Histiocytic Sarcoma Involving Lymph Nodes
Imaging Appearance on Gallium-67 and F-18 FDG PET/CT
William Makis, MD,* Anthony Ciarallo, MD,† Vilma Derbekyan, MD,† and Robert Lisbona, MD†
Abstract: This report of an 82-year-old man who presented with a 3-week
history of an enlarging left axillary mass and mild fevers, highlights the
usefulness of both gallium-67 and F-18 FDG PET/CT imaging in the staging
of histiocytic sarcoma. While PET/CT was superior in determining the extent
of the disease, gallium can be used to help stage the disease in centers where
PET/CT is not available.
Key Words: histiocytic sarcoma, gallium, FDG, PET/CT, lymph nodes
(Clin Nucl Med 2011;36: e37–e38)
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Received for publication August 13, 2010; revision accepted October 17, 2010.
From the *Department of Nuclear Medicine, Brandon Regional Health Centre,
Brandon, MB, Canada; and †Department of Nuclear Medicine, Royal Victoria
Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
None of the authors have any financial or other relationships that might lead to a
conflict of interest.
This manuscript or any containing figures or tables have not been submitted to any
publication previously. None of the authors have any financial or other
relationships that might lead to a conflict of interest. The manuscript has been
read and approved by all the authors, and the requirements for authorship have
been met. Each author believes that the manuscript represents honest work.
Reprint: William Makis, MD, Department of Nuclear Medicine, Brandon Re-
gional Health, 150 McTavish Ave E, Brandon, MB R7A 2B3, Canada.
Copyright © 2011 by Lippincott Williams & Wilkins
Clinical Nuclear Medicine • Volume 36, Number 6, June 2011 www.nuclearmed.com | e37
FIGURE 1. An 82-year-old man with no prior history of malignancy presented with a 3-week history of a rapidly enlarging left Download full-text
axillary mass. The patient was also complaining of mild fevers for the same duration, but no weight loss or night sweats. He
was referred for a gallium-67 scan for the evaluation of possible lymphoma. A, Upper body gallium-67 images with anterior
and posterior views show intense gallium uptake in the left axilla, and mild uptake in the left supraclavicular region. Lower
body images did not show any gallium-avid abnormalities. B, An F-18 FDG PET/CT (Discovery ST, GE Healthcare, Canada)
was performed on the following day. Maximum intensity projection images with anterior and posterior views, showed
intensely FDG-avid left axillary and supraclavicular lymphadenopathy that was more extensive than on the gallium scan.
Maximum standardized uptake value was 18. Transaxial views of the (C) CT portion of the PET/CT, (D) PET, and (E) PET/CT
fusion images show the extent of the axillary adenopathy. Histopathological evaluation of one of the left axillary lymph nodes
showed tissue whose architecture was effaced by a loose proliferation of very large pleomorphic cells with markedly irregular
nuclei having moderately clumped chromatin, variable nucleoli, and moderate numbers of mitoses. Some had the features of
histiocytic cells with reniform nuclei. Immunohistochemistry revealed positivity of CD45 (on many of the large cells), CD45RO,
and CD68; and negativity of CD20, CD30, CD43, CD56, CD57, CD79a, CD138, CD3, CD5, myeloperoxidase, Mart/Melan,
Alk1, perforin, Keratin AE1/3, CK7, CK20, TTF1, compatible with histiocytic sarcoma (HS). HS is a very rare hematological
neoplasm, comprising ?1% of all non-Hodgkin lymphomas.1World Health Organization defines HS as a malignancy with
morphologic and immunophenotypic features that resemble those of mature tissue histiocytes.2Very few cases of true HS
exist in the literature, as advances in immunohistochemistry have shown that many of the previously identified cases were
other types of non-Hodgkin lymphoma and anaplastic large cell lymphoma.3–5HS can arise in lymph nodes, skin, and at
extranodal sites (particularly the gastrointestinal tract), often presenting with clinically advanced disease and pursuing an
aggressive clinical course. Cases arising primarily at extranodal sites often appear to go unsuspected and unrecognized.6F-18
FDG uptake has been noted in several conditions with histiocytic lineage, including Langerhans cell histiocytosis,7
Erdheim-Chester disease,8juvenile xanthogranuloma (also known as inflammatory pseudotumor),9Rosai-Dorfman disease,10
malignant fibrous histiocytoma,11monocytic leukemia,12and HS.13This is a rare report highlighting the usefulness of
gallium-67 and F-18 FDG PET/CT in staging and determining the extent of HS, and while F-18 FDG PET/CT is superior in
determining the extent of the disease, gallium-67 can be used to help stage the disease in centers where a PET/CT is not
Makis et al
Clinical Nuclear Medicine • Volume 36, Number 6, June 2011
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© 2011 Lippincott Williams & Wilkins