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Pulmonary tumor embolus with high 18FDG uptake mimicking lung metastasis from renal-cell cancer
Embolia pulmonar tumoral con alta captación de 18FDG imitando metástasis pulmonar de cáncer de células renales
Giovanni Leuzzi
, Enrico Melis, Daniele Forcella, Francesco Facciolo
Corresponding author
Department of Surgical Oncology, Thoracic Surgery Unit, Regina Elena National Cancer Institute, IFO, Rome, Italy
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Resected paraganglioma in left mastoid lesion. (A) SPECT with <span class="elsevierStyleSup">111</span>In-octreotide showing left nodular lesion with high expression of SSR; (B) MR: lesion in the anterior wall of the tympanic cavity which does not differentiate between residual tissue, recurrence or scar tissue; (C) fused images of SPECT-MR. Characterization of persistent post-surgical tumour tissue.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Castillo-Berrio, M. Castrillón, F. Zelaya, D. Ruíz, F. Loira, J.M. Nogueiras, A. López, R. Guitián, J. Outomuro, A. Serena, L.M. Campos" "autores" => array:11 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Castillo-Berrio" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Castrillón" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Zelaya" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Ruíz" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Loira" ] 5 => array:2 [ "nombre" => "J.M." 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Due to macroscopic infiltration of the arterial posterior wall, a left lower lobectomy was carried out in order to obtain a radical resection. Final pathology was consistent with tumor embolus from RCC.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 60-year-old Caucasian man referred to our Department for chest pain and dry cough from 15 days. His medical history was unremarkable with the exception of renal-cell cancer (RCC) diagnosed and resected six months earlier by a right radical nephrectomy. Few days before the admission, a whole body <span class="elsevierStyleSup">18</span>FDG positron emission tomography (PET-CT) scan was performed: nuclear images evidenced a left hilar hyper-metabolism (SUV max 6.7) suggestive of intrapulmonary recurrence (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A–C). After the admission, due to symptoms aggravation, a contrast-enhanced computed tomography (CT) scan was carried out disclosing a hyper-vascularized solid nodule (measuring 19<span class="elsevierStyleHsp" style=""></span>mm in the major axis) localized into the left inferior pulmonary artery and with extension through the lingular artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D), consistent with tumor embolus. After a multidisciplinary meeting, the patient underwent surgery in order to obtain immediate arterial desobstruction. Intra-operatively, an infiltration of the vascular posterior wall was disclosed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) so the patient underwent a left lower lobectomy for radical intent without complication. Final pathology was consistent with RCC embolus. No evidence of recurrence was found at 1 year of follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In literature, thrombosis in cancer patients is usually reported, while tumor thrombosis is very uncommon. As a rule, such complication may develop in patients with tumors arising from liver, pancreas, kidney and colon as a result of direct infiltration of vena cava or other major vessels.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this setting, discrimination between regular and tumor thrombus is a challenging clinical issue in RCC patients<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> because of the different treatments proposed (antithrombotic therapy vs endovascular/surgical removal). PET-CT has been evaluated by others in the assessment of embolism, however, due to low sensitivity rate reported, its utility for metastases identification is still controversial in RCC.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">According to these findings and to the case we presented, we believe that contrast-enhanced CT scan may be more sensitive in diagnosing lung tumor embolism. When this condition is suspected, radiological (CT-scan) and nuclear (PET-CT) imaging should be jointly employed in order to obtain a more accurate evaluation in RCC patients and to distinguish between benign or malignant thrombus and lung metastases. Furthermore, a thromboarteriectomy (and pulmonary resection if vascular infiltration is evidenced) is mandatory to perform oncological and vascular treatment simultaneously.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-21" "fechaAceptado" => "2014-12-16" "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3051 "Ancho" => 1658 "Tamanyo" => 437233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Whole body PET-CT performed 1<span class="elsevierStyleHsp" style=""></span>h after the administration of 296<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">18</span>FDG: the images evidenced an increased uptake of a round-shaped solid nodule localized in the left pulmonary hilum (SUV max 6.7). No sign of mediastinal or extra-thoracic disease was disclosed. (D) Contrast-enhanced CT scan performed after patient's admission: CT slice showed a hyper-vascularized solid nodule (measuring 19<span class="elsevierStyleHsp" style=""></span>mm in the major axis) localized into the left inferior pulmonary artery and with extension through the lingular artery. Based on nuclear and radiological imaging, a diagnosis of tumor thrombus was achieved.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1246 "Ancho" => 1660 "Tamanyo" => 490579 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intraoperative findings: after arteriotomy of the lower pulmonary artery, an attempt to remove the thrombus was performed. Due to macroscopic infiltration of the arterial posterior wall, a left lower lobectomy was carried out in order to obtain a radical resection. Final pathology was consistent with tumor embolus from RCC.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malignancies, prothrombotic mutations, and the risk of venous thrombosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.W. Blom" 1 => "C.J. Doggen" 2 => "S. Osanto" 3 => "F.R. Rosendaal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.293.6.715" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2005" "volumen" => "293" "paginaInicial" => "715" "paginaFinal" => "722" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15701913" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Positron emission tomography-computed tomography imaging characteristics of an inferior vena cava tumor thrombus with magnetic resonance imaging correlation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.N. Rydberg" 1 => "G.S. Sudakoff" 2 => "R.S. Hellman" 3 => "W.A. See" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Comput Assist Tomogr" "fecha" => "2004" "volumen" => "28" "paginaInicial" => "517" "paginaFinal" => "519" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15232383" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Positron emission tomography enhancing tumor thrombus in patient with renal cell carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Snow" 1 => "D. Cohen" 2 => "W.C. Chapman" 3 => "R.L. Grubb 3rd" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urology.2008.08.463" "Revista" => array:6 [ "tituloSerie" => "Urology" "fecha" => "2009" "volumen" => "73" "paginaInicial" => "270" "paginaFinal" => "271" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18950838" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22538089/0000003400000005/v1_201508130058/S2253808915000841/v1_201508130058/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/22538089/0000003400000005/v1_201508130058/S2253808915000841/v1_201508130058/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808915000841?idApp=UINPBA00004N" ]
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