dr cynthia (jurnal) clinical utility of petct in lymphoma

8/16/2019 Dr Cynthia (Jurnal) Clinical Utility of PETCT in Lymphoma

1/15

AJR:19 4, January 2010 W91

ing role. Optimal management of lymphoma

requires that the interpreting radiologist be

familiar with the role of PET/CT in base-

line staging and assessment of therapeutic

response, be aware of the imaging pitfalls

that may be encountered, and understand the

natural behavior of lymphoma and the thera-

peutic options available. The most effective

use of PET/CT therefore requires multidis-

ciplinary collaboration between radiologist,

clinical oncologist, and radiation oncologist.

Overview of Classification of

Lymphoproliferative Disorders

The lymphoproliferative disorders en-

compass a collection of lymphoid neoplasms

with different clinical and histologic presen-

tations. These malignant diseases are linked

by origin within the lymphoid system and

its various cellular components. Hodgkin’s

lymphoma is separated from other lympho-

mas by the light microscopic identificationof Reed-Sternberg cells within the tumor tis-

sue. Non-Hodgkin’s lymphoma accounts for

approximately 2.6% of all cancer deaths, and

the incidence is increasing annually, largely

because of the increasing size of the elder-

ly population, greater accuracy in diagnosis,

the HIV epidemic, and unknown environ-

mental factors. Interestingly, this increasing

incidence has not been reported for Hodg-

kin’s lymphoma, which has a steady annual

Clinical Utility of PET/CTin Lymphoma

Carmel G. Cronin1

Ronan Swords2

Mylene T. Truong3

Chitra Viswanathan3

Eric Rohren3

Francis J. Giles2

Michael O’Dwyer4

John F. Bruzzi1

Cronin CG, Swords R, Truong MT, et al.

1Department of Radiology, University College Hospital

Galway, Galway University Hospitals, Newcastle Rd.,

Galway, Ireland. Address correspondence to C. G. Cronin.

2Division of Hematology and Medical Oncology, Cancer

Therapy and Research Center, Institute for Drug

Development, University of Texas Health Science Center,

San Antonio, TX.

3Department of Diagnostic Imaging, M. D. Anderson

Cancer Center, Houston, TX

4Department of Hematology, University College Hospital

Galway, Galway University Hospitals, Galway, Ireland.

Nuclear Medic ine and Molecular Imaging • Review

WEB

This is a Web exclusive article.

AJR 2010; 194:W91–W103

0361–803X/10/1941–W91

© American Roentgen Ray Society

The lymphoproliferative disorders,

broadly divided into Hodgkin’s

and non-Hodgkin’s lymphoma,

as a group account for one of the

most common malignant diseases in the gen-

eral population. The estimated incidence of

lymphoma in the United States for 2008 was

74,340 cases (66,120 new cases of non-Hodg-

kin’s and 8,220 cases of Hodgkin’s lympho-

ma) and 20,150 deaths [1]. Although the an-

nual incidence of non-Hodgkin’s lymphoma

appears to be slowly increasing, the 5-year

survival rate has been steadily improving in

conjunction with constant refinements in

clinical management aimed at achieving the

highest remission rates with the lowest risk of

therapy-related complications.

Imaging traditionally has played an inte-

gral role in the initial staging and surveil-

lance of lymphoma, primarily through the

use of CT for detection of sites of disease

and monitoring of morphologic changes af-ter treatment. The relatively recent integra-

tion of PET/CT into routine oncologic im-

aging has further improved baseline staging

and facilitated functional evaluation of dis-

ease behavior, metabolic response to therapy,

and earlier detection of disease recurrence.

Consensus guidelines [2, 3] have been pub-

lished that set out updated response criteria

for evaluation of tumor response to thera-

py, and PET/CT is assigned a central imag-

Keywords: lymphoma, PET/CT

DOI:10.2214/AJR.09.2637

Received February 22, 200 9; accepted after revision

July 6, 2009.

OBJECTIVE. The purpose of this review is to assist interpret ing radiologists in becoming

familiar with the role of PET/CT in baseline staging and therapeutic response assessment in

the management of lymphoma, in becoming aware of imaging pitfalls, and in understanding

the natural behavior of lymphoma and the therapeutic options.

CONCLUSION. Therapeutic strategies for the management of lymphoma are constant-

ly being refined to improve long-term survival with the lowest risk of toxicity to the patient.

PET/CT is accurate for baseline staging and yields important prognostic information for de-termining the most appropriate initial treatment. Used for evaluation of treatment response,

PET/CT can depict residual viable malignant lesions with greater accuracy than can other

imaging techniques. The findings thereby influence decisions about the need for additional

or alternative treatment.

Cronin et al.PET/CT of Lymphoma

Nuclear Medicine and Molecular ImagingReview


2/15

W92 AJR:194 , January 2010

Cronin et al.

incidence of approximately three cases per

100,000 persons.

The classification of lymphoid malignant

diseases has been beset by difficulties. Initial-

ly, the existence of several classification sys-

tems resulted in confusion and difficulty in

comparing the results of clinical trials. With

increasing knowledge of immunophenotyp-ing, cell biology, molecular genetics, and the

recognition of new lymphoma entities, a cen-

sus for universal lymphoma classification

came in 1994 in the form of the revised Eu-

ropean-American classification of lymphoid

neoplasms [4]. In the current World Health

Organization system, which was derived

from the revised European-American clas-

sification, non-Hodgkin’s lymphoma is cat-

egorized into more than 20 subtypes on the

basis of cell of origin (B- or T-cell precur-

sor) and morphologic and immunophenotyp-

ic data [5]. Diffuse large B-cell lymphoma

and follicular lymphoma account for more

than 50% of cases of non-Hodgkin’s lym-

phoma. The clinical behavior of lymphomas

informs management strategies in clinical

practice. Systems in which non-Hodgkin’s

lymphoma is grouped into indolent, aggres-

sive, and very aggressive disorders are prac-

tically very useful. Classification systems are

not static, and it is inevitable that the current

World Health Organization model will be su-

perseded by other systems as more is learned

about the biologic and genetic characteristics

of these disorders.

Diagnosis

As a rule, no specific surface markers are

diagnostic of malignancy of lymphocytes,

and diagnosis is based on an integration of

morphologic (lymph nodes, blood and bone

marrow), immunophenotyping, and molecu-

lar and cytogenetic data. Many lymphomas

have characteristic morphologic features. Ex-

cisional biopsy is preferable over core biop-

sy and fine-needle aspiration for acquisition

of information on structural detail of diagnos-

tic value. In the absence of clinically palpable

lymphadenopathy, suitable sites of biopsy can

be localized with CT or PET/CT. PET/CT hasthe advantage over CT of depicting sites of

lymphoma that are both accessible and meta-

bolically active and therefore most likely to

yield a true-positive result [6].

Several lymphoid neoplasms have unique

antigenic expression on the cell surface that

can be identified with flow cytometry. The

presence of certain antigens, such as CD5,

CD10, and CD23, is helpful in differentiating

clonal B-cell tumors, such as follicular lym-

phoma (CD10+, CD5–, CD23+), from mantle

cell lymphoma (CD10–, CD5+, CD23–). The

immunophenotyping of T-cell neoplasms is

less conclusive than that of B-cell neoplasms

because the former lack the equivalent of

light-chain restriction. Chromosomal trans-

locations in lymphoma often provide diag-

nostic and prognostic information and can

serve as useful response variables over the

course of treatment. Specific translocations,

such as t(14;18) in follicular lymphoma and

t(11;14) in mantle cell lymphoma, often are

sought for these reasons [7].

Staging Systems and Prognosis

Assessment

Staging procedures define the anatom-ic extent of disease and influence choice of

therapy. The Ann Arbor system (Table 1)

was initially devised for use in Hodgkin’s

lymphoma but was later adapted for use in

non-Hodgkin’s lymphoma. Staging is based

on the number and location of nodal stations

involved and the presence or absence of ex-

tranodal lymphoma.

Assessment of prognosis is important for

formulating management strategies. The In-

ternational Prognostic Index (Table 2) is the

most widely used prognostic index for adult

non-Hodgkin’s lymphoma. This index is

based on both clinical and imaging findings

at baseline. The following five factors are

used to predict clinical outcome: age, stage

(modified Ann Arbor), serum lactate dehy-

drogenase (LDH) level, number of extrano-

dal sites of disease, and performance status.

The International Prognostic Index score is

derived from an additive score of 0 to 5 to

stratify patients as having low, intermediate,

or high prognostic risk [8]. Variations of theInternational Prognostic Index are adjusted

for age and presence of follicular lymphoma.

In patients with Hodgkin’s lymphoma,

seven clinical parameters influence outcome

(Table 3). In patients with advanced disease,

TABLE 1: Modif ied Ann Arbor Staging System for Hodgkin’s andNon-Hodgkin’s Lymphoma

Stage Area of Involvement

I Single lymph node region

IE Single extranodal organ or site

II Two or more lymph node regions on the same side of the diaphragm

IIE Localized extranodal extension in addition to criteria for stage II

III Lymph node regions on both sides of the diaphragm

IIIE Localized extralymphatic extension in addition to criteria for stage III

IIIS Splenic involvement (S) in addition to criteria for stage III

IV Dissemination to one or more extralymphatic organs with or without associated lymph nodeinvolvement; involved organs designated by subscript letters (P, lung; H, liver; M, bonemarrow); A used to indicate asymptomatic and B, symptomatic; unexplained fever≥ 38°C;unexplained drenching night sweats; loss of > 10% body weight within previous 6 mo

TABLE 2: International Prognostic Index

Prognosis 0 Points 1 Point Point Total

Parameter

Age < 60 y ≥ 60 y

Modified Ann Arbor stage I, II III, IV

Serum lactate dehydrogenase level Normal Elevated

Extranodal involvement 0–1 site > 1 site

Performance status 0–1 2–4

Risk category

Low 0–1

Low–intermediate 2

Intermediate–high 3

High 4–5


3/15


PET/CT of Lymphoma

scores of 0–2 are predictive of a 75% chance

of having no progression of disease 5 years af-

ter diagnosis compared with 55% for scores of

3 or higher [9]. Treatment decisions are based

on several parameters, of which the histologic

features of the tumor, baseline prognostic in-

dicators [9], and stage of disease are of criti-

cal importance.

