AJR 2005; 184:185-192
© American Roentgen Ray Society
Primary Lymphoma of Bone: MRI and CT Characteristics During and After Successful Treatment
Bernard Mengiardi1,
Hanspeter Honegger2,
Juerg Hodler1,
Ulrich G. Exner1,
Miklos D. Csherhati3 and
Werner Brühlmann2
1 Departments of Radiology and Orthopedic Surgery, Orthopedic University
Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland.
2 Departments of Radiology and Oncology, City Hospital Triemli,
Birmensdorferstrasse 497, CH-8063 Zurich, Switzerland.
3 Private practice, orthopedic surgery, Zurich, Switzerland.
Received January 6, 2004;
accepted after revision March 24, 2004.
Address correspondence to B. Mengiardi
(mengiardi{at}yahoo.de).
Abstract
OBJECTIVE. Our aim was to describe MRI and CT characteristics of
primary lymphoma of bone during and after successful treatment.
CONCLUSION. MRI showed a rapid decrease of tumor volume with
complete disappearance of the soft-tissue component. Minor signal
abnormalities of bone marrow without clinical relevance persisted for up to 2
years. CT showed bone remodeling within months with a persistent architecture
similar to that of Paget's disease of the bone.
Introduction
Primary lymphoma of bone constitutes approximately 5% of all extranodal
non-Hodgkin's lymphomas and 5-7% of primary bone tumors
[1,
2]. Initially, the term
"reticulum cell sarcoma" was used for this type of neoplasm
[3,
4]. According to the currently
used classification, almost all primary lymphomas of bone are B cell
non-Hodgkin's lymphoma with a diffuse mixed cell or diffuse large cell
histology [5]. Primary lymphoma
of bone responds well to combined chemotherapy and adjuvant local radiation
therapy or, alternatively, to chemotherapy alone
[6]. The reported 5-year
survival rate after combined therapy is better than 90%
[7].
MRI is a standard imaging procedure in the management of malignant bone
tumors, including primary lymphoma of bone. It shows the extent of bone marrow
and soft-tissue invasion but is inferior to radiography in predicting the
histology of bone tumors at initial assessment
[8]. The differentiation of
residual tumor and treatment-associated changes, including tumor necrosis and
granulation tissue, may be challenging on MR images of bone tumors after
treatment [9,
10]. There are few reports
about MRI characteristics of primary bone lymphoma after treatment
[11-13].
In some patients, prolonged persistence of signal abnormalities
[13], no significant size
reduction of bone marrow abnormalities
[12], or even progression of
the MRI findings despite clinically complete remission
[11] was described.
CT of the chest and abdomen is often performed to monitor patients with
lymphoma [6], and the involved
bone is commonly visible on these scans. As for MRI, treatment effects may not
be differentiated easily from residual tumor. Precise knowledge of the MRI and
CT morphology and of the time course of changes of successfully treated
primary lymphoma of bone helps to differentiate residual tumor and recurrence
from nonspecific abnormalities. The purpose of this study was to describe MRI
and CT characteristics of primary lymphoma during and after treatment
resulting in complete remission.
Materials and Methods
Patients
Relevant treatment and imaging data are summarized in
Table 1.
This study is based on a review of 25 consecutive cases of primary lymphoma
of bone treated in the oncology and orthopedic surgery departments of the
involved hospitals between 1986 and 2003. In seven patients (three females and
four males; age range, 17-57 years), MR images obtained before, during, and
after treatment were available for review. Before and after therapy, five of
these seven patients also underwent CT, which included scanning the area of
primary lymphoma of bone. One patient underwent CT only before treatment, and
in one patient, no CT scans were available.
All patients had histologic confirmation of intraosseous B cell (large cell
type) non-Hodgkin's lymphoma based on surgical biopsy. One patient had
multifocal primary lymphoma of bone with tumor manifestations in the third
rib, the third thoracic vertebra, and the sacrum. In this patient, only the
main tumor mass was analyzed (third rib and third vertebra).
