Hodnota zobrazenia 18- FDG PET/ CT u pacientov s atypickým metastatickým karcinómom – kazuistika: 18- FDG PET/CT pri kolorektálnych karcinómoch
Východiská: Metastázovanie do kostrových svalov je veľmi vzácne. Najčastejšie referovanými primárnymi nádormi bývajú pľúcny karcinóm, nádor obličky a malígny melanóm. Je viac ako problematické stanoviť diagnózu svalovej metastázy z iného primárneho nádoru. Prípad: V našej kazuistike popisujeme prípad 44- ročného muža s metastatickým kolorektálnym karcinómom, ktorý podstúpil ľavostrannú hemikolektómiu pre nádor lienálnej flexúry s následnou metastazektómiou pečeňových ložísk a kryodeštrukciou neresekovateľnej metastázy v VII. segmente. V ďalšom období bol pacient liečený dvoma líniami chemoterapie. Krátko po zahájení druhej línie chemoterapie však začal trpieť neznesiteľnou bolesťou v lumbosakrálnej oblasti. Ani MR vyšetrenie, ani abdominálne CT vyšetrenie ako aj scintigrafia skeletu neobjasnili pôvod bolestí. Až zrealizované PET/ CT vyšetrenie preukázalo masívne hypermetabolické metastatické ložiská vo svaloch, čo potvrdili aj pitevné nálezy. Záver: Prípad dokumentuje, že spomedzi rôznych zobrazovacích techník FDG PET/ CT ponúka zachytenie vysoko metabolicky aktívnych nádorových lézií, ktoré sa konvenčnými vyšetreniami detekovať nedali.
Z. Hlavatá 1; N. Pazderová 1; P. Povinec 2; P. Paulíny 2; A. Majidi 3; P. Fiala 3; P. Martanovič 3; T. Šálek 1
Authors place of work:
National Cancer Institute, Bratislava, Slovak Republic
1; PET Center BIONT, Bratislava, Slovak Republic
2; Pathology Department of the Slovak Health Care Surveillance Authority, Bratislava, Slovak Republic
Published in the journal:
Klin Onkol 2009; 22(6): 284-287
Backgrounds: Cancer metastasis to skeletal muscle is very rare. Lung cancer, renal cell carcinoma and malignant melanoma have been reported as the most frequent primary tumours. Diagnosis of muscle metastasis from other primary cancer sites is more than problematic.Case:In this paper we report a case of metastasis of colorectal cancer in a 44‑year‑ old man who underwent left‑ sided hemicolectomy due to the tumour mass in his left colic flexure followed by liver metastasectomy and cryocautery of the non‑resectable metastasis in the VII segment. Subsequently, the patient was treated with two lines of chemotherapy. However, shortly after initiation of the second chemotherapy line he started to suffer from unbearable pain in the lumbosacral region. Neither a whole spinal cord MRI nor abdominal CT scan and scintigraphy explained the origin of the pain. Finally, PET/ CT examination clarified the origin of the pain and showed massive hypermetabolic metastatic lesions in the muscles, further confirmed by autopsy.Conclusion:Thus, among the different imaging techniques, FDG PET/ CT enables the detection of metabolically highly active tumour cells, undetectable by other conventional imaging means.
metastasis to the skeletal muscle is very rare. While only 8 cases
were reported till 2000, now, due to rapid improvements in the field
of modern imaging techniques the clinicians are confronted with
increasing amount of atypical metastatic sites in cancer patients in
general. The most frequent primary tumours reported are lung cancer,
renal cell carcinoma and malignant melanoma . Usually, metastases
of adenocarcinoma to the skeletal muscle form painfull mass of
different sizes predominantly localised in lower extremity [2–3].
Diagnosis of muscle disturbance from other primary cancer sites is
more problematic. Several imaging techniques like CT alone, MRI and
can be employed to detect recurrence of cancer disease. Rappeport and
colleagues compared specificity and sensitivity of each paricular
technique in liver metastases and extrahepatic colorectal cancer. The
most important conclusion from this study was, that PET/CT
can detect more patients with extrahepatic tumour than CT alone .
44 year old
man suffered from change of constipation and diarrhoea was examined
by colonoscopy. He also noticed blood in his stool. The colonoscopy
proved the finding of the tumour mass in left colic flexure. CT scan
showed synchronously metastatic disease in his liver, specifically of
the VI and VII segments. In July 2005 hemicolectomy on the left
side followed by liver metastasectomy of segments VI, II, III and
cryocautery of the metastases in VII segment was perfomed.
Histopathologically, the resected
colorectal carcinoma confirmed the ulcerative, moderately to poorly
differentiated adenocarcinoma of the large bowel (G 2–3).
The tumour had an invasive growth pattern, invading intramurally all
the layers of the large bowel, focally with incipient signs of
invading the pericolic fat tissue. In some parts were caught foci of
extracellular mucus as well as signs of intracellular mucus
production with the formation of sigiloid elements and foci of
endolymphatic embolisation too. Foci of perineural spreading of the
tumour masses were seen. Fifteen lymph nodes were examined; 13 out
of them were positive for metastases of the adenocarcinoma, in one
case a perinodal spreading was presented as well; pT3N3M1.