PET/CT in Initial Staging:

Indications and Utility

CT is the most readily available and most

commonly used tool for staging lymphoma.Fundamental l imitations of CT, however, are

that recognition of lymph node involvement

in disease is based solely on size and that de-

tection of bone marrow and extranodal tissue

involvement may be limited. In addition to de-

picting nodal sites of lymphoma with greater

accuracy than CT, PET/CT has greater sensi-

tivity for sites of extranodal involvement and

correspondingly has been found to improve

baseline staging compared with conventional

staging with CT alone [10, 11] (Figs. 1 and 2).

PET/CT findings also can indicate the over-

all level of metabolic activity of lymphoma,

which correlates with level of aggressivenessand with LDH level (a prognostic predictor).

In general, indolent follicular lymphoma is

associated with low-grade FDG uptake and a

low LDH level, whereas higher intensities of

FDG uptake are seen in more aggressive lym-

phoma with higher LDH levels [12].

Systematic staging of lymphoma by the

radiologist should include the following:

description of nodal stations involved; rep-

resentative unilinear measurements of en-

larged lymph nodes in the long axis; iden-

tification of sites of extranodal involvement;

and detection of coexisting abnormalities

that can affect management, such as infec-

tion in the lungs and facial sinuses and inci-

dental pathologic and malignant changes [2,

3, 9–12] (Fig. 3).

A number of imaging findings are specif-

ically associated with poor prognosis. The

number and location of nodal stations in-

volved by lymphoma adversely affect prog-

nosis and influence the immediate and subse-quent management strategies (Figs. 1, 2, and

4). The presence of bulky disease (any lymph

node mass larger than 10 cm in diameter or an

intrathoracic mass larger than one third the di-

ameter of the thorax) is a poor prognostic in-

dicator and often mandates involved-field ra-

diotherapy after combination chemotherapy.

The presence of extranodal lymphoma also is

a poor prognostic indicator (signifying stage

IV disease) and generally mandates systemic

rather than local treatment. Extranodal sites

of lymphoma include the bone marrow, liver,

lungs, pleura, and other nonlymphoid organs

(Figs. 2 and 5). It is important to differentiatelymphoma originating in an extranodal loca-

tion and thus stage III or IV (e.g., bone mar-

row, liver, or node involvement of the lungs)

from involvement of an extranodal location by

direct extension from a contiguous site of nod-

al disease. Extranodal involvement due to di-

rect extension does not directly influence nodal

stage, and disease remains stage I or II de-

pending on whether lymph nodes are involved

above or below the diaphragm, but the nodal

stage is assigned an E denominator to signify

that disease has spread from lymph nodes to

adjacent extranodal tissue. This differentiation

can be difficult and usually is determined by

the location of the epicenter of disease.

Low-Grade Lymphoma

Low-grade lymphoproliferative disorders

include both B-cell (e.g., chronic lymphocytic

leukemia, follicular lymphoma, marginal zone

lymphoma, and small lymphocytic lymphoma)

and T-cell (peripheral T-cell lymphoma) disor-ders. In general, these disorders progress slow-

ly and are considered incurable. Treatment is

directed at control of symptoms (fatigue, dis-

figuring lymphadenopathy) when they become

clinically important. These lesions typically

have low metabolic activity and have only

low-grade or no FDG uptake. The qualitative

appearance on PET images can be variable,

however, showing a large degree of overlap

Fig. 1—44-year-old man with follicular lymphoma andpalpable left axillary lymphadenopathy. After clinicalexamination and initial CT, patient was believed tohave stage II disease. Additional staging with PET/CT was performed. Coronal maximum-intensity-projection PET image shows enlarged FDG-avidlymph nodes (arrowhead ) in left axilla. Additionalfocus of abnormal FDG uptake (arrow ) is present inleft inguinal region. Because of this finding, diseaseseverity was increased to stage III (involvement oflymph nodes above and below diaphragm).

TABLE 3: Factors Adversely Influencing Outcome of Hodgkin’s Lymphoma

Factor Value

Early stage disease (I–IIIA)

Age > 50 y

Ery throcyte sedimentat ion rate > 50 mm/h

> 30 mm/h with B symptoms (fever, night sweats, weightloss > 10%)

No. of separate nodal sites involved ≥ 4

Mediastinal mass > 10 cm

Advanced stage disease (IIIB–IV)

Age > 45 years

Sex Male

Stage IV

Hemoglobin concentration < 10.5 g/dL

Albumin concentration < 40 g/L

Lymphocyte count < 0.6 × 109 /L or < 8%

WBC count > 15 × 109 /L

http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-000.jpg&w=161&h=275


4/15


Cronin et al.

with more aggressive extranodal marginal

zone lymphoma [13, 14].

Because the stage of the disease is less im-

portant than the clinical manifestations, PET/

CT is not used for routine staging. In certain

instances, however, PET/CT can be useful in

the management of low-grade lymphoma. Pa-

tients with low-grade, aggressive, or highly

aggressive lymphoma in the early stage or lo-

calized (stage I or II, comprising involvement

of a single lymph node station or two lymph

node stations on one side of the diaphragm,

respectively) without bulky disease can be

treated with curative intent with involved-

field radiotherapy with or without an abbrevi-ated course of chemotherapy [15, 16]. In the

care of such patients, PET/CT is important for

excluding unexpected sites of nodal or extra-

nodal lymphoma [17] (Figs. 1 and 4), which

would necessitate prolonged chemotherapy

(six to eight cycles). Radiotherapy would be

reserved for bulky disease. PET/CT also can

be useful for baseline assessment of patients

with refractory disease undergoing new lines

of treatment. It thereby facilitates assessment

of response to therapy (see later, Assessmentof Therapeutic Response).

In a small percentage of patients, trans-

formation of indolent lymphoma to a higher

grade of lymphoma can occur, most common-

ly in diffuse large B-cell lymphoma (known

as Richter’s transformation). Lymphomatous

transformation is associated with a very poor

prognosis and is an indication for high-dose

chemoimmunotherapy and postremission stem

cell transplantation [18]. Transformation is sus-

pected in patients with rapidly enlarging lymph

nodes, an increasing LDH level, or new onset of

B symptoms (fever, night sweats, and weight

loss greater than 10%). In the care of such pa-

tients, PET/CT has been found to be of value

in detecting transformation by depicting ab-

normally elevated FDG uptake at sites of trans-

formation (indolent lymphoma normally has

only low-grade FDG uptake) [18, 19] (Fig. 6).

Sites of suspected transformation should be

biopsied for confirmation of the diagnosis.

Aggressive and Highly Aggressive

Lymphoma

Aggressive and highly aggressive non-Hodg-

kin’s lymphomas, of which diffuse large B-cell

lymphoma is the most common, generally ex-hibit marked elevation in FDG uptake at PET/

CT. Compared with conventional staging with

CT alone, staging with PET/CT can lead to an

BA

Fig. 2—20-year-old man with recently diagnosedBurkitt’s lymphoma. Example of PET/CT patterns ofextranodal involvement by lymphoma and baselinestaging with PET/CT.A and B, Coronal (A) and axial (B) fused PET/CTimages show extent of disease involvement, intenseFDG uptake being evident within retroperitoneallymphadenopathy (arrowhead, A). Activity withinliver (short arrow, B) and peritoneum (long arrows )

indicates extranodal lymphoma, representing stageIV disease. Diffuse bone marrow involvement alsois present. Extranodal involvement of bones, liver(short arrow, B), and peritoneum (long arrows ) wasindeterminate or occult on conventional contrast-enhanced CT images, and stage IV disease was notdiagnosed prospectively.

A CB

Fig. 3—53-year-old man with stage III diffuse large B-cell lymphoma.A, Coronal maximum-intensity-projection PET image from baseline staging PET/CT scan shows FDG-avidlymphadenopathy above and below diaphragm. Focus of increased FDG uptake in left side of pelvis (arrow ) waspresumed to represent additional site of lymphoma.B and C, Axial fused PET/CT (B) and contrast-enhanced diagnostic CT (C) images show abnormal activity(arrow ) in segment of thick-walled sigmoid colon. Colonoscopy confirmed area represents incidental coloniccarcinoma, not residual lymphoma.

http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-005.jpg&w=161&h=135http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-004.jpg&w=161&h=135http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-003.jpg&w=161&h=255http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-002.jpg&w=160&h=130http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-001.jpg&w=161&h=276


5/15


PET/CT of Lymphoma

increase in stage because active lymphoma

can be depicted in subcentimeter lymph nodes;

unexpected extranodal sites of disease and vis-

ceral involvement of liver and spleen also can

be depicted [20–22] (Figs. 1, 2, and 4).

Although a baseline PET/CT examina-

tion is strongly advised in the care of all pa-

tients with aggressive or highly aggressive

non-Hodgkin’s lymphoma for refining initialstaging and prognosis assessment, it is not al-

ways strictly necessary. For example, when

the initial stage is clear from conventional

imaging findings (e.g., unequivocal stage IV

disease) or the initial treatment plan incorpo-

rates a full course of chemotherapy, baseline

PET/CT findings are unlikely to change the

management decision [2, 3].

Patients with poor baseline prognostic in-

dicators are at risk of having disease refrac-

tory to treatment or of having a relapse soon

after completing therapy. These patients may

be candidates for stem cell transplantation im-

mediately or at first relapse. In such instances,

posttherapy PET/CT findings may be difficult

to interpret without baseline PET/CT images

for comparison, particularly if residual areas

of abnormal FDG uptake are present (see later,

Assessment of Therapeutic Response) [2, 3].

Hodgkin’s Lymphoma

Although Hodgkin’s lymphoma is staged

the same way as non-Hodgkin’s lymphoma

(modified Ann-Arbor classification), it dif-

fers from non-Hodgkin’s lymphoma in its

propensity to spread by contiguous nodal in-

volvement rather than multifocal nodal in-

volvement. Nodular sclerosing Hodgkin’s

lymphoma, the most common histologic type,

usually manifests itself as lymphadenopathy

above the diaphragm; isolated infradiaphrag-

matic lymph node involvement is rare. Hodg-kin’s lymphoma is FDG avid, and PET/CT is

a more accurate initial staging examination

than conventional diagnostic CT [20], par-

ticularly for detection of unexpected sites of

extranodal lymphoma.