One patient had a distant recurrence after 14 months. The primary site was
the iliac bone and sacrum; the recurrence was located in the proximal
metaphysis of the femur. This patient underwent additional chemotherapy,
immunotherapy, blood stem cell transplantation, and adjuvant local radiation
therapy of the femur. In two patients, an open biopsy was performed after
treatment because of persistent signal abnormalities (patient 4, 4 months
after the start of therapy) or because new signal abnormalities appeared in
the field of radiation therapy (patient 2, 16 months after start of therapy).
At the time of data review, all patients were clinically in complete remission
(follow-up range, 12-96 months; mean, 37 months).
MRI
MRI was performed in four institutions using magnets with field strengths
between 0.5 and 1.5 T. A combination of T1-weighted and T2-weighted spin-echo
or fast spin-echo images in both the axial and perpendicular (sagittal or
coronal) imaging planes was obtained. In addition, either T2-weighted or
proton density-weighted images with fat suppression or STIR sequences in at
least one imaging plane were available. In all patients, contrast-enhanced
T1-weighted fat-suppressed images were obtained in at least one plane. In one
patient, the pretreatment examination was incomplete. Only axial T1-weighted
images obtained before and sagittal T1-weighted fat-suppressed images obtained
after gadopentetate administration were available for review.
CT
Examinations were performed in three institutions with either a helical CT
scanner (2- to 5-mm collimation) or a 4-MDCT scanner (4 x 2.5 mm
collimation; reconstructed slice thickness, 3.2 or 5 mm). In all patients,
axial images with soft-tissue and bone window settings were available as hard
copies. Whereas in four patients the CT scans were contrast-enhanced, in two
patients the CT scans were unenhanced. In a single patient, coronal
reformations were available for review.
Image Evaluation
MR and CT images were analyzed by two musculoskeletal radiologists (a staff
radiologist with 15 years' experience in musculoskeletal radiology and a
fellow in musculoskeletal radiology). The evaluation was performed in
consensus, and the reviewers were aware of the clinical data.
MRI.—The following parameters were evaluated: tumor volume,
extent of soft-tissue component, signal intensities, and contrast enhancement.
Height, width, and depth of the total tumor mass (including the soft-tissue
mass) were measured, and the tumor volume was calculated according to the
following formula:
After the beginning of treatment, tumor volumes were expressed in
percentages of the tumor size before treatment. The maximal diameter of the
soft-tissue component was measured on transverse images. All measurements were
performed on hard copies to the nearest millimeter. The results were corrected
to real size according to the reference ruler printed on the hard copies.
All lesions were assessed for homogeneity or heterogeneity of T1- and
T2-weighted signals. Signal intensities were graded as hypo-, iso-, or
hyperintense relative to skeletal muscle on both sequence types. The pattern
of contrast enhancement was graded as homogeneous or heterogeneous. Tumor
necrosis was defined as hyperintense signal on T2-weighted images without
contrast enhancement. The amount of necrosis was graded as follows: no
necrosis, up to 10%, 10-25%, 25-50%, and more than 50%.
CT.—In the initial examination before treatment, the
patterns of bone destruction (osteolytic, mixed, or sclerotic) and types of
osteolysis (geographic with or without cortical destruction, moth-eaten, or
permeative) were analyzed. On follow-up CT scans, we evaluated the following
changes of bone morphology: correct anatomic shape, volume of affected bone
(decreased, normal, or increased), and presence of new bone formation. If any
new bone formation was present, the structure was judged as unstructured (no
differentiation of cortex and trabecular bone), structured (cortex and
trabecular bone present) with coarse appearance, or normal. In addition, the
extraosseous soft-tissue extension was graded as follows: no soft-tissue
component visible, visible and ill-defined, and visible and well-defined. The
findings were compared with those seen on MRI.
