INTERESTING IMAGE
Parapharyngeal Ganglioneuroma Detected by
18
F-FDG PET/CT in a Patient With Hodgkin Lymphoma
Wan-Ling Yi, BS,* Tzu-Pai Chen, BS,* Nan-Tsing Chiu, MD,†
Chiang-Shin Liu, DDS,‡ and Yu-Hsuan Lin, MD§||
Abstract: A 38-year-old woman with anterior mediastinal Hodgkin lym-
phoma underwent 18F-FDG PET/CT, revealing abnormal uptake at the left
retrostyloid parapharyngeal space. After chemotherapy, follow-up PET/CT
showed regression of previously avid lesions but not the left retropharyngeal
mass. Subsequent MRI revealed findings suggestive of neurogenic tumor.
Transoral biopsy revealed ganglioneuroma, which is uncommon in the
Downloaded from http://journals.lww.com/nuclearmed by BhDMf5ePHKbH4TTImqenVChdHhRBUo+1HfDwvkZqMKKJ6O4OeS+bk6lNpcXnAxqx on 12/15/2019
parapharyngeal space, although usually of benign nature. This case therefore
highlights the importance of PET/CT in both initial diagnostic screening for
tumor development and posttreatment evaluation of ambiguous lesions.
Key Words: 18F-FDG PET/CT, CT, ganglioneuroma, Hodgkin lymphoma,
MRI, parapharyngeal space
(Clin Nucl Med 2019;44: 240–243)
Received for publication August 21, 2018; revision accepted November 26, 2018.
From the *Medical College of National Cheng Kung University; Departments of
†Nuclear Medicine, and ‡Pathology, National Cheng Kung University Hos-
pital, College of Medicine, National Cheng Kung University, Tainan;
§Department of Otolaryngology, Head and Neck Surgery, Kaohsiung
Veterans General Hospital, Kaohsiung; and ||Departmentof Otolaryngology,
Head and Neck surgery, National Defense Medical Center, Taipei, Taiwan.
Conflicts of interest and sources of funding: none declared.
This manuscript is original and it, or any part of it, has not been previously published;
nor is it under consideration for publication elsewhere.
Authors' contributions: Y.-H.L. had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy of the data
analysis. Concept and design: W.-L.Y., Y.-H.L. Acquisition, analysis, or
interpretation of data: W.-L.Y., T.-P.C., N.-T.C., C.-S.L., Y.-H.L. Drafting the
manuscript: Y.-H.L., W.-L.Y., T.-P.C. Critical revision of the manuscript for
important intellectual content: W.-L.Y., T.-P.C., N.-T.C., C.-S.L., Y.-H.L.
Final approval: W.-L.Y., T.-P.C., N.-T.C., C.-S.L., Y.-H.L.
Correspondence to: Yu-Hsuan Lin, MD, Department of Otolaryngology-
Head and Neck Surgery, Kaohsiung Veterans General Hospital, No 386,
Ta-Chung 1st Road, Kaohsiung City 813, Taiwan, Republic of China.
E-mail: mdlinyh@gmail.com.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0363-9762/19/4403–0240
DOI: 10.1097/RLU.0000000000002444
240 www.nuclearmed.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
REFERENCES
1. Abouzied MM, Crawford ES, Nabi HA. 18F-FDG imaging: pitfalls and arti-
facts. J Nucl Med Technol. 2005;33:145–155.
2. Sugawara Y, Fisher SJ, Zasadny KR, et al. Preclinical and clinical studies of
bone marrow uptake of fluorine-1-fluorodeoxyglucose with or without gran-
ulocyte colony-stimulating factor during chemotherapy. J Clin Oncol. 1998;
16:173–180.
3. Blodgett TM, Ames JT, Torok FS, et al. Diffuse bone marrow uptake on
whole-body F-18 fluorodeoxyglucose positron emission tomography in a pa-
tient taking recombinant erythropoietin. Clin Nucl Med. 2004;29:161–163.
4. Danosos DA, Santos VB, Ruffy ML, et al. Ganglioneuroma of the
parapharyngeal space. Bull N Y Acad Med. 1980;56:616–622.
5. Lonergan GJ, Schwab CM, Suarez ES, et al. Neuroblastoma,
ganglioneuroblastoma, and ganglioneuroma: radiologic-pathologic correla-
tion. Radiographics. 2002;22:911–934.
6. Rodriguez FJ, Folpe AL, Giannini C, et al. Pathology of peripheral nerve
sheath tumors: diagnostic overview and update on selected diagnostic prob-
lems. Acta Neuropathol. 2012;123:295–319.
7. Okamatsu C, London WB, Naranjo A, et al. Clinicopathological characteris-
tics of ganglioneuroma and ganglioneuroblastoma: a report from the CCG
and COG. Pediatr Blood Cancer. 2009;53:563–569.
8. De Bernardi B, Gambini C, Haupt R, et al. Retrospective study of childhood
ganglioneuroma. J Clin Oncol. 2008;26:1710–1716.
9. Sinha P, Sharma SC, Agarwal S, et al. Parapharyngeal ganglioneuroma with
neurofibromatosis: an unusual presentation. Ann Otol Rhinol Laryngol. 2011;
120:769–774.
10. Lu Y, Fox J, Dunphy M. Coincidental presentations of ganglioneuroma and
atypical perforated appendicitis detected by fluorodeoxyglucose positron emis-
sion tomography/computed tomography. Clin Nucl Med. 2009;34:719–721.
11. Miyake M, Tateishi U, Maeda T, et al. A case of ganglioneuroma presenting
abnormal FDG uptake. Ann Nucl Med. 2006;20:357–360.
Clinical Nuclear Medicine • Volume 44, Number 3, March 2019
Clinical Nuclear Medicine • Volume 44, Number 3, March 2019 Parapharyngeal Neuroganglioma and HL