In clinical practice, assessment of progno-

sis determines the role of PET/CT in base-

line staging and response assessment. For

example, for patients with a good prognostic

index at baseline and eminently curable lym-

phoma (e.g., diffuse large B-cell lymphoma

or Hodgkin’s lymphoma), baseline PET/CT

is less important than posttreatment PET/

CT, which is used to confirm the success of

treatment and exclude residual viable malig-

nancy (see later, Assessment of Therapeutic

Response). In patients with a poor prognos-

tic index at baseline, it may be appropriate

to perform PET/CT early in the course of

therapy (e.g., after two to four cycles of che-

motherapy) to detect refractory disease, the

presence of which can influence subsequent

treatment decisions.

Imaging Pitfalls

Lymphoma With Variable FDG Uptake

Certain subtypes of lymphoma, such asextranodal marginal zone lymphoma [23]

and T-cell cutaneous lymphoma [24], exhib-

it variable FDG uptake (Fig. 7) and can be

difficult to detect with conventional contrast-

enhanced CT. In such cases, initial baseline

PET/CT is particularly important for facili-

tating assessment of therapeutic response. It

would be difficult to interpret the true clini-

cal meaning of residual abnormal FDG up-

take after therapy if there were no baseline

scan for comparison.

Lymphoma Difficult to Detect With PET/CT

Subtypes of lymphoma difficult or impos-sible to detect with PET/CT include prima-

ry CNS lymphoma, testicular lymphoma,

and gastric lymphoma. Because of the in-

tense physiologic uptake of FDG by normal

cerebral tissue, CNS lymphoma can be diffi-

cult to detect without appropriate adjustment

of the image intensity thresholds. In the case

of testicular lymphoma, for which patients

are normally treated with orchiectomy and

combination chemotherapy, it is impossible

to differentiate FDG uptake by the malignant

tumor from normal physiologic testicular ac-

tivity. It is important to note that on follow-up

PET/CT scans, FDG uptake in the contralat-

eral testis is normal and without further eval-

uation should not be presumed to represent

recurrent testicular lymphoma. Gastric lym-

phoma typically exhibits no FDG uptake or ex-

hibits variable FDG uptake that is difficult or

impossible to differentiate from normal activi-

ty in the gastric mucosa. These patients may be

candidates for radiation therapy only, particu-

larly in cases of gastric mucosa–associated

A

Fig. 4—63-year-old woman with follicular lymphomanewly diagnosed after biopsy of retroperitonealmass. Baseline staging with PET/CT.A, Coronal CT image shows large retroperitonealmass consistent with known site of biopsy-proven lymphoma (arrowhead ). Also present areindeterminate subcentimeter lymph nodes in axillae(long arrows ). Spleen (short arrow ) is of normal size.At CT, mass was considered stage II, represent ing

involvement of more than one lymph node station onone side of diaphragm.B, Coronal fused PET/CT image shows intense FDGuptake by retroperitoneal mass (arrowhead ) andabnormal FDG uptake in small axillary lymph nodes(long arrows ). Unexpected FDG-avid lymph node (thick short arrow ) was found in left infraclavicular region.Diffuse intermediate-grade FDG uptake in spleen (thin short arrow ) greater than that in liver is considered torepresent diffuse lymphomatous infiltration. Diseaseseverity was increased to stage IIIS.

B

http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-007.jpg&w=161&h=269http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-006.jpg&w=161&h=270


6/15


Cronin et al.

lymphoid tissue lymphoma or mucosa-related

lymphoid tissue lymphoma, if disease is lim-

ited to the stomach. In these cases the main

purpose of PET/CT is to exclude lymphoma

elsewhere [25–28].

Lymphoma With Particular Patterns

of Spread and Relapse

Certain types of aggressive lymphoma not-

ed for their patterns of spread and relapse re-

quire particular attention. CNS involvement

is relatively common with sporadic Burkitt’s

lymphoma, and interpretation of the baseline

PET/CT images should include examination

of the brain with appropriate threshold set-

tings. Lymphoblastic lymphoma and adult

T-cell lymphoma commonly manifest them-

selves as large mediastinal masses that can

be associated with pericardial involvement.These findings can be difficult to detect with

CT alone. Identification of abnormal peri-

cardial uptake of FDG at PET/CT suggests

the presence of lymphomatous involvement

in these cases [29]. A very high-fat, low-

carbohydrate, protein-permitted meal 3–6

hours before FDG injection has been found

to suppress myocardial FDG uptake and may

be beneficial in these circumstances for de-

picting mediastinal, pericardial, and cardiac

lymphomatous disease [30].

Bone Marrow InvolvementAlthough PET/CT can depict bone mar-

row involvement in patients with negative re-

sults of iliac crest biopsy [31] (Fig. 8), fre-

quent false-positive findings are caused by

diffuse or heterogeneous FDG uptake sec-

ondary to reactive marrow hyperplasia (Fig.

5). In addition, microscopic marrow involve-

A C D EB

Fig. 5—Patterns of bone marrow involvement by lymphoma.A and B, 24-year-old woman with Hodgkin’s lymphoma. Sagit tal fused PET/CT image (A) shows multiple foci of intense FDG uptake (arrows ). Sagittal T1-weighted MRimage (B) shows multifocal pattern of bone marrow involvement (arrows ). CT-guided biopsy of L3 lesion confirmed marrow involvement by Hodgkin’s lymphoma (stage IV) .C and D, 56-year-old man with mantle cell lymphoma (stage IV). Coronal (C) and sagittal (D) PET images show diffuse patchy heterogeneous pattern of FDG uptake. Bonemarrow biopsy result was positive for lymphoma.E, 64-year-old man treated for non-Hodgkin’s lymphoma. Sagittal PET image shows diffuse homogeneous pattern of FDG uptake within bone marrow of vertebralbodies caused by bone marrow hyperplasia secondary to cytokine administration. In absence of adequate clinical information, it is often impossible to differentiate thisappearance from diffuse lymphomatous infiltration of bone marrow (C and D).

A

Fig. 6—57-year-old man with long-standing smalllymphocytic lymphoma and suspected Richter’s

transformation.A, Axial fused PET/CT image from baseline PET/CT examination shows extensive intraabdominallymphadenopathy (arrowhead ) associated with

diffuse low-grade or intermediate-grade FDGuptake consistent with low-grade small lymphocyticlymphoma. More-marked FDG uptake is present inlymphadenopathy (arrow ) in left side of pelvis. Finding issuspicious for transformation to high-grade lymphoma,which was subsequently confirmed with biopsy.B, Axial fused PET/CT image obtained for restagingafter chemotherapy shows almost completeresolution of metabolic activity in transformedhigh-grade lymphoma (arrow ) in pelvis butpersistent activity in low-grade small lymphocyticlymphoma (arrowhead ), which is more resistant tochemotherapy.

B

http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-010.jpg&w=91&h=167http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-009.jpg&w=161&h=161http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-008.jpg&w=161&h=161


7/15


PET/CT of Lymphoma

ment can be below the limits of detection

with PET/CT, accounting for the relatively

low sensitivity of this technique in the detec-

tion of bone marrow lymphoma (≈ 43% for

non-Hodgkin’s lymphoma) [32]. For these

reasons, bone marrow biopsy remains the

reference standard for assessment of bone

marrow. However, focal areas of intense

FDG uptake in the bone marrow remain sus-

picious for lymphoma even when the findings

at iliac crest biopsy are negative and should

be further evaluated with targeted biopsy or

MRI (Fig. 5).

Assessment of Therapeutic Response

Imaging evaluation of therapeutic re-

sponse once was limited to monitoring of

changes in lymph node size with CT. The

residual lymph node mass was a common-

ly encountered diagnostic challenge because

it is difficult at CT to differentiate posttreat-

ment fibrosis from residual viable malig-

nant changes. PET/CT has been found use-

ful in assessment of therapeutic response

because of its improved utility in discrimi-

nating benign fibrosis (low-grade or absent

FDG uptake) and residual active lymphoma

(elevated FDG uptake). PET/CT cannot be

used, however, to exclude microscopic ma-

lignant change below its threshold of detect-

ability. In 2007, the International Harmo-

nization Project was convened to revise the

older CT-based response criteria [2, 3]. The

A B

Fig. 7—53-year-old man with progressive blasticnatural killer cell cutaneous T-cell lymphoma of upperback. Baseline staging PET/CT showed FDG-avidcutaneous nodule but no disease elsewhere (notshown). Restaging PET/CT was performed becauseof progressive enlargement of cutaneous mass.A, Axial PET/CT image shows marked FDG uptake bylarge cutaneous soft-tissue mass in upper back.B, Coronal fused PET/CT image shows diffuse FDG

uptake within enlarged spleen (arrowhead ) andpatchy uptake in bone marrow (arrows ) consistentwith stage IV lymphoma. Patient underwent systemicchemotherapy.

A

Fig. 8—31-year-old man with progressive refractory Hodgkin’s lymphoma and history of tuberculosis undergoing assessment for bone marrow transplantation.A, Axial CT image from PET/CT examination shows area of bone sclerosis (arrow ) adjacent to right sacroiliac joint.B, Axial fused PET/CT image shows no abnormal FDG uptake in area of sclerosis, but abnormal activity (arrow ) is present in left sacral ala. Subsequent biopsy of rightsacroiliac joint showed no evidence of lymphoma but showed acid-fast bacilli. Patient was treated with 2-month regimen of antituberculous therapy.C, Follow-up axial fused PET/CT image shows new area of abnormal FDG uptake (arrow ) in region of sclerosis in lower thoracic spine. Biopsy confirmed recurrentlymphoma. Appearance of bone marrow involvement by lymphoma is variable at CT, and correlation with pattern of FDG uptake and with previous imaging findings isessential to avoiding confusion.

CB



8/15


Cronin et al.

recommendations emphasize the importance

to the interpreting radiologist of having ad-

equate clinical information available and ofbeing familiar with the limitations and inter-

pretative pitfalls of PET/CT. These new ther-

apeutic response criteria are summarized in

Table 4.

Definition of Positive PET/CT Findings

After Treatment

Because of variability among patients,

scans, and observers in calculation of semi-

quantitative measurements of FDG activity,

such as maximum standardized uptake val-

ue, visual analysis is sufficient for assessment

of therapeutic response. Any lymph node

smaller than 2 cm in diameter with FDG up-

take greater than the uptake in surrounding

background tissue is considered positive for

active lymphomatous involvement [2, 3]. For

lymph node masses larger than 2 cm, any ac-

tivity greater than that in mediastinal blood

pool structures is considered positive for

active lymphoma, which allows low-grade

FDG uptake secondary to blood pool activ-

ity after treatment [2, 3].