Results
MRI
The time course of tumor volume after treatment is shown in
Figure 1. There was a rapid
reduction of tumor volume as a result of chemotherapy. In five (patients 2-6)
of the seven patients, short-term follow-up of MR images obtained during and
shortly after chemotherapy was available. Findings in four (patients 2-4 and
6) of these five patients revealed a tumor volume reduction of at least 71%
(range, 71-96%; mean, 81%) after chemotherapy. In one patient (patient 4), an
open biopsy of the persistent signal abnormalities was performed after
chemotherapy. The pathologic examination revealed necrosis without any tumor
cells.
View larger version (20K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1. —Time course of tumor volume after treatment. Graph shows
tumor volumes for each patient after beginning of treatment expressed in
percentage of original tumor size before treatment. Duration of chemotherapy
and radiation therapy is indicated with dotted lines (exact duration,
Table 1). RaTh = local
radiation therapy.
|
|
The main reduction was observed during the first 3 months of chemotherapy.
In one patient (patient 5), the tumor volume reduction was less pronounced
(39% after 5 months and 50% after 10 months). The MRI appearance was similar
to bone infarction with linear peripheral hypointense rim on T1-weighted
images and with adjacent high signal on T2-weighted images (Figs.
2A,
2B,
2C, and
2D). In three patients with the
longest follow-up (range, 18-25 months), the measured residual volume of bone
marrow signal abnormalities accounted for 1.4% (range, 1-2.2%) of the original
tumor volume. In one of these three patients (patient 2), an open biopsy was
performed 16 months after start of treatment because new signal abnormalities
appeared in the field of radiation therapy immediately adjacent to the primary
tumor site. The pathologic examinations revealed necrosis and scar tissue
without any tumor cells (Figs.
3A,
3B,
3C, and
3D).
View larger version (134K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —20-year-old woman with primary lymphoma of bone in proximal
metaepiphysis of tibia and development of infarctionlike pattern after therapy
(patient 5). Anteroposterior radiograph obtained before treatment shows
predominantly permeative osteolysis. Despite slight fuzziness
(arrowheads), cortical layer is intact.
|
|
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —20-year-old woman with primary lymphoma of bone in proximal
metaepiphysis of tibia and development of infarctionlike pattern after therapy
(patient 5). Coronal T1-weighted image (TR/TE, 640/13) obtained at same time
as A reveals hypointense homogeneous tumor mass (white
arrowheads) with focal destruction of medial cortical bone and small
soft-tissue component (black arrowheads).
|
|
View larger version (127K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —20-year-old woman with primary lymphoma of bone in proximal
metaepiphysis of tibia and development of infarctionlike pattern after therapy
(patient 5). Coronal T1-weighted (520/11) (C) and coronal proton
density-weighed fat-saturated (4,870/42) (D) images obtained 10 months
after start of therapy show pattern similar to that found in bone infarction
with linear peripheral hypointense rim (arrows, C) on
T1-weighted images and partial hyperintensity (arrows, D) on
proton density-weighted image.
|
|
View larger version (124K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D. —20-year-old woman with primary lymphoma of bone in proximal
metaepiphysis of tibia and development of infarctionlike pattern after therapy
(patient 5). Coronal T1-weighted (520/11) (C) and coronal proton
density-weighed fat-saturated (4,870/42) (D) images obtained 10 months
after start of therapy show pattern similar to that found in bone infarction
with linear peripheral hypointense rim (arrows, C) on
T1-weighted images and partial hyperintensity (arrows, D) on
proton density-weighted image.
|
|
View larger version (178K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A. —24-year-old man with primary lymphoma of bone of distal
metaepiphysis of femur and histologically proven, probably radiation-induced,
necrosis adjacent to primary tumor site (patient 2). Coronal T1-weighted
(TR/TE, 755/20) (A) and axial fat-saturated T2-weighted (4,500/96)
(B) images reveal primary lymphoma of bone (arrowheads) 2
months before start of chemotherapy.
|
|
View larger version (140K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B. —24-year-old man with primary lymphoma of bone of distal
metaepiphysis of femur and histologically proven, probably radiation-induced,
necrosis adjacent to primary tumor site (patient 2). Coronal T1-weighted
(TR/TE, 755/20) (A) and axial fat-saturated T2-weighted (4,500/96)
(B) images reveal primary lymphoma of bone (arrowheads) 2
months before start of chemotherapy.
