Presentation
History of Hodgkin lymphoma. On follow-up.
Patient Data
The PET-CT scan revealed a nodular increased capitation in the left sacrum. The remainder of the exam was unremarkable.
No destructive sacral alar lesion identified to account for the increased uptake seen at this sites on PET; could the change be due to degenerative change at this level?
Technique: Multiplanar multisequence imaging including contrast enhanced images.
Findings: There is transitional lumbosacral anatomy, and the highest complete sacral level has been designated S1. There is clearly an abnormal marrow infiltrate in the left half of the S1, extending medially to reach the midline and extending superiorly into the left transverse process of L5 and inferiorly into S2 ala. Extraosseous extension involves the left S1 posterior foramina, and the interosseous portion of the upper sacroiliac joints. There are abnormal left common and external hilar lymph nodes consistent with lymphoma. No sacroiliitis.
Conclusion: Findings compatible with lymphoma involving the sacrum. The extent of disease appears slightly greater than demonstrated on the PET scan. This is straightforward to biopsy under CT guidance, if required.
CT Guided Left Sacral Biopsy: The procedure and possible complications were explained to the patient and informed consent was obtained. CT guidance was used for the biopsy. The biopsy was performed using sterile techniques. Lignocaine local anesthetic and IV Fent6anyl 75ug were administered. Three bone biopsies of the left sacral ala were performed with two specimens obtained. There were no immediate complications. The patient was recovered in the Radiology Department day ward.
MACROSCOPIC DESCRIPTION: "Left sacral ala": Two cores of pale tan tissue 11 and 17mm in length and up to 2mm in diameter. A1. (SLS)
MICROSCOPIC DESCRIPTION: Sections show two cores of bone, including periosteum, cortex and medullar. The marrow space is replaced by fibrosis and a polymorphous infiltrate of Hodgkin's cells, lymphocytes and eosinophils. Crush artifact is prominent in many areas. Immunostains confirm that there are numerous CD15+, CD30+, MUM-1+ Hodgkin's cells in a background of numerous CD3+ small T-cells and some CD20+, CD79a+ small B-cells, often in dense sheets. There is no staining for EMA.
DIAGNOSIS: Biopsy of left sacral ala: Classical Hodgkin lymphoma, nodular sclerosis type.
Case Discussion
This case illustrates how a subtle bone lesion identified on the PET-CT was managed with other radiology imaging modalities and finally assessed with a CT-guided bone biopsy, which confirmed the lymphoma recurrence.
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