Case Author(s): Yungao Ding, M.D., Ph.D. and Keith Fisher, M.D. , 11/15/2000 . Rating: #D3, #Q3
Diagnosis: Lymphoma with inferior vena cava obstruction
Brief history:
73 year old man with retroperitoneal mass found on CT examination being evaluated for bony metastasis
Images:
Anterior and posterior delayed whole-body images of bone scintigraphy
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CT of the upper chest
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CT of the lower chest
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CT of the abdomen
Full history/Diagnosis is available below
Diagnosis: Lymphoma with inferior vena cava obstruction
Full history:
73 year old man presented with three month history of increasing swelling of the lower extremities and the scrotum. CT at another institution demonstrated a retroperitoneal mass. Bone scintigraphy is performed to evaluate for bony metastasis. The patient is also status post left nephrectomy more than ten years ago which was reported as a benign lesion.
Radiopharmaceutical:
21.8 mCi Tc-99m MDP i.v.
Findings:
Bone scintigraphy demonstrates diffuse increased activity in the soft tissue in the lower thorax, abdomen, pelvis and lower extremities. There is increased activity in the left acromioclavicular joint and knees, and mildly increased activity in the right ischium.
CT of the chest and abdomen shows a right retroperitoneal mass with obliteration of the inferior vena cava which was diagnosed as a large cell lymphoma by CT-guided biopsy. There is stranding in the subcutaneous fat of the abdomen and lower thorax due to edema. CT of the upper thorax shows normal subcutaneous fat without edema. A small right pleural effusion is present.
Discussion:
Obstruction of the inferior vena cava by retroperitoneal lymphoma with generalized edema of the lower thorax, abdomen, pelvis and lower extremities results in delayed clearance and persistence of Tc-99m MDP from the soft tissues. The possibility that the increased activity in the soft tissues is due to error/malfunction of gamma camera or data processing can be ruled out based on the fact that there is no abnormal soft tissue activity in the arms positioned at the sides of the abdomen and pelvis. The increased activity in the left acromioclavicular joint and knees is consistent with degerative change. The mildly increased activity in the right ischium may be due to post-traumatic change but no further examination was pursued.
Major teaching point(s):
Venous or lymphatic stasis will cause delayed soft tissue clearance of the radiotracer. Inferior vena caval should be suspected in the presence of an abrupt transition of soft tissue prominance over the chest.
ACR Codes and Keywords:
References and General Discussion of Bone Scintigraphy (Anatomic field:Vascular and Lymphatic Systems, Category:Neoplasm, Neoplastic-like condition)
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Case number: bs123
Copyright by Wash U MO
