|Year : 2016 | Volume
| Issue : 4 | Page : 307-308
Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in a rare case of carcinoma stomach with concomitant silicosis
Arun Sasikumar1, Ajith Joy1, Madhavan Unni2, Jayaprakash Madhavan3
1 Department of Nuclear Medicine and PET/CT, KIMS-DDNMRC, Trivandrum, Kerala, India
2 Department of Radiology, KIMS Hospital, Trivandrum, Kerala, India
3 Department of Radiation Oncology, KIMS Hospital, Trivandrum, Kerala, India
|Date of Web Publication||19-Sep-2016|
KIMS-DDNMRC, KIMS Hospital North Block, Anayara P.O, Thiruvananthapuram - 695 029, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The role of fluorine-18 fluorodeoxyglucose. (18F-FDG) positron emission tomography. (PET)/computed tomography. (CT) in the initial staging of various malignancies is now well established. However, nonspecificity of FDG occasionally results in tracer uptake in benign lung lesions. The authors describe a complicated case of carcinoma stomach with multiple nodules and a cavitary lesion in lungs where 18F-FDG PET CT done for initial staging revealed FDG avid mass in stomach, FDG avid multiple mediastinal lymph nodes and multiple intensely FDG avid bilateral lung lesions. The FDG avid lung lesions turned out to be due to silicosis as confirmed by histopathology.
Keywords: Carcinoma stomach, fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography, silicosis
|How to cite this article:|
Sasikumar A, Joy A, Unni M, Madhavan J. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in a rare case of carcinoma stomach with concomitant silicosis. Indian J Nucl Med 2016;31:307-8
|How to cite this URL:|
Sasikumar A, Joy A, Unni M, Madhavan J. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in a rare case of carcinoma stomach with concomitant silicosis. Indian J Nucl Med [serial online] 2016 [cited 2020 May 28];31:307-8. Available from: http://www.ijnm.in/text.asp?2016/31/4/307/187470
| Introduction|| |
The role of 18F-FDG PET/CT in initial staging of gastric carcinoma is well studied. It is also well known that findings on 18F-FDG PET/CT scan needs to be interpreted correlating with the clinical history and findings of adjunct investigations. We describe a rare case of gastric carcinoma with concomitant silicosis resulting in unusual lung findings in 18F-FDG PET/CT scan.
| Case Report|| |
A 48-year-old man presented with persistent dyspnea and melena. An upper gastrointestinal endoscopy revealed a mass lesion in the antrum of stomach, which on biopsy proved to be a well-differentiated adenocarcinoma. The patient was a nonsmoker, however, an occupational history of exposure to silica dust was present. Past history of pulmonary tuberculosis 20 years back which was treated with a complete course of anti-tubercular medications could be noted. Fluorine-18 fluorodeoxyglucose (18 F-FDG) positron emission tomography (PET)/computed tomography (CT) scan was done for initial staging of gastric carcinoma.18 F-FDG PET/CT scan revealed intense FDG uptake in the mass lesion in the antrum of the stomach [Figure 1]a,[Figure 1]b,[Figure 1]c. No abnormal FDG avid abdominal lymph nodes were noted however a few FDG nonavid regional lymph nodes were noted. Intensely FDG avid thick walled cavitary lesion in the right lung upper lobe [Figure 1]d with multiple intensely FDG avid parenchymal and pleural-based nodules were noted in both the lung fields [Figure 1]f, largest measuring 2.8 cm × 2.7 cm in the left lower lobe. FDG avid right supraclavicular [Figure 1]g and multiple mediastinal lymph nodes were also noted [Figure 1]e. The possibility of a second primary in the lung with lymph nodal and lung metastases was also considered as carcinoma stomach with such extensive lung metastases in the absence of regional lymph node involvement is very unusual. Bronchoscopy-guided biopsy of the mediastinal lesions was done which revealed changes suggestive of silicosis. CT-guided fine needle cytology of the largest peripheral lung nodule also revealed features suggestive of silicosis.
