without associated hematological neoplasm: Unusual fluorodeoxyglucose positron emission tomography/computed tomography presentation
Nosheen Fatima1, Areeba Zaman2, Sidra Zaman3, Unaiza Zaman4, Maseeh U Z. Zaman1
1 Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
2 Department of Medicine, Sunny Down State Hospital, New York, USA
3 Resident Medicine, Dr. Ruth Pfau Hospital, DUHS, Karachi, Pakistan
4 Fellow Haem-Oncology, Oklahoma University, Oklahoma, USA
| Date of Submission | 20-May-2022 |
| Date of Decision | 17-Jun-2022 |
| Date of Acceptance | 27-Jun-2022 |
| Date of Web Publication | 24-Feb-2023 |
Correspondence Address:
Prof. Maseeh U Z. Zaman
Department of Radiology, Aga Khan University Hospital, Karachi
Pakistan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijnm.ijnm_88_22
 Abstract | | |
Systemic mastocytosis (SM) is a relatively rare heterogeneous group of disorders characterized by uncontrolled proliferation and accumulation of clonal mast cells in one or more organs. Indolent SM is the most common variety. Less common variety is aggressive systemic mastocytosis (aSM) type with or without associated hematological neopalsm (AHN). Fludeoxyglucose (FDG) positron emission tomography/computed tomography has a limited role in aSM without AHN as these exhibit low FDG avidity. We are presenting a biopsy-proven case of aSM without AHN showing abnormally high FDG uptake in lesions involving skin, nodes, marrow, and muscles.
Keywords: Aggressive systemic mastocytosis with associated hematological neopalsm, Aggressive systemic mastocytosis without associated hematological neopalsm, fludeoxyglucose positron emission tomography/computed tomography presentation, systemic mastocytosis
How to cite this article:
Fatima N, Zaman A, Zaman S, Zaman U, Zaman MU. Intense fluorodeoxyglucose uptake in aggressive systemic mastocytosis without associated hematological neoplasm: Unusual fluorodeoxyglucose positron emission tomography/computed tomography presentation. Indian J Nucl Med 2023;38:65-6 |
How to cite this URL:
Fatima N, Zaman A, Zaman S, Zaman U, Zaman MU. Intense fluorodeoxyglucose uptake in aggressive systemic mastocytosis without associated hematological neoplasm: Unusual fluorodeoxyglucose positron emission tomography/computed tomography presentation. Indian J Nucl Med [serial online] 2023 [cited 2023 Mar 28];38:65-6. Available from: https://www.ijnm.in/text.asp?2023/38/1/65/370418 |
| Introduction | |  |
Mastocytosis is a heterogeneous group of disorders characterized by uncontrolled proliferation and accumulation of clonal mast cells in one or more organs.[1] Molecular hallmark is c-kit D816V mutation, and in <20% of cases, either a different mutation or no mutation has been reported.[2] The most common presentation is a cutaneous lesion (urticarial pigmentosa) without organ dysfunction and anaphylaxis caused by the release of mast cell mediators (80% – Indolent systemic mastocytosis [ISM]). In 15% of cases, it follows an advanced course such as aggressive SM (aSM), SM with associated hematological neoplasm (AHN), MC leukemia, or sarcoma with dysfunction of one or more organs.[2] The low prevalence and unusual features of SM often hinder its diagnosis for several years.[3] Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging is considered not a sensitive tool for mast cell activation and proliferation which cannot distinguish between indolent and purely aSM.[2]
We are presenting a case of a young man with biopsy-proven aSM without AHN disease showing abnormally high metabolic activity on FDG PET/CT imaging which is atypical and unusual for the condition.
| Case Report | | |
A 37-year-old male presented with a 3-month history of maculopapular cutaneous lesions (urticaria pigmentosa) over the neck and both upper arms, recurrent low-grade fever, and episodes of bronchospasms. Contrast-enhanced computerized tomography performed revealed lymphadenopathy in the bilateral neck and mediastinum, with splenomegaly and areas of skin thickenings in the neck and both upper arms. His skin biopsy (December 28, 2021) revealed mastocytosis, and bone trephine from the sternum (January 12, 2022) revealed bone marrow involvement by mastocytosis with normal erythroid and myeloid precursors. Histopathological diagnosis was aSM without AHN. To evaluate the extent of disease and response evaluation to therapy, an FDG PET/CT was performed. Noncontrast low-dose FDG PET/CT was performed using Celestion, Cannon (Japan).
