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FDG PET/CT Manifestations of Hematopoietic Malignancies of the Breast

Posted Jul 31, 2010 Updated Apr 7, 2023
By Daniel T. Ginat MD MS , Savita Puri MD
9 min read

Hematopoietic malignancies that can be encountered in the breast include lymphoma, leukemia, and multiple myeloma/plasmacytoma. These are readily imaged via [18]F-fluorodeoxyglucose position emission tomography (PET)/computed tomography (CT) and can manifest as unilateral, bilateral, single, multiple, round/oval masses, or diffuse. These malignancies can occasionally mimic primary breast cancers. Conversely, benign conditions, such as the lactating breast can resemble hematopoietic malignancies of the breast. Although uncommon, familiarity with hematopoietic malignancies of the breast is important for proper interpretation of PET/CT. In this pictorial review, the PET/CT imaging features of patients with hematopoietic malignancies of the breast will be described, including pathology-proven cases of acute myelogenous leukemia, diffuse B-cell lymphoma, follicular lymphoma, acute myeloid leukemia with neutropenic granulocytic) sarcoma, and plasmacytoma. In addition, potential pitfalls will be discussed.

Hematopoietic neoplasms of the breast are rare lesions that are much less common than breast carcinoma. Hematopoietic malignancies of the breast include non-Hodgkin’s extranodal lymphoma, extramedullary leukemia, mainly acute myeloid leukemia with associated myeloid (granulocytic) sarcoma, and multiple myeloma/plasmacytoma, among other even less common neoplasms. These lesions may be primary, occurring only in the breast, versus more commonly secondary lesions. [18]F-fluorodeoxyglucose (FDG-18) position emission tomography (PET)/computed tomography (CT) has an important role in imaging hematopoietic malignancies . Overall, the sensitivity and specificity for initial staging of lymphoma is 87% and 100%, respectively . Similarly, PET/CT is a suitable modality evaluating the extent of multiple myeloma involvement, with a reported sensitivity of 85% and specificity of 92% . Furthermore, PET/CT is useful for differentiating post-treatment changes from residual tumor or recurrence . Although PET/CT is not indicated for assessment of leukemia, it can be helpful for cases of granulocytic sarcoma . In addition, PET/CT can effectively assess the extent of disease and help differentiate primary from secondary hematological breast malignancies. This modality is particularly helpful in patients with dense breast tissue. PET/CT is also an appropriate modality for evaluating breast lymphoma/leukemia treatment response . In addition, PET/CT can provide reliable prognostic information that is superior to other nuclear medicine studies and CT alone . The imaging features of a variety of hematopoietic malignancies of the breast are described and illustrated. In addition, potential pitfalls of imaging these neoplasms and their mimics on PET/CT are reviewed.

Lymphoma

Overall, extranodal lymphomas constitute up to 40% of all lymphomas . However, involvement of the breast is unusual. Indeed, primary breast lymphomas comprise 0.04%–1.1% of all breast tumors and of 1.7%–2.2% of all extranodal non-Hodgkin’s lymphomas . The peak incidence of breast lymphoma is in the sixth and seventh decades . Most are intermediate or high grade . Large B-cell lymphoma is the most common subtype of non-Hodgkin’s to occur in the breast, comprising 40%–70% of breast lymphomas . Most primary breast lymphomas present as solitary masses and, less commonly, as diffuse breast enlargement . These tumors can be associated with skin changes, such as hypermetabolic skin thickening that can resemble inflammatory breast carcinomas ( Fig 1 ). The presence of axillary lymph node enlargement, hilar adenopathy, or adenopathy elsewhere may be a prominent feature of secondary breast lymphomas.

Figure 1, A 60-year-old female with 2 months of fevers, night sweats, lower extremity edema, and skin lesions. On positron emission tomography (PET)/computed tomography, there is a hypermetabolic (standard uptake value up to 15) left breast mass () and mildly hypermetabolic skin thickening greatest at the lateral aspect of the left breast (arrow), measuring up to 3.5 cm in depth (a) . There is also axillary ( arrow ) and right hilar lymphadenopathy (b) . The PET maximum intensity projection (MIP) image reveals widespread lymphadenopathy (c) . Needle biopsy of a right inguinal lymph node yielded B-cell lymphoma.

