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Malignant somatic transformation arising from teratoma in metastatic testicular germ cell tumor detected on 18F-FDG PET/CT
Transformación somática maligna derivada de un teratoma en un tumor testicular metastásico de células germinales detectado mediante PET/TC con 18F-FDG
Rodrigo Cárdenas-Perilla
Nuclear Medicine Department, Clínica Imbanaco (Cali-Colombia), Cra 38bis # 5b2-04, Cali, Colombia
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En la RM, dicha masa es hiperintensa en T2 (flecha en D) e hipointensa en T1, y con captación de contraste periférica (flecha en E), además, existe aparentemente infiltración del foramen intervertebral izquierdo de L2. No hubo evidencia de afectación en otras localizaciones.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Cárdenas-Perilla" "autores" => array:1 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Cárdenas-Perilla" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2253808921001257" "doi" => "10.1016/j.remnie.2021.07.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808921001257?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X21001311?idApp=UINPBA00004N" "url" => "/2253654X/00000041000000S1/v1_202207160644/S2253654X21001311/v1_202207160644/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2253808921001233" "issn" => "22538089" "doi" => "10.1016/j.remnie.2021.07.002" "estado" => "S300" "fechaPublicacion" => "2022-01-01" "aid" => "1317" "copyright" => "Sociedad Española de Medicina Nuclear e Imagen Molecular" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Esp Med Nucl Imagen Mol. 2022;41 Supl 1:S42-S43" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Interesting images</span>" "titulo" => "<span class="elsevierStyleSup">68</span>Ga-PSMA uptake in a radioiodine-refractory metastatic differentiated thyroid cancer patient" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S42" "paginaFinal" => "S43" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Captación de <span class="elsevierStyleSup">68</span>Ga-PSMA en un paciente con cáncer de tiroides diferenciado metastásico resistente al yodo radiactivo" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1516 "Ancho" => 2507 "Tamanyo" => 371212 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We represent a 64-year-old man with Radioiodine-Refractory Differentiated Thyroid Cancer (RrDTC) who had progressive metastatic disease in the neck, lungs, liver and bones. He was diagnosed with differentiated thyroid cancer (DTC) in 2009 and underwent total thyroidectomy. After that, he developed disease progression in the follow-up despite radioiodine (RAI) treatments. He was treated with 37 GBq (1000 mCi) <span class="elsevierStyleSup">131</span>I between 2011 to 2017, radiotherapy for bone metastases in 2018, and sorafenib for six months in 2018. Because of the rising thyroglobulin (TG) level (TSH:48, TG > 494), it was decided to give an additional 7.4 GBq (200 mCi) RAI therapy in 2019. However, the whole-body RAI scan after the therapy was negative (1A). Therefore, considering the limited treatment options available, it was decided to perform a <span class="elsevierStyleSup">68</span>Ga-DOTATATE PET/CT, and for the somatostatin-receptor positive lesions, he had two cycles of 3.7 GBq (100 mCi) <span class="elsevierStyleSup">177</span>Lu-DOTATATE therapy. Unfortunately, after two cycles of <span class="elsevierStyleSup">177</span>Lu-DOTATATE therapy, the TG levels were still being elevated. Therefore, it was decided to perform <span class="elsevierStyleSup">18</span>F-FDG PET/CT and <span class="elsevierStyleSup">68</span>Ga-PSMA PET/CT as a last option. It revealed intense <span class="elsevierStyleSup">18</span>F-FDG uptake in the anterior lower neck, mediastinal lymph nodes, and right iliac bone metastasis (1B, arrowheads). Additionally, <span class="elsevierStyleSup">68</span>Ga-PSMA PET/CT imaging demonstrated brain metastasis (1C, arrow) and multiple intense liver metastases (1C, arrows). Also, some of the metastatic skeletal sites showed higher <span class="elsevierStyleSup">68</span>Ga-PSMA uptake than <span class="elsevierStyleSup">18</span>F-FDG (1C, arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Göksel Alçın, Esra Arslan, Tamer Aksoy, Tevfik Fikret Çermik" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Göksel" "apellidos" => "Alçın" ] 1 => array:2 [ "nombre" => "Esra" "apellidos" => "Arslan" ] 2 => array:2 [ "nombre" => "Tamer" "apellidos" => "Aksoy" ] 3 => array:2 [ "nombre" => "Tevfik Fikret" "apellidos" => "Çermik" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S2253654X21001335" "doi" => "10.1016/j.remn.2021.06.002" "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/S2253654X21001335?