|
|
View larger version (169K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C. —24-year-old man with primary lymphoma of bone of distal
metaepiphysis of femur and histologically proven, probably radiation-induced,
necrosis adjacent to primary tumor site (patient 2). Coronal proton
density-weighted fat-saturated image (3,900/40) obtained 5 months after start
of therapy shows only small residual signal abnormalities
(arrowheads).
|
|
View larger version (140K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3D. —24-year-old man with primary lymphoma of bone of distal
metaepiphysis of femur and histologically proven, probably radiation-induced,
necrosis adjacent to primary tumor site (patient 2). Coronal proton
density-weighted fat-saturated image (3,950/45) obtained 16 months after start
of radiation therapy shows new signal abnormalities in field of therapy
adjacent to primary tumor site (straight arrows). Susceptibility
artifacts (curved arrow) are due to surgical biopsy. Pathologic
examination after biopsy revealed necrosis and scar tissue without any tumor
cells.
|
|
In all seven patients, a soft-tissue component was detected on
presentation. Three patients (patients 2, 4, and 5) had a soft-tissue
component of less than 1 cm (maximal diameter, 0.4-0.6 cm). In four patients
(patients 1, 3, 6, and 7), a larger soft-tissue component was found (maximal
diameters, 2.3-9.7 cm). In four (patients 2-5) of the five patients (patients
2-6) with short-term follow-up during and shortly after chemotherapy, the
soft-tissue component completely disappeared within 3 months (Figs.
4A and
4B). In one patient (patient
6) with an initially large soft-tissue component, a minor portion was still
visible after 2 months but disappeared after 8 months. In one patient (patient
1), only one follow-up examination was performed after 25 months. At this
time, the soft-tissue component had completely disappeared. The one patient
(patient 7) with persistence of a soft-tissue component after termination of
chemotherapy (15 months after the start of therapy) later presented with
distant recurrence of primary lymphoma of bone, which was successfully
treated.
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A. —57-year-old woman with primary lymphoma of bone of proximal
femur with large soft-tissue component and fast dissolution during therapy
(patient 3). Transverse T1-weighted fat-saturated images (TR/TE, 600/15) on
level of lesser trochanter (arrow) obtained after gadopentetate
administration show large circumferential soft-tissue component
(arrowheads, A) before treatment with complete infiltration of
bone marrow and complete disappearance of soft-tissue mass (B) after
only 2 months of chemotherapy.
|
|
View larger version (127K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B. —57-year-old woman with primary lymphoma of bone of proximal
femur with large soft-tissue component and fast dissolution during therapy
(patient 3). Transverse T1-weighted fat-saturated images (TR/TE, 600/15) on
level of lesser trochanter (arrow) obtained after gadopentetate
administration show large circumferential soft-tissue component
(arrowheads, A) before treatment with complete infiltration of
bone marrow and complete disappearance of soft-tissue mass (B) after
only 2 months of chemotherapy.
|
|
Signal intensities of primary lymphoma of bone were rather similar at
initial presentation and remained unchanged at follow-up: On T1-weighted
images, the lesion was isointense in all patients compared with surrounding
muscle. It was slightly heterogeneous in five patients and homogenous in two
(patients 3 and 6). On T2-weighted images, the lesion was hyperintense in five
patients. In one patient (patient 2), the T2-weigthed signal intensities were
partially iso- and partially hyperintense in comparison with surrounding
muscle. In one patient, no T2-weighted images were available before therapy.
All lesions were heterogeneous on T2-weigthed images. After contrast
administration, heterogeneous enhancement was noted in all patients. On
follow-up images, classifications of signal intensities did not change either
on unenhanced T1- and T2-weighted images or after contrast injection except in
the signal intensities that we considered to represent necrosis. Findings in
three patients (patients 2, 6, and 7) did not show necrosis either at the
initial or at the follow-up examinations. In three patients (patients 1, 4,
and 5), the amount of tumor necrosis was initially below 10%, and in one
patient (patient 3), it was 10-25%. At follow-up examinations, necrosis
disappeared in all four patients.
