CASE REPORT Year : 2023  |  Volume : 38  |  Issue : 1  |  Page : 50-52  

18F-Fluorodeoxyglucose positron emission tomography/computed tomography scan findings in a rare case of subcutaneous panniculitis-like T-Cell lymphoma

Madan Gopal Vishnoi1, Anurag Jain2, Amit Sharma1, Rajan Kapoor3, Abhishek Mahato2, Awadhesh Tiwari2
1 Department of Nuclear Medicine, Command Hospital Eastern Command, Kolkata, West Bengal, India
2 Department of Nuclear Medicine, Command Hospital Central Command, Lucknow, Uttar Pradesh, India
3 Department of Hemato-Oncology, Command Hospital Eastern Command, Kolkata, West Bengal, India

Date of Submission09-May-2022Date of Acceptance08-Aug-2022Date of Web Publication24-Feb-2023

Correspondence Address:
Dr. Anurag Jain
Department of Nuclear Medicine, Command Hospital Central Command, Lucknow, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0972-3919.370417

   Abstract 

Skin lymphomas are less common and subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a fairly rare subtype of primary cutaneous lymphoma. Skin lymphomas involve subcutaneous adipose tissues with no involvement of lymph nodes. Diagnosis of these cases is generally a challenge to clinicians. These cases present with fever, weight loss, and local discomfort in the region of involvement of subcutaneous tissues and sometime with skin eczema and rashes. Positron emission tomography/computed tomography (PET/CT) scan can guide in determining the extent of involvement being whole-body imaging and can guide the site of biopsy and can help to prevent misdiagnosis. It also helps in correct and early diagnosis and successful treatment. We report a case of a young adult who presented with pyrexia of unknown origin in which PET/CT scan revealed mildly fluorodeoxyglucose-avid diffuse subcutaneous panniculitis involving the whole body, trunk, and extremities. Biopsy was taken from the most appropriate site according to the PET/CT scan report and reported as SPTCL.

Keywords: 18F-fluorodeoxyglucose positron emission tomography/computed tomography, pyrexia of unknown origin, subcutaneous panniculitis

How to cite this article:
Vishnoi MG, Jain A, Sharma A, Kapoor R, Mahato A, Tiwari A. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography scan findings in a rare case of subcutaneous panniculitis-like T-Cell lymphoma. Indian J Nucl Med 2023;38:50-2
How to cite this URL:
Vishnoi MG, Jain A, Sharma A, Kapoor R, Mahato A, Tiwari A. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography scan findings in a rare case of subcutaneous panniculitis-like T-Cell lymphoma. Indian J Nucl Med [serial online] 2023 [cited 2023 Feb 25];38:50-2. Available from: https://www.ijnm.in/text.asp?2023/38/1/50/370417    Introduction 

Gonzalez et al described a new type of T-cell lymphoma with clinicopathologic features simulating a panniculitis, in year 1991 which was often associated with an aggressive clinical course. Under the term subcutaneous panniculitis-like T-cell lymphoma (SPTL), which is rare form of skin lymphoma and this new condition was included subsequently as a distinct disease entity in the World Health Organization (WHO) classification. Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) preferentially infiltrates the subcutaneous adipose tissue. It was categorized as a type of mature T-cell and natural killer cell lymphoma in year 2008. We report a young male who presented with multiple subcutaneous lesions and was diagnosed with SPTCL.[1],[2]

   Case Report 

A 24-year-old male presented with facial puffiness, chest wall heaviness, and fever. On evaluation, contrast-enhanced computed tomography (CECT) abdomen revealed hepatosplenomegaly, minimal ascites, diffuse subcutaneous thickening, and fat stranding in the abdominal wall; CECT chest revealed subcutaneous edema in the anterior chest wall and splenomegaly. Biochemical investigations showed increased inflammatory markers like raised lactate dehydrogenase, ferritin, Creactive protein was positive with mild transaminitis, (Erythrocyte sedimentation rate) ESR – 22 mm in 1st hour, raised Immunoglobulin G (Ig G), and Ddimer was positive. Anti Nuclear antibody/peri nuclear antineutrophil cytoplasmic antibody/Anti neutrophil cytoplasmic antibody (ANA/pANCA/cANCA) were negative; serum procalcitonin was – 2.72ng/ml, (Rheumatoid Arthritis factor) RA factor was negative. Bone marrow studies were carried out which showed myeloid preponderance with left shift. Reverse transcriptionpolymerase chain reaction test for COVID-negative. In view of no definitive diagnosis of fever (pyrexia of unknown origin), the patient was subjected to 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT which reveals diffuse subcutaneous panniculitis involving the whole body with hepatosplenomegaly and diffuse bone marrow uptake [Figure 1]. Skin biopsy was taken from most metabolic active subcutaneous thickening in the anterior chest wall which reveals subcutaneous panniculitis-like T-cell lymphoma (SPTCL). Patient treated with Hemophagocytic Lymphohistiocytosis (HLH)-2004 protocol with steroid, etoposide, dexamethasone, and cyclosporine. Four weeks post initial treatment follow-up, PET/CT scan reveals minimal subcutaneous fat stranding in the anterior chest wall with a metabolic resolution of preexisting diffuse subcutaneous panniculitis involving the whole body [Figure 2]. There was a resolution of diffusely FDG-avid subcutaneous fat stranding and normalization of marrow uptake as well.