In the liver and spleen, focal lesions with

activity greater than that in surrounding liv-

er or spleen parenchyma are considered posi-tive for viable lymphoma. Diffuse FDG up-

take by the spleen with an intensity greater

than that in the liver also is considered pos-

itive for lymphoma in the absence of other

confounding factors, such as physiologic hy-

perplasia after cytokine administration [2, 3]

(Fig. 9). The presence of single or multiple

foci of clearly elevated FDG uptake within

the bone marrow also is considered positive

for active lymphoma [2, 3] (Fig. 5). In cases

in which vertebral body involvement is sus-

pected, the CT images should be carefully

examined for signs of spinal canal encroach-

ment that warrant radiotherapy.

Utility of PET/CT for Assessment

of Treatment Response

The objective of posttreatment PET/CT

depends on the clinical situation and the tim-

ing of the examination (during or after com-

pletion of therapy). In most instances PET/

CT is performed after completion of treat-

ment, in which case the primary purpose is to

detect residual active lymphoma (i.e., to con-

firm or exclude complete remission according

to the response criteria). Persistent disease isassociated with early relapse and poor clini-

cal outcome, and further therapy may be in-

dicated [33, 34]. Studies [35, 36] have shown

the prognostic value of PET/CT during and

after chemotherapy for identifying cases in

which the patient needs further, intensified

treatment. PET/CT occasionally is performed

earlier in the course of treatment (after two to

four cycles of a six- to eight-cycle regimen),

when evidence of refractory disease may lead

to changes in treatment regimens [37] (Fig.

10). Convincing evidence shows that persis-

tent FDG uptake after two to four cycles of

chemotherapy is associated with poor clini-

cal outcome [38–41]. It has not yet been con-

clusively proven, however, that changing che-

motherapeutic regimens midway through

treatment on the basis of PET/CT findings

improves outcome [42].

Low-Grade Lymphoma

In patients with indolent or otherwise in-

curable lymphoma (e.g., chronic lymphocytic

TABLE 4: International Harmonization Project Criteria for Assessment of Response to Therapy for Lymphoma

Response FDG-Avid at Baseline Not FDG-Avid at Baseline

Complete remission Complete resolution of FDG-avid lesions and negative result of bone marrowbiopsy

Return to normal size of lymphadenopathy withcomplete resolution of ex tranodal disease

Partial remission > 50% decrease in sum or product of diameters of lesions with persistentresidual FDG uptake in at least one site

> 50% decrease in sum or product of diameters oflesions

Progressive disease Any new FDG-avid lesion; ≥ 50% increase in sum or product of diameters ofpreviously involved sites with respect to nadir sum or product of diametersassociated with abnormal FDG uptake; or new or recurrent bone marrowinvolvement

Any new lesion > 1.5 cm in any axis; ≥ 50% increase insum or product of diameters of previously involvedsites with respect to nadir sum or product ofdiameters; or new or recurrent bone marrowinvolvement

Stable disease No complete remission, partial remission, or progressive disease No complete remission, partial remission, orprogressive disease

Note—Summarized from [2].

A

Fig. 9—Patterns of splenic involvement bylymphoma.A, 66-year-old man with relapsed diffuse large B-celllymphoma. Axial fused PET/CT image shows multiplehypodense masses (arrows ) in enlarged spleen thatare FDG avid.B, 68-year-old woman with relapsed diffuse large

B-cell lymphoma. Axial PET/CT image showsdiffuse FDG uptake (arrow ) greater than that in liver.Finding is consistent with diffuse lymphomatousinvolvement.

B

http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-021.jpg&w=161&h=161http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-020.jpg&w=161&h=161


9/15


PET/CT of Lymphoma

leukemia, small lymphocytic lymphoma,

and marginal zone lymphoma), therapeutic

response generally is measured in terms of

symptom relief, progression- and event-freesurvival, and overall survival.

Aggressive and Highly Aggressive

Non-Hodgkin’s Lymphoma

In patients with potentially curable non-

Hodgkin’s lymphoma, a complete metabol-

ic response after treatment is a good indi-

cator of long-term disease-free survival. In

these patients, a complete response to treat-

ment is defined as total absence of abnormal

FDG uptake, as defined earlier. Posttherapy

PET/CT findings of complete response are

considered to indicate the disease is in com-plete remission. Further treatment may con-

sist of two cycles of consolidation chemo-

therapy or routine surveillance. In the care

of patients with PET/CT findings of residual

disease, a clinical decision is required that

may involve continuing therapy, switching

therapy, or consideration of stem cell t rans-

plantation (Fig. 11). The International Har-

monization Project consensus guidelines

recommend that restaging PET/CT ideally

be performed 6–8 weeks after completion

of treatment to minimize confounding FDG

uptake secondary to posttreatment inflam-mation. In the care of patients with poten-

tially curable lymphoma in whom refracto-

ry disease will lead to changes in treatment,

particularly patients who have poor prog-

nostic indices at baseline evaluation, it may

not be practical to wait this long. Never-

theless, PET/CT should generally be per-

formed no sooner than 3 weeks after com-

pletion of therapy [3].

A

Fig. 10—66-year-old man with stage IV diffuse largeB-cell lymphoma.A, Axial fused PET/CT image from baseline PET/CTexamination shows FDG-avid lymphadenopathy inparaaortic regions in addition to splenic involvement(arrowhead ).B, Three cycles of systemic chemotherapy resultedin marked anatomic response with almost completeinterval resolution of lymphadenopathy on CT

images. Fused PET/CT image, however, showspersistent abnormal FDG uptake within small residuallymph node in retroperitoneum (arrow ). Finding isconsistent with residual viable lymphoma, whichis associated with higher probability of refractorylymphoma and is indication for extended therapy.

B

A

Fig. 11—67-year-old man with myelodysplastic syndrome and mantle cell lymphoma who underwent reevaluation with PET/CT after chemotherapy.A, Axial unenhanced CT image from PET/CT examination shows persistent lymphadenopathy measuring more than 2 cm in diameter in retroperitoneum ( arrowhead ) andsmall-bowel mesentery (arrow ).B, Axial fused PET/CT image at same level as A shows FDG uptake in retroperitoneal lymphadenopathy (arrowhead ) is no greater than that in surrounding normal tissue,consistent with absence of detectable metabolically active lymphoma. Arrow indicates lymphadenopathy in small-bowel mesentery.C, PET image shows low-grade FDG uptake within lymphadenopathy in small-bowel mesentery (white arrow ), which is greater than that in mediastinum (black arrow ),consistent with persis tent viable lymphoma. Because of this abnormal FDG uptake, complete remission was not achieved, and second-line chemotherapy was initiated.

B C



10/15


Cronin et al.

Hodgkin’s Lymphoma

Like aggressive and highly aggressive non-Hodgkin’s lymphoma, Hodgkin’s lymphoma

is routinely FDG avid, and the primary pur-

pose of posttreatment PET/CT is to confirm

or exclude complete remission, that is, the

presence or absence of residual viable ma-

lignancy. PET has consistently been found to

have a high negative predictive value (≈ 90%)

and a somewhat lower positive predictive val-

ue (≈ 65%, lower than in diffuse large B-cell

non-Hodgkin’s lymphoma) in the detection

of viable lymphoma in residual masses af-

ter therapy [33, 34, 36, 43, 44]. The relatively

low positive predictive value is due to postra-

diotherapy inflammation, which can persistas long as 8–12 weeks, and to interobserver

variability in the assessment of posttherapy

FDG uptake. The International Harmoniza-

tion Project guidelines address these issues

for improving the predictive value of PET in

Hodgkin’s lymphoma and to ensure standard-

ization of response assessment.

For early-stage Hodgkin’s lymphoma, sin-

gle-modality radiotherapy is less commonly

used than in the past and usually is combined

with abbreviated chemotherapy (e.g., fourcycles of doxorubicin hydrochloride [Adri-

amycin, Pharmacia] bleomycin, vinblastine,

and dacarbazine). Persistent abnormal FDG

uptake signifies the presence of residual vi-

able lymphoma and is an indication for ex-

tending chemotherapy to a full course. In pa-

tients who have completed six to eight cycles

of standard therapy (with or without the ad-

dition of radiation), persistent FDG uptake

indicates the presence of refractory disease

and is associated with poor long-term sur-

vival. These patients may proceed to high-

dose chemotherapy and autologous stem cell

transplantation, but salvage radiotherapy forlocalized residual disease is still an option in

selected cases.

Pitfalls in Interpretation of

Posttreatment PET/CT Findings

The most frequent difficulties encountered

in interpretation of posttreatment PET/CT

scans include differentiating residual FDG

uptake due to lymphoma from FDG uptake

due to posttreatment inflammation, coexisting

infection, and normal physiologic metabol-ic activity [45–49] (Figs. 5, 8, and 12). Post-

treatment inflammation can persist as long as

2 weeks after completion of chemotherapy

and as long as 3 months after chemoradiation

therapy [2, 3]. Low-grade FDG uptake within

residual lymph node masses should be inter-

preted in light of information about the type

and timing of previous treatment and accord-

ing to the criteria described by the Interna-

tional Harmonization Project. Activity with-

in small lymph nodes (< 2 cm) that is equal to

or less than surrounding background activity

and activity within larger lymph node masses

that is equal to or less than mediastinal bloodpool activity are considered to represent post-

treatment inflammation and not residual vi-

able malignant tissue.

It is useful to be aware of the patient’s cur-

rent treatment, the presence or absence of

neutropenia, and history of infection. Persis-

tent neutropenia increases susceptibility to

opportunistic infections such as fungal pneu-

monia, sinusitis, and typhlitis. Fungal pneu-

A

Fig. 12—56-year-old man with stage IV Burkitt’s lymphoma, which can cause potential false-positive PET/CT findings after chemotherapy.A, Coronal maximum-intensity-projection PET image from baseline staging PET/CT examination shows marked FDG uptake within intraabdominal (mesenteric andretroperitoneal) lymphadenopathy. Patchy bone marrow uptake also is evident.B, Coronal PET image from restaging PET/CT examination after completion of systemic chemotherapy shows interval resolution of abnormal FDG uptake with oneisolated focus of residual abnormal activity in right side of retroperitoneum (arrow ) anterior to psoas muscle. Finding was suspicious for res idual viable lymphoma.C, Axial fused PET/CT image shows abnormal FDG uptake corresponding to physiologic activity within right ureter (arrow ). Appearance represents complete metabolicresponse to therapy.

