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In total, 102 patients were included in this study, 56 males (54.9%) and 46 females (45.1%). The cohort comprised 88 (86.3%) patients with Ann Arbor stage IV, 0 (0%) with stage III, and 14 (13.7%) with an international prognostic index (IPI) score of 4−5. The median and average ages at onset were 50 and 47 (range, 18–65) years, respectively. The clinical characteristics of the 102 patients with newly treated DLBCL are presented in Table 1.
Clinical characteristics N (%) Age (year) ≥ 60 30 (29.4) Sex Male 56 (54.9) Female 46 (45.1) Ann-Arbor stage I 10 (9.8) II 4 (3.9) III 0 (0) IV 88 (86.3) IPI Score 3 15 (14.7) 4–5 14 (13.7) B symptoms 85 (83.3) ECOG score ≥ 3 38 (37.3) LDH > 250 U/L 79 (77.5) Hans subtype GCB 36 (35.3) Non-GCB 66 (64.7) Ki-67 ≥ 75% 34 (33.3) Blood routine HGB < 100 g/L 48 (47.1) WBC < 4.0 × 109/L 16 (15.7) PLT < 100 × 109/L 27 (26.5) Splenomegaly 32 (31.4) Hepatomegaly 10 (9.8) Lymphadenopathy 92 (90.2) Note. IPI: International prognostic index; ECOG: Eastern cooperative oncology group performance score; LDH: Lactate dehydrogenase; GCB: Germinal center B cell-like; HGB: Hemoglobin; WBC: White blood cell; PLT: Platelet count. Table 1. Clinical baseline characteristics of 102 diffuse large B-cell lymphoma patients
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Among the 102 patients, 21 cases of bone marrow infiltration were detected by initial bone marrow aspiration and biopsy (14 bone marrow smears, 21 immunopathology biopsies, and 18 flow cytometry results). The total detection rate was 20.6% (21/102); the detection rate of bone marrow smears was 13.7% (14/102), biopsy immunopathology was 20.6% (21/102), and flow cytometry was 17.6% (18/102).
Patients with negative bone biopsy results but abnormal metabolic signals on PET/CT underwent a second biopsy of the abnormal bone marrow metabolic sites (Figure 1). Consequently, eight cases of bone marrow infiltration were detected. In total, 29/102 cases of bone marrow infiltration were detected in patients with DLBCL by bone marrow bone marrow aspiration and biopsy (including 20 iliums, 28 biopsy immunopathology, and 24 flow cytometry). The total detection rate of bone marrow infiltration in the combination of the first and second bone marrow aspiration and biopsy was 28.4% (29/102), and the detection rates of bone marrow smear, biopsy immunopathology, and flow cytometry were 19.6% (20/102), 27.5% (28/102), and 23.5% (24/102), respectively.
Figure 1. 18F-FDG PET/CT image of a patient with diffuse large B-cell lymphoma. (A) Maximum intensity projection (MIP)-PET/CT shows an increased FDG uptake in the pelvic cavity and bones. (B) Coronal PET, (C) Coronal CT, (D) Coronal fused PET/CT images show high metabolism in the left anterior superior iliac spine.
A total of 26/102 (25.5%) cases of bone marrow infiltration were detected using PET/CT, and the detection rate was not significantly different from that of the first bone marrow aspiration and biopsy (P = 0.302) or the combination of the two procedures (P = 0.453) (Table 2). However, the detection rate of PET/CT was higher than that of the initial bone marrow smear examination (P = 0.002) (Table 2). Moderate agreement was observed between PET/CT and the first DLBCL bone marrow infiltration (k = 0.587, P < 0.001), while strong agreement was detected between PET/CT and the combination of the two DLBCL bone marrow infiltrations (k = 0.826, P < 0.001).
