British Journal of Radiology (2007) 80, e283-e286
© 2007 British Institute of Radiology
doi: 10.1259/bjr/31280356
Multimodality imaging of direct ureteric involvement in non-Hodgkin's lymphoma using PET/CT, CT urography and antegrade CT pyelography
E Ghersin, MD
1,5
Z Keidar, MD, PhD
2,5
D J Eldad, MD
3,5
R Bar-Shalom, MD
2,5
D Fischer, MD
1 and
S Halachmi, MD
4,5
Departments of 1 Diagnostic Imaging, 2 Nuclear Medicine, 3 Hematology and 4 Urology, Rambam Health Care Campus, B. Rapaport School of Medicine and 5 Technion – Israel Institute of Technology, Haifa, Israel
Correspondence: Eduard Ghersin, MD, Department of Diagnostic Radiology, Rambam Health Care Campus, P.O.B 9602, Haifa 31096, Israel. E-mail: e_ghersin{at}rambam.health.gov.il
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Abstract
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Positron emission tomography/computed tomography (PET/CT), CT urography (CTU) and antegrade CT pyelography (ACTP) findings of ureteric involvement in non-Hodgkin's lymphoma (NHL) are presented. PET/CT performed for restaging in a patient with a 2-year history of Stage 4 NHL showed increased 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG) activity in a distended ureteric segment. CTU and ACTP, performed to further evaluate PET/CT findings, demonstrated diffuse, irregular and concentric thickening of the affected ureteric walls, accompanied by severe irregular narrowing of affected ureteric lumen. Tissue sampling using percutaneous CT-guided biopsy revealed NHL involvement of the ureter. To the best of our knowledge, this is the first report of PET/CT, CTU and ACTP findings of ureteric NHL.
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Introduction
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Ureteric involvement of low-grade non-Hodgkin's lymphoma (NHL), although rare, can impose diagnostic difficulties despite the use of well-established imaging modalities such as intravenous urography and antegrade and retrograde pyelography. To the best of our knowledge, we describe for the first time the value of a multimodality imaging approach — involving positron emission tomography/computed tomography (PET/CT), CT urography (CTU) and antegrade CT pyelography (ACTP) — for the accurate diagnosis, staging and follow-up of NHL involving the ureter.
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Case report
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A 36-year-old man with recurrent Stage 4 NHL was referred to a follow-up PET/CT for restaging after four courses of chemotherapy. PET/CT (Discovery LS; GE Healthcare Technologies, Milwaukee, WI) was performed 90 min after the injection of 555 MBq (15 mCi) 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG). PET/CT demonstrated multiple foci of increased FDG uptake above and below the diaphragm that were localized to enlarged lymph nodes. In addition, an area of linearly increased FDG activity, not previously demonstrated, was depicted in the left abdomen, and was localized by PET/CT to a distended left ureter (Figure 1
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Figure 1. Positron emission tomography/computed tomography (PET/CT) for restaging of recurrent non-Hodgkin's lymphoma (NHL): (a) whole body maximal intensity projection (MIP) PET; (b) transaxial PET; (c) fused PET/CT; and (d) transaxial CT images. The MIP image shows multiple foci of FDG uptake above and below the diaphragm. Linear activity is demonstrated in the left abdomen (solid arrow). Transaxial PET/CT images at the level of the mid-abdomen localize the finding to a distended left ureter (+).
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CTU was further performed to differentiate between increased FDG activity resulting from hydro-ureteronephrosis secondary to a suspected distal ureteric obstruction and that resulting from lymphomatous involvement of the affected ureteric segment. CTU was performed before, as well as 80 s and 480 s after, intravenous contrast material administration with a Brilliance 16-slice CT scanner (Philips Medical Systems, Cleveland, OH) using the following imaging parameters: collimation of 16x1.5 mm; pitch = 0.95; kV = 120; mAs = 300; slice width = 3 mm; increment = 1.5 mm. The non-enhanced scan ruled out urinary tract calculi, whereas the nephrographic and excretory scans showed marked left hydronephrosis and an 11 cm elongated enhancing concentric thickening of the left-middle ureteric segment wall, accompanied by filiform narrowing of the affected ureteric lumen. Retroperitoneal lymphadenopathy was absent (Figure 2).