CB

http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-029.jpg&w=161&h=161http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-028.jpg&w=161&h=270http://www.ajronline.org/action/showImage?doi=10.2214/AJR.09.2637&iName=master.img-027.jpg&w=161&h=270


11/15


PET/CT of Lymphoma

monia can manifest itself as ill-defined areas

of consolidation, pulmonary nodules, and

masses and can be associated with abnor-

mal FDG uptake. Differentiation from pul-

monary lymphoma based on the CT appear-

ance alone can be difficult if not interpreted

in the context of the patient’s previous dis-

ease distribution, response to treatment, andhistory of episodes of fungal pneumonia [50,

51]. Previous pneumonia of any cause also

can be associated with low- or intermediate-

grade uptake in draining lymph nodes in the

hila and mediastinum, which can persist for

several weeks after the acute infectious epi-

sode has resolved.

In patients with evidence of previous

granulomatous disease such as tuberculosis

or sarcoidosis, it is common to see low-grade

FDG uptake in hilar and mediastinal lymph

nodes and even in the axillae and abdomen

[52–55]. FDG uptake in the facial sinuses

secondary to active sinusitis or in the colon

secondary to typhlitis or neutropenic colitis

is not easily confused with lymphoma but is

important to note in the interests of imme-

diate management and further immunosup-

pressive treatment [56, 57].

It is important for the interpreting radiolo-

gist to be familiar with other, more generic

causes of FDG uptake due to normal physio-

logic uptake or benign disease [2, 3, 46–48].

Diffuse FDG uptake within the marrow-

containing bony skeleton (vertebral bodies,

proximal long bones, and sternum) may be

physiologic marrow activity secondary to re-bound hyperplasia after chemotherapy or af-

ter cytokine administration (Fig. 5). Bone

marrow biopsy may be required for problem-

solving in selected cases. Physiologic FDG

uptake also can be caused by normal muscle

activity, thymic hyperplasia, brown fat, ath-

erosclerosis, venous thrombosis, and previ-

ous medical and surgical interventions [2, 3].

These common interpretative pitfalls have

been described thoroughly [46, 52, 53, 58].

In all cases, correct PET/CT interpreta-

tion depends on having an adequate knowl-

edge of the clinical history, correlation with

findings of other imaging studies, and famil-iarity with the wide range of potential im-

aging artifacts and interpretative pitfalls that

can be encountered.

Complications of Treatment

In all patients undergoing response assess-

ment with PET/CT, attention should be paid

not only to areas of persistent FDG uptake but

also to signs of possible drug or radiothera-

py toxicity, which can be most evident on the

CT component. Evidence of such toxicity is

important for decisions regarding changes in

treatment regimen, duration of treatment, and

alternative treatments. Treatment-related com-

plications include pulmonary pneumonitis or

fibrosis, which occurs in as many as 18% of

patients receiving bleomycin (part of the Adri-amycin, bleomycin, vinblastine, and dacarba-

zine regimen for Hodgkin’s lymphoma) and

has an associated mortality of 4.2% [59]; car-

diomyopathy secondary to anthracycline (e.g.,

doxorubicin) toxicity, resulting in a 28% in-

creased risk of congestive heart failure [60]; ra-

diation pneumonitis, radiation pericarditis, and

radiation enteritis (less clinically significant in

lymphoma than in the past owing to targeted

3D conformal therapy); and infections second-

ary to neutropenia.

Utility of PET/CT in Stem Cell

Transplantation

In general, patients with aggressive lym-

phoma who have primary refractory disease

or a relapse within a year of achieving com-

plete remission have a poor prognosis. Stem

cell transplantation with autologous or allo-

genic stem cells should be considered in the

care of these patients. The choice of trans-

plantation depends on several factors, in-

cluding the performance status and age of

the patient, the availability of a histocompat-

ible donor, and several other factors that are

beyond the scope of this review.

There is evidence that PET/CT can beused for selection of patients for stem cell

transplantation [56, 57, 59]. In a retrospec-

tive analysis of 60 patients with Hodgkin’s

or non-Hodgkin’s lymphoma scheduled for

high-dose chemotherapy and stem cell trans-

plantation, Spaepen et al. [57] found that per-

sistently abnormal PET findings after salvage

chemotherapy but before stem cell transplan-

tation are predictive of poor progression-free

and overall survival. In a different retrospec-

tive study of patients with Hodgkin’s or non-

Hodgkin’s lymphoma undergoing reinduction

chemotherapy before stem cell transplanta-

tion, Schot et al. [56] found that early PET af-ter two cycles of reinduction therapy can be

combined with a baseline clinical risk score

(secondary age-adjusted International Prog-

nostic Index for recurring non-Hodgkin’s

lymphoma and recurring Hodgkin score for

Hodgkin’s lymphoma) to predict outcome.

Those authors identified four main risk groups

predictive of the rate of success of stem cell

transplantation. They documented success

rates of 80–100% among patients with a low

combined risk score to success rates of 0–7%

among patients with a high combined risk

score. PET/CT therefore may be useful for

selecting patients most likely to respond to

stem cell transplantation, although prospec-

tive data showing changes in treatment based

on PET/CT findings are still lacking.

Conclusion

The lymphoproliferative disorders encom-

pass a wide range of malignant diseases with

differing histologic characteristics, behav-

ior patterns, imaging appearances, and treat-

ment options. Although it is not necessary

for radiologists to have an extensive knowl-

edge of each lymphoma subtype, it is useful

to consider them in terms of a clinicopatho-

logic grading system (indolent, aggressive,

and highly aggressive) that broadly correlates

with management approach and FDG avidi-

ty. PET/CT is most effectively and efficient-

ly used when both the referring clinician and

the radiologist understand the uses and limi-

tations of PET/CT within the context of the

treatment strategy for each patient. Optimal

interpretation of baseline staging and post-

treatment PET/CT scans relies heavily on the

radiologist’s having adequate clinical infor-

mation about the patient, the disease, and the

treatment history. Participation in multidisci-

plinary case conferences is strongly advised.

References

1. Jemal A, Siegel R, Ward E, et al. Cancer statistics,2008. CA Cancer J Clin 2008; 58:71–96

2. Cheson BD, Pfistner B, Juweid ME, et al. The In-

ternational Harmonization Project on Lymphoma:

revised response criteria for malignant lympho-

ma. J Clin Oncol 2007; 25:579–586

3. Juweid ME, Stroobants S, Hoekstra OS, et al.; Im-

aging Subcommittee of International Harmoniza-

tion Project in Lymphoma. Use of positron emis-

sion tomography for response assessment of

lymphoma: consensus of the Imaging Subcom-

mittee of International Harmonization Project in

Lymphoma. J Clin Oncol 2007; 25:571–578

4. Harris NL, Jaffe ES, Stein H, et al. A revised Eu-

ropean-American classification of lymphoid neo-

plasms: a proposal from the International Lym-

phoma Study Group. Blood 1994; 84:1361–1392

5. Harris NL, Jaffe ES, Diebold J, et al. The World

Health Organization classification of neoplastic

diseases of the haematopoietic and lymphoid tis-

sues: report of the Clinical Advisory Committee

Meeting, Airlie House, Virginia, November 1997.

Histopathology 2000; 36:69–86

6. Bruzzi JF, Macapinlac H, Tsimberidou AM, et al.

http://www.ajronline.org/action/showLinks?pmid=18287387&crossref=10.3322%2FCA.2007.0010http://www.ajronline.org/action/showLinks?pmid=17242396&crossref=10.1200%2FJCO.2006.09.2403http://www.ajronline.org/action/showLinks?pmid=17242397&crossref=10.1200%2FJCO.2006.08.2305http://www.ajronline.org/action/showLinks?pmid=8068936http://www.ajronline.org/action/showLinks?pmid=10632755&crossref=10.1046%2Fj.1365-2559.2000.00895.xhttp://www.ajronline.org/action/showLinks?pmid=16883004http://www.ajronline.org/action/showLinks?pmid=16883004http://www.ajronline.org/action/showLinks?pmid=8068936http://www.ajronline.org/action/showLinks?pmid=17242396&crossref=10.1200%2FJCO.2006.09.2403http://www.ajronline.org/action/showLinks?pmid=10632755&crossref=10.1046%2Fj.1365-2559.2000.00895.xhttp://www.ajronline.org/action/showLinks?pmid=17242397&crossref=10.1200%2FJCO.2006.08.2305http://www.ajronline.org/action/showLinks?pmid=18287387&crossref=10.3322%2FCA.2007.0010


12/15


Cronin et al.

Detection of Richter’s transformation of chronic

lymphocytic leukaemia by PET/CT. J Nucl Med

2006; 47:1267–1273

7. Higgins RA, Blankenship JE, Kinney MC. Appli-

cation of immunohistochemistry in the diagnosis

of non-Hodgkin and Hodgkin lymphoma. Arch

Pathol Lab Med 2008; 132:441–461

8. Shipp MA. Prognostic factors in aggressive non-

Hodgkin’s lymphoma: who has “high-risk” dis-

ease? Blood 1994; 83:1165–1173

9. Hasenclever D, Diehl V. A prognostic score for

advanced Hodgkin’s disease: International Prog-

nostic Factors Project on Advanced Hodgkin’s

Disease. N Engl J Med 1998; 339:1506–1514

10. Tatsumi M, Cohade C, Nakamoto Y, Fishman

EK, Wahl RL. Direct comparison of FDG PET

and CT findings in patients with lymphoma: ini-

tial experience. Radiology 2005; 237:1038–1045

11. Freudenberg LS, Antoch G, Schütt P, et al. FDG-

PET/CT in re-staging of patients with lymphoma.

