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Year : 2014  |  Volume : 29  |  Issue : 2  |  Page : 122-123  

Carcinoma of unknown primary of neuroendocrine origin: Accurate detection of primary with 68 Ga-labelled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI3-Octreotide positron emission tomography/computed tomography enterography


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication9-Apr-2014

Correspondence Address:
Rakesh Kumar
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.130320

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   Abstract 

68 Ga-labelled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI3-Octreotide ( 68 Ga-DOTANOC) positron emission tomography/computed tomography (PET/CT) is an excellent modality in patients with carcinoma of unknown primary of neuroendocrine origin. Most of the primary lesions are located in mid gut region where the lesions have poor resolution due to undistended and overlapping intestinal loops and motility-related artifacts. Although PET/CT enteroclysis, enterography and colonography have been described with 18 F-fluorodeoxyglucose, PET/CT enterography with 68 Ga-DOTANOC has not been described in the literature. Here, we present a case where 68 Ga-DOTANOC PET/CT enterography was useful in identifying the primary neuroendocrine tumor lesion in small intestine with accurate delineation.

Keywords: 68 Ga-labelled (1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid)-1-NaI3-octreotide, enterography, neuroendocrine tumor, positron emission tomography/computed tomography


How to cite this article:
Jain TK, Karunanithi S, Dhull VS, Roy SG, Kumar R. Carcinoma of unknown primary of neuroendocrine origin: Accurate detection of primary with 68 Ga-labelled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI3-Octreotide positron emission tomography/computed tomography enterography. Indian J Nucl Med 2014;29:122-3

How to cite this URL:
Jain TK, Karunanithi S, Dhull VS, Roy SG, Kumar R. Carcinoma of unknown primary of neuroendocrine origin: Accurate detection of primary with 68 Ga-labelled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI3-Octreotide positron emission tomography/computed tomography enterography. Indian J Nucl Med [serial online] 2014 [cited 2019 Jul 23];29:122-3. Available from: http://www.ijnm.in/text.asp?2014/29/2/122/130320

We present a case of 73-year-old male patient who presented with the complaints of weight loss and flushing for 6-7 months. Hematological parameters including erythrocyte sedimentation rate, fasting blood sugar and thyroid function tests were normal. An initial abdominal ultrasound revealed multiple hypoechoic lesions in bilateral lobes of liver and multiple enlarged mesenteric lymph nodes. Contrast enhanced computed tomography abdomen and chest revealed the same extent of disease. Patient underwent fine-needle aspiration cytology (FNAC) of liver lesion, which revealed metastatic neuroendocrine tumor. Serum chromogranin A (CgA) level was also elevated (CgA ~ 656.46 U/ml). Colonoscopy was performed in search of primary and found to be normal. Finally the treating oncologist advised 68 Ga-labelled (1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid)-1-NaI3-Octreotide ( 68 Ga-DOTANOC) positron emission tomography/computed tomography (PET/CT) in order to search for primary tumor and to define the disease extent. 68 Ga-DOTANOC PET/CT was performed which revealed metastatic 68 Ga-DOTANOC avid lesions in liver and mesenteric lymph nodes [Figure 1]a. Multifocal DOTANOC uptake in the region of distal ileum was also noted [Figure 1]b-e. For better delineation of the small intestinal lesion, we performed PET/CT enterography by orally administrating 100 ml of polyethylene glycol (PEG) mixed in 1 l of water. After 1 h of PEG administration, 68 Ga-DOTANOC was injected intravenously and a spot view of abdomen was acquired after 45-50 min. The preparation is arranged in a manner that whole procedure including the scan was completed within 2 h. 68 Ga-DOTANOC PET/CT enterography helped in accurate delineation of the ileal lesions in the background of distended intestinal loops [Figure 1]f-i. FNAC/biopsy was not accessible as the lesions were located in the distal ileum. He was put on somatostatin based therapy in view of metastatic disease.
Figure 1: 68Ga-labelled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI3-Octreotide (68Ga-DOTANOC) positron emission tomography/computed tomography (PET/CT) maximum intensity projection PET image and trans-axial PET/CT images revealing DOTANOC avid lesions in liver (a) and multifocal DOTANOC uptake in the distal ileum (b-e, arrow). The ileal lesions after performing 68Ga-DOTANOC enterography showed accurate delineation in the background of distended intestinal loops (f-i, arrow)

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68 Ga-DOTANOC PET/CT is a better modality in patients with carcinoma of unknown primary of neuroendocrine origin. [1] Most of the primary lesions are located in a midgut region and mid gut lesions have a poor resolution due to undistended and overlapping intestinal loops and motility-related artifacts. For better delineation and evaluation of intestinal lesions, a complete evaluation of lumen, wall and adjacent structures of gut is required. Both CT and magnetic resonance enteroclysis depict mucosal abnormalities and extra intestinal complications in a highly accurate way but these fail to show the metabolic status of the disease. [2] Therefore, we conceptualized a fusion of a metabolic imaging technique like PET and an anatomical imaging modality like CT enterography to derive information both on the morphology and the functional activity of the lesions at the same time. [3] Although PET/CT enteroclysis, enterography and colonography have been described with 18 F-fluorodeoxyglucose, [3],[4],[5] PET/CT enterography with 68 Ga-DOTANOC has not been described in the literature. Here in this case, 68 Ga-DOTANOC PET/CT enterography was useful in identifying the primary lesion in small intestine with accurate delineation.

 
   References Top

1.Naswa N, Sharma P, Kumar A, Soundararajan R, Kumar R, Malhotra A, et al. 68Ga-DOTANOC PET/CT in patients with carcinoma of unknown primary of neuroendocrine origin. Clin Nucl Med 2012;37:245-51.  Back to cited text no. 1
    
2.Sailer J, Peloschek P, Schober E, Schima W, Reinisch W, Vogelsang H, et al. Diagnostic value of CT enteroclysis compared with conventional enteroclysis in patients with Crohn's disease. AJR Am J Roentgenol 2005;185:1575-81.  Back to cited text no. 2
    
3.Das CJ, Makharia G, Kumar R, Chawla M, Goswami P, Sharma R, et al. PET-CT enteroclysis: A new technique for evaluation of inflammatory diseases of the intestine. Eur J Nucl Med Mol Imaging 2007;34:2106-14.  Back to cited text no. 3
    
4.Groshar D, Bernstine H, Stern D, Sosna J, Eligalashvili M, Gurbuz EG, et al. PET/CT enterography in Crohn disease: Correlation of disease activity on CT enterography with 18F-FDG uptake. J Nucl Med 2010;51:1009-14.  Back to cited text no. 4
    
5.Das CJ, Makharia GK, Kumar R, Kumar R, Tiwari RP, Sharma R, et al. PET/CT colonography: A novel non-invasive technique for assessment of extent and activity of ulcerative colitis. Eur J Nucl Med Mol Imaging 2010;37:714-21.  Back to cited text no. 5
    


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[Pubmed] | [DOI]



 

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