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Figure 2. (a,b) CT urography: curved multiplanar reformats of the left collecting system and ureter, projected in (a) coronal and (b) sagittal planes, respectively. Note the left hydronephrosis (*) and dilatation of the upper left ureter secondary to moderate concentric thickening of the left-middle ureteric segment wall, accompanied by filiform narrowing of the affected ureteric lumen (solid arrows). Also note the normal opacification of the distal left ureteric lumen, indicating moderate obstruction (dotted arrows). (c,d) Antegrade CT pyelography several months later: curved multiplanar reformats of the left collecting system and ureter, projected in (c) coronal and (d) sagittal planes, respectively. Note the left hydronephrosis (*) owing to progression of the ureteric pathology, with continuous involvement of upper and middle-left ureteric segments, and the more pronounced thickening of the affected ureteric segments wall (solid arrows). Also note the poor opacification of the distal left ureteric lumen, indicating significant obstruction (dotted arrows).
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At this point, the diagnosis of a middle ureteric neoplasm, such as transitional cell carcinoma or lymphoma, was suspected. Although left ureteroscopy confirmed ureteric segmental luminal narrowing, the biopsy findings were non-conclusive for malignancy. Initially, urinary tract decompression was achieved by double J ureteric stent insertion, which was later removed owing to an improvement in urinary obstruction. However, several months later, placement of a left percutaneous nephrostomy catheter was performed because of the recurrence of severe left hydronephrosis.
Additional evaluation with ACTP was accomplished via injection of 20 ml of diluted 30 mg ml–1 non-ionic iodinated contrast material (Iomeron®; Bracco SpA, Milan, Italy) directly into the renal pelvis through the previously placed percutaneous nephrostomy catheter. On CT, using the same imaging parameters as described for the CTU examination, progression of the ureteric pathology with continuous involvement of upper and middle-left ureteric segments was demonstrated (Figure 2
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CT-guided percutaneous true-cut needle biopsy of the affected left ureteric segment wall was performed to obtain definitive histological diagnosis, and indicated the presence of follicular lymphoma infiltrating the muscular and adventitial layers of the ureter. The patient was treated with anti-CD20 monoclonal antibodies (rituximab (Rituxan®; Genentech, Inc, South San Francisco, CA)) with no apparent response. 3 months later, the patient showed enlargement of the lymph nodes in his neck and axilla, and PET/CT revealed pathological uptake above and below the diaphragm. The patient was consulted regarding the decision to undergo salvage therapy with ifosfamide, cisplatinum, etoposide, and dexamethazone for two cycles. Repeated PET/CT revealed partial remission and the patient underwent high-dose carmustine, etoposide, cytarabine and cyclophosphamide (BEAC protocol). The patient was discharged on day 13 following stem cell re-infusion; repeated PET/CT 6 weeks after transplantation revealed complete resolution of the findings, both on the PET and CT components (Figure 3).
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Figure 3. Positron emission tomography/computed tomography (PET/CT) for evaluation after chemotherapy and autologous bone marrow transplantation: (a) whole-body maximal intensity projection (MIP) PET; (b) transaxial PET; (c) fused PET/CT; and (d) transaxial CT images show no foci of abnormal tracer distribution and no evidence of disease. There is no increased uptake in the left ureter, which appears of normal thickness (+). The left kidney is drained using a left percutaneous nephrostomy catheter.
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Discussion
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Ureteric involvement in lymphoma is rare, and has largely been reported in patients with aggressive NHL. When it does occur, it is usually secondary to renal involvement or retroperitoneal lymphadenopathy. Direct ureteric involvement in lymphoma is extremely rare [1–3]. Lymphoma can affect the ureter either by displacement or encasement owing to retroperitoneal adenopathy or lymphomatous masses, or by direct involvement of ureteric tissues [4]. Direct involvement may be subdivided into three subgroups: periureteric, showing infiltration of the adventitia; transmural, with infiltration of the muscularis; and submucosal/mucosal, demonstrating lymphatic spread in the submucosa.
Various well-established imaging modalities such as intravenous urography, as well as antegrade and retrograde pyelography, are commonly used for the diagnosis of ureteric lymphoma. These examinations provide accurate two-dimensional delineation of the affected ureteric lumen; however, they do not depict the ureteric wall and adjacent soft tissues, which can both harbour extensive disease involvement. More recently, various cross-sectional imaging modalities, including CT and MRI, have been introduced for the diagnosis and staging of ureteric lymphoma. These methods allow identification and accurate localization of the affected ureteric segment and adjacent soft tissues, with subsequent accurate staging [1–3, 5].
With the advent of multidetector CT (MDCT) technology, CTU and ACTP are gaining a dominant role as expeditious, robust and comprehensive imaging modalities of the entire urinary system, including the kidneys, collecting systems, ureter and urinary bladder [6–10]. The superior spatial and contrast resolutions of MDCT compared with conventional spiral CT enable accurate diagnosis of various pathological processes, including urolithiasis, renal and uroepithelial masses and congenital anomalies. These imaging modalities enable accurate three-dimensional (3D) anatomical assessment of the ureteric wall and lumen and, in the case of ACTP, can do so even in highly obstructed urinary systems.
