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Multiple focal uptake of 67Ga in cutaneous tissue
Multiple Focal Uptake of 67Ga in Cutaneous Tissue Nir Hod, Lena Pinkas, and "lqfha Horne
69-YEAR-OLD woman presented with multiple skin lesions over the upper extremities. The most prominent lesions were on the left forehead and right zygomatic region and were first noted by the patient 1 year previously. The lesions started as painless areas of erythema with elevation of the skin. Physical examination at presentation showed several erythematous plaquelike lesions on the forehead, chest, and upper extremities. There were no palpable lesions on the right side of the chest, upper abdomen, or buttocks. Skin biopsy was consistent with cutaneous B-cell lymphoma. Bone marrow biopsy was positive for B-cell lymphoma. The patient had pathologic right femoral neck fracture followed by hip replacement. Histopathologic examination showed femoral head and neck involvement with malignant B-cell lymphoma. The patient was referred for 67Ga scan, which was performed 48 hours after the administration of 10 mCi of 67Ga citrate (Fig 1). Computed tomographic scan of the chest, abdomen, and buttocks was performed (Figs 2 and 3). Three months later, the patient underwent a gallium scan to assess the effects of therapy (Fig 4). Cutaneous lymphomas can involve the skin primarily or secondarily and are usually of the T-cell origin 1'2, mycosis fungoides and S6zary syndrome are the most common. Cutaneous B-cell tymphoma is not usually seen and, in most cases, represents secondary cutaneous involvement by systemic lymphoma. Gallium uptake by cutaneous T-cell lymphoma has been reported3; however, 67Ga imaging in cutaneous B-cell lymphoma has rarely been described. 4 Presented here is an unusual case of cutaneous B-cell lymphoma with
multiple focal areas of increased gallium uptake; most of them were not clinically detectable. This case demonstrates the high diagnostic value of 67Ga scintigraphy in detecting the extent of the disease and in the assessment of the response to treatment. Review of the literature discloses that the causes of increased gallium uptake in cutaneous tissue are as follows:
From the Department of Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin and SackIer Faculty of Medicine, Tel Aviv University, Israel. Address reprint requests to Tifha Home, MD, Department of Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin 70300, Israel. Copyright 2002, Elsevier Science (USA). All rights reserved. 0001-2998/02/3202-0006535.00/0 doi: 10.1053/snuc.2002.124180
10. Mycobacterial infections in acquired immunodeficiency syndrome and in immunosuppression 19,2~ 11. Disseminated sporotrichosis 21 12. Polyarteritis nodosa 22 13. Cutaneous antibiotic injection sites 9 14. Silicone injection sites23
A
220
COMMON CAUSES
1. Cutaneous lymphoma: B cell (this article) and T cell, including mycosis fungoides and S6zary syndrome 3 2. Melanoma 5'6 3. Abscess 7 4. Cellulitis 7 5. Skin incisions and lacerations or surgical wounds up to 4 weeks 8 6. Pressure lesions 9
UNCOMMON OR RARE CAUSES
1. 2. 3. 4. 5.
Acne vulgaris w Herpetic skin lesion ll Leprosy 12 Neurofibroma a3 Multiple myeloma and cutaneous components 14
6. 7. 8. 9.
Cutaneous metastases 15 Cutaneous sarcoidosis a6 Panniculitis 17 Erythema nodosum 18
Seminars in Nuclear Medicine, Vol XXXII, No 3 (July), 2002: pp 220-222
UPTAKE OF 67GA IN CUTANEOUS TISSUE
221
GALLIUM SC
Fig 3. Computed tomographlc scan of the region of the buttocks, demonstrating a large malignant lymphatic mass (arrow).
GALLIUM SC
Fig 1. A 48-hour whole-body eTGa scan (anterior and posterior) demonstrating multiple, superficial, focal areas of Increased uptake In the skin of the forehead, face, right zygomatlc region, chest, end the upper extremities. There ere two large focl of Increased uptake: one In the region of the right upper abdomen near the liver and the other In the region of the right buttock. All the clinically detected lesions were seen on the a7Ga scan, which also revealed multiple other lesions. Biopsy of the lesions demonstrated B-cell lymphoma.
RT
FINT
LT
LT
POST
RT
Fig 4. Posttherapy 67Ga scan showed a dramatic resolution of the lesions.
