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Year : 2015  |  Volume : 30  |  Issue : 1  |  Page : 86-88  

Forced diuresis 18 F-fluorodeoxyglucose positron emission tomography/contrast enhanced in detection of carcinoma of urinary bladder diverticulum


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

Date of Web Publication23-Dec-2014

Correspondence Address:
Dr. Rakesh Kumar
Room No. 57A, Department of Nuclear Medicine and PET, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.147559

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   Abstract 

Urinary bladder diverticular carcinomas are uncommon with a lesser incidence of 0.8-10% and its diagnosis still remains a challenge. Cystoscopy is the most reliable method, but evaluating diverticulum with narrow orifices is difficult. Before the initiation of appropriate treatment, proper detection of bladder diverticular carcinoma and its locoregional and distant sites of involvement is necessary. Here, we present a case of 48-year-old male with urinary bladder diverticular carcinoma detected by forced diuretic 18 F-fluorodeoxyglucose positron emission tomography/computerized tomography ( 18 F-FDG PET/CT). This case also highlights the significance of forced diuretic 18 F-FDG PET/CT in the detection, staging, and response evaluation of bladder diverticular carcinoma.

Keywords: 18 F-fluorodeoxyglucose positron emission tomography/computerized tomography, bladder diverticular carcinoma, forced diuresis


How to cite this article:
Soundararajan R, Singh H, Arora S, Nayak B, Shamim SA, Bal C, Kumar R. Forced diuresis 18 F-fluorodeoxyglucose positron emission tomography/contrast enhanced in detection of carcinoma of urinary bladder diverticulum. Indian J Nucl Med 2015;30:86-8

How to cite this URL:
Soundararajan R, Singh H, Arora S, Nayak B, Shamim SA, Bal C, Kumar R. Forced diuresis 18 F-fluorodeoxyglucose positron emission tomography/contrast enhanced in detection of carcinoma of urinary bladder diverticulum. Indian J Nucl Med [serial online] 2015 [cited 2020 Aug 11];30:86-8. Available from: http://www.ijnm.in/text.asp?2015/30/1/86/147559

A 48-year-old male presented with painless hematuria and left hip pain since 2 months. Atypical cells were found on urine cytology. Noncontrast computerized tomography of abdomen and pelvis showed a bladder diverticulum arising from right lateral wall of the urinary bladder and a lytic expansile lesion in sacrum and right acetabulum. Fine-needle aspiration cytology from the right acetabular lesion showed high grade metastatic poorly differentiated carcinoma. For localization of primary tumor and extent of metastatic involvement, 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/contrast enhanced computerized tomography (CECT) was done, which revealed metabolically active metastatic disease in retroperitoneal and pelvic lymph nodes, right adrenal gland, multiple skeletal sites, and bilateral lungs in maximum intensity projection images. Due to suspected bladder malignancy, forced diuresis pelvic PET/computerized tomography (CT) was planned. Patient was given furosemide at a dose of 1 mg/kg body weight. Patient was advised oral fluid intake (around 1.5-2 L) and to hold urine after voiding for 2-3 times to allow maximum bladder distension. Forced diuresis pelvic PET/CT images were acquired approximately 2 h after whole body PET/CT imaging. It showed FDG avid soft tissue lesion in the diverticulum arising from right lateral wall of the urinary bladder [Figure 1] which was suggested as the primary malignant site. In view of multiple metastatic lesions and strongly suggested primary site in forced diuretic pelvic PET/CT, patient was given three cycles of chemotherapy and local radiotherapy to pelvis. Post treatment, whole body and forced diuretic 18 F-FDG PET/CT showed a significant response in metastatic and primary sites [Figure 2], and it retrospectively confirmed the bladder diverticular malignancy. Prediuretic PET images did not reveal the primary in bladder diverticulum in both baseline and follow-up.
Figure 1: Maximum intensity projection images of 18F-fluorodeoxyglucose positron emission tomography/contrast enhanced computerized tomography (18F-FDG PET/ CECT): (a) Revealed active metastatic disease in retroperitoneal and pelvic lymph nodes, right adrenal gland, multiple skeletal sites, and bilateral lungs (arrows). Prediuretic PET image (b) did not reveal the primary site. Axial sections of CECT (c, arrow) showed irregular opacification with contrast and thickening of mucosa of bladder diverticulum and forced diuresis pelvic PET/computerized tomography images (d and e) showed FDG avid soft tissue lesion in the diverticulum arising from right lateral wall of urinary bladder (arrows) suggested as the primary malignant site