Nevertheless, although highly accurate in terms of anatomical delineation, these imaging modalities do not convey any information concerning the metabolic activity of potential ureteric neoplasms. FDG PET and, more recently, PET/CT are well-established functional modalities for the diagnosis and follow-up of various malignancies [11]. Their unique ability to detect and accurately localize malignant lesions, owing to the enhanced glucose metabolism of malignant cells, has proven valuable for the management of cancer patients [12–14]. However, in the context of urinary tract pathology in general and ureteric pathology in particular, increased FDG activity may reflect physiological urine accumulation of the tracer. The differentiation between such physiological uptake and pathological uptake owing to malignant processes can therefore be very difficult, or even impossible, using PET alone. The combination of PET/CT with the accurate 3D depictions of both the ureteric wall and the lumen offered by CTU and ACTP provides specific data for the accurate diagnosis of a malignancy in the urinary tract.
This case report offers, for the first time, a description of direct ureteric involvement by lymphoma using a multimodality imaging approach including dedicated CTU, ACTP and PET/CT. Additionally, this case demonstrates the advantage of a multidisciplinary team of clinicians and imaging physicians in achieving temporary relief of ureteric obstruction, while allowing definitive treatment of NHL with chemotherapy and bone marrow transplantation, to achieve complete remission of ureteric obstruction.
Hence, both clinicians and imaging physicians should be familiar with the potential advantages of such a diagnostic approach, incorporating detailed valuable anatomical and metabolic information of direct ureteric involvement by lymphoma.
Received for publication June 26, 2006.
Revision received August 29, 2006.
Accepted for publication August 31, 2006.
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References
|
|---|
- Hara M, Satake M, Ogino H, Itoh M, Miyagawa H, Hashimoto Y, et al. Primary ureteral mucosa-associated lymphoid tissue (MALT) lymphoma--pathological and radiological findings. Radiat Med 2002;20:41–4.[Medline]
- Hashimoto H, Tsugawa M, Nasu Y, Tsushima T, Kumon H. Primary non-Hodgkin lymphoma of the ureter. BJU Int 1999;83:148–9.[CrossRef][Medline]
- Tozzini A, Bulleri A, Orsitto E, Morelli G, Pieri L. Hodgkin's lymphoma: an isolated case of involvement of the ureter. Eur Radiol 1999;9:344–6.[CrossRef][Medline]
- Winalski CS, Lipman JC, Tumeh SS. Ureteral neoplasms. Radiographics 1990;10:271–83.[Abstract]
- Lebowitz JA, Rofsky NM, Weinreb JC, Friedmann P. Ureteral lymphoma: MRI demonstration. Abdom Imaging 1995;20:173–5.[CrossRef][Medline]
- Caoili EM, Cohan RH, Korobkin M, Platt JF, Francis IR, Faerber GJ, et al. Urinary tract abnormalities: initial experience with multi-detector row CT urography. Radiology 2002;222:353–60.[Abstract/Free Full Text]
- Caoili EM. Imaging of the urinary tract using multidetector computed tomography urography. Semin Urol Oncol 2002;20:174–9.[CrossRef][Medline]
- Chow LC, Sommer FG. Multidetector CT urography with abdominal compression and three-dimensional reconstruction. AJR Am J Roentgenol 2001;177:849–55.[Free Full Text]
- Foley WD. Renal MDCT. Eur J Radiol 2003;45(Suppl 1):S73–8.
- Ghersin E, Brook OR, Meretik S, Kaftori JK, Ofer A, Amendola MA. Antegrade MDCT pyelography for the evaluation of patients with obstructed urinary tract. AJR Am J Roentgenol 2004;183:1691–6.[Abstract/Free Full Text]
- Bar-Shalom R, Valdivia AY, Blaufox MD. PET imaging in oncology. Semin Nucl Med 2000;30:150–85.[CrossRef][Medline]
- Bar-Shalom R, Yefremov N, Guralnik L, Gaitini D, Frenkel A, Kuten A, et al. Clinical performance of PET/CT in evaluation of cancer: additional value for diagnostic imaging and patient management. J Nucl Med 2003;44:1200–9.[Abstract/Free Full Text]
- Kapoor V, McCook BM, Torok FS. An introduction to PET-CT imaging. Radiographics 2004;24:523–43.[Abstract/Free Full Text]
- Messa C, Bettinardi V, Picchio M, Pelosi E, Landoni C, Gianolli L, et al. PET/CT in diagnostic oncology. J Nucl Med Mol Imaging 2004;48:66–75.
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Abstract
Introduction