Between 10/2005 and
patient received „mIFL“ as first line chemotherapy with
Bevacizumab regimen (Irinotecan 100mg/m2,
5FU 450mg/m2 and
CaLV weekly on D1,8,15,22, one week pause, Bevacizumab 5mg/kg
on D1,15). Because of the disease progression, again only in the
liver, the patient underwent second cryocautery of three metastases
in segments V, VII and VIII. From 10/2006 Irinotecan
with Cetuximab as a second line of chemotherapy was administered
(Irinotecan 100mg/m2 on
D1,8,15,22, one week pause, Cetuximab 400mg/m2 initially,
subsequent weeks). In the following months the patient was suffering
from severe pain in the lumbosacral region with irradiation along the
spinal cord into the gluteal muscles bilaterally. Neither a whole
spinal cord MRI nor abdominal CT scan (both recommended by the
neurologist) explained the origin of the pain. However, disease
progression in the liver was proved. Scintigraphy of the skeleton was
negative. An increasing tendency for unbearable pain resulted in
continual high dose opiate derivates application. Disease progression
was supposed in lumbosacral region, however crucial origin of the
pain was still unclear. The lumbar puncture was not performed due to
severe pain. The paraneoplastic myopathy was also considered in
examination showed massive hypermetabolic metastatic lesions in the
muscles; the largest lesion was in the deconfigurated left psoas
major muscle (Fig. 1A, thick arrow) with many smaller lesions in
the other psoas and iliopsoas muscles, and a smaller metastatic
lesion on the jejunum wall (Fig. 1A, thin arrow), in the muscles
of the pelvis, in the gluteal muscles, and in the adductor magnum
(Fig. 1B, thin arrows), in the muscles of the thorax and
abdominal wall, in the muscles of the upper and lower extremities,
which elucidated the cause of pain. In addition, hypermetabolic
metastatic lymphadenopathy in different regions, multiple metastatic
lesions in the liver, other multiple intraabdominal lesions and two
intrapulmonary metastases as well as two metastatic lesions in the
in the left hemisphere of the cerebellum and in the area of the right
meatus acusticus internus were detected (Fig. 2). Palliative
external beam radiotherapy on the cranium was applied. In March
2007 the patient died of disease progression. The autopsy
confirmed the presence of metastases in all localities, as shown
previously on PET/CT.
Histopathological analysis showed
metastasis of adenocarcinoma to the psoas major muscle with
adenostructures (black thick arrow) infiltrating the muscle fibers
(white arrows) and endolymphatic spreading of the tumour cells (black
thin arrow) (Fig. 3A) and infiltration of the adenostructures (black
thick arrow) into the muscle (white arrow) and perineural spreading
(black thin arrow) (Fig. 3B).
the fact, that metastasis of carcinoma to the skeletal muscle is
a rare event, it should be taken into consideration by the
clinicians especially in the case of unexplainable pain occurence.
Based on the literature data, the size of the painful mass ranged
from 2 to 12cm
. The skeletal muscle metastases occurred either as a solitary
mass without any other clinically detectable metastases or as part of
disseminated disease similar as in our case. The metastatic lesions
can be treated with wide excision or radiotherapy or with combination
Overall, there is not universal
and specific imaging technique for skeletal muscle metastasis.
However MR imaging with intravenous gadolinium enhancement is useful
to evaluate the vascularity of the tumour which is helpful for the
planning of further biopsy . The authors believe that the
extensive peritumoral enhancement associated with central necrosis in
patients with painful soft tissue mass is one of the characteristic
features of the skeletal muscle metastasis.
is a molecular imaging technique enabling non invasive in
vivo visualisation of glucose metabolism. This „functional“
diagnostic modality has proven to be invaluable for the detection,
staging and restaging of many malignancies. The increased sensitivity
of PET in comparison to with CT or MRI can be attributed to the
ability of PET to detect changes in metabolic activity that precede
the morphological abnormalities. Fused 18-FDG PET/CT
significantly improves the anatomic localisation of abnormal FDG
activity, which is paramount for the surgical evaluation .
However, sensitivity of FDG PET varies with the size of the lesion
and its anatomic location and specificity depends on histology of the
primary tumor, where well differentiated tumours may exhibit
very low or even absent FDG uptake. On the other hand relatively high
FDG activity may be observed at the sites of inflammation or
granulation tissue, that can be indistiguishable from malignant
disease . The reported sensitivity and specificity of FDG PET
for the detection of recurrent disease have been estimated at
97% (95% CI 95–99%)
and 76% (95% CI 64–88%)
respectively, with a change at clinical management in 29% of
patients . The FDG PET
scan identifies recurrence in two out of three cases of patients with
occult metastatic disease with increased tumour markers (CEA) and
negative conventional imaging .
This manuscript documents the
occurrence of metastasis of the colorectal cancer at atypical muscle
location. We can speculate that this atypical biological
behaviour could be connected with the application of targeted
biological molecules, such as Bevacizumab. Consistent with
increasing frequency of administration of targeted therapy we should
be prepared to handle various unusual clinical pictures. Among the
different imaging techniques, 18-FDG PET/CT
allows detection of high metabolic active tumour cells, undetectable
by means of other conventional imaging. Consistent with previous
literature data 18-FDG PET/CT
represents a valuable source of additional information about
extrahepatic lesions with an impact on clinical management of the
patient. In light of these facts we feel that our case report offers
multiple questions and speculations useful for daily practice with
cancer patients in the presence and for the future.
authors declare they have no potential conflicts of interest
concerning drugs, pruducts, or services
used in the study. Autoři
deklarují, že v souvislosti s předmětem studie nemají žádné
Editorial Board declares that the manuscript met the ICMJE “uniform
requirements” for biomedical papers. Redakční
rada potvrzuje, že rukopis práce splnil ICMJE kritéria pro
publikace zasílané do biomedicínských
Zuzana Hlavatá Department
of Internal Medicine National
Cancer Institute Klenova
10 Bratislava Slovak
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