Fig 2. Computed tomographlc scan demonstrated the extent of the large Isslon In the rlght upper abdomen (arrow).
REFERENCES
1. Willemze R: Primary cutaneous lymphoma. Curr Opin Oncol 12:419-425, 2000 2. Santucci M, Pimpinelli N, Arganini L: Primary cutaneous B-cell lymphoma: A unique type of low-grade lymphoma. Clinicopathologic and immunologic study of 83 cases. Cancer 67:2311-2326, 1991
3. Nishimi L, Chen D, Ansari A, et al: Ga-67 uptake in cutaneous lesions of mycosis fungoides. Clin Nucl Med 13:120122, 1987 4. Assassa GS, Siegel ME, Chen DC, et ah Gallium-67 uptake in cutaneous B-cell lymphoma. Clin Nucl Med 19:614616, 1994
222
5. Jackson FI, McPherson TA, Lentle BC: Gallium-67 scintigraphy in multisystem malignant melanoma. Radiology 122:163-167, 1977 6. Milder MS, Frankel RS, Bulkey GB, et al: Gallium-67 scintigraphy in malignant melanoma. Cancer 32:1350-1356, 1973 7. Lisbona R, Rosenthall L: Observations on the sequential use of 99mTc-phosphate complex and Ga-67 imaging in osteomyelitis, cellulitis and septic arthritis. Radiology 123:123-129, 1997 8. Bell EG, O'Mara RE, Henry CA, et al: Non-neoplastic localization of 67Ga-citrate. J Nucl Ned 12:338-339, 1971 (abstr) 9. Lenfle BC, Scott JR, Noujaim AA, et al: Iatrogenic alterations in radionuclide biodistributions. Semin Nucl Med 9:131-143, 1979 10. Kipper MS, Taylor A, Ashburn WL: Gallium-67-citrate uptake in a case of acne vulgaris. Clin Nucl Med 6:409-410, 1981 11. Acio ER, Balasubramanian N, Vieras F, et al: Gallium-67 localization in herpetic lesion. Clin Nucl Med 13:667-668, 1988 12. Primeau M, Carrier L, Verrault JM, et al: Gallium-67 uptake in cutaneous lepromatous lesions. Clin Nucl Med 13:924-925, 1988 13. Kaplan IL, Swayne LC, Baydin JA: Uptake of Ga-67 citrate in benign neurofibroma. Clin Nucl Med 14:224, 1989 14. Waxman AD, Siemsen JK, Levine AM, et al: Radiographic and radionuclide imaging in multiple myeloma: The
HOD, PINKAS, AND HORNE
role of gallium scintigraphy~oncise communication. J Nucl Med 22:232-236, 1981 15. Palestro CJ, Coscia A, Richman AH: Technetium-99mMDP and Ga-67-citrate accumulation in cutaneous metastases from colon carcinoma. J Nucl Med 24:1202-1203, 1983 16. Rohatgi PK: Cutaneous localization of Ga-67 in systemic sarcoidosis. Clin Nucl Med 6:109-110, 1981 17. Choy D, Murray IE Ford JC: Gallium scintigraphy in acute panniculitis. J Nucl Med 22:973-974, 1981 18. Winzelberg GG, Rabinowitz J: Whole-body gallium-67citrate scintigraphy in a patient with sarcoidosis and biopsyproven erythema nodosmn. Clin Nucl Med 9:418, 1984 19. Allwright SJ, Chapman PR, Antico VF, et al: Cutaneous gallium uptake in patients with AIDS with Mycobacterium avium intracellulare septicemia. Clin Nucl Med 13:506-508, 1988 20. Lee NK, Salvin JD Jr, Spencer RP, et al: "Speckled" radiogallium images in disseminated Mycobacterium fortuitum skin infection. Clin Nucl Med 17:226-227, 1992 21. Patange V, Cesani F, Phillpott J, et al: Three-phase bone and Ga-67 scintigraphy in disseminated sporotrichosis. Clin Nucl Med 20:909-912, 1995 22. Alexander JE, Seibert J J, Lowe BE: Cutaneous uptake of gallium-67 in polyarteritis nodosa. Clin Nucl Med 12:883-885, 1987 23. Palestro CJ, Chau P, Goldsmith SJ: Gallium-67 uptake after breast and hip augmentation with silicone. Clin Nucl Med 17:897-898, 1992