Figure 1: MIP, sagittal, coronal, and axial images of the thorax region show diffuse subcutaneous panniculitis involving the whole body both trunk and extremities. MIP: Maximum intensity projection

Click here to view

Figure 2: MIP, sagittal, coronal, and axial images of the thorax region show metabolic resolution of diffuse subcutaneous panniculitis (posttreatment) involving the whole body. MIP: Maximum intensity projection

Click here to view

   Discussion 

SPTCL is a rare subtype of primary cutaneous lymphoma, it is about <1% of all cutaneous lymphomas.[3] It is a subtype of T-cell lymphoma, which mimics panniculitis.[1] SPTCL was considered a distinct entity in 2008 update of the World Health Organization-European Organization for Research and Treatment of Cancer classification.[2] Subcutaneous adipose tissue involvement is the main clinical feature of SPTCL.[4] There were no typical imaging features found in CT, ultrasound, and magnetic resonance imaging.[5],[6] 18F-FDG PET/CT is useful in providing the burden of tumor, detecting disease extent, and staging of SPTCL.[7]

SPTCL involves subcutaneous fat and presents as panniculitis.[8] SPTLC commonly presents in young adults with a reported median age of 36-year. Patients usually present with fever, weight loss, skin discomfort, and rarely with eczema and skin rashes.[9] Given the rarity of the condition, diagnosis is generally challenging.

   Conclusion 

18F-FDG PET/CT demonstrates to be valuable in detecting disease extent, providing diagnostic work-up, staging, and monitoring treatment response for patients with SPTCL. 18F-FDG PET/CT scan can also guide the most appropriate site for a skin biopsy.

SPTCL is a rare and distinct clinicopathological condition. It has a protracted clinical course and presents as recurrent panniculitis. It has a favorable prognosis. Awareness of these types of rare clinical conditions facilitates early diagnosis and appropriate management of these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

   References 
1.Gonzalez CL, Medeiros LJ, Braziel RM, Jaffe ES. T-cell lymphoma involving subcutaneous tissue. A clinicopathologic entity commonly associated with hemophagocytic syndrome. Am J Surg Pathol 1991;15:17-27.  
    2.Willemze R, Cerroni L, Kempf W, Berti E, Facchetti F, Swerdlow SH, et al. The 2018 update of the WHO-EORTC classification for primary cutaneous lymphomas. Blood 2019;133:1703-14.  
    3.Incidence patterns in the United States: A population based study of 3884 cases by Porcia T. Bradford, Susan S. Devesa, William F. Adenson and Jorge R.Toro; Blood 2009;13:5064-73.  
    4.Hoque SR, Child FJ, Whittaker SJ, Ferreira S, Orchard G, Jenner K, et al. Subcutaneous panniculitis-like T-cell lymphoma: A clinicopathological, immunophenotypic and molecular analysis of six patients. Br J Dermatol 2003;148:516-25.  
    5.Levine BD, Seeger LL, James AW, Motamedi K. Subcutaneous panniculitis-like T-cell lymphoma: MRI features and literature review. Skeletal Radiol 2014;43:1307-11.  
    6.Kang BS, Choi SH, Cha HJ, Jung YK, Lee JH, Jeong AK, et al. Subcutaneous panniculitis-like T-cell lymphoma: US and CT findings in three patients. Skeletal Radiol 2007;36 Suppl 1:S67-71.  
    7.Jiang M, Zhao L, Zheng J, Zhang J, Chen P, Zhou W. Report of eleven patients of subcutaneous panniculitis-like T-cell lymphoma: Clinicopathologic features, 18F-FDG PET/CT findings and outcome. Front Oncol 2021;11:650822.  
    8.Jaffe ES, Gaulard P, Ralfkiaer E, Cerroni L, Meijer CJ. Subcutaneous panniculitis-like T-cell lymphoma. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., editors. World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues, World Health Organization Classification of tumors. 4th ed. Lyon, France: IARC Press; 2008. p. 294-5.  
    9.Willemze R, Jansen PM, Cerroni L, Berti E, Santucci M, Assaf C, et al. Subcutaneous panniculitis-like T-cell lymphoma: Definition, classification, and prognostic factors: An EORTC Cutaneous Lymphoma Group Study of 83 cases. Blood 2008;111:838-45.  
    
  [Figure 1], [Figure 2]