FDG PET/CT revealed hypermetabolic enlarged lymph nodes in bilateral neck (largest in left supraclavicular (47 mm × 36 mm SUVmax 10), axillae (right 22 mm × 34 mm SUVmax 11.4), and mediastinum (largest right paratracheal 44 mm × 30 mm SUVmax 10) [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h, [Figure 1]i. The spleen was enlarged (170 mm CC) with diffuse FDG uptake (SUVmax 5.8). Mild diffuse marrow uptake with small focal deposits was seen to suggest marrow disease. There were also multiple hypermetabolic deposits in muscles of the neck, shoulders, and both pectoral regions and hypermetabolic skin lesions over the right anterolateral chest wall and sternal (SUVmax 10.5) regions [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h, [Figure 1]i. | Figure 1: (a-i) FDG PET/CT (without intravenous contrast) scan (a) MIP image showing areas of hypermetabolism in the neck, chest, splenomegaly, and enhanced marrow uptake (b and c) Axial images showing intense FDG uptake in nodes and muscles (d and e) hypermetabolic skin thickening anterior to manubrium sterni (f and g) enlarged spleen with diffusely increased FDG uptake (h and i) Focal marrow uptake of FDG in right sacral ala. FDG PET/CT: Fludeoxyglucose positron emission tomography/computed tomography presentation, MIP: Maximum intensity projection
Click here to view |
| Discussion | | |
SM is a relatively rare disease with a reported prevalence of 1 in 10,000 persons.[4],[5] According to a multicenter French study, FDG PET/CT imaging shows no significant metabolic activity in smoldering and purely aSM without AHN but intense FDG uptake in the marrow and other sites seen in aSM with AHN.[2] In a recently published case report by Koukalová et al., a patient with aSM had diffusely low FDG uptake on lesions seen on CT but enhanced marrow uptake and marrow biopsy revealed kit D816V mutation, which is considered minor criteria for diagnosing SM.[6] In contrary to above mentioned case, our case revealed intense FDG uptake overall. Based on these published facts, FDG PET/CT is considered to have limited utility for estimating the prognosis and assessing the therapeutic effects in ISM and aSM without AHN. Interestingly, our patient with aSM without AHN revealed intense hypermetabolism. It is also important to mention that our case also exhibited significant mast cell infiltration in various muscle groups, which is an unusual finding. This case report also favors the utility of FDG PET/CT in response evaluation in such rare with positive baseline FDG PET/CT (although we do not have a posttreatment FDG PET/CT). We conclude that this case report would add to existing data showing an unusual presentation of aSM without AHN showing intense FDG uptake which is considered to have low-to-no FDG avidity. In these patients, FDG PET/CT may be used for response assessment.
| Informed consent | | |
Written informed consent was obtained from the patient for publication.
Declaration of patient consent
The authors certify that they have obtained appropriate patient consent for conducting tests and using clinical information for publication as per institutional policy. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Rama TA, Martins D, Gomes N, Pinheiro J, Nogueira A, Delgado L, et al. Case report: Mastocytosis: The long road to diagnosis. Front Immunol 2021;12:635909.  |
| 2. | Djelbani-Ahmed S, Chandesris MO, Mekinian A, Canioni D, Brouzes C, Hanssens K, et al. FDG-PET/CT findings in systemic mastocytosis: A French multicentre study. Eur J Nucl Med Mol Imaging 2015;42:2013-20. |
| 3. | Jennings S, Russell N, Jennings B, Slee V, Sterling L, Castells M, et al. The Mastocytosis Society survey on mast cell disorders: Patient experiences and perceptions. J Allergy Clin Immunol Pract 2014;2:70-6. |
| 4. | Cohen SS, Skovbo S, Vestergaard H, Kristensen T, Møller M, Bindslev-Jensen C, et al. Epidemiology of systemic mastocytosis in Denmark. Br J Haematol 2014;166:521-8. |
| 5. | Brockow K. Epidemiology, prognosis, and risk factors in mastocytosis. Immunol Allergy Clin North Am 2014;34:283-95. |
| 6. | Koukalová R, Vašina J, Štika J, Doubek M, Szturz P. Aggressive systemic mastocytosis with diffuse bone marrow 18F-FDG uptake. Nuklearmedizin 2022;61:58-61. |
[Figure 1]
|
