Rationale and Objectives
This study aimed to determine the diagnostic utility of standardized uptake values (SUV) and apparent diffusion coefficients (ADC) for assessment of focal and diffuse bone marrow involvement in patients with malignant lymphoma.
Materials and Methods
Sixty treatment-naive patients (28 males; mean age 51.2 ± 16.7 years) with histologically proven lymphoma, who underwent fludeoxyglucose ( 18 F) positron emission tomography-computed tomography ([F18]-FDG-PET/CT) and whole-body diffusion-weighted imaging (WB-DWI) within 7 days, and also routine bone marrow biopsy, were included in this institutional review board-approved, retrospective study. The maximum SUV (SUVmax) on [F18]-FDG-PET/CT, and the mean ADC (ADCmean, ×10 −3 mm 2 /s) on whole-body-DWI, were extracted from focal lesions, or, in their absence, from the thoracic (Th8) and lumbar vertebral bodies (L4), the sacral bone (S1), and the iliac crest. Lesion-to-liver-ratios (SUVmax-ratio) were calculated. Pearson correlation coefficients were used to assess the correlation between SUVmax-ratios and ADCmean values.
Results
Bone marrow involvement was observed in 16 of 60 patients (8 of 16 with diffuse infiltration). The SUVmax-ratio cutoff value was 95.25% for focal and 70.2% for diffuse bone marrow involvement (sensitivity/specificity of 87.5%/86.4% and 100%/43.2%, respectively). The ADCmean cutoff value was 0.498 for focal and 0.401 for diffuse bone marrow involvement (sensitivity/specificity of 100%/90.9% and 87.5%/56.8%, respectively). No significant correlations were found between SUVmax-ratios and ADCmean values in the different groups.
Conclusion
With the liver as reference tissue, quantitative [F18]-FDG-PET/CT may be useful to differentiate bone marrow involvement from normal bone marrow in patients with lymphoma, even though the specificity for diffuse marrow involvement is rather low. Quantitative DWI can be used only to distinguish focal bone marrow lesions from normal bone marrow.
Introduction
Bone marrow is defined as an extranodal site of disease in patients with malignant lymphoma . Therefore, patients with multifocal or diffuse bone marrow involvement are assigned to the highest stage (IV) of the Ann Arbor system, which affects prognosis and treatment. Blind, unilateral bone marrow trephine biopsy (BMB) of the iliac crest is the standard method for the diagnosis of bone marrow involvement .
Fludeoxyglucose ( 18 F) positron emission tomography-computed tomography ([18F]-FDG-PET/CT) is increasingly used as a staging and response assessment tool in malignant lymphomas . In clinical PET imaging, the glucose uptake of cancer cells is measured semiquantitatively by the maximum standardized uptake value (SUVmax). Because the degree of FDG avidity depends on the histologic lymphoma subtypes, [18F]-FDG-PET/CT has a varying sensitivity for the detection of bone marrow involvement , which can show either a focal or a diffuse uptake pattern . The present consensus is that, for patients with Hodgkin lymphoma (HL), [18F]-FDG-PET can completely replace BMB, whereas for patients with diffuse large B-cell Lymphoma (DLBCL), BMB is necessary only if there is a negative [18F]-FDG-PET result . For all other lymphoma subtypes, and particularly for the indolent types, BMB cannot be replaced by [18F]-FDG-PET as yet .
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Materials and Methods
Study Design and Patients
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Imaging Protocols
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Bone Marrow Biopsy
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Standard of Reference
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Image Analysis
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Statistical Analysis
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Results
Patient Characteristics
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TABLE 1
Demographics
Total number of patients 60 Age (years) 51.2 (20–80) Male Gender 28 (46.7%) Hodgkin Lymphoma 18 (30%) Diffuse Large B-cell Lymphoma 16 (26.7%) Follicular Lymphoma 11 (18.3%) MALT Lymphoma 6 (10%) Mantle Cell Lymphoma 4 (6.7%) Nodal Marginal Zone Lymphoma 4 (6.7%) Anaplastic Large Cell Lymphoma 1 (1.7%) Bone Marrow Involvement 16 (26.7%) Focal Bone Marrow Involvement 8 (13.3%) Diffuse Bone Marrow Involvement 8 (13.3%)
MALT Lymphoma, extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue.
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Quantitative Measurements
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TABLE 2
Mean SUVmax-ratio and ADC (×10 −3 mm 2 /s) values
N Mean SUVmax-ratio ADCmean Normal 44 74.79 ± 21.67 (95%CI: 68.20–81.38) 0.348 ± 0.138 (95%CI: 0.306–0.390) Focal 8 324.13 ± 266.82 (95%CI: 101.07–547.20) 0.769 ± 0.348 (95%CI: 0.477–1.061) Diffuse 8 100.63 ± 32.75 (95%CI: 73.25–128.00) 0.407 ± 0.125 (95%CI: 0.303–0.512) All 60 111.48 ± 126.76 (95%CI: 78.74–144.23) 0.412 ± 0.225 (95%CI: 0.354–0.470)
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Correlations Between SUV and ADC Measurements
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Discussion
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