69-YEAR-OLD woman presented with multiple skin lesions over the upper extremities. The most prominent lesions were on the left forehead and right zygomatic region and were first noted by the patient 1 year previously. The lesions started as painless areas of erythema with elevation of the skin. Physical examination at presentation showed several erythematous plaquelike lesions on the forehead, chest, and upper extremities. There were no palpable lesions on the right side of the chest, upper abdomen, or buttocks. Skin biopsy was consistent with cutaneous B-cell lymphoma. Bone marrow biopsy was positive for B-cell lymphoma. The patient had pathologic right femoral neck fracture followed by hip replacement. Histopathologic examination showed femoral head and neck involvement with malignant B-cell lymphoma. The patient was referred for 67Ga scan, which was performed 48 hours after the administration of 10 mCi of 67Ga citrate (Fig 1). Computed tomographic scan of the chest, abdomen, and buttocks was performed (Figs 2 and 3). Three months later, the patient underwent a gallium scan to assess the effects of therapy (Fig 4). Cutaneous lymphomas can involve the skin primarily or secondarily and are usually of the T-cell origin 1'2, mycosis fungoides and S6zary syndrome are the most common. Cutaneous B-cell tymphoma is not usually seen and, in most cases, represents secondary cutaneous involvement by systemic lymphoma. Gallium uptake by cutaneous T-cell lymphoma has been reported3; however, 67Ga imaging in cutaneous B-cell lymphoma has rarely been described. 4 Presented here is an unusual case of cutaneous B-cell lymphoma with
multiple focal areas of increased gallium uptake; most of them were not clinically detectable. This case demonstrates the high diagnostic value of 67Ga scintigraphy in detecting the extent of the disease and in the assessment of the response to treatment. Review of the literature discloses that the causes of increased gallium uptake in cutaneous tissue are as follows:
From the Department of Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin and SackIer Faculty of Medicine, Tel Aviv University, Israel. Address reprint requests to Tifha Home, MD, Department of Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin 70300, Israel. Copyright 2002, Elsevier Science (USA). All rights reserved. 0001-2998/02/3202-0006535.00/0 doi: 10.1053/snuc.2002.124180
10. Mycobacterial infections in acquired immunodeficiency syndrome and in immunosuppression 19,2~ 11. Disseminated sporotrichosis 21 12. Polyarteritis nodosa 22 13. Cutaneous antibiotic injection sites 9 14. Silicone injection sites23
A
220
COMMON CAUSES
1. Cutaneous lymphoma: B cell (this article) and T cell, including mycosis fungoides and S6zary syndrome 3 2. Melanoma 5'6 3. Abscess 7 4. Cellulitis 7 5. Skin incisions and lacerations or surgical wounds up to 4 weeks 8 6. Pressure lesions 9
UNCOMMON OR RARE CAUSES
1. 2. 3. 4. 5.
Acne vulgaris w Herpetic skin lesion ll Leprosy 12 Neurofibroma a3 Multiple myeloma and cutaneous components 14
6. 7. 8. 9.
Cutaneous metastases 15 Cutaneous sarcoidosis a6 Panniculitis 17 Erythema nodosum 18
Seminars in Nuclear Medicine, Vol XXXII, No 3 (July), 2002: pp 220-222
UPTAKE OF 67GA IN CUTANEOUS TISSUE
221
GALLIUM SC
Fig 3. Computed tomographlc scan of the region of the buttocks, demonstrating a large malignant lymphatic mass (arrow).
GALLIUM SC
Fig 1. A 48-hour whole-body eTGa scan (anterior and posterior) demonstrating multiple, superficial, focal areas of Increased uptake In the skin of the forehead, face, right zygomatlc region, chest, end the upper extremities. There ere two large focl of Increased uptake: one In the region of the right upper abdomen near the liver and the other In the region of the right buttock. All the clinically detected lesions were seen on the a7Ga scan, which also revealed multiple other lesions. Biopsy of the lesions demonstrated B-cell lymphoma.
RT
FINT
LT
LT
POST
RT
Fig 4. Posttherapy 67Ga scan showed a dramatic resolution of the lesions.
Fig 2. Computed tomographlc scan demonstrated the extent of the large Isslon In the rlght upper abdomen (arrow).