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808921001233?idApp=UINPBA00004N" "url" => "/22538089/00000041000000S1/v1_202207210552/S2253808921001233/v1_202207210552/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2253808922000155" "issn" => "22538089" "doi" => "10.1016/j.remnie.2022.02.005" "estado" => "S300" "fechaPublicacion" => "2022-01-01" "aid" => "1311" "copyright" => "Sociedad Española de Medicina Nuclear e Imagen Molecular" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Esp Med Nucl Imagen Mol. 2022;41 Supl 1:S37-S38" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Interesting images</span>" "titulo" => "Right ventricular metastasis from rhabdomyosarcoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S37" "paginaFinal" => "S38" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis de rabdomiosarcoma en ventrículo derecho" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3588 "Ancho" => 2925 "Tamanyo" => 559048 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Espejo Nino" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Espejo Nino" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808922000155?idApp=UINPBA00004N" "url" => "/22538089/00000041000000S1/v1_202207210552/S2253808922000155/v1_202207210552/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Interesting images</span>" "titulo" => "Malignant somatic transformation arising from teratoma in metastatic testicular germ cell tumor detected on <span class="elsevierStyleSup">18</span>F-FDG PET/CT" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S39" "paginaFinal" => "S41" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Rodrigo Cárdenas-Perilla" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Rodrigo" "apellidos" => "Cárdenas-Perilla" "email" => array:1 [ 0 => "rodrigo.cardenas@imbanaco.com.co" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Nuclear Medicine Department, Clínica Imbanaco (Cali-Colombia), Cra 38bis # 5b2-04, Cali, Colombia" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Transformación somática maligna derivada de un teratoma en un tumor testicular metastásico de células germinales detectado mediante PET/TC con <span class="elsevierStyleSup">18</span>F-FDG" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1644 "Ancho" => 3340 "Tamanyo" => 390135 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET/CT shows a para-aortic retroperitoneal mass of 6 × 8 × 12 cm (extending from L2 to L5), with a mild tracer uptake (SUVmax 5) (arrow in B). On MRI, this mass is hyper-intense in T2 (arrow in D) and hypo-intense in T1 and with a peripheral contrast-enhanced (arrow in E), moreover, there is an apparently infiltration of L2 left neural foramen. There was no evidence of other sites of disease.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Two patients with malignant somatic transformation (MST) are described. The first is a 42-year-old man with a testicular non-seminoma germ cell tumor (NS-GCT) stage III diagnosed in 2007, who was initially treated with orchiectomy and chemotherapy (BEP for 3 cycles). Three months after he had progressive disease in form of teratoma in the mediastinum and supraclavicular, subsequently he received a second-line chemotherapy. In 2012, he had biochemical recurrence treated with third-line chemotherapy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">One year later an <span class="elsevierStyleSup">18</span>F-FDG PET/CT showed progression in retroperitoneal and mediastinal masses (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The right retroperitoneal solid component was biopsied with a diagnosis of adenocarcinoma with mucinous differentiation from the colon. At this time, endoscopies, beta-hCG and alfa-fetoprotein (AFP) were negative, however, carcinoembryonic antigen (CEA) was elevated. There was no KRAS, NRAS or BRAF mutations. In this setting, the diagnosis was revised to a MST of teratoma. The patient commenced treatment with FOLFOX and then changed it to FOLFIRI and Panitumumab, in the setting of a rising CEA.