Positive Predictive Value of [18F]FDG PET/CT for the Detection of Bone Marrow Infiltration in Diffuse Large B-Cell Lymphoma: Impact of Focal versus Diffuse Pattern
DOI:
https://doi.org/10.59667/sjoranm.v30i2.14Keywords:
Bone Marrow, Diffuse Large B-Cell LymphomaAbstract
Background: Bone marrow involvement in diffuse large B-cell lymphoma (DLBCL) is a major prognostic factor corresponding to Ann Arbor stage IV disease. While [18F]FDG PET/CT has largely replaced bone marrow biopsy (BMB) in many staging algorithms, the interpretation of bone marrow uptake patterns—particularly focal versus diffuse—remains a clinical challenge.
Purpose: To evaluate the positive predictive value (PPV) of [18F]FDG PET/CT for bone marrow infiltration in DLBCL and to assess the diagnostic impact of focal versus diffuse uptake patterns.
Methods: This retrospective single-center study included 142 newly diagnosed DLBCL patients. Among them, 91 patients with PET-positive bone marrow findings underwent BMB. PET/CT patterns were categorized as focal or diffuse based on uptake relative to hepatic activity. PPV was calculated, and associations between imaging patterns, clinical parameters, and histological confirmation were analyzed.
Results: Bone marrow involvement on PET/CT was observed in 91 patients, with histological confirmation in 67 cases (overall PPV: 73.6%). All patients with focal uptake (18/18) had confirmed marrow infiltration (PPV: 100%), whereas only 49/73 patients with diffuse uptake showed histological involvement (PPV: 67.1%). Focal uptake was strongly associated with confirmed infiltration (OR = 19.5; p = 0.003). In the diffuse pattern subgroup, anemia (OR = 12.5; p < 0.001) and leukopenia (OR = 3.7; p = 0.02) were significantly associated with negative biopsy findings, suggesting reactive bone marrow activation.
Conclusion: [18F]FDG PET/CT demonstrates high predictive value for bone marrow involvement in DLBCL, particularly in the presence of focal uptake. In contrast, diffuse bone marrow hypermetabolism requires cautious interpretation and should be integrated with clinical and biological parameters. These findings support a more selective and individualized approach to bone marrow biopsy in DLBCL staging.
References
1. Alaggio R, Amador C, Anagnostopoulos I, Attygalle AD, Araujo IBO, et al. The 5th edition of the World Health Organization Classification of Haematolymphoid Tumours: Lymphoid Neoplasms. Leukemia. 2022;36(7):1720-1748. doi: 10.1038/s41375-022-01620-2
2. Sehn LH, Salles G. Lymphome diffus à grandes cellules B. N Engl J Med. 2021;384:842–58. doi : 10.1056/NEJMra2027612
3. Connors JM. State-of-the-art therapeutics: Hodgkin's lymphoma. J Clin Oncol. 2005 Sep 10;23(26):6400-8. doi: 10.1200/JCO.2005.05.016.
4. Bain BJ. Bone marrow biopsy morbidity and mortality: 2002 data. Clin Lab Haematol. 2004;26(5):315-8. doi: 10.1111/j.1365-2257.2004.00630.x.
5. Kwee TC, de Klerk JM, Nievelstein RA. Imaging of bone marrow involvement in lymphoma: state of the art and future directions. ScientificWorldJournal. 2011;11:391-402. doi: 10.1100/tsw.2011.40.
6. Hutchings M, Loft A, Hansen M, Pedersen LM, Berthelsen AK, Keiding S, D'Amore F, Boesen AM, Roemer L, Specht L. Position emission tomography with or without computed tomography in the primary staging of Hodgkin's lymphoma. Haematologica. 2006;91(4):482-9.
7. Tilly H, Gomes da Silva M, Vitolo U, Jack A, Meignan M, Lopez-Guillermo A, et al. Diffuse large B-cell lymphoma (DLBCL): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann Oncol. 2015;26:v116. doi: 10.1093/annonc/mdv304
8. Doma, Andrej, et al. "Detection performance and prognostic value of initial bone marrow involvement in diffuse large B-cell lymphoma: a single centre 18F-FDG PET/CT and bone marrow biopsy evaluation study" Radiology and Oncology, vol. 58, no. 1, Association of Radiology and Oncology, 2024, pp. 15-22. doi :10.2478/raon-2024-0004
9. Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. 2014;32(27):3059–3068
10. Alyamany R, El Fakih R, Alnughmush A, Albabtain A, Kharfan-Dabaja MA, Aljurf M. A comprehensive review of the role of bone marrow biopsy and PET-CT in the evaluation of bone marrow involvement in adults newly diagnosed with DLBCL. Front Oncol. 2024 Mar 21;14:1301979. doi: 10.3389/fonc.2024.1301979.
11. Berthet L, Cochet A, Kanoun S, Berriolo-Riedinger A, Humbert O, Toubeau M, et al. In newly diagnosed diffuse large B-cell lymphoma, determination of bone marrow involvement with 18F-FDG PET/CT provides better diagnostic performance and prognostic stratification than does biopsy. J Nucl Med. 2013;54(8):1244-50. doi: 10.2967/jnumed.112.114710.
12. Alderuccio JP, Reis IM, Koff JL, Larson MC, Chihara D, Zhao W, et al. Predictive value of staging PET/CT to detect bone marrow involvement and early outcomes in marginal zone lymphoma. Blood. 2023;141(15):1888-1893. doi: 10.1182/blood.2022019294. P.
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Copyright (c) 2026 Zakaria Ouassafrar, Abdel Amide Gbadamassi, Sophia Berrada, Hafsa Bensimimou, Halima Batani, Nizar Dahmaoui, Cosme Boutros Nato, Meryem Qachouh, Amal Guensi
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