Original Article
Copyright ©2012 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Nov 28, 2012; 18(44): 6427-6436
Published online Nov 28, 2012. doi: 10.3748/wjg.v18.i44.6427
Diagnostic role of 18F-fluorodeoxyglucose positron emission tomography for follicular lymphoma with gastrointestinal involvement
Masaya Iwamuro, Hiroyuki Okada, Katsuyoshi Takata, Katsuji Shinagawa, Shigeatsu Fujiki, Junji Shiode, Atsushi Imagawa, Masashi Araki, Toshiaki Morito, Mamoru Nishimura, Motowo Mizuno, Tomoki Inaba, Seiyu Suzuki, Yoshinari Kawai, Tadashi Yoshino, Yoshiro Kawahara, Akinobu Takaki, Kazuhide Yamamoto
Masaya Iwamuro, Akinobu Takaki, Kazuhide Yamamoto, Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
Hiroyuki Okada, Yoshiro Kawahara, Department of Endoscopy, Okayama University Hospital, Okayama 700-8558, Japan
Katsuyoshi Takata, Tadashi Yoshino, Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
Katsuji Shinagawa, Department of Hematology and Oncology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
Shigeatsu Fujiki, Department of Internal Medicine, Tsuyama Central Hospital, Tsuyama 708-0841, Japan
Junji Shiode, Department of Internal Medicine, Okayama Saiseikai General Hospital, Okayama 700-8511, Japan
Atsushi Imagawa, Department of Gastroenterology, Mitoyo General Hospital, Kanonji 769-1695, Japan
Masashi Araki, Department of Internal Medicine, Kagawa Rosai Hospital, Marugame 763-8502, Japan
Toshiaki Morito, Department of Anatomic Pathology, Kagawa Rosai Hospital, Marugame 763-8502, Japan
Mamoru Nishimura, Department of Internal Medicine, Okayama Citizens' Hospital, Okayama 700-8557, Japan
Motowo Mizuno, Department of Internal Medicine, Hiroshima City Hospital, Hiroshima 730-8518, Japan
Tomoki Inaba, Department of Gastroenterology, Kagawa Prefectural Central Hospital, Takamatsu 760-8557, Japan
Seiyu Suzuki, Department of Internal Medicine, Sumitomo Besshi Hospital, Niihama 792-8543, Japan
Yoshinari Kawai, Department of Gastroenterology, Onomichi Municipal Hospital, Onomichi 722-8503, Japan
Author contributions: Iwamuro M designed the study, analysised and analyzed the data, and wrote the manuscript; Okada H designed the study; Yoshino T, Takata K, Shinagawa K, Kawahara Y and Takaki A revised the manuscript for important intellectual content; Fujiki S, Shiode J, Imagawa A, Araki M, Morito T, Nishimura M, Mizuno M, Inaba T, Suzuki S, Kawai Y acquainted the data; Yamamoto K final approved the version to be published.
Correspondence to: Masaya Iwamuro, MD, PhD, Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-Ku, Okayama 700-8558, Japan. iwamuromasaya@yahoo.co.jp
Telephone: +81-86-2357219 Fax: +81-86-2255991
Received: June 18, 2012
Revised: August 29, 2012
Accepted: September 12, 2012
Published online: November 28, 2012
Abstract

AIM: To investigate the capacity for 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) to evaluate patients with gastrointestinal lesions of follicular lymphoma.

METHODS: This retrospective case series consisted of 41 patients with follicular lymphoma and gastrointestinal involvement who underwent 18F-FDG-PET and endoscopic evaluations at ten different institutions between November 1996 and October 2011. Data for endoscopic, radiological, and biological examinations performed were retrospectively reviewed from clinical records. A semi-quantitative analysis of 18F-FDG uptake was performed for each involved area by calculating the maximum standardized uptake value (SUVmax). Based on the positivity of 18F-FDG uptake in the gastrointestinal lesions analyzed, patients were subdivided into two groups. To identify potential predictive factors for 18F-FDG positivity, these two groups were compared with respect to gender, age at diagnosis of lymphoma, histopathological grade, pattern of follicular dendritic cells, mitotic rate, clinical stage, soluble interleukin-2 receptor levels detected by 18F-FDG-PET, lactate dehydrogenase (LDH) levels, hemoglobin levels, bone marrow involvement, detectability of gastrointestinal lesions by computed tomography (CT) scanning, and follicular lymphoma international prognostic index (FLIPI) risk.

RESULTS: Involvement of follicular lymphoma in the stomach, duodenum, jejunum, ileum, cecum, colon, and rectum was identified in 1, 34, 6, 3, 2, 3, and 6 patients, respectively. No patient had esophageal involvement. In total, 19/41 (46.3%) patients exhibited true-positive 18F-FDG uptake in the lesions present in their gastrointestinal tract. In contrast, false-negative 18F-FDG uptake was detected in 24 patients (58.5%), while false-positive 18F-FDG uptake was detected in 5 patients (12.2%). In the former case, 2/19 patients had both 18F-FDG-positive lesions and 18F-FDG-negative lesions in the gastrointestinal tract. In patients with 18F-FDG avidity, the SUVmax value of the involved gastrointestinal tract ranged from 2.6 to 17.4 (median: 4.7). For the 18F-FDG-negative (n = 22) and -positive (n = 19) groups, there were no differences in the male to female ratios (10/12 vs 4/15, P = 0.186), patient age (63.6 ± 2.4 years vs 60.1 ± 2.6 years, P = 0.323), presence of histopathological grade 1 vs 2 (20/2 and 17/2, P = 1.000), follicular dendritic cell pattern (duodenal/nodal: 13/5 vs 10/3, P = 1.000), mitotic rate (low/partly high, 14/1 vs 10/3, P = 0.311), clinical stage according to the Ann Arbor system (stages IE and IIE/other, 15/7 vs 15/4, P = 0.499), clinical stage according to the Lugano system (stages I and II-1/other, 14/8 vs 14/5, P = 0.489), soluble interleukin-2 receptor levels (495 ± 78 vs 402 ± 83, P = 0.884), LDH levels (188 ± 7 vs 183 ± 8, P = 0.749), hemoglobin levels (13.5 ± 0.3 vs 12.8 ± 0.4, P = 0.197), bone marrow involvement (positive/negative, 1/8 vs 1/10, P = 1.000), detectability by CT scanning (positive/negative, 1/16 vs 4/13, P = 0.335), and FLIPI risk (low risk/other, 16/6 vs 13/6, P = 0.763), respectively in each case.

CONCLUSION: These findings indicate that it is not feasible to predict 18F-FDG-avidity. Therefore, 18F-FDG-PET scans represent a complementary modality for the detection of gastrointestinal involvements in follicular lymphoma patients, and surveillance of the entire gastrointestinal tract by endoscopic examinations is required.

Keywords: Follicular lymphoma; Gastrointestinal endoscopy; 18F-fluorodeoxyglucose positron emission tomography; Gastrointestinal lymphoma; Duodenal neoplasm