Eur J Nucl Med Mol Imaging 2004; 31:325–329

12. Schöder H, Noy A, Gönen M, et al. Intensity of

18fluorodeoxyglucose uptake in positron emission

tomography distinguishes between indolent and

aggressive non-Hodgkin’s lymphoma. J Clin On-

col 2005; 23:4643–4651

13. Juweid ME, Cheson BD. Role of positron emis-

sion tomography in lymphoma. J Clin Oncol

2005; 23:4577–4580

14. 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 Med 1991; 32:686–691

15. Tsang RW, Gospodarowicz MK, Pintilie M, et al.

Stage I and II MALT lymphoma: results of treat-ment with radiotherapy. Int J Radiat Oncol Biol

Phys 2001; 50:1258–1264

16. MacDermed D, Thurber L, George TI, Hoppe RT,

Le QT. Extranodal nonorbital indolent lympho-

mas of the head and neck: relationship between

tumor control and radiotherapy. Int J Radiat On-

col Biol Phys 2004; 59:788–795

17. Wirth A, Foo M, Seymour JF, Macmanus MP,

Hicks RJ. Impact of [18f] fluorodeoxyglucose

positron emission tomography on staging and

management of early-stage follicular non-Hodg-

kin lymphoma. Int J Radiat Oncol Biol Phys

2008; 71:213–219

18. Tsimberidou AM, Wierda WG, Plunkett W, et al.

Phase I-II study of oxaliplatin, fludarabine, cytar-

abine, and rituximab combination therapy in pa-

tients with Richter’s syndrome or fludarabine-re-

fractory chronic lymphocytic leukemia. J Clin

Oncol 2008; 26:196–203

19. Bodet-Mil in C, Kraeber-Bodéré F, Moreau P,

Campion L, Dupas B, Le Gouill S. Investigation of

FDG-PET/CT imaging to guide biopsies in the de-

tection of histological transformation of indolent

lymphoma. Haematologica 2008; 93:471–472

20. Naumann R, Beuthien-Baumann B, Reiss A, e t

al. Substantial impact of FDG PET imaging on

the therapy decision in patients with early-stage

Hodgkin’s lymphoma. Br J Cancer 2004;

90:620–625

21. Buchmann I, Reinhardt M, Elsner K, et al. 2-(fluo-

rine-18)fluoro-2-deoxy-D-glucose positron emis-

sion tomography in the detection and staging of

malignant lymphoma: a bicenter trial. Cancer 2001;

91:889–899

22. Schoder H, Meta J, Yap C, et al. Effect of whole-

body 18F-FDG PET imaging on clinical staging

and management of patients with malignant lym-

phoma. J Nucl Med 2001; 42:1139–1143

23. Hoffmann M, Kietter K, Becherer A, Jager U,

Chott A, Raderer M. 18F-fluorodeoxyglucose posi-

tron emission tomography (18F-FDG-PET) for

staging and follow-up of marginal zone B-cell

lymphoma. Oncology 2003; 64:336–340

24. Bishu S, Quigley JM, Schmitz J, et al. F-18-fluo-

ro-deoxy-glucose positron emission tomography

in the assessment of periphera l T-cell lymphomas.

Leuk Lymphoma 2007; 48:1531–1538

25. Chua SC, Rozalli FI, O’Connor SR. Imaging fea-

tures of primary extranodal lymphomas. Clin Ra-

diol 2009; 64:574–588

26. Hwang S. Imaging of lymphoma of the musculo-

skeletal system. Radiol Clin North Am 2008; 46:

379–396

27. Hampson FA, Shaw AS. Response assessment in

lymphoma. Clin Radiol 2008; 63:125–135

28. Lee WK, Lau EW, Duddalwar VA, Stanley AJ,

Ho YY. Abdominal manifestations of extranodal

lymphoma: spectrum of imaging findings. AJR 2008; 191:198–206

29. Weijs LE, Arsos G, Baarslag HJ, Wittebol S, de

Klerk JM. Pericardial involvement in a non-

Hodgkin lymphoma patient: coregistered FDG-

PET and CT imaging. Eur Heart J 2007; 28:2698

30. Williams G, Kolodny GM. Suppression of myo-

cardial 18F-FDG uptake by preparing patients

with a high-fat, low-carbohydrate diet. AJR 2008;

190:1406; [web]W151–W156

31. Moog F, Bangerter M, Kotzerke J, Guhlmann A,

Frickhofen N, Reske SN. 18-F-fluorodeoxyglu-

cose-positron emission tomography as a new ap-

proach to detect lymphomatous bone marrow. J

Clin Oncol 1998; 16:603–609

32. Pakos EE, Fotopoulos AD, Ioannidis JP. 18F-FDG

PET for evaluation of bone marrow infiltration in

staging of lymphoma: a meta-analysis. J Nucl

Med 2005; 46:958–963

33. Jerusa lem 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 lympho-

ma has higher diagnostic and prognostic value

than classical computed tomography scan imag-

ing. Blood 1999; 94:429–433

34. Zijlstra JM, van der Werf GL, Hoekstra OS, et al.

18F-fluoro-deoxyglucose positron emission to-

mography for post-treatment evaluation of malig-

nant lymphoma: a systematic review. Haemato-

logica 2006; 91:522–529

35. Spaepen K, Stroobants S, Dupont P, et al. Prognos-

tic value of positron emission tomography (PET)

with fluorine-18 fluorodeoxyglucose after first-line

chemotherapy in non-Hodgkin’s lymphoma: is

[18F]FDG-PET a valid alternative to convention

diagnostic methods? J Clin Oncol 2001; 19:414–

419

36. Spaepen K, Stroobants S, Dupont P, et al. Can

positron emission tomography with 18F-fluorode-

oxyglucose after first-line treatment distinguish

Hodgkin’s disease patients who need additional

therapy from others in whom additional therapy

would mean avoidable toxicity? Br J Haematol

2001; 115:272–278

37. Juweid ME, Cheson BD. Positron emission to-

mography and assessment of cancer therapy. N

Engl J Med 2006; 354:496–507

38. Kostakoglu L, Coleman M, Leonard JP, et al. PET

predicts prognosis after 1 cycle of chemotherapy

in aggressive lymphoma and Hodgkin’s disease. J

Nucl Med 2002; 43:1018–1027

39. Jerusalem G, Beguin Y, Fassotte MF, et al. Persis-

tent tumor 18F-FDG uptake after a few cycles of

polychemotherapy is predictive of treatment fail-

ure in non-Hodgkin’s lymphoma. Haematologica

2000; 85:613–618

40. Hutchings M, Loft A, Hansen M, et al. FDG-PET

after two cycles of chemotherapy predicts treat-ment failure and progression-free survival in

Hodgkin lymphoma. Blood 2006; 107:52–59

41. Mikhaeel NG, Hutchings M, Fields PA, O’Doherty

MJ, Timothy AR. FDG-PET after two to three

cycles of chemotherapy predicts progression-free

and overall survival in high-grade non-Hodgkin

lymphoma. Ann Oncol 2005; 16:1514–1523

42. Gallamini A, Hutchings M, Avigdor A, Polliack

A. Early interim PET scan in Hodgkin lymphoma:

where do we stand? Leuk Lymphoma 2008; 49:

659–662

43. Mikhaeel NG, Timothy AR, Hain SF, O’Doherty

MJ. 18-FDG-PET for the assessment of residual

masses on CT following treatment of lymphomas.

