Interesting images
Giant cardiac tumour thrombus on staging contrast enhanced 18F-FDG PET/CT in a case of non-Hodgkin's lymphoma
Trombo tumoral gigante cardíaco en la estadificación por 18F-FDG PET/TC con contraste endovenoso en un caso de linfoma no Hodgkin
S. Jeph
, K. Thakur, S.A. Shamim, K. Verma, B. Aggarwal, A. Aggarwal
Corresponding author
Department of Radiology and PET/CT, Diwan Chand Aggarwal Imaging and Research Centre, New Delhi, India
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No signs suggestive of chemical alteration of the quality of the radiopharmaceutical such as free <span class="elsevierStyleSup">99m</span>Tc (gastric uptake) or reduced/hydrolyzed <span class="elsevierStyleSup">99m</span>Tc (hepatosplenic uptake) can be seen. (B) Coronal section of the abdominopelvic CT showing a large calcified mass in the peritoneal omentum fat (white arrows). (C) and (D) CT transaxial sections showing smaller calcified masses in the left iliac fossa and Douglas pouch (white arrows), consistent with the scintigraphic findings.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C.A. Achury, A. Domènech, L.L. Geraldo, J. Duch, I. Carrió, A. Flotats" "autores" => array:6 [ 0 => array:2 [ "nombre" => "C.A." "apellidos" => "Achury" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Domènech" ] 2 => array:2 [ "nombre" => "L.L." "apellidos" => "Geraldo" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Duch" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Carrió" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Flotats" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S2253654X14000651" "doi" => "10.1016/j.remn.2013.12.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X14000651?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808914000482?idApp=UINPBA00004N" "url" => "/22538089/0000003300000005/v1_201408200020/S2253808914000482/v1_201408200020/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Interesting images</span>" "titulo" => "Giant cardiac tumour thrombus on staging contrast enhanced <span class="elsevierStyleSup">18</span>F-FDG PET/CT in a case of non-Hodgkin's lymphoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "328" "paginaFinal" => "329" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Jeph, K. Thakur, S.A. Shamim, K. Verma, B. Aggarwal, A. Aggarwal" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Jeph" "email" => array:1 [ 0 => "suniljeph@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "K." "apellidos" => "Thakur" ] 2 => array:2 [ "nombre" => "S.A." "apellidos" => "Shamim" ] 3 => array:2 [ "nombre" => "K." "apellidos" => "Verma" ] 4 => array:2 [ "nombre" => "B." "apellidos" => "Aggarwal" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Aggarwal" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Radiology and PET/CT, Diwan Chand Aggarwal Imaging and Research Centre, New Delhi, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombo tumoral gigante cardíaco en la estadificación por <span class="elsevierStyleSup">18</span>F-FDG PET/TC con contraste endovenoso en un caso de linfoma no Hodgkin" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 622 "Ancho" => 1500 "Tamanyo" => 146211 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET/CECT images obtained for staging. PET/CECT showing multiple focal areas of intense <span class="elsevierStyleSup">18</span>F-FDG uptake at various lymph node sites (<span class="elsevierStyleItalic">dashed arrows</span>) with a large <span class="elsevierStyleSup">18</span>F-FDG avid intra-cardiac tumour thrombus (<span class="elsevierStyleItalic">solid arrows</span>) demonstrated in PET MIP (maximum intensity projection) image (A) and PET coronal images (D, E). The mass is also appreciated on CECT images (B, C) and better seen on fused PET/CECT images (F, G). Hence, <span class="elsevierStyleSup">18</span>F-FDG PET/CECT is useful to identify and differentiate tumour thrombus from venous thrombus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 42-year-old man presented with on and off fever for 2–3 months, cough, chest pain, breathlessness and headache. On chest X-ray there was bilateral pleural effusion. A month later he developed cervical lymphadenopathy. Fine needle aspiration cytology from right cervical lymph node was inconclusive twice. On further work-up serum LDH levels were raised (1279.0<span class="elsevierStyleHsp" style=""></span>U/L; normal <240<span class="elsevierStyleHsp" style=""></span>U/L). <span class="elsevierStyleSup">18</span>F-Fluorodeoxyglucose (<span class="elsevierStyleSup">18</span>F-FDG) positron emission tomography/contrast enhanced computed tomography (PET/CECT) was performed to look for any focus of infection/mitotic aetiology. PET/CECT revealed hypermetabolic bilateral cervical, mediastinal and abdominal lymph nodes, bilateral pleural and pericardial effusion. In addition, also noted was a giant <span class="elsevierStyleSup">18</span>F-FDG avid (SUVmax<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21.2) thrombus in the right atrium and superior vena cava. Based on <span class="elsevierStyleSup">18</span>F-FDG PET/CECT findings, a presumptive diagnosis of lymphoproliferatve disorder with tumour thrombosis in the right atrium and superior vena cava was made. Excision biopsy from cervical lymph node and histopathology revealed