CT
Three primary lymphomas of bone presented as pure osteolysis, and three had
a mixed osteolytic-osteosclerotic pattern. The osteolytic component was
permeative or moth-eaten in all patients. In two patients, there was extensive
osteolytic destruction of bone (Figs.
5A,
5B,
5C,
6A,
6B, and
6C). In two (patients 2 and 4)
of the three patients with a soft-tissue component of less than 1 cm (as
measured on MR images), unenhanced CT scans were available before treatment.
In both cases, the soft-tissue component could not be depicted on CT. In all
four patients (patients 1, 3, 6, and 7) with a larger soft-tissue component
before treatment, the soft-tissue component was visible on contrast-enhanced
CT. In two cases, the borders were ill-defined.
View larger version (87K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5A. —17-year-old boy with remodeling of scapular osteolysis
(patient 1). Helical CT scan of shoulder (3-mm slice thickness with arm
positioned at patient's side) obtained 1 month before chemotherapy shows
extensive osteolysis with destruction of cortical bone
(arrowheads).
|
|
View larger version (144K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5B. —17-year-old boy with remodeling of scapular osteolysis
(patient 1). Helical CT scan of chest (5-mm slice thickness with arms
positioned above patient's head) obtained 2 months after start of chemotherapy
shows that initially present osteolysis is nearly completely filled with new
unstructured bone (arrowheads). Scapula is slightly enlarged but has
expected shape.
|
|
View larger version (157K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5C. —17-year-old boy with remodeling of scapular osteolysis
(patient 1). Helical CT scan of chest (5-mm slice thickness with arms
positioned over patient's head) obtained 6 months after start of therapy shows
architecture similar to that of Paget's disease of remodeled bone, with new
cortical layer (arrows) and coarse trabecular bone.
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6A. —52-year-old man with remodeling of extensive osteolysis of
third right rib and third vertebra (patient 6). Helical CT scan of chest (5-mm
slice thickness) obtained 1 month before start of chemotherapy reveals large
mass with extensive destruction of rib (white arrowheads), vertebral
pedicle, and transverse process (black arrowheads).
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6B. —52-year-old man with remodeling of extensive osteolysis of
third right rib and third vertebra (patient 6). MDCT scans of chest (4 x
2.5 mm collimation with 5-mm reconstructed slice thickness) were obtained 4
(B) and 14 (C) months after start of therapy. After 4 months,
mass has disappeared. New unstructured bone formation of rib (straight
arrows), vertebral pedicle (curved arrow), and transverse
process can be seen. After 14 months, bones were remodeled with slightly
enlarged volume and architecture similar to that of Paget's disease.
|
|
View larger version (137K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6C. —52-year-old man with remodeling of extensive osteolysis of
third right rib and third vertebra (patient 6). MDCT scans of chest (4 x
2.5 mm collimation with 5-mm reconstructed slice thickness) were obtained 4
(B) and 14 (C) months after start of therapy. After 4 months,
mass has disappeared. New unstructured bone formation of rib (straight
arrows), vertebral pedicle (curved arrow), and transverse
process can be seen. After 14 months, bones were remodeled with slightly
enlarged volume and architecture similar to that of Paget's disease.
|
|
Two patients (patients 1 and 7) underwent CT during chemotherapy. Findings
showed unstructured new bone formation after 2 months of chemotherapy. One of
these patients (patient 1) had extensive osteolysis of the scapula initially,
which was nearly totally filled with new bone during therapy. The scapula was
slightly enlarged after therapy but had the anatomically correct shape (Figs.