Ann Oncol 2000; 11:147–150

44. Naumann R, Vaic A, Beuthien-Baumann B, et al.

Prognostic value of positron emission tomography

in the evaluation of post-treatment residual mass in

patients with Hodgkin’s disease and non-Hodgkin’s

lymphoma. Br J Haematol 2001; 115:793–800

45. Prabhakar HB, Sahani DV, Fischman AJ, Mueller

PR, Blake MA. Bowel hot spots at PET-CT. Ra-

dioGraphics 2007; 27:145–159

http://www.ajronline.org/action/showLinks?pmid=18318586http://www.ajronline.org/action/showLinks?pmid=8118021http://www.ajronline.org/action/showLinks?pmid=9819449&crossref=10.1056%2FNEJM199811193392104http://www.ajronline.org/action/showLinks?pmid=16304117&crossref=10.1148%2Fradiol.2373040555http://www.ajronline.org/action/showLinks?pmid=14647988&crossref=10.1007%2Fs00259-003-1375-yhttp://www.ajronline.org/action/showLinks?pmid=15837966&crossref=10.1200%2FJCO.2005.12.072http://www.ajronline.org/action/showLinks?pmid=15837974&crossref=10.1200%2FJCO.2005.01.904http://www.ajronline.org/action/showLinks?pmid=2013808http://www.ajronline.org/action/showLinks?pmid=11483337&crossref=10.1016%2FS0360-3016%2801%2901549-8http://www.ajronline.org/action/showLinks?pmid=15183482&crossref=10.1016%2Fj.ijrobp.2003.11.007http://www.ajronline.org/action/showLinks?pmid=18295982&crossref=10.1016%2Fj.ijrobp.2007.09.051http://www.ajronline.org/action/showLinks?pmid=18182662&crossref=10.1200%2FJCO.2007.11.8513http://www.ajronline.org/action/showLinks?pmid=18310543&crossref=10.3324%2Fhaematol.12013http://www.ajronline.org/action/showLinks?pmid=18194687&crossref=10.1016%2Fj.crad.2007.10.005http://www.ajronline.org/action/showLinks?pmid=17567624&crossref=10.1093%2Feurheartj%2Fehm218http://www.ajronline.org/action/showLinks?pmid=9469348http://www.ajronline.org/action/showLinks?pmid=10397709http://www.ajronline.org/action/showLinks?pmid=11208833http://www.ajronline.org/action/showLinks?pmid=16452561&crossref=10.1056%2FNEJMra050276http://www.ajronline.org/action/showLinks?pmid=10870118http://www.ajronline.org/action/showLinks?pmid=15980161&crossref=10.1093%2Fannonc%2Fmdi272http://www.ajronline.org/action/showLinks?pmid=10707798&crossref=10.1023%2FA%3A1008381115131http://www.ajronline.org/action/showLinks?pmid=17235004&crossref=10.1148%2Frg.271065080http://www.ajronline.org/action/showLinks?pmid=9469348http://www.ajronline.org/action/showLinks?pmid=12163626http://www.ajronline.org/action/showLinks?pmid=11483671http://www.ajronline.org/action/showLinks?pmid=17567624&crossref=10.1093%2Feurheartj%2Fehm218http://www.ajronline.org/action/showLinks?pmid=15837974&crossref=10.1200%2FJCO.2005.01.904http://www.ajronline.org/action/showLinks?pmid=17235004&crossref=10.1148%2Frg.271065080http://www.ajronline.org/action/showLinks?pmid=11703321&crossref=10.1046%2Fj.1365-2141.2001.03169.xhttp://www.ajronline.org/action/showLinks?pmid=14760374&crossref=10.1038%2Fsj.bjc.6601561http://www.ajronline.org/action/showLinks?pmid=18194687&crossref=10.1016%2Fj.crad.2007.10.005http://www.ajronline.org/action/showLinks?pmid=14647988&crossref=10.1007%2Fs00259-003-1375-yhttp://www.ajronline.org/action/showLinks?pmid=10707798&crossref=10.1023%2FA%3A1008381115131http://www.ajronline.org/action/showLinks?pmid=18182662&crossref=10.1200%2FJCO.2007.11.8513http://www.ajronline.org/action/showLinks?pmid=16585017http://www.ajronline.org/action/showLinks?pmid=19414080&crossref=10.1016%2Fj.crad.2008.11.001http://www.ajronline.org/action/showLinks?pmid=15980161&crossref=10.1093%2Fannonc%2Fmdi272http://www.ajronline.org/action/showLinks?pmid=9819449&crossref=10.1056%2FNEJM199811193392104http://www.ajronline.org/action/showLinks?pmid=15183482&crossref=10.1016%2Fj.ijrobp.2003.11.007http://www.ajronline.org/action/showLinks?pmid=15937306http://www.ajronline.org/action/showLinks?pmid=10870118http://www.ajronline.org/action/showLinks?pmid=12759529&crossref=10.1159%2F000070290http://www.ajronline.org/action/showLinks?pmid=18318586http://www.ajronline.org/action/showLinks?pmid=2013808http://www.ajronline.org/action/showLinks?system=10.2214%2FAJR.07.3205&pmid=18430862http://www.ajronline.org/action/showLinks?pmid=16452561&crossref=10.1056%2FNEJMra050276http://www.ajronline.org/action/showLinks?pmid=11251940&crossref=10.1002%2F1097-0142%2820010301%2991%3A5%3C889%3A%3AAID-CNCR1078%3E3.0.CO%3B2-5http://www.ajronline.org/action/showLinks?system=10.2214%2FAJR.07.3146&pmid=18562746http://www.ajronline.org/action/showLinks?pmid=15837966&crossref=10.1200%2FJCO.2005.12.072http://www.ajronline.org/action/showLinks?pmid=11843811&crossref=10.1046%2Fj.1365-2141.2001.03147.xhttp://www.ajronline.org/action/showLinks?pmid=18310543&crossref=10.3324%2Fhaematol.12013http://www.ajronline.org/action/showLinks?pmid=11208833http://www.ajronline.org/action/showLinks?pmid=18619386&crossref=10.1016%2Fj.rcl.2008.03.008http://www.ajronline.org/action/showLinks?pmid=16304117&crossref=10.1148%2Fradiol.2373040555http://www.ajronline.org/action/showLinks?pmid=18398732&crossref=10.1080%2F10428190801888704http://www.ajronline.org/action/showLinks?pmid=18295982&crossref=10.1016%2Fj.ijrobp.2007.09.051http://www.ajronline.org/action/showLinks?pmid=10397709http://www.ajronline.org/action/showLinks?pmid=17701584&crossref=10.1080%2F10428190701344915http://www.ajronline.org/action/showLinks?pmid=16150944&crossref=10.1182%2Fblood-2005-06-2252http://www.ajronline.org/action/showLinks?pmid=8118021http://www.ajronline.org/action/showLinks?pmid=11483337&crossref=10.1016%2FS0360-3016%2801%2901549-8


13/15


PET/CT of Lymphoma

46. Blake MA, Singh A, Setty BN, et al. Pearls and

pitfalls in interpretation of abdominal and pelvic

PET-CT. RadioGraphics 2006; 26:1335–1353

47. Castellucci P, Nanni C, Farsad M, et al. Potential

pitfalls of 18F-FDG PET in a large series of pa-

tients treated for malignant lymphoma: prevalence

and scan interpretation. Nucl Med Commun 2005;

26:689–694

48. Metser U, Miller E, Lerman H, Even-Sapir E. Be-

nign nonphysiologic lesions with increased 18F-

FDG uptake on PET/CT: characterization and

incidence. AJR 2007; 189:1203–1210

49. Love C, Tomas MB, Tronco GG, Palestro CJ.

FDG PET of infection and inflammation. Radio-

Graphics 2005; 25:1357–1368

50. Hsu CH, Lee CM, Wang FC, Lin YH. F-18 fluoro-

deoxyglucose positron emission tomography in

pulmonary cryptococcoma. Clin Nucl Med 2003;

28:791–793

51. Kamel EM, McKee TA, Calcagni ML, et al. Oc-

cult lung infarction may induce false interpretation

of 18F-FDG PET in primary staging of pulmonary

malignancies. Eur J Nucl Med Mol Imaging 2005;

32:641–646

52. Truong MT, Erasmus JJ, Munden RF, et a l. Focal

FDG uptake in mediastinal brown fat mimicking

malignancy: a potential pitfall resolved on PET/

CT. AJR 2004; 183:1127–1132

53. Truong MT, Pan T, Erasmus JJ. Pitfalls in integrated

CT-PET of the thorax: implications in oncologic

imaging. J Thorac Imaging 2006; 21:111–122

54. Sonet A, Graux C, Nollevaux MC, Krug B, Bosly

A, Vander Borght T. Unsuspected FDG-PET find-

ings in the follow-up of patients with lymphoma.

Ann Hematol 2007; 86:9–15

55. Prabhakar HB, Rabinowitz CB, Gibbons FK,

O’Donnell WJ, Shepard JAO, Aquino SL. Imag-

ing features of sarcoidosis on MDCT, FDG PET,

and PET/CT. AJR 2008; 190:[3 suppl]:S1–S6

56. Schot BW, Zijlstra JM, Sluiter WJ, van Imhoff

GW, Pruim J, Vaalburg W. Early FDG-PET as-

sessment in combination with clinical risk scores

determines prognosis in recurring lymphoma.

Blood 2007; 109:486–491

57. Spaepen K, Stroobants S, Dupont P, et al. Prog-

nostic value of pretransplantation positron emis-

sion tomography using fluorine 18-fluorodeoxy-

glucose in patients with aggressive lymphoma

treated with high-dose chemotherapy and stem

cell transplantation. Blood 2003; 102:53–59

58. Martin WG, Ristow KM, Habermann TM, et al.

Bleomycin pulmonary toxicity has a negative im-

pact on the outcome of patients with Hodgkin’s

lymphoma. J Clin Oncol 2005; 23:7614–7620

59. Belakhlef A, Jani C, Church C, Fraser R, Lakhan-

pal S. Fat necrosis mimicking B-cell lymphoma: a

PET/CT and FDG study. Clin Nucl Med 2008;

33:271–272

60. Hershma n DL, McBride RB, Eisenberger A, Tsai

WY, Grann VR, Jacobson JS. Doxorubicin, car-

diac risk factors, and cardiac toxicity in elderly

patients with diffuse B-cell non-Hodgkin’s lym-

phoma. J Clin Oncol 2008; 26 :3159–3165

http://www.ajronline.org/action/showLinks?pmid=16973768&crossref=10.1148%2Frg.265055208http://www.ajronline.org/action/showLinks?pmid=16000986&crossref=10.1097%2F01.mnm.0000171781.11027.bbhttp://www.ajronline.org/action/showLinks?system=10.2214%2FAJR.07.2083&pmid=17954662http://www.ajronline.org/action/showLinks?pmid=12973014&crossref=10.1097%2F01.rlu.0000082680.98898.2bhttp://www.ajronline.org/action/showLinks?pmid=15726357&crossref=10.1007%2Fs00259-004-1718-3http://www.ajronline.org/action/showLinks?system=10.2214%2FAJR.07.7001&pmid=18287458http://www.ajronline.org/action/showLinks?pmid=12609836&crossref=10.1182%2Fblood-2002-12-3842http://www.ajronline.org/action/showLinks?pmid=18356666&crossref=10.1097%2FRLU.0b013e3181662bbfhttp://www.ajronline.org/action/showLinks?pmid=17021839&crossref=10.1007%2Fs00277-006-0167-4http://www.ajronline.org/action/showLinks?system=10.2214%2Fajr.183.4.1831127&pmid=15385319http://www.ajronline.org/action/showLinks?pmid=18356666&crossref=10.1097%2FRLU.0b013e3181662bbfhttp://www.ajronline.org/action/showLinks?pmid=12973014&crossref=10.1097%2F01.rlu.0000082680.98898.2bhttp://www.ajronline.org/action/showLinks?pmid=12609836&crossref=10.1182%2Fblood-2002-12-3842http://www.ajronline.org/action/showLinks?system=10.2214%2FAJR.07.2083&pmid=17954662http://www.ajronline.org/action/showLinks?system=10.2214%2FAJR.07.7001&pmid=18287458http://www.ajronline.org/action/showLinks?pmid=16973768&crossref=10.1148%2Frg.265055208http://www.ajronline.org/action/showLinks?pmid=16770228&crossref=10.1097%2F00005382-200605000-00003http://www.ajronline.org/action/showLinks?pmid=18591554&crossref=10.1200%2FJCO.2007.14.1242http://www.ajronline.org/action/showLinks?pmid=15726357&crossref=10.1007%2Fs00259-004-1718-3http://www.ajronline.org/action/showLinks?pmid=16186594&crossref=10.1200%2FJCO.2005.02.7243http://www.ajronline.org/action/showLinks?pmid=17003382&crossref=10.1182%2Fblood-2005-11-006957http://www.ajronline.org/action/showLinks?pmid=16000986&crossref=10.1097%2F01.mnm.0000171781.11027.bb


14/15

This article has been cited by:

1. Laura Heacock, Joseph Weissbrot, Roy Raad, Naomi Campbell, Kent P. Friedman, Fabio Ponzo, Hersh Chandarana. 2015.PET/MRI for the Evaluation of Patients With Lymphoma: Initial Observations. American Journal of Roentgenology 204:4,842-848. [ Abstract] [Full Text] [PDF] [PDF Plus]

2. Scott Johnson, Myra Feldman, Venkatesh Krishnamurthi. 2015. Primary Testicular Lymphoma. The Journal of Urology 193,315-316. [CrossRef ]