REFERENCES
1. Willemze R: Primary cutaneous lymphoma. Curr Opin Oncol 12:419-425, 2000 2. Santucci M, Pimpinelli N, Arganini L: Primary cutaneous B-cell lymphoma: A unique type of low-grade lymphoma. Clinicopathologic and immunologic study of 83 cases. Cancer 67:2311-2326, 1991
3. Nishimi L, Chen D, Ansari A, et al: Ga-67 uptake in cutaneous lesions of mycosis fungoides. Clin Nucl Med 13:120122, 1987 4. Assassa GS, Siegel ME, Chen DC, et ah Gallium-67 uptake in cutaneous B-cell lymphoma. Clin Nucl Med 19:614616, 1994
222
5. Jackson FI, McPherson TA, Lentle BC: Gallium-67 scintigraphy in multisystem malignant melanoma. Radiology 122:163-167, 1977 6. Milder MS, Frankel RS, Bulkey GB, et al: Gallium-67 scintigraphy in malignant melanoma. Cancer 32:1350-1356, 1973 7. Lisbona R, Rosenthall L: Observations on the sequential use of 99mTc-phosphate complex and Ga-67 imaging in osteomyelitis, cellulitis and septic arthritis. Radiology 123:123-129, 1997 8. Bell EG, O'Mara RE, Henry CA, et al: Non-neoplastic localization of 67Ga-citrate. J Nucl Ned 12:338-339, 1971 (abstr) 9. Lenfle BC, Scott JR, Noujaim AA, et al: Iatrogenic alterations in radionuclide biodistributions. Semin Nucl Med 9:131-143, 1979 10. Kipper MS, Taylor A, Ashburn WL: Gallium-67-citrate uptake in a case of acne vulgaris. Clin Nucl Med 6:409-410, 1981 11. Acio ER, Balasubramanian N, Vieras F, et al: Gallium-67 localization in herpetic lesion. Clin Nucl Med 13:667-668, 1988 12. Primeau M, Carrier L, Verrault JM, et al: Gallium-67 uptake in cutaneous lepromatous lesions. Clin Nucl Med 13:924-925, 1988 13. Kaplan IL, Swayne LC, Baydin JA: Uptake of Ga-67 citrate in benign neurofibroma. Clin Nucl Med 14:224, 1989 14. Waxman AD, Siemsen JK, Levine AM, et al: Radiographic and radionuclide imaging in multiple myeloma: The
HOD, PINKAS, AND HORNE
role of gallium scintigraphy~oncise communication. J Nucl Med 22:232-236, 1981 15. Palestro CJ, Coscia A, Richman AH: Technetium-99mMDP and Ga-67-citrate accumulation in cutaneous metastases from colon carcinoma. J Nucl Med 24:1202-1203, 1983 16. Rohatgi PK: Cutaneous localization of Ga-67 in systemic sarcoidosis. Clin Nucl Med 6:109-110, 1981 17. Choy D, Murray IE Ford JC: Gallium scintigraphy in acute panniculitis. J Nucl Med 22:973-974, 1981 18. Winzelberg GG, Rabinowitz J: Whole-body gallium-67citrate scintigraphy in a patient with sarcoidosis and biopsyproven erythema nodosmn. Clin Nucl Med 9:418, 1984 19. Allwright SJ, Chapman PR, Antico VF, et al: Cutaneous gallium uptake in patients with AIDS with Mycobacterium avium intracellulare septicemia. Clin Nucl Med 13:506-508, 1988 20. Lee NK, Salvin JD Jr, Spencer RP, et al: "Speckled" radiogallium images in disseminated Mycobacterium fortuitum skin infection. Clin Nucl Med 17:226-227, 1992 21. Patange V, Cesani F, Phillpott J, et al: Three-phase bone and Ga-67 scintigraphy in disseminated sporotrichosis. Clin Nucl Med 20:909-912, 1995 22. Alexander JE, Seibert J J, Lowe BE: Cutaneous uptake of gallium-67 in polyarteritis nodosa. Clin Nucl Med 12:883-885, 1987 23. Palestro CJ, Chau P, Goldsmith SJ: Gallium-67 uptake after breast and hip augmentation with silicone. Clin Nucl Med 17:897-898, 1992