5A,
5B, and
5C). A similar pattern was
visible in patient 6 with osteolysis of the rib at first follow-up after
chemotherapy (Figs. 6A,
6B, and
6C); 4 months after the
beginning of treatment, there was unstructured new bone formation. On the next
follow-up scans of these patients, at 6 (patient 1), 11 (patient 6), and 12
months (patient 7) after the start of therapy, the morphology of the newly
formed bone changed from unstructured to structured with cortex and trabecular
bone having a coarse appearance. On the last available CT examinations (after
14-33 months), all five patients showed a structured new-bone formation with a
thickened cortex and irregular cancellous bone. In no patient was a normal
bone structure visible.
Although CT and MRI were not performed at the same time, the findings of
soft-tissue-component extension during and after treatment correlated well
with one exception: In patient 7, no soft-tissue component was visible on CT
after 14 months, whereas a soft-tissue mass with a width of 1.5 cm was present
on the basis of MR images obtained after 15 months. In patient 1, the first
MRI examination after treatment was performed only after 25 months. However, a
CT scan obtained after 2 months showed complete disappearance of the
soft-tissue component, which had an initial width of 2.3 cm.
Discussion
Primary lymphoma of bone currently is treated by chemotherapy, radiation
therapy, or a combination of chemotherapy followed by adjuvant local radiation
therapy. Reported 5-year survival rates are better than 90%
[7]. The imaging appearance of
primary lymphoma of bone before treatment is well documented
[2,
14-17].
Precise knowledge of the appearance of successfully treated primary lymphoma
of bone on different imaging techniques is important for further treatment
decisions. Although FDG PET is a well-established technique for staging and
evaluating treatment response in patients with non-Hodgkin's lymphoma
[18-22],
to our knowledge there is only one case report of monitoring primary lymphoma
of bone with FDG PET [23]. MRI
is still a standard imaging procedure in the management of primary lymphoma of
bone, but there are few studies about monitoring primary lymphoma of bone.
Stroszczynski et al. [12]
investigated the value of MRI and 67Ga scintigraphy after therapy
of bone lymphomas. They included both primary lymphoma of bone and secondary
involvement of bone by extraosseous non-Hodgkin's lymphoma and Hodgkin's
lymphoma in their investigation. The type of therapy was not further
specified. In this population, 67Ga scintigraphy had a sensitivity
of 70% and a specificity of 93% for evaluating tumor activity. Dynamic
contrast-enhanced MRI had a sensitivity of 90% and a specificity of 80%. The
standard of reference was based on clinical, radiologic (radiography, CT, and
bone scintigraphy), and histologic data. Yuki et al.
[13] described a case of
primary lymphoma of bone in complete remission, monitored with 67Ga
citrate, 99mTc hydroxymethylene diphosphonate, and 201Tl
scintigraphy and MRI [9].
Gallium-67 citrate scintigraphy reflected the change in tumor activity very
rapidly, whereas bone marrow signal abnormalities persisted on MRI after six
cycles of chemotherapy. Melamed et al.
[11] investigated multifocal
primary lymphoma of bone in five patients with MRI after treatment. Despite a
clinical report of complete remission, the authors described progression of
most of the lesions on MRI. They did not describe the MRI criteria of
progression and the type of therapy used in these patients, however.
In our patients, tumor volume decreased in a pronounced fashion during the
first 3 months after initiation of therapy and was reduced by 71-96% after 5
months (Fig. 1) with one
exception. In this case, the MRI pattern during and after chemotherapy was
similar to that of bone infarction (Figs.
2A,
2B,
2C, and
2D). After 18-25 months, only
residual bone marrow abnormalities with 1-2% of the original tumor volume were
seen. Parallel to the fast volume reduction, the soft-tissue component
disappeared within a few months after the start of chemotherapy (Figs.
4A and
4B). In one patient, we
observed incomplete disappearance of the soft-tissue component (
15
months). This patient later presented with a distant recurrence. Although this
finding is based on a single case, partial persistence of a soft-tissue
component may represent a predictor for poor therapy response. The results of
therapy seen in our patients are superior to those previously published
[11,
12]. This fact may relate to
advances in therapy or to a more aggressive approach used at the involved
oncology department. On the basis of this data, we suggest performing MRI for
monitoring at 2-3 months and 6-12 months after the start of therapy.
