Diagnostic challenges in assessing treatment responds of primary bone lymphoma: A case report

Arlene Angelina; Kharisma Kusumahstuti; Budi Darmawan; Basuki Hidayat

doi:10.69863/dim.2025.e570

Authors

Arlene Angelina Department of Nuclear Medicine and Molecular Theragnostics, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia; Department of Nuclear Medicine and Molecular Theragnostics, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
Kharisma Perdani Kusumahstuti Department of Nuclear Medicine and Molecular Theragnostics, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia; Department of Nuclear Medicine and Molecular Theragnostics, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
Budi Darmawan Department of Nuclear Medicine and Molecular Theragnostics, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia; Department of Nuclear Medicine and Molecular Theragnostics, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
Basuki Hidayat Department of Nuclear Medicine and Molecular Theragnostics, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia; Department of Nuclear Medicine and Molecular Theragnostics, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

DOI:

https://doi.org/10.69863/dim.2025.e570

Keywords:

Diffuse large b-cell lymphoma, Technetium Tc 99m Medronate, Technetium Tc 99m Sestamibi, bone neoplasms, radionuclide imaging

Abstract

BACKGROUND: Primary Bone Lymphoma (PBL) is quite difficult to assess treatment responses because of limited access to 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). Therefore, this study intends to highlight one case regarding alternative imaging modalities, such as technetium-99m methylene diphosphonate (99mTc-MDP) and technetium-99m methoxyisobutyl isonitrile (99mTc-MIBI), for activity assessment in tumors as well as their involvement in the marrow.

CASE: A 17-year-old male with persistent pain and swelling in the left knee over one month underwent a bone biopsy that confirmed the diagnosis of Diffuse Large B-Cell Lymphoma (DLBCL) in the tibia. The patient was subjected to chemotherapy using cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), followed by radiotherapy. PET/CT was unavailable; therefore, metabolic tumor evaluation was performed through 99mTc-MDP and 99mTc-MIBI scintigraphy for tumor activity and bone marrow involvement assessment. Bone scintigraphy with 99mTc-MDP showed increased tracer uptake in the proximal left tibia and distal left femur, indicating ongoing tumor activity. These findings were reinforced by the further assessment with 99mTc-MIBI, which confirmed high metabolic activity in these areas. Subsequently, a bone marrow biopsy evidenced infiltrative lymphoblasts constituting 24.8 percent infiltrating the involved marrow space, thus confirming the bone marrow being infiltrated. Hence, this patient received additional rituximab treatment to enhance treatment outcome.

CONCLUSION: This case portrays the difficulties one faces while evaluating the treatment response in Primary Bone Lymphoma (PBL), as well as the role of 99mTc-MDP and 99mTc-MIBI scintigraphy as alternative metabolic imaging modalities in the absence of PET/CT.

References

1. Bindal P, Desai A, Delasos L, et al. Primary Bone Lymphoma: A Case Series and Review of Literature. Case Rep Hematol 2020;2020 (1):4254803. doi: 10.1155/2020/4254803. PMID: 32328322.

2. Jain A, Alam K, Maheshwari V, et al. Primary bone lymphomas-Clinical cases and review of literature. J Bone Oncol 2013;2 (3):132-136. doi: 10.1016/j.jbo.2013.07.003. PMID: 26909283.

3. Kanavos T, Birbas E, Papoudou-Bai A, et al. Primary Bone Lymphoma: A Review of the Literature with Emphasis on Histopathology and Histogenesis. Diseases 2023;11 (1):42. doi: 10.3390/diseases11010042. PMID: 36975591.

4. Papalexis P, Georgakopoulou VE, Keramydas D, et al. Clinical, Histopathological, and Immunohistochemical Characteristics of Predictive Biomarkers of Breast Cancer: A Retrospective Study. Cancer Diagn Progn 2024;4 (3):340-351. doi: 10.21873/cdp.10330. PMID: 38707726.

5. Puranik AD, Dev ID, Rangarajan V, et al. FET PET to differentiate between post-treatment changes and recurrence in high-grade gliomas: a single center multidisciplinary clinic controlled study. Neuroradiology 2025;67 (2):363-369. doi: 10.1007/s00234-024-03495-9. PMID: 39527264.

6. Almuhaideb A, Papathanasiou N, Bomanji J. 18F-FDG PET/CT imaging in oncology. Ann Saudi Med 2011;31 (1):3-13. doi: 10.4103/0256-4947.75771. PMID: 21245592.

7. Glaudemans AW, Signore A. FDG-PET/CT in infections: the imaging method of choice? Eur J Nucl Med Mol Imaging 2010;37 (10):1986-1991. doi: 10.1007/s00259-010-1587-x. PMID: 20700737.

8. Srivastava MK, Pagala RM, Kendarla V, et al. Technetium-99m methylene diphosphonate bone scan in evaluation of insufficiency fractures - A pictorial assay and experience from South India. World J Nucl Med 2021;20 (4):355-360. doi: 10.4103/wjnm.wjnm_155_20. PMID: 35018150.