non-Hodgkin's lymphoma (NHL). The patient was started on chemotherapy and he showed symptomatic improvement in 2 weeks. Echocardiography was performed 3 weeks later and it revealed significant reduction in size of the intra-cardiac thrombus. The patient received 7 cycles of combination chemotherapy including cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP). CECT performed 2 months later showed marked reduction in the size of the tumour thrombus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Unlike bland, venous thromboembolism (VTE) thrombus, tumour thrombus is a rare complication and is seen in solid cancers including renal cell carcinoma, Wilms’ tumour, testicular tumour, adrenal cortical carcinoma, lymphoma, pancreatic cancer, osteosarcoma and Ewing's sarcoma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In patients with advanced stage NHL, the incidence of VTE is high, but tumour thrombus is very rare. Rare cases of tumour thrombus in NHL have been reported with CECT,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but none on PET/CECT. PET/CECT has a very useful role in differentiating tumour thrombus from VTE owing to complementary functional information provided by PET/CECT. A SUV max cut-off of 3.63 has been suggested to differentiate tumour thrombus from benign VTE with reasonable certainty in a mixed population of tumours.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Whether the same cut-off is suitable for all types of tumours needs further evaluation. In the patient studied, a giant tumour thrombus was incidentally discovered on PET/CECT and it was characterised as such. Early recognition of this rare complication by PET/CECT is important to change the management plan and prevent unnecessary long-term anti-coagulation therapy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Also, it can be fatal if not managed appropriately in time. The incidence of thrombosis is high in patients suffering from malignancy. <span class="elsevierStyleSup">18</span>F-FDG PET/CECT can play a very important role in detecting tumour thrombus in oncology patients. As, PET/CECT is routinely used for evaluation of cancer patients, it can be used for assessment and characterisation of thrombosis in this population.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-28" "fechaAceptado" => "2013-10-03" "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 622 "Ancho" => 1500 "Tamanyo" => 146211 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET/CECT images obtained for staging. PET/CECT showing multiple focal areas of intense <span class="elsevierStyleSup">18</span>F-FDG uptake at various lymph node sites (<span class="elsevierStyleItalic">dashed arrows</span>) with a large <span class="elsevierStyleSup">18</span>F-FDG avid intra-cardiac tumour thrombus (<span class="elsevierStyleItalic">solid arrows</span>) demonstrated in PET MIP (maximum intensity projection) image (A) and PET coronal images (D, E). The mass is also appreciated on CECT images (B, C) and better seen on fused PET/CECT images (F, G). Hence, <span class="elsevierStyleSup">18</span>F-FDG PET/CECT is useful to identify and differentiate tumour thrombus from venous thrombus.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Detection of tumour thrombus by 18F-FDG-PET/CT imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Lai" 1 => "J.B. Bomanji" 2 => "S. Mahmood" 3 => "N. Nagabhushan" 4 => "R. Syed" 5 => "S. Gacinovic" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.cej.0000220641.46470.77" "Revista" => array:6 [ "tituloSerie" => "Eur J Cancer Prev" "fecha" => "2007" "volumen" => "16" "paginaInicial" => "90" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17220710" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malignant lymphoma with tumor thrombus in the portal venous system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Matsumoto" 1 => "H. Mori" 2 => "H. Takaki" 3 => "F. Ishitobi" 4 => "R. Shuto" 5 => "S. Yokoyama" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00261-003-0138-3" "Revista" => array:6 [ "tituloSerie" => "Abdom Imaging" "fecha" => "2004" "volumen" => "29" "paginaInicial" => "460" "paginaFinal" => "462" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15024520" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "18F-FDG PET-CT in the diagnosis of tumor thrombus: can it be differentiated from benign thrombus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Sharma" 1 => "R. Kumar" 2 => "S. Jeph" 3 => "S. Karunanithi" 4 => "N. Naswa" 5 => "A. Gupta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MNM.0b013e32834774c8" "Revista" => array:6 [ "tituloSerie" => "Nucl Med Commun" "fecha" => "2011" "volumen" => "32" "paginaInicial" => "782" "paginaFinal" => "788" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21799368" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22538089/0000003300000005/v1_201408200020/S2253808914001049/v1_201408200020/en/main.assets" "Apartado" => array:4 [ "identificador" => "7927" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Interesting images" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22538089/0000003300000005/v1_201408200020/S2253808914001049/v1_201408200020/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808914001049?idApp=UINPBA00004N" ]
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