3. Heba Nabil, Karima M. Maher, Sameh A.R. Mahdy. 2014. Follow up in chest tumors: Value of integrated PET/CT. The Egyptian Journal of Radiology and Nuclear Medicine 45, 679-688. [CrossRef ]

4. Dina M. ABO-Sheisha, Omnia Abdel Fattah. 2014. Prognostic evaluation of PET/CT in residual post-chemotherapy masses inpatients with diffuse large B-cell lymphoma and its impact on survival. The Egyptian Journal of Radiology and Nuclear Medicine

45, 921-928. [CrossRef ]

5. Brett W. Carter, Carol C. Wu, Leila Khorashadi, Myrna C.B. Godoy, Patricia M. de Groot, Gerald F. Abbott, John P.Lichtenberger III. 2014. Multimodality ima ging of cardiothoracic lymphoma. European Journal of Radiology 83, 1470-1482.[CrossRef ]

6. Benaissa Azzedine, Moussa-Bouharati Kahina, Papathanassiou Dimitri, Portefaix Christophe, Delmer Alain, Marcus Claude.2014. Whole-body diffusion-weighted MRI for staging lymphoma at 3.0T: comparative study with MR imaging at 1.5T.Clinical Imagin g . [CrossRef ]

7. Róisín Hamilton, Iain Andrews, Pamela McKay, Mike Leach. 2014. Loss of utility of bone marrow biopsy as a staging evaluationfor Hodgkin lymphoma in the positron emission tomography–computed tomography era: a West of Scotland study. Leukemia& Lymphoma 55, 1049-1052. [CrossRef ]

8. Noha Hosam EL Din Behairy, Tarek Ahmed Rafaat, Amr Salah EL Din El Nayal, Magdy Ibrahim Bassiouny. 2014. PET/CT in initial staging and therapy response assessment of early mediastinal lymphoma. The Egyptian Journal of Radiology and Nuclear Medicine 45, 61-67. [CrossRef ]

9. Carlos S. Restrepo, Jorge Carrillo, Melissa Rosado de Christenson, Paulina Ojeda Leon, Aura Lucia Rivera, Micheal N. Koss.2013. Lymphoproliferative Lung Disorders: A Radiologic-Pathologic Overview. Part II: Neoplastic Disorders. Semi nars inUltrasound, CT and MRI 34, 535-549. [CrossRef ]

10. Bouthaina S. Dabaja, Jack Phan, Osama Mawlawi, L. Jeffrey Medeiros, Carol Etzel, Fu-Wen Liang, Donald Podoloff, YasuhiroOki, Fredrick B. Hagemeister, Hubert Chuang, Luis E. Fayad, Jason Robert Westin, Ferial Shihadeh, Pamela K. Allen, ChristineF. Wogan, Maria A. Rodriguez. 2013. Clinical implications of positron emission tomography-negative residual computed

tomography masses after chemotherapy for diffuse large B-cell lymphoma. Leukemia & Lymphoma 1-8. [CrossRef ]11. J.P. Pilkington Woll, A.M. García Vicente, M.P. Talavera Rubio, A.M. Palomar Muñoz, G. Jiménez Londoño, A. León Martín,

C. Calle Primo, A.M. Soriano Castejón. 2013. Evaluación cuantitativa y cualitativa de la PET/TC a mitad del tratamientoen linfomas en la predicción de respuesta metabólica completa. Revista Española de Medicina Nuclear e Imagen Molecular 32,70-76. [CrossRef ]

12. Bing Bai, Hui-Qiang Huang, Qi-Chun Cai, Wei Fan, Xiao-Xiao Wang, Xu Zhang, Ze-Xiao Lin, Yan Gao, Yun-Fei Xia, Ying Guo, Qing-Qing Cai, Wen-Qi Jiang, Tong-Yu Lin. 2013. Predictive value of pretreatment positron emission tomography/computed tomography in patients with newly diagnosed extranodal natural killer/T-cell lymphoma. Medical Oncology 30. .[CrossRef ]

13. J.P. Pilkington Woll, A.M. García Vicente, M.P. Talavera Rubio, A.M. Palomar Muñoz, G. Jiménez Londoño, A. León Martín,C. Calle Primo, A.M. Soriano Castejón. 2013. Quantitative and qualitative evaluation of the interim PET/CT in lymphoma treatment in the prediction of complete metabolic response. Revista Española de Medicina Nuclear e Imagen Molecular (English

Edition) 32, 70-76. [CrossRef ]

14. Frank Lenze, Johannes Wessling, Janbernd Bremer, Hansjoerg Ullerich, Tillmann Spieker, Matthias Weckesser, SaridGonschorrek, Klaus Kanneng ieer, Emile Rijcken, Jan Heidemann, Andreas Luegering, Otmar Schober, Wolfram Domschke,Torsten Kucharzik, Christian Maaser. 2012. Detection and differentiation of inflammatory versus fibromatous Crohnʼs diseasestrictures: Prospective comparison of 18F-FDG-PET/CT, MR-enteroclysis, and transabdominal ultrasound versus endoscopic/histologic evaluation. Inflammatory Bowel Diseases 18, 2252-2260. [CrossRef ]

15. A. Orlacchio, O. Schillaci, E. Gaspari, F. Gatta, R. Danieli, F. Bolacchi, C. Ragano Caracciolo, A. Mancini, G. Simonetti. 2012.Role of [18F]-FDG-PET/MDCT in evaluating early response in patients with Hodgkin’s lymphoma. La radiologia medica117, 1250-1263. [CrossRef ]

http://dx.doi.org/10.1007/s11547-012-0792-8http://dx.doi.org/10.1016/j.remnie.2013.01.007http://dx.doi.org/10.1007/s12032-012-0339-0http://dx.doi.org/10.1007/s12032-012-0339-0http://dx.doi.org/10.1007/s12032-012-0339-0http://dx.doi.org/10.1016/j.remn.2012.03.003http://dx.doi.org/10.3109/10428194.2013.784967http://dx.doi.org/10.1053/j.sult.2013.05.003http://dx.doi.org/10.1016/j.ejrnm.2013.11.009http://dx.doi.org/10.3109/10428194.2013.821201http://dx.doi.org/10.1016/j.ejrad.2014.05.018http://dx.doi.org/10.1016/j.ejrnm.2014.04.008http://dx.doi.org/10.1016/j.juro.2014.10.051http://dx.doi.org/10.1007/s11547-012-0792-8http://dx.doi.org/10.1002/ibd.22930http://dx.doi.org/10.1016/j.remnie.2013.01.007http://dx.doi.org/10.1007/s12032-012-0339-0http://dx.doi.org/10.1016/j.remn.2012.03.003http://dx.doi.org/10.3109/10428194.2013.784967http://dx.doi.org/10.1053/j.sult.2013.05.003http://dx.doi.org/10.1016/j.ejrnm.2013.11.009http://dx.doi.org/10.3109/10428194.2013.821201http://dx.doi.org/10.1016/j.clinimag.2014.06.017http://dx.doi.org/10.1016/j.ejrad.2014.05.018http://dx.doi.org/10.1016/j.ejrnm.2014.04.008http://dx.doi.org/10.1016/j.ejrnm.2014.03.012http://dx.doi.org/10.1016/j.juro.2014.10.051http://www.ajronline.org/doi/pdfplus/10.2214/AJR.14.13181http://www.ajronline.org/doi/pdf/10.2214/AJR.14.13181http://www.ajronline.org/doi/full/10.2214/AJR.14.13181http://dx.doi.org/10.2214/AJR.14.13181


15/15

16. Scott T. Tagawa, Naveed H. Akhtar, Brian D. Robinson, Himisha BeltranUncommon Cancers of the Prostate 47-75. [CrossRef ]

17. Delicia Love, Elyse Stratton, Michael Stocum. 2012. Best practices for companion diagnostic and therapeutic development:translating between the stakeholders. New Biotechnology 29, 689-694. [CrossRef ]

18. E. Broussalis, M. Hutterer, K. Oppermann, P. Wipfler, G. Pilz, A. Harrer, E. Haschke-Becher, S. Golaszewski, U. Schönauer,S. Weis, M. Killer-Oberpfalzer, M. Mc Coy, E. Trinka, J. Kraus. 2012. Isolated leptomeningeal infiltration of a primary CNS B-cell lymphoma diagnosed by flow cytometry and confirmed by necropsy. Acta Neurologica Scandinavica 126:10.1111/ane.2012.126.issue-3, e11-e16. [CrossRef ]

19. C G Cronin, J Scott, A Kambadakone, O A Catalano, D Sahani, M A Blake, S Mcdermott. 2012. Utility of positron emissiontomography/CT in the evaluation of small bowel pathology. The British Journal of Radiology 85, 1211-1221. [CrossRef ]

20. Daniel Spira, Wichard Vogel, Martin Sökler, Sarah Löffler, Alexander Sauter, Maximilian Schulze, Marius Horger. 2012. Sizeand attenuation CT (SACT) of residual masses in patients with follicular Non-Hodgkin Lymphoma: More than a status quo?.European Journal of Radiology 81, 1657-1661. [CrossRef ]

21. Daniel Spira, Patrick Adam, Catharina Linder, Sven Michael Spira, Jan Pintoffl, Claus Detlef Claussen, Marius Horger.2012. Perfusion and Flow Extraction Product as Potential Discriminators in Untreated Follicular and Diffuse Large B CellLymphomas Using Volume Perfusion CT With Attempt at Histopathologic Explanation. American Journal of Roentgenology198:6, 1239-1246. [ Abstract] [Full Text] [PDF] [PDF Plus]

22. Mario Otto, Barry L. Shulkin, Mondira Kundu, John T. Sandlund, Scott E. Snyder, Monika L. Metzger. 2012. Histiocyte-rich Xanthomatous Pseudotumor Mimicking Relapse on Positron Emission Tomography Imaging in an Adolescent With Primary

Mediastinal Diffuse Large B-cell Lymphoma. Journal of Pediatric Hematology/Oncology 34, 232-235. [CrossRef ]23. M. J. Shelly, S. McDermott, O. J. O'Connor, M. A. Blake. 2012. 18-Fluorodeoxyglucose Positron Emission Tomog

dr cynthia (jurnal) clinical utility of petct in lymphoma

Documents