In our series, signal characteristics of primary lymphoma of bone before
treatment were noncharacteristic and uniform. Similar findings have been
described by other investigators
[2]. During treatment, signal
intensities and pattern of enhancement were not altered. The previously
described increase of T2-weighted signal intensity of Ewing's sarcoma during
therapy [24,
25] was not observed in our
patients with primary lymphoma of bone. Necrotic areas (as diagnosed on the
basis of MRI criteria) were rarely observed before and during therapy. In two
patients in whom histologic examination of the bone marrow abnormalities was
available during therapy, necrosis and inflammatory changes were seen
microscopically (Figs. 3A,
3B,
3C, and
3D). Such findings underline
the fact that MRI signal abnormalities may not differentiate bone marrow
abnormalities after treatment from an active neoplasm
[10].
Although CT is less commonly used than MRI in the follow-up of bone and
soft-tissue neoplasms, it is important to know the CT appearance of primary
lymphoma of bone because CT is used for thoracoabdominal staging and follow-up
examinations that may include the bones most commonly involved in primary
lymphoma of bone [6].
Israel et al. [26] reported
that CT abnormalities may persist even 1 year after treatment with a tendency
to show a decrease of initially predominant osteolysis accompanied by an
increase of sclerosis. Based on our data, even large osteolytic lesions with
aggressive appearance quickly (within 2 months) show some remodeling of bone.
In the ensuing months, this primitive type of bone slowly differentiates into
cortical and trabecular bone with persistence of a coarse pattern for the
observed period of time ( 3 years). This appearance has some resemblance
to the bone abnormalities seen in Paget's disease (Figs.
5A,
5B,
5C,
6A,
6B, and
6C).
In conclusion, in successfully treated primary lymphoma of bone, MRI shows
a rapid decrease of tumor volume with complete disappearance of the
soft-tissue component. Minor signal abnormalities of bone marrow without
clinical relevance may persist for up to 2 years. CT showed bone remodeling
within months, with a persistent appearance similar to that of Paget's disease
of the involved region.
References
- Freeman C, Berg JW, Cutler SJ. Occurrence and prognosis of
extranodal lymphomas. Cancer1972; 29:252
-260[Medline]
- Mulligan ME, McRae GA, Murphey MD. Imaging features of primary
lymphoma of bone. AJR1999; 173:1691
-1697[Abstract]
- Oberling C. Les reticulosarcomes et les reticuloendotheliosarcomes
de la moelle osseuse (sarcoma d'Ewing). Bull del'Assoc Franc p
l'Etude du Cancer 1928;17:259
-296
- Parker F, Jackson H. Primary reticulum cell sarcoma of bone.
Surg Gynecol Obstet1939; 68:45
-53
- Clayton F, Butler JJ, Ayala AG, Ro JY, Zornoza J. Non-Hodgkin's
lymphoma in bone: pathologic and radiologic features with clinical correlates.
Cancer 1987;60:2494
-2501[Medline]
- Baar J, Burkes RL, Bell R, Blackstein ME, Fernandes B, Langer F.
Primary non-Hodgkin's lymphoma of bone: a clinicopathologic study.
Cancer 1994;73:1194
-1199[Medline]
- Stein ME, Kuten A, Gez E, et al. Primary lymphoma of bone: a
retrospective study—experience at the Northern Israel Oncology Center
(1979-2000). Oncology2003; 64:322
-327[Medline]
- Sundaram M, McGuire MH. Computed tomography or magnetic resonance
for evaluating the solitary tumor or tumor-like lesion of bone?
Skeletal Radiol1988; 17:393
-401[Medline]
- Panicek DM, Schwartz LH, Heelan RT, Caravelli JF. Non-neoplastic
causes of high signal intensity at T2-weighted MR imaging after treatment for
musculoskeletal neoplasm. Skeletal Radiol1995; 24:185
-190[Medline]
- Vanel D, Lacombe MJ, Couanet D, Kalifa C, Spielmann M, Genin J.