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The second case is a 47-year-old man with a right testicular NS-GCT diagnosed in 2002 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), who was initially treated with orchiectomy and chemotherapy (BEP 4 cycles). Six months and seven years after completion of chemotherapy, the patient had left supraclavicular and retroperitoneal progression, respectively, both resected. In 2019, left nephrectomy was performed due to progressive disease in the retroperitoneum and a left renal mass, in both locations, a mucinous adenocarcinoma well-differentiated was diagnosed. Endoscopies, beta-hCG, AFP and CEA were normal.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">MST is a rare phenomenon in NS-GCT, with an incidence of 3–9%. This entity arises from a teratoma and encompasses various types of malignancies including sarcomas, carcinomas (adenocarcinomas and squamous cell carcinoma), PNETs or others. MST could present as primary gonadal or extra-gonadal or metastatic tumor. MST has worse prognosis compared to GCT, with a cancer specific survival (CSS) of 50–60% vs 80–95%, respectively<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Two-thirds of MST patients had stage II and III at diagnosis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Surgery with complete resection and negative margins is the gold-standard and improves the CSS significantly<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. Histology-specific chemotherapy regimens have been suggested, due to the resistance of MST to GCT schemes<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. In recent published articles, carcinomas appear to have better prognosis than sarcomas<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">MST should be suspected in patients with non-seminomas in whom metastasis remains stable or enlarging with descending or normal tumoral markers<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As in the index clinical cases, adenocarcinoma is appeared in the late relapse after five years of the initial diagnosis, compared to sarcomas who tend to appear promptly<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET/CT has clinical indications and apparently prognostic implications in patients with testicular cancer, however, there are no cases described in the MST context. In these cases, <span class="elsevierStyleSup">18</span>F-FDG PET/CT was useful to provide disease surveillance, guide biopsy and assess treatment response.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</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: Cárdenas-Perilla R. Transformación somática maligna derivada de un teratoma en un tumor testicular metastásico de células germinales detectado mediante PET/TC con <span class="elsevierStyleSup">18</span>F-FDG. Rev Esp Med Nucl Imagen Mol. 2022;41:S39–S41.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2950 "Ancho" => 3340 "Tamanyo" => 670436 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Maximum projection intensity (MIP) in the upper row and <span class="elsevierStyleSup">18</span>F-FDG PET/CT fused image in mid and bottom rows. In B, there are mixed retroperitoneal and mediastinal masses (solid and cystic). The retroperitoneal measured 52 × 47 mm in axial axes with a SUVmax: 14.7 in the solid component, both masses had progression compared to prior study (column A). This solid component (white arrow in B, bottom row) was biopsied. On column C, there is an <span class="elsevierStyleSup">18</span>F-FDG PET/CT with partial response after the last chemotherapy cycle in the solid component of the index retroperitoneal mass. Mediastinal, left retroperitoneal and pelvic masses (not shown) remained stable in the three scans and with low FDG-uptake likely related to low-grade tumor (teratoma).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1644 "Ancho" => 3340 "Tamanyo" => 390135 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET/CT shows a para-aortic retroperitoneal mass of 6 × 8 × 12 cm (extending from L2 to L5), with a mild tracer uptake (SUVmax 5) (arrow in B). On MRI, this mass is hyper-intense in T2 (arrow in D) and hypo-intense in T1 and with a peripheral contrast-enhanced (arrow in E), moreover, there is an apparently infiltration of L2 left neural foramen. There was no evidence of other sites of disease.</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" => "Treatment and clinical outcomes of patients with teratoma with somatic-type malignant transformation: an international collaboration" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Giannatempo" 1 => "G.R. Pond" 2 => "G. Sonpavde" 3 => "C. Albany" 4 => "Y. Loriot" 5 => "C.J. 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