9. Tataru OS, Marchioni M, Crocetto F, et al. Molecular Imaging Diagnosis of Renal Cancer Using (99m)Tc-Sestamibi SPECT/CT and Girentuximab PET-CT-Current Evidence and Future Development of Novel Techniques. Diagnostics (Basel) 2023;13 (4):593. doi: 10.3390/diagnostics13040593. PMID: 36832081.

10. Kessler AT, Bhatt AA. Brain tumour post-treatment imaging and treatment-related complications. Insights Imaging 2018;9 (6):1057-1075. doi: 10.1007/s13244-018-0661-y. PMID: 30411280.

11. Wang SS. Epidemiology and etiology of diffuse large B-cell lymphoma. Semin Hematol 2023;60 (5):255-266. doi: 10.1053/j.seminhematol.2023.11.004. PMID: 38242772.

12. Tsukamoto E, Nagashima Y, Nishimura Y, et al. Primary Bone Lymphoma of the Spine: A Case Report Highlighting Diagnostic Complexities and Treatment. Cureus 2024;16 (1):e52524. doi: 10.7759/cureus.52524. PMID: 38371100.

13. Zarghooni K, Bratke G, Landgraf P, et al. The Diagnosis and Treatment of Osteosarcoma and Ewing's Sarcoma in Children and Adolescents. Dtsch Arztebl Int 2023;120 (24):405-412. doi: 10.3238/arztebl.m2023.0079. PMID: 37097079.

14. Khan AQ, Qamar R, Chowdhry M, et al. Extranodal Diffuse Large B-Cell Lymphoma (DLBCL) Presenting as Diffuse Joint Pain: A Diagnostic Dilemma. Indian J Orthop 2023;57 (4):603-607. doi: 10.1007/s43465-023-00831-8. PMID: 37006730.

15. Hussain S, Mubeen I, Ullah N, et al. Modern Diagnostic Imaging Technique Applications and Risk Factors in the Medical Field: A Review. Biomed Res Int 2022;2022 (1):5164970. doi: 10.1155/2022/5164970. PMID: 35707373.

16. Mena E, Choyke P, Tan E, et al. Molecular imaging in myeloma precursor disease. Semin Hematol 2011;48 (1):22-31. doi: 10.1053/j.seminhematol.2010.11.006. PMID: 21232655.

17. Vandecaveye V, Amant F, Lecouvet F, et al. Imaging modalities in pregnant cancer patients. Int J Gynecol Cancer 2021;31 (3):423-431. doi: 10.1136/ijgc-2020-001779. PMID: 33649009.

18. Daldrup-Link HE, Henning T, Link TM. MR imaging of therapy-induced changes of bone marrow. Eur Radiol 2007;17 (3):743-761. doi: 10.1007/s00330-006-0404-1. PMID: 17021706.

19. Crisan G, Moldovean-Cioroianu NS, Timaru DG, et al. Radiopharmaceuticals for PET and SPECT Imaging: A Literature Review over the Last Decade. Int J Mol Sci 2022;23 (9):5023. doi: 10.3390/ijms23095023. PMID: 35563414.

20. Jayarangaiah A, Kemp AK, Theetha Kariyanna P. Bone Metastasis. StatPearls. Treasure Island (FL) with ineligible companies. Disclosure: Alysia Kemp declares no relevant financial relationships with ineligible companies. Disclosure: Pramod Theetha Kariyanna declares no relevant financial relationships with ineligible companies.2025.

21. Askari E, Shakeri S, Roustaei H, et al. Superscan Pattern on Bone Scintigraphy: A Comprehensive Review. Diagnostics (Basel) 2024;14 (19):2229. doi: 10.3390/diagnostics14192229. PMID: 39410633.

22. Jia Z, Deng H. [Preliminary application of 99Tc(m)-MIBI scintigraphy for judgment of bone malignant and benign lesions]. Sichuan da xue xue bao Yi xue ban = Journal of Sichuan University Medical science edition 2007;38 (4):689-692. doi.

23. Hines-Thomas MR, Howard SC, Hudson MM, et al. Utility of bone marrow biopsy at diagnosis in pediatric Hodgkin's lymphoma. Haematologica 2010;95 (10):1691-1696. doi: 10.3324/haematol.2010.025072. PMID: 20494933.

24. Sehn LH, Salles G. Diffuse Large B-Cell Lymphoma. N Engl J Med 2021;384 (9):842-858. doi: 10.1056/NEJMra2027612. PMID: 33657296.

25. Fischer L, Jiang L, Bittenbring JT, et al. The addition of rituximab to chemotherapy improves overall survival in mantle cell lymphoma-a pooled trials analysis. Ann Hematol 2023;102 (10):2791-2801. doi: 10.1007/s00277-023-05385-1. PMID: 37552322.