Interesting images
A rare case of diffuse and bilateral pulmonary uptake in 18F-FDG PET/CT scan
Un caso raro de captación pulmonar difusa y bilateral en 18F-FDG PET/TC
P. Oliván-Sasota,
, R. Sánchez-Vañób, P. Calvillo-Batllésc, J. Belda Ramirezd, P. Bello-Arquesb
Corresponding author
a Servicio de Medicina Nuclear, Hospital Universitario de La Ribera, Alzira, Valencia, Spain
b Servicio de Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, Spain
c Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
d Servicio de Neumología, Hospital Arnau de Vilanova, Valencia, Spain
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Oliván-Sasot, R. Sánchez-Vañó, P. Calvillo-Batllés, J. Belda Ramirez, P. Bello-Arques" "autores" => array:5 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Oliván-Sasot" "email" => array:1 [ 0 => "olivan_pat@gva.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Sánchez-Vañó" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Calvillo-Batllés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J." 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"apellidos" => "Bello-Arques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario de La Ribera, Alzira, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Arnau de Vilanova, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Un caso raro de captación pulmonar difusa y bilateral en <span class="elsevierStyleSup">18</span>F-FDG PET/TC" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 730 "Ancho" => 1750 "Tamanyo" => 126743 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">[<span class="elsevierStyleSup">18</span>F] FDG-PET / CT. A) MIP image (maximum intensity projection) of FDG-PET showing diffuse pulmonary hypermetabolism of decreasing intensity to the bases and homogeneous uptake in axial and extra axial bonerrow. No other significant metabolic findings suggestive of malignancy. B, C and D) Axial, coronal and sagittal plane of fusioned [<span class="elsevierStyleSup">18</span>F]FDG-PET/CT showing extensive areas of bilateral ground glass with predominantly apical radiopharmaceutical avidity (SUVmax 10.8). E, F and G) Axial, coronal and sagittal CT sections: extensive areas of ground glass and consolidations.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 66-year-old male was studied for febrile syndrome without apparent focus for 3 weeks. During his admission, a mild ground glass infiltrate appeared on the chest computed tomography (CT) scan, with no clinical or radiological response to antibiotic or steroidal treatment. Blood cultures, abdominal-pelvic CT, gastroscopy and colonoscopy were negative. Blood tests revealed anemia with an inflammatory pattern and elevated acute phase reactants (erythrocyte sedimentation rate and C-reactive protein).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Initially, given the findings seen on CT, it was oriented as an interstitial disease. Given the poor evolution of the patient and the rapid deterioration, a positron emission tomography/CT (PET/ CT) with [<span class="elsevierStyleSup">18</span>F]fludeoxyglucose ([<span class="elsevierStyleSup">18</span>F]FDG) was performed 12 days after the chest CT scan, looking for a febrile focus or tumor of unknown origin. On PET/CT, intense diffuse pulmonary activity was observed, of greater intensity in the upper lung fields, which decreased in a decreasing way to the bases, over large areas of ground glass on CT. Additionally, a diffuse axial and extra-axial increase in bone marrow metabolism was observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were no supra or infradiaphragmatic lymphadenopathy, or other metabolic findings suggestive of malignancy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A viral infectious process with bacterial superinfection was assessed as the first diagnostic option, without being able to rule out other less frequent causes such as: inflammatory disease, pulmonary toxicity or tumor infiltration.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A lung and bone marrow biopsy were performed, guided by PET/CT findings, resulting on 70% undifferentiated carcinoma with an infiltrative alveolar pattern, with negative immunohistochemical markers for squamous carcinoma (p40) and adenocarcinoma (TTF-1), and with probable bone marrow infiltration (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Additionally, a lepidic growth was observed, consisting of tumor infiltration of the walls of the alveolus, without producing mass or occupying the alveolus itself. Therefore, in the CT image we observed a ground glass pattern, without a clear mass effect.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, the patient died from complications derived from a newly established pancytopenia, which was attributed to neoplastic infiltration of the bone marrow.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This histology is not included in the most recent WHO classification,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> but cases of lung adenocarcinoma associated with a fibrous reaction have been described, and it raises two hypotheses: a growing tumor on a lung parenchyma with previous interstitial disease or a reaction of the lung parenchyma to neoplastic development.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Causes described in the literature as possible diffuse and bilateral pulmonary uptake are chemotherapy-induced pneumonitis, aspiration pneumonia, carcinomatous lymphangitis, acute respiratory distress syndrome, and idiopathic pulmonary fibrosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This case would add one more cause to the possible differential diagnosis of diffuse pulmonary uptake.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Oliván-Sasot P, Sánchez-Vañó R, Calvillo-Batllés P, Belda Ramirez J, Bello-Arques P. Un caso raro de captación pulmonar difusa y bilateral en <span class="elsevierStyleSup">18</span>F-FDG PET/TC. Rev Esp Med Nucl Imagen Mol. 2021;40:337–338.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 730 "Ancho" => 1750 "Tamanyo" => 126743 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">[<span class="elsevierStyleSup">18</span>F] FDG-PET / CT. A) MIP image (maximum intensity projection) of FDG-PET showing diffuse pulmonary hypermetabolism of decreasing intensity to the bases and homogeneous uptake in axial and extra axial bonerrow. No other significant metabolic findings suggestive of malignancy. B, C and D) Axial, coronal and sagittal plane of fusioned [<span class="elsevierStyleSup">18</span>F]FDG-PET/CT showing extensive areas of bilateral ground glass with predominantly apical radiopharmaceutical avidity (SUVmax 10.8). E, F and G) Axial, coronal and sagittal CT sections: extensive areas of ground glass and consolidations.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 496 "Ancho" => 1750 "Tamanyo" => 255972 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Images at 4x (A) and 40x (B) in Papanicolau stain, where we can identify neoplastic cells with lax chromatin thickening the alveolar walls, without observing a mass or alveolus invasion, integrating into the walls of the tissue itself.</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" => "The 2015 World Health Organization Classification of Lung Tumors: Impact of Genetic, Clinical and Radiologic Advances snce the 2004 Classification" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.D. 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