|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 3 | Page : 437-438
18F-FDG positron emission tomography scan findings in a case of rituximab-CHOP-induced pneumonitis
N Saini1, V Saini2, V Kumar3, A Bhatia4, S Qazi1
1 Department of Internal Medicine, North Shore Medical Center, Salem, Tamilnadu, India
2 Simches Research Center, Massachusetts General Hospital, Boston, USA
3 Department of Internal Medicine, Pravara Institute of Medical Sciences, Maharashtra, India
4 Department of Medical Oncology, Kimmel Cancer Center, Philadelphia, USA
|Date of Web Publication||18-Feb-2016|
Department of Internal Medicine, North Shore Medical Center, Salem, Tamilnadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Saini N, Saini V, Kumar V, Bhatia A, Qazi S. 18F-FDG positron emission tomography scan findings in a case of rituximab-CHOP-induced pneumonitis. Indian J Cancer 2015;52:437-8
|How to cite this URL:|
Saini N, Saini V, Kumar V, Bhatia A, Qazi S. 18F-FDG positron emission tomography scan findings in a case of rituximab-CHOP-induced pneumonitis. Indian J Cancer [serial online] 2015 [cited 2017 Sep 20];52:437-8. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/437/176738
Rituximab (R) along with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) is safe and effective treatment for patients with Non-Hodgkin's lymphoma. 18F-fluorodeoxyglucose (18F-FDG) Positron emission Tomography (PET)-Computed tomography (CT) has been widely used for staging, disease monitoring, detecting recurrences, and restaging after completion of chemotherapy in patients with lymphoma. Rituximab and cyclophosphamide have both been implicated in the development of interstitial lung disease (ILD) and CT scan is the modality of choice to diagnose ILD. Here, we describe a case with findings of R-CHOP induced ILD through 18F-FDG-PET/CT scan.
A 47-year-old male presented with low-grade intermittent fever, chills and night sweats, and a slowly enlarging and hardening 2 × 3 cm right neck lymph node in the posterior triangle region of 3 months duration. The biopsy of the mass revealed it to be a diffuse large B-cell lymphoma, anaplastic type, with 18F-FDG PET/CT scan showing uptake only in lymph node (Stage - IB) [Figure 1] and [Figure 2]. It was decided to give him four cycles of Rituximab/CHOP therapy followed by consolidation radiation therapy. By the end of the 4th cycle, patient developed fatigue and mild shortness of breath only on exertion. The repeat 18F PET-CT for the restaging showed mild diffuse uptake throughout both the lungs that corresponded to minute ground glass opacities seen on CT scan [Figure 3] and [Figure 4]. This finding was suggestive of chemotherapy-induced ILD.
|Figure 1: Positron emission tomography/Computed tomography scan showing 18F-fluorodeoxyglucose uptake in the lymph node of the right posterior neck before the start of chemotherapy|
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|Figure 2: Positron emission tomography scan showing no uptake of 18F-.fluorodeoxyglucose in the lung parenchyma before the start of the chemotherapy|
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|Figure 3: Repeat positron emission tomography/computed tomography scan after four cycles of R-CHOP shows 'no' uptake of 18F-fluorodeoxyglucose in the right posterior neck after four cycles of R-CHOP|
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|Figure 4: (a) Repeat positron emission tomography/computed tomography scan of chest showing diffuse uptake of 18F-FDG bilaterally in the lung parenchyma after four cycles of R-CHOP; (b) Repeat Positron emission tomography/Computed tomography scan of chest showing diffuse uptake of 18F-FDG bilaterally in the lung parenchyma after four cycles of R-CHOP|
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Given the mild symptomatology and the fact that the patient had finished his chemotherapy treatment, it was decided not to treat with steroids with anticipation of improvement clinically and radio-graphically on watchful waiting. However, the patient's condition deteriorated with progressive shortness of breath at rest and was admitted to hospital 1 week later with fever and increasing oxygen requirements. During the hospitalization, an extensive search for an infection, which included analysis of blood, urine, and bronchioalveolar lavage specimen, yielded negative results. Chest X-ray showed worsening diffuse haziness in the lung parenchyma with no focal infiltrates and a repeat CT scan was not requested as the diagnosis of R-CHOP-induced ILD was evident. Patient was treated with steroid with improvement in a week. A repeat CT scan of the lung after 2 weeks showed resolution of ILD.
It is difficult to ascertain whether rituximab or cyclophosphamide was the causal agent for ILD in our case, however, the addition of rituximab to CHOP regimen has shown increased frequency in pulmonary complications compared to CHOP alone. In our patient, PET/CT scan, which was scheduled for restaging, coincided with the early stages of clinical evolution of ILD. 18F-FDG PET had earlier been shown to detect abnormalities in rituximab-induced pneumonitis earlier than the conventional radiological modalities, possibly due to early detection of the metabolic changes compared to CT scan. This case report illustrates the need for a clinician's attention to possible pulmonary complications during the R-CHOP regimen and the utility of 18F-FDG PET in early detection of findings related to chemotherapy-related ILD.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]