Follicular lymphoma is the second most common histological subtype of extranodal breast lymphoma . On PET, these neoplasms may manifest as ill-defined foci of hypermetabolism with infiltrative changes on the corresponding CT ( Fig 2 ). In general, non-Hodgkin’s lymphomas measure less than 3 cm in diameter and lack calcifications, which can help discern these from breast carcinomas, although no imaging features are pathognomonic. Uptake is typically homogeneous and strong, with a reported average standard uptake value of 10.6 . Alternatively, a “ring-shaped” pattern of hypermetabolism is sometimes encountered, particularly in rapidly growing or large tumors . Central necrosis or hemorrhage is likely responsible for this appearance. In contrast to primary breast lymphomas, up to 36% of secondary neoplasms are multiple and well-defined . Burkitt’s lymphoma of the breast is a distinctly rare condition, but may be related to pregnancy . This entity characteristically involves the bilateral breasts diffusely and tends to occur in younger women . Similar to other types of breast lymphomas, avid FDG uptake is apparent on PET ( Fig 3 ). These tumors may also be inconspicuous on ultrasound and mammography . Hodgkin’s lymphoma in the breast is even more unusual and its features on PET/CT are not well-characterized. Mucosa-associated lymphoid tissue lymphoma is a low-grade malignancy that has a reported incidence ranging from 0% to 64.3% among various series . These lesions may be bilateral as well .

Figure 2, A 59-year-old female with an abnormality on screening mammogram. Positron emission tomography (a) and computed tomography (CT) (b) demonstrate an ill-defined low-grade hypermetabolism corresponding to infiltrative changes on CT ( arrows ). Biopsy of the lesion revealed follicular lymphoma, World Health Organization histological grade 1.

Figure 3, 29-year-old female with stage 4 Burkitt's lymphoma. The axial CT demonstrates massive enlargement of the bilateral breasts by soft tissue masses (a) . Despite initial response to R-Hyper-CVAD, the disease progressed, as evidence by the PET-CT fusion image, which demonstrates hypermetabolic, well-defined, rounded masses in the bilateral breasts (b) . Courtesy of Dr. Qazi at Mallinckrodt Institute of Radiology.

Leukemia

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Figure 4, A 63-year-old female with residual/recurrent acute myeloid leukemia, manifesting as myeloid sarcoma. A MIP from the positron emission tomography (PET)/computed tomography (CT) shows ill-defined low-grade hypermetabolic lesions in the bilateral breasts ( encircled ) (a) . A MIP from the PET/CT performed at 6 months' follow-up demonstrates interval increase in size and activity of the left breast nodules ( arrows ) and resolution of the right breast lesions (b) .

Figure 5, A 62-year-old female with extramedullary acute myeloid leukemia manifesting as hypermetabolic foci involving the right parotid (standard uptake value [SUV] 9.7) ( open arrow ), an axillary lymph node (SUV 5.2), bilateral breasts (SUV up to 5.6) ( arrowheads ), soft tissue in the paravertebral region ( arrow ), and muscles ( encircled ) on the coronal positron emission tomography/computed tomography (a) fusion and MIP (b) images.

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Multiple myeloma/plasmacytoma

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Figure 6, A 61-year-old female with a history of multiple myeloma. There is a mildly hypermetabolic 1.6 cm right inferior breast mass ( arrow ).

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Potential pitfalls and mimics

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Figure 7, A 37-year-old female with a history of breast cancer status post left mastectomy. The patient was lactating at the time of the positron emission tomography/computed tomography, which showed diffuse increase in uptake by the right breast ( arrow ) consistent with a lactating breast: (a) coronal fusion, (b) MIP.

Figure 8, A 42-year-old male with a history of non-Hodgkin's lymphoma status post chemoradiation therapy. Positron emission tomography/computed tomography demonstrates a hypermetabolic (standard uptake value 2.9) subareolar focus in the right breast that proved to be fibroadenomatous change ( arrow ).

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Figure 9, A 53-year-old female an invasive ductal carcinoma with high nuclear grade in the right breast. An axial positron emission tomography (PET)/computed tomography fusion image demonstrates intense activity in a right breast mass () (a) . The PET MIP reveals additional small hypermetabolic right axillary lymph nodes (b) . The patient is status post left mastectomy.

Figure 10, A 58-year-old female with right breast inflammatory cancer. The sagittal positron emission tomography (PET)/computed tomography (CT) fusion image (a) demonstrates the mass and overlying skin thickening ( arrows ). Hypermetabolic (standard uptake value) axillary lymphadenopathy ( asterisk ) is also apparent on the axial PET/CT image (b) .

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Conclusion

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Academic Radiology, Volume 17, Issue 8
Journals General Radiology
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