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Usefulness of combined imaging with 68Ga-DOTATOC PET/CT and spleen scintigraphy in differentiating a neuroendocrine tumour of the pancreatic tail from splenic lesions in a patient with posttraumatic splenosis
Utilidad de la imagen combinada de PET/TC con 68Ga-DOTATOC y gammagrafía de bazo para la diferenciación entre tumor neuroendocrino de la cola del páncreas y lesiones esplénicas en un paciente con esplenosis post-traumática
Johanna Maffey-Steffan, Christian Uprimny
, Roy Moncayo, Alexander Stephan Kroiss, Irene Johanna Virgolini
Corresponding author
Department of Nuclear Medicine, Medical University Innsbruck, Austria
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In addition an unclear lesion in the pancreatic tail was found, a distinction between a neuroendocrine tumour and an intrapancreatic splenosis foci was not possible with CT. <span class="elsevierStyleSup">68</span>Ga-DOTATOC PET/CT could not yield a differentiation, showing high tracer accumulation in the pancreatic lesion as well as in the areas of splenosis. However, spleen scintigraphy did not demonstrate an increased tracer uptake in the pancreatic lesion ruling out spleen tissue and rendering the diagnosis of a neuroendocrine tumour very likely.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 52 year-old patient was referred to our clinic for evaluation of a previously diagnosed lesion in the left kidney, highly suspicious for renal cell carcinoma on contrast enhanced CT (ceCT) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> blue arrow), subsequently resected and histologically confirmed as light cell carcinoma. Multiple lesions with contrast enhancement in the abdomen and in the pelvis were found on staging CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> green arrows). As the patient underwent splenectomy due to traumatic rupture of the spleen several years before, these lesions were interpreted as splenosis, a condition occurring in up to 66% of patients after splenectomy because of trauma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> In addition, CT revealed a lesion in the pancreatic tail with a diameter of 19<span class="elsevierStyleHsp" style=""></span>mm, showing similar characteristics as splenic tissue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> red arrow). However, a clear differentiation of another splenic foci and a malignant tumour was not possible.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">As CT could not rule out a neuroendocrine tumour and Chromogranin A was slightly elevated (110.9<span class="elsevierStyleHsp" style=""></span>μg/l) a <span class="elsevierStyleSup">68</span>Ga-DOTATOC PET/CT scan with low-dose CT was performed after the resection of the renal tumour, histologically classified as a clear cell carcinoma, grade II, pT1pN0. Somatostatin receptor imaging with the PET tracer <span class="elsevierStyleSup">68</span>Ga-DOTATOC has been proven to constitute a very sensitive method in the diagnosis of well differentiated neuroendocrine tumours showing higher sensitivity than conventional somatostatin receptor scintigraphy in this indication.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> In our patient the pancreatic lesion revealed a markedly increased tracer accumulation on <span class="elsevierStyleSup">68</span>Ga-DOTATOC-PET/CT with a maximum standardised uptake value (SUV<span class="elsevierStyleInf">max</span>) of 28.9. However, the areas of splenosis also showed a similar tracer uptake with an almost identical SUV<span class="elsevierStyleInf">max</span> of 33.9, measured in the largest lesion in the paragastral region. A final diagnosis was not possible due to the physiologically increased expression of somatostatin receptors in the red pulpa of splenic tissue as can be visualised by somatostatin receptor scintigraphy, sometimes mimicking neuroendocrine tumour lesions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">As a further diagnostic step a <span class="elsevierStyleSup">99m</span>Tc heat-denatured red blood cell SPECT/CT scan was conducted. This method has been proven to establish a very specific exam in the detection of splenosis and accessory spleen<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> and seems to be very helpful in distinguishing pancreatic neuroendocrine tumours from intrapancreatic accessory spleen tissue. MIP image of the patient showed multiple lesions with high tracer uptake in the abdomen (green arrows) corresponding to the known lesions diagnosed as splenosis on diagnostic CT. In contrast the lesion in the pancreatic tail did not demonstrate an increased tracer accumulation (red arrow pointing at the site of the lesion on low-dose CT) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). This finding with markedly elevated somatostatin receptor expression on <span class="elsevierStyleSup">68</span>Ga-DOTATOC PET/CT and negative result on spleen scintigraphy is not compatible with a splenic lesion and consistent with a well differentiated neuroendocrine tumour. Unfortunately no histologic confirmation was available as the patient did not consent to perform a biopsy. However, on a follow-up CT-scan performed 22 months after the base-line the pancreatic lesion increased in size from 16 to 21<span class="elsevierStyleHsp" style=""></span>mm, rendering the diagnosis of a slowly growing malignant tumour very likely, as it is the case in well differentiated neuroendocroine tumours. This case highlights the complementary information obtained from spleen scintigraphy and <span class="elsevierStyleSup">68</span>Ga-DOTATOC PET/CT. Both modalities should be applied in the diagnostic work-up of patients with splenosis and accessory spleens in whom neuroendocrine tumours are suspected prior to biopsy and/or operation.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><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 "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Maffey-Steffan J, Uprimny C, Moncayo R, Kroiss AS, Virgolini IJ. Utilidad de la imagen combinada de PET/CT con 68Ga-DOTATOC y gammagrafía de bazo para la diferenciación entre tumor neuroendocrino de la cola del páncreas y lesiones esplénicas en un paciente con esplenosis post-traumática. Rev Esp Med Nucl Imagen Mol. 2018;37:325–327.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 689 "Ancho" => 1500 "Tamanyo" => 140826 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial images of diagnostic, contrast enhanced CT.</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" => 1097 "Ancho" => 1500 "Tamanyo" => 154537 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Maximum intensity projection (MIP) and fused axial <span class="elsevierStyleSup">68</span>Ga-DOTATOC PET/CT images (low-dose CT).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 666 "Ancho" => 1500 "Tamanyo" => 82584 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Maximum intensity projection (MIP) and fused axial spleen scintigraphy images (SPECT fused with low-dose CT).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Splenosis – important differential diagnosis in splenectomized patients presenting with abdominal masses of unknown origin" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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