Musculoskeletal tumors: follow-up with MR imaging after treatment with surgery
and radiation therapy. Radiology1987; 164:243
-245[Abstract/Free Full Text]
- Melamed JW, Martinez S, Hoffman CJ. Imaging of primary multifocal
osseous lymphoma. Skeletal Radiol1997; 26:35
-41[Medline]
- Stroszczynski C, Oellinger J, Hosten N, et al. Staging and
monitoring of malignant lymphoma of the bone: comparison of 67Ga
scintigraphy and MRI. J Nucl Med1999; 40:387
-393[Abstract/Free Full Text]
- Yuki M, Narabayashi I, Yamamoto K, et al. Multifocal primary
lymphoma of bone: scintigraphy and MR findings before and after treatment.
Radiat Med2000; 18:305
-310[Medline]
- Mulligan ME, Kransdorf MJ. Sequestra in primary lymphoma of bone:
prevalence and radiologic features. AJR1993; 160:1245
-1248[Abstract/Free Full Text]
- Edeiken-Monroe B, Edeiken J, Kim EE. Radiologic concepts of
lymphoma of bone. Radiol Clin North Am1990; 28:841
-864[Medline]
- Hicks DG, Gokan T, O'Keefe RJ, et al. Primary lymphoma of bone:
correlation of magnetic resonance imaging features with cytokine production by
tumor cells. Cancer1995; 75:973
-980[Medline]
- Stiglbauer R, Augustin I, Kramer J, Schurawitzki H, Imhof H,
Radaszkiewicz T. MRI in the diagnosis of primary lymphoma of bone: correlation
with histopathology. J Comput Assist Tomogr1992; 16:248
-253[Medline]
- Okada J, Yoshikawa K, Imazeki K, et al. The use of FDG-PET in the
detection and management of malignant lymphoma: correlation of uptake with
prognosis. J Nucl Med1991; 32:686
-691[Abstract/Free Full Text]
- Newman JS, Francis IR, Kaminski MS, Wahl RL. Imaging of lymphoma
with PET with 2-[F-18]fluoro-2-deoxy-D-glucose: correlation with
CT. Radiology1994; 190:111
-116[Abstract/Free Full Text]
- Moog F, Bangerter M, Diederichs CG, et al. Lymphoma: role of
whole-body 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) PET in nodal
staging. Radiology1997; 203:795
-800[Abstract/Free Full Text]
- Romer W, Hanauske AR, Ziegler S, et al. Positron emission
tomography in non-Hodgkin's lymphoma: assessment of chemotherapy with
fluorodeoxyglucose. Blood1998; 91:4464
-4471[Abstract/Free Full Text]
- Jerusalem G, Beguin Y, Fassotte MF, et al. Whole-body positron
emission tomography using 18F-fluorodeoxyglucose for posttreatment evaluation
in Hodgkin's disease and non-Hodgkin's lymphoma has higher diagnostic and
prognostic value than classical computed tomography scan imaging.
Blood 1999;94:429
-433[Abstract/Free Full Text]
- Matthies A, Schuster SJ, Alavi A. Staging and monitoring response
to treatment in primary non-Hodgkin's lymphoma of bone marrow using
(18)F-fluorodeoxyglucose positron emission tomography. Clin
Lymphoma 2001;1:303
-306, discussion 307[Medline]
- MacVicar AD, Olliff JF, Pringle J, Pinkerton CR, Husband JE. Ewing
sarcoma: MR imaging of chemotherapy-induced changes with histologic
correlation. Radiology1992; 184:859
-864[Abstract/Free Full Text]
- Lemmi MA, Fletcher BD, Marina NM, et al. Use of MR imaging to
assess results of chemotherapy for Ewing sarcoma. AJR1990; 155:343
-346[Abstract/Free Full Text]
- Israel O, Mekel M, Bar-Shalom R, et al. Bone lymphoma:
67Ga scintigraphy and CT for prediction of outcome after treatment.
J Nucl Med2002; 43:1295
-1303[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