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Figure 2: Maximum intensity projection images of 18F-fluorodeoxyglucose positron emission tomography/computerized tomography (18F-FDG PET/CT) post three cycles of chemotherapy and local radiotherapy showed a significant response in metastatic sites. (a) Prediuretic PET image (b) did not reveal the primary site even after posttreatment. Axial sections of CT images of pelvis (c, arrow) showed a soft tissue lesion in bladder diverticulum. Axial sections of forced diuresis fused pelvic PET/CT images (d and e) showed response to treatment in the bladder diverticular lesion (arrows)

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Urinary bladder diverticular carcinomas are uncommon with a lesser incidence of 0.8-10%. [1] Multiple modalities such as cystoscopy, CECT, and magnetic resonance imaging (MRI) are used for its diagnosis and staging. Cystoscopy is the most reliable method, but evaluation of tumors with narrow orifices is challenging. [2] Ultrasonography is useful for diagnosing patients with bladder diverticulum tumors, but evaluation of tumors in the dome or neck of the bladder is difficult. [3] With CECT, nonopacification of diverticulum due to occlusion of diverticular orifice by tumor occurs limits the detection of the primary tumor in some cases. [4] High intrinsic tissue contrast between urine and the tumor in the diverticulum makes T1- and T2-weighted MRI suitable for detection of primary bladder diverticular tumor and its perivesical spread. [4] But the major limitation of CECT and MRI is that only enlarged lymph nodes are considered abnormal for locoregional involvement. [2] Not much literature is available regarding role of 18 F-FDG PET/CT in the detection of bladder diverticulum malignancy. 18 F-FDG PET is limited in the detection of bladder cancers due to normal physiological excretion of FDG into the bladder which obscures the bladder wall lesions. [5] Forced diuretic 18 F-FDG PET/CT has an important role in detection and staging of bladder diverticular carcinoma. Forced diuresis washes out FDG from the bladder, provides good lesion to background contrast, and enables detection of bladder tumors. [6],[7] 18 F-FDG PET/CT has got high sensitivity and specificity for distant metastasis detection in bladder carcinomas [8] and especially forced diuretic FDG PET/CT is more sensitive than CT in detecting locoregional lymph node metastases. [6] In the present case, detection of urinary bladder diverticular carcinoma by combination of the whole body and forced diuretic 18 F-FDG PET/CT imaging is an interesting diagnostic feature. It also played a significant role in the detection of locoregional lymph node and distant metastatic involvement and response evaluation of bladder diverticular carcinoma which impacted patient management and prognosis.

 
   References Top

1.
Golijanin D, Yossepowitch O, Beck SD, Sogani P, Dalbagni G. Carcinoma in a bladder diverticulum: Presentation and treatment outcome. J Urol 2003;170:1761-4.  Back to cited text no. 1
    
2.
Dondalski M, White EM, Ghahremani GG, Patel SK. Carcinoma arising in urinary bladder diverticula: Imaging findings in six patients. AJR Am J Roentgenol 1993;161:817-20.  Back to cited text no. 2
    
3.
Saez F, Peña JM, Martinez A, Lopez JA, Marco A, Reyzabal J. Carcinomas in vesical diverticula: The role of ultrasound. J Clin Ultrasound 1985;13:45-8.  Back to cited text no. 3
    
4.
Durfee SM, Schwartz LH, Panicek DM, Russo P. MR imaging of carcinoma within urinary bladder diverticulum. Clin Imaging 1997;21:290-2.  Back to cited text no. 4
    
5.
Swinnen G, Maes A, Pottel H, Vanneste A, Billiet I, Lesage K, et al. FDG-PET/CT for the preoperative lymph node staging of invasive bladder cancer. Eur Urol 2010;57:641-7.  Back to cited text no. 5
    
6.
Nayak B, Dogra PN, Naswa N, Kumar R. Diuretic 18F-FDG PET/CT imaging for detection and locoregional staging of urinary bladder cancer: Prospective evaluation of a novel technique. Eur J Nucl Med Mol Imaging 2013;40:386-93.  Back to cited text no. 6
    
7.
Anjos DA, Etchebehere EC, Ramos CD, Santos AO, Albertotti C, Camargo EE. 18F-FDG PET/CT delayed images after diuretic for restaging invasive bladder cancer. J Nucl Med 2007;48:764-70.  Back to cited text no. 7
    
8.
Apolo AB, Riches J, Schöder H, Akin O, Trout A, Milowsky MI, et al. Clinical value of fluorine-18 2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in bladder cancer. J Clin Oncol 2010;28:3973-8.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2]



 

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