|Figure 1: Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan for initial staging of gastric carcinoma. (a) Abnormal tracer concentration in the stomach, mediastinum and bilateral lungs. (b) Intense fluorodeoxyglucose uptake in the mass lesion in the antrum of the stomach. (c) Mass lesion in the antrum of the stomach on computed tomography. (d) Intensely fluorodeoxyglucose avid thick walled cavitary lesion in the right lung upper lobe. (e) Calcified mediastinal lymph node (red arrow). (f) Multiple intensely fluorodeoxyglucose avid parenchymal and pleural-based nodules. (g) Fluorodeoxyglucose avid right supraclavicular lymph node (blue arrow)|
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| Discussion|| |
Silicosis is a form of pneumoconiosis, and an occupational disease associated with occupations such as mining, quarrying, and tunneling caused by the inhalation of fine particles of crystalline silicon dioxide., Silicosis occurs in two clinical forms - simple silicosis, radiologically defined by a pattern of small and round or irregular opacities, whereas complicated silicosis, or progressive massive fibrosis, is characterized by large conglomerate opacities. The CT features of progressive massive fibrosis include focal soft-tissue masses, often with irregular or ill-defined margins and calcifications, surrounded by areas of emphysematous change., Cavitation in the mass lesion may occur secondary to ischemic necrosis, which was noted in this case too. The list of differentials of cavitary lung nodules is quite exhaustive including neoplasms such as primary bronchogenic carcinoma, metastatic disease; bacterial infections (Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas); granulomatous (endemic fungi, mycobacterial, Nocardia); parasitic (Paragonimus, Echinococcus); inflammatory granulomatosis with polyangitis, langerhans cell histiocytosis, rheumatoid arthritis or sarcoidosis; vascular pulmonary embolism with infarction; pneumoconioses; (berylliosis, Caplan syndrome, coal-worker's lung, silicosis); adverse effects of drugs such as amiodarone, infliximab, bleomycin, carbamazepine, and amyloidosis. Carcinoma and tuberculosis are potential serious complications of silicosis which are often characterized by an acute worsening of symptoms. The role of 18 F-FDG PET/CT in initial staging of gastric carcinomas is well studied. Extensive search of literature did not reveal any reported case of isolated lung metastases from gastric carcinomas. The ability of 18 F-FDG PET/CT in identifying the lung cancer focus developing in the background of pneumoconiosis is restricted to a few case reports.,, However, there were reported cases of false positive FDG uptake in cases of some forms of pneumoconiosis including silicosis ,,, which makes the clinical conversion of findings on 18 F-FDG PET/CT scan difficult. Our case reiterates the importance of establishing clinical correlation of the lung findings on 18 F-FDG PET/CT scan including occupational history, which helps in establishing the nature of the lung findings.
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| References|| |
Weil I, Jones R, Parkes W. Silicosis and related diseases. In: Parkes W, editor. Occupational Lung Disorders. 3rd
ed. London, England: Butterworths; 1994. p. 285-339.
McLoud TC. Occupational lung disease. Radiol Clin North Am 1991;29:931-41.
Bégin R, Bergeron D, Samson L, Boctor M, Cantin A. CT assessment of silicosis in exposed workers. AJR Am J Roentgenol 1987;148:509-14.
Bégin R, Ostiguy G, Fillion R, Colman N. Computed tomography scan in the early detection of silicosis. Am Rev Respir Dis 1991;144(3 Pt 1):697-705.
Chong S, Lee KS, Chung MJ, Han J, Kwon OJ, Kim TS. Pneumoconiosis: Comparison of imaging and pathologic findings. Radiographics 2006;26:59-77.
Rozenberg D, Shapera S. What to do with all of these lung nodules? Can Respir J 2014;21:e52-4.
Fraser R, Müller NL, Colman N, editors. Inhalation of inorganic dust (pneumoconiosis). In: Diagnosis of Diseases of the Chest. 4th
ed. Philadelphia, PA: Saunders; 1999. p. 2386-484.
Altini C, Niccoli Asabella A, Di Palo A, Fanelli M, Ferrari C, Moschetta M, et al.
18F-FDG PET/CT role in staging of gastric carcinomas: Comparison with conventional contrast enhancement computed tomography. Medicine (Baltimore) 2015;94:e864.
Je SK, Ahn MI, Park YH, Kim CH. Detection of a small lung cancer hidden in pneumoconiosis with progressive massive fibrosis using F-18 fluorodeoxyglucose PET/CT. Clin Nucl Med 2007;32:247-8.
Bandoh S, Fujita J, Yamamoto Y, Nishiyama Y, Ueda Y, Tojo Y, et al.
A case of lung cancer associated with pneumoconiosis diagnosed by fluorine-18 fluorodeoxyglucose positron emission tomography. Ann Nucl Med 2003;17:597-600.
Williams HT, Solis V, Dillard TA, Gossage JR Jr., Freant LJ. Malignancy in kaolin pneumoconiosis found with F-18 FDG positron emission tomography. Clin Nucl Med 2008;33:4-7.
Canbaz F, Kefeli M, Sahin Z, Basoglu T. Anthracotic solitary pulmonary nodule imitating lung malignancy on F-18 FDG PET/CT imaging. Clin Nucl Med 2011;36:955-6.
Ozkan M, Ayan A, Arik D, Balkan A, Ongürü O, Gümüs S. FDG PET findings in a case with acute pulmonary silicosis. Ann Nucl Med 2009;23:883-6.
Konishi J, Yamazaki K, Tsukamoto E, Tamaki N, Onodera Y, Otake T, et al.
Mediastinal lymph node staging by FDG-PET in patients with non-small cell lung cancer: Analysis of false-positive FDG-PET findings. Respiration 2003;70:500-6.
Ji C, Zhang B, Zhu W, Ling C, Hu X, Chen Y, et al.
Evaluation of 18
F-fluorodeoxyglucose uptake in enlarged mediastinal lymph nodes in patients with lung cancer. Int J Clin Exp Pathol 2014;7:8227-34.