Detection methods S+T+ S+T- S-T+ S-T- P (McNemar test) Kappa P (Kappa) Total of first bone marrow examination 16 5 10 71 0.302 0.587 < 0.001 Bone marrow smear 13 1 13 75 0.002 0.574 < 0.001 Bone marrow biopsy immunopathology 16 5 10 71 0.302 0.587 < 0.001 Bone marrow flow cytometry 14 4 12 72 0.077 0.541 < 0.001 Combination of the first and second bone marrow examination 24 5 2 71 0.453 0.826 < 0.001 Bone marrow smear 19 1 7 75 0.070 0.777 < 0.001 Bone marrow biopsy immunopathology 23 5 3 71 0.727 0.799 < 0.001 Bone marrow flow cytometry 20 4 6 72 0.754 0.735 < 0.001 Note. S+, Gold standard positive; S-, Gold standard negative; T+, PET/CT positive; T-, PET/CT negative. DLBCL: Diffuse large B-cell lymphoma. Table 2. Comparison of detection rate of DLBCL bone marrow infiltration between biopsy and PET/CT
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Compared to standard first bone marrow aspiration and biopsy, the sensitivity of PET/CT in the diagnosis of DLBCL bone marrow infiltration was 0.615 [95% confidence interval (CI): 0.425−0.776], the specificity was 0.934 (95% CI: 0.855−0.972), and Youden’s index was 0.549 (Table 3). When the first and second bone marrow aspiration and biopsy were combined as the gold standard, the sensitivity, specificity, and Youden’s index of PET/CT were 0.923 (95% CI: 0.759−0.979), 0.934 (95% CI: 0.855−0.972), and 0.857, respectively (Table 3).
Variables S+T+ S+T- S-T+ S-T- Sensitivity
(95% CI)Specificity
(95% CI)Youden’s index First bone marrow examination 16 5 10 71 0.615 (0.425–0.776) 0.934 (0.855–0.972) 0.549 Combination of the first and second bone marrow examination 24 5 2 71 0.923 (0.759–0.979) 0.934 (0.855–0.972) 0.857 Note. S: Diagnosis by DLBCL; T: Diagnosis by PET/CT; DLBCL: Diffuse large B-cell lymphoma. Table 3. Diagnostic efficacy of PET/CT for DLBCL bone marrow infiltration
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A total of 26 patients were diagnosed with bone marrow infiltration by PET/CT according to the ESMO clinical practice guidelines: 23/26 (88.5%) showed focally increased 18FDG uptake and 3/26 (11.5%) showed an increase in diffuse FDG metabolism in the bone marrow throughout the body. Among them, the top three incidence sites of increased focal metabolism were the ilium (21/26), 3−5 lumbar vertebrae (16/26), and femur (8/26), and the lower incidence sites were the sternum (1/26), humerus (1/26), and ribs (1/26). Of the three patients with diffuse FDG metabolism in the whole-body bone marrow, one patient was diagnosed with bone marrow infiltration by two bone biopsies and two patients were diagnosed without bone marrow infiltration (Table 4).
Site and characteristics Cases (%) Focal increased 18FDG uptake 23 (88.5) Focal and systematic diffuse bone marrow 18FDG uptake 3 (11.5) Ilium 2 (80.8) Lumbar vertebra (L3–L5) 16 (61.5) Femur 8 (30.8) Sternum 1 (3.8) Humerus 1 (3.8) Ribs 1 (3.8) Table 4. Distribution and characteristics of bone marrow infiltration sites detected by PET-CT (a total of 26 cases)
Among the 29 patients with DLBCL diagnosed by bone marrow infiltration, 23 showed only focally increased 18FDG uptake, one showed focally increased 18FDG uptake with increased systemic bone marrow diffuse FDG metabolism, two showed only increased systemic bone marrow diffuse FDG metabolism, and three did not show obvious abnormalities in bone marrow FDG metabolism.
Diagnostic Efficacy of 18F-FDG PET/CT in Detecting Bone Marrow Infiltration in Patients with Newly Diagnosed Diffuse Large B-Cell Lymphoma
doi: 10.3967/bes2023.062
- Received Date: 2023-02-07
- Accepted Date: 2023-04-20
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Key words:
- Diffuse large B-cell lymphoma /
- Bone marrow infiltration /
- Positron emission computed tomography (PET/CT) /
- Bone marrow biopsy /
- Diagnostic efficacy
Abstract:
The authors declare that they have no conflict of interest.
&These authors contributed equally to this work.
Citation: | GUO Bo, QIN Ran, GU Zhen Yang, LI Yan Fen, GAO Lei, HUANG Wen Rong. Diagnostic Efficacy of 18F-FDG PET/CT in Detecting Bone Marrow Infiltration in Patients with Newly Diagnosed Diffuse Large B-Cell Lymphoma[J]. Biomedical and Environmental Sciences, 2023, 36(6): 510-516. doi: 10.3967/bes2023.062 |