FIGURE 1. Selected whole-body 18F-FDG PET/CT images (A, MIP; B–D, PET; E–G, CT; H–J, fused PET/CT; parapharyngeal lesion
annotated by arrow). A 38-year-old woman was admitted to our hospital with a palpable right upper chest wall mass. There
were no neurological deficits upon initial presentation, and patient underwent chest CT and CT-guided biopsy of mediastinal
mass; histopathology confirmed diagnosis of Hodgkin lymphoma (HL), nodular sclerosis type. Maximal intensity projection
showed abnormal 18F-FDG accumulations of multiple foci across the anterior mediastinum, bilateral lung nodules, and
lymphadenopathies of cervical and thoracic regions (A). PET/CT noted bone marrow positivity despite aspiration revealing
negative, which may be explained by hematopoietic reactions.1–3 Abnormal focal tracer uptake within the left parapharyngeal
space was observed, with SUVmax of 9.55. Additionally, sagittal CT (F) displayed an isodense mass extending from the C2
spinal level to the level of hyoid bone. Ann Arbor staging with Cotswolds modification classified this patient as HL stage IV, and
she was treated with ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) chemotherapy for 4 cycles.

© 2019 Wolters Kluwer Health, Inc. All rights reserved. www.nuclearmed.com 241

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Yi et al Clinical Nuclear Medicine • Volume 44, Number 3, March 2019

FIGURE 2. Posttreatment evaluation of therapeutic response 4 months later with 18F-FDG PET/CT and MRI. Confirmed
regression of most previously visualized lesions, but unexpected increase of FDG uptake (SUVmax 10.64) at left parapharyngeal
space (A). Coronal CT displays a heterogeneously enhanced lesion of irregular contour surrounding the carotid arteries (B) with
associated tumor growth measuring 3.6 to 4 cm. Metabolic profile was further assessed via head and neck MRI, which revealed
a retrostyloid parapharyngeal mass involving the left carotid space. Axial images found lesion to be isointense to hypointense,
with mixed signals on T1- and T2-weighted sequences (C and D, respectively), whereas fat-saturated T1-weighted MRI (E)
revealed heterogeneous enhancement upon contrast administration. The lesion is associated with encasement and
posterolateral displacement of the left carotid arteries, as well as focal internal jugular vein narrowing, suggestive of neurogenic
origin instead of metastatic lymphadenopathy.4

242 www.nuclearmed.com © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Clinical Nuclear Medicine • Volume 44, Number 3, March 2019 Parapharyngeal Neuroganglioma and HL

FIGURE 3. Left oropharyngeal prominence (A, arrow) and hematoxylin-eosin stain (B). Laryngoscopy observed bulging lesion at
level of left oropharynx, with subsequent histopathology revealing characteristic schwannian stroma (star) admixed with
ganglion cells5 (arrow) that stained positive for S-100 and synaptophysin, confirming the diagnosis of maturing-type
ganglioneuroma. The patient decided wait-and-scan approach because of possible adverse events associated with complete
excision.6,7 Ganglioneuroma is a generally benign peripheral neurogenic tumor, with occasional coexistence of neuroblastoma
and/or development of de novo malignant changes.6,7 Located mostly at the mediastinum and retroperitoneal space,
ganglioneuroma within the parapharyngeal space is rare,8,9 with predominance in older patients.6–9 Recent studies have
reported likelihood of 18F-FDG PET/CT possessing mild avidity in ganglioneuroma lesions,10,11 which may be useful in
detecting newly developed neurogenic tumors. Our case of HL coinciding with parapharyngeal ganglioneuroma was only
detected upon PET/CT revealing lack of retropharyngeal lesion regression post-ABVD treatment, thereby highlighting the role
of PET/CT in both initial diagnostic detection of tumors and posttreatment evaluation of ambiguous lesions. Considering
potential PET/CT similarities between ganglioneuroma and HL presentations, the need for additional CT and/or MRI survey for
better identification of second primary disease is further illustrated.

© 2019 Wolters Kluwer Health, Inc. All rights reserved